Stimulant use disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2]

Synonyms and keywords: Stimulant intoxication; stimulant withdrawal

Overview

Stimulant use disorder is a substance use disease characterized by the stimulant misuse leading to tolerance, dependence, and abuse. Acute stimulant intoxication is associated with euphoria with affective blunting, hypervigilance, anxiety, and impaired judgment with somatic symptoms characteristic of stimulant drugs such as tachycardia, hypertension, perspiration, and psychomotor agitation. Abrupt discontinuation of stimulants is associated with a withdrawal syndrome characterized by a dysphoric mood with fatigue, vivid, unpleasant dreams, increased appetite, and sleep disturbances.

Stimulant Use Disorder

Differential Diagnosis

• Depressive and bipolar disorder
• Generalized anxiety disorder
• Schizophrenia
• Stimulant intoxication
• Stimulant withdrawal
• Panic disorder
• Phencyclidine intoxication

Epidemiology and Demographics

The prevalence of stimulant use disorder is 2,000 per 100,000 (0.2%) of the overall population.

Risk Factors

• Adult antisocial personality disorder
• Antisocial personality disorder
• Bipolar disorder
• Childhood conduct disorder
• Exposure to community violence during childhood
• Schizophrenia
• Substance use disorder
• Impulsivity
• Prenatal cocaine exposure,
• Postnatal cocaine use by parents
• Unstable home environment, having a psychiatric condition

Prognosis

Poor prognostic factors include:

• Antisocial personality
• Impulsivity
• Substance use disorders
• Living in an unstable home environment

DSM-V Diagnostic Criteria for Stimulant Use Disorder

“

A. A pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: The stimulant is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use. A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects. Craving, or a strong desire or urge to use the stimulant. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home. Continued stimulant use despite having persistent or recurrent social or intepersonal problems caused or exacerbated by the effects of the stimulant. Important social, occupational, or recreational activities are given up or reduced because of stimulant use. Recurrent stimulant use in situations in which it is physically hazardous. Stimulant use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of the stimulant.Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal). b. The stimulant (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit hyperactivity disorder or narcolepsy. Specify if: In early remission: After full criteria for stimulant use disorder were previously met, none of the criteria for stimulant use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the stimulant,” may be met). In sustained remission: After full criteria for stimulant use disorder were previously met, none of the criteria for stimulant use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the stimulant,” may be met). Specify if: In a controlled environment: This additional specifier is used if the individual is in an environment where access to stimulants is restricted. Specify current severity: Mild: Presence of 2-3 symptoms. Amphetamine-type substance Cocaine Other or unspecified stimulant Moderate: Presence of 4-5 symptoms. Amphetamine-type substance Cocaine Other or unspecified stimulant Severe: Presence of 6 or more symptoms. Amphetamine-type substance Cocaine Other or unspecified stimulant

”

Stimulant Intoxication

Differential Diagnosis

• Anxiety disorder
• Bipolar disorder
• Depressive disorder
• Psychotic disorder
• Stimulant intoxication delirium
• Schizophrenia
• Stimulant-induced depressive disorder
• Generalized anxiety disorder
• Panic disorder

Risk Factors

• High chronicity of use
• Low tolerance
• High rate of absortion

Prognosis

Poor prognostic factors include:

• Convulsions
• Cardiac arrhythmia
• Hyperpyrexia
• Impaired social or occupational functioning

DSM-V Diagnostic Criteria for Stimulant Intoxication

“

A. Recent use of an amphetamine-type substance, cocaine, or other stimulant. AND B. Clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting: changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment) that developed during, or shortly after, use of a stimulant. AND C. Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use: Tachycardia or bradycardia. Pupillary dilation. Elevated or lowered blood pressure. Perspiration or chills. Nausea or vomiting. Evidence of weight loss. Psychomotor agitation or retardation. Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias. Confusion, seizures, dyskinesias, dystonias, or coma. AND D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance. Specify the specific intoxicant (i.e., amphetamine-type substance, cocaine, or other stimulant). Specify if: With perceptual disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium.

”

Stimulant Withdrawal

Differential Diagnosis

• Anxiety disorder
• Bipolar disorder
• Depressive disorder
• Psychotic disorder
• Sexual dysfunction
• Sleep disorder
• Stimulant-induced intoxication delirium

Risk Factors

Repetitive high-dose use

Natural History, Complications and Prognosis

Poor prognostic factors include:

• Anhedonia
• Drug craving
• Impairment in a functional area (social, work, school)

Diagnostic Criteria

• A. Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use.

AND

• B. Dysphoric mood and two (or more) of the following physiological changes, developing within a few hours to several days after Criterion A:

1. Fatigue.
2. Vivid, unpleasant dreams.
3. Insomnia or hypersomnia.
4. Increased appetite.
5. Psychomotor retardation or agitation.

AND

• C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

• D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specify the specific substance that causes the withdrawal syndrome (i.e., amphetamine-type substance, cocaine, or other stimulant).