Chapter 5Medical Aspects of Stimulant Use Disorders

Thischapteraddressesthesymptoms,complaints,andothermedicalsequelaecommonlyseeninpersonsusingvariousformsofstimulants
(e.g.,cocaine,crack,amphetamines,methamphetamine[MA])whoappearathospitalemergencyrooms(ERs)andothermedical
settings,orwhoneedspecializedmedicalcarewhileparticipatinginresidentialoroutpatientsubstanceusedisorderprograms.The
purposeofthechapteristoassistmedicalpersonnelinrecognizingandtreatingproblemsthatmayariseforstimulantuserswithacuteor
chronicintoxicationorinvariousphasesofwithdrawalafterprotracteduseofthesedrugsanddifferentiatingthesefromsimilar
presentationsofothermedicalandpsychiatricconditions.Anotheremphasisistheneedforestablishingandensuringlinkagesbetween
medicalfacilitiesandappropriate,comprehensivesubstanceusedisordertreatment/rehabilitationprograms.

Inametaanalysisof555consecutivecocainerelatedvisitstohospitalERsinfourcitiesbetween1989and1992,Schrankconcludedthat
catastrophiccomplicationsdirectlyrelatedtotheuseofthisstimulantcompriseonlyasmallfractionofthesequelae(Schrank,1993).
Deathswererelativelyrare,occurringinonlyfourpatients.Inthissequenceofcases,therewerenoreportsofmyocardialinfarction,
intracranialhemorrhage,ischemicstroke,infarctedbowel,orpulmonarybarotrauma.ThemostcommonreasonsforERvisitsbycocaine
userswerecardiopulmonarysymptoms(usuallychestpainsorpalpitations)psychiatriccomplaints,rangingfromalteredmentalstatesto
suicidalideationandneurologicalproblems,includingseizuresanddelirium.

Mostofthepatientshadmultipleproblems,manyrelatedtointravenoussubstanceuse.Rapidmedicalinterventionwascrucialforcocaine
userswithseizures,hyperthermia,potentiallylethalarrhythmias,ortoxicdelirium.However,mostpatientsrespondedwelltosimple
evaluation,observation,andsupportivecare.Pharmacologicalinterventionwasrequiredinlessthanonefourthofthe555cases.Schrank
emphasizedtheimportanceofrecognizingconcurrentuseofmultiplesubstancesandthepresenceofcocaineorotherdrugsinvictimsof
traumaticinjuryandinobstetricalpatients.

MAusersaremuchlesslikelythanindividualsusingcocainetoarriveattheERwithsuchacutemedicalproblemsascerebrovascular
accidents,acutecardiacischemiaandfailure,hyperthermia,orseizures.ThemajorpresentingsymptomsforMAuserspertainprimarily
toalteredmentalstatus,includingconfusion,delusions,paranoidreactions,hallucinations,andsuicidalideation.Therapiddevelopmentof
tolerancetoitsphysiologicaleffectsamongchronicMAusersmayexplaintherelativeinfrequencyofcardiaccomplicationsinthisgroup
(HeischobarandMiller,1991).

Toxicity, Addiction, and Other Adverse Reactions

ThepreciseclinicaleffectsofcocaineandMAdependonacomplexmixtureofthepharmacologicalpropertiesandpurityofthedrug
usedthedose,frequencyofuse,androuteofdrugadministrationtheuser'sstateofintoxicationorwithdrawalandpreviousexperience
withthedrugandotherconcomitantmedicalandpsychiatricconditions,includingsimultaneoususeofothersubstancesaswellas
personalityattributesandexpectationsregardingdrugreactions.Allofthesefactorsnotonlymediatedrugeffects,butalsoinfluencethe
user'ssusceptibilitytosubstanceabuseordependence(EllinwoodandLee,1989Gold,1997).

Route of Administration
Themethodbywhichstimulantsaretakentherouteofadministrationdeterminesthedosageandtherapidityandintensityofeffects.
Routeofadministrationalsoaffectsthepotentialforadversereactionsandthelikelihoodofaddiction.Theprincipalroutesusedto
administercocaineandMAareoralingestion,nasalinsufflation(snorting),intravenousinjection,andinhalationofsmokevapors
(smoking/inhalation).Thesestimulantscanalsobetakenvaginally,rectally,orsublingually.

Ingeneral,smokingandintravenoususerapidlyevokesimilarlyintenseresponses,whereasoralingestionandintranasaladministration
areslowerdeliverymechanisms,causinglowerandmoregraduallyrisingbloodlevelsandlessintensesubjectiveresponses.Indeed,
cocaineisseldomtakenbymouthinthiscountrybecausefirstpasshepaticbiotransformationmetabolizes70to80percentofthedoseand
substantiallydiminishesthedrug'seffects(GoldandMiller,1997).Whencrackcocaineissmoked,ahighlyconcentrateddoseisrapidly
deliveredtothebrain.Severalstudieshavereportedaclosecorrelationbetweensubjects'plasmalevelsandthesubjectiveeffectsfrom
singledosesgiventorelativelynaiveuserswhohavenotdevelopedtolerance(EllinwoodandLee,1989GoldandMiller,1997Volkow
etal.,1997a).Astheefficiencyofthedeliverysystemincreases,sodoestheintensityofboththepleasurableandadverseeffects.
Figure51depictsthesegeneralvariationsinresponsetimesaccordingtothedifferentroutesofadministrationforcocaineandMA.

Table
Figure51:EffectsofRouteofAdministrationforCocaineandMA.

Tosomeextent,thedangerousconsequencesandaddictivepotentialofstimulantsalsoreflecttherouteofdrugadministration.Oral
ingestionofMAisthoughttoprotecttheuserfromcardiotoxicity(Cooketal.,1993),andthelowerandmoreslopedpeakbloodlevels
achievedbythisroutearealsothoughttoberesponsibleforlowerratesofaddiction(GoldandMiller,1997).Also,cocaineappearstobe
lessaddictiveifdosesremainsmall,peakplasmalevelsandtheonsetofdrugeffectsareslow,andunpleasantwithdrawaleffectsare
absentorminimal.Oralingestionand,tosomeextent,intranasalroutesfulfillthesecriteriaofslower,lesshazardousconsequences
(Gold,1997).

Intravenoususeismoretoxicthanintranasalororalroutes,butinhalationisgenerallyperceivedasthequickestand,fromtheuser's
perspective,themostdesirabledeliverymethodbecausesmokedcrackcocaineandiceMAproducethehighestpeakbloodlevelsandthe
mostpotentsubjectiveimpactwithoutattendanthazardsfromsyringeneedleuse(Cho,1990Cook,1991Gold,1997).Otherinvestigators
reportthatsmokedicedoesnotseemtoproducethesameintense"rush"asinjection.Thereissomeindicationthatinuteroexposurealters
cocainereinforcementpropertiesforadultsor,atleast,increasesratesofcocaineselfadministrationinthelaboratory(GoldandMiller,
1997).

Differentroutesofdrugadministrationalsoproducedifferentsideeffects.Intravenoususersfrequentlydevelopillnessesassociatedwith
thepreparationofdrugsforuse(i.e.,mixing/making)andtheuseorsharingofunsterileneedles,includingHIVinfection,hepatitis,
tuberculosis,lunginfectionsandpneumonia,bacterialorviralendocarditis,cellulitis,woundabscesses,sepsis,thrombosis,renal
infarction,andthrombophlebitis(SowderandBeschner,1993Gold,1997).

Nasalinsufflationisassociatedwithsinusitis,lossofsenseofsmell,congestion,atrophyofnasalmucosa,nosebleeds,perforationor
necrosisofthenasalseptum,hoarseness,andproblemswithswallowing.Crackuserscomplainofthroatailmentsandaproductivecough
withblacksputum(Gold,1997GoldandMiller,1997).IntravenoususeofMAisassociatedwithgreaterseverityofmedicalandsocial
problemscomparedwithotherroutesofadministration(SowderandBeschner,1993).

Figure52comparesdifferencesinuseandconsequentproblemsbetweenintravenousandnonintravenousMAusers.Apparently,MA
usersrecognizetheserouterelatedeffectsandtendtovarytheroutesofadministrationbecausethedrugcausesirritationtonasalmucosa
andlungs(CenterforSubstanceAbuseTreatment[CSAT],1997).Evenprolongeduseofamphetaminecontainingdietpillshasresulted
inischemiccolitisandpulmonaryedema(SowderandBeschner,1993).

Figure
Figure52:DoseFrequencyEscalationPatterns,CocaineandAmphetamine.

Differences Between Cocaine and MA

ThemajordifferencesbetweencocaineandMApertaintotherapidityofresponsesandthedurationoftheireffects.Thesoughtafter
effectsofMAcanpersistforhours,whereasthosefromcocaineareoverinminutes.Thishasimportantconsequencesforthechoiceof
drugandthepatternsofadministrationadoptedbyusers.Theplasmalevelsfromsmokedcrackcocainebothpeakanddeclinerapidly,
whereasthosefromsmokedMAalsopeakrelativelyrapidlybutdeclinemoreslowlybecausemetabolismtakeslonger.Regularly
repeatedusemaybemorecommonamongcocaineuserstryingtosustainthedrug'seffects,whereaswithdrawalismoreprotractedfor
MAusers(Cook,1991GoldandMiller,1997).Figure53showssomeofthedifferencesbetweencocaineandMA.

Table
Figure53:DifferencesBetweenCocaineandMA.

Theplasmalevelsofcocaine/crackpeakanddeclinerapidly,withaterminalhalflifeofabout56to60minutes.MAplasma
concentrationsalsopeakrapidlybutremainhighformuchlonger(Cho,1990Cook,1991).Innormalsubjects,theplasmahalflifeof
cocainerangesfrom40to90minutes(Rowbotham,1993).

Becausethebiologicalhalflifeofcocaineisrelativelyshort,repeateddosingisnecessarytosustainaneffect(GoldandMiller,1997).
Bycontrast,repeateddosingwithMA,beforemetabolismandeliminationarecomplete,canresultinsubstantialaccumulationofthedrug
inthebodywithincreasedlikelihoodforaddiction(Cho,1990Cook,1991).

OtherfactorsinthegrowingpreferenceforsmokableformsofMA,aswellascrackcocaine,includeavailabilityandprice.Crackis
generallylessexpensiveandmoreavailablethanpowderedcocainehydrochlorideandproduces,intheinitialsmoker,averyintensebut
briefrushdescribedbysomeasa"fullbodyorgasm"(Gold,1997).BecauseicecostslessthanotherformsofMAperdose,andbecause
theeuphoriaattainedmaypersistforseveralhours,thisformofMAdeliversthemost"bangforthebuck."Becauseabuseliability
increasesastimebeforeonsetofactiondecreases,andtheconcentrationsofthedrugthatreachthebrainandreceptorsitesincrease
(CornishandO'Brien,1996),thecurrentconcernaboutincreaseduseofstimulantspertainstoboththesmokablepreparations(crackand
ice)andtocontinuingintravenoususeofbothdrugs.

Dose
TheincidenceandseverityofMAandcocaineinducedsideeffectsandtoxicreactionsarealsodoserelated.Asthedoseincreases,the
profileofsideeffectsprogressesfrommildexcitementtomoreintensereactions,evenpsychosis(CSAT,1997).Becausetolerance
developsrapidlytothedesiredeuphoriceffects,stimulantusersnearlyalwaysescalatedosesizeandfrequencyofdruguseinpursuitof
thevanishingrush.Ifinitialusewasbyoralorintranasalroutes,usersalsotendtoswitchtointravenousadministrationorinhalation,
methodsthatpromisemorerapidresponseratesandpeakplasmalevels(EllinwoodandLee,1989).

ChronicMAusersmayconsumeasmuchas15gramsofthedrugperdayindosesexceeding1gramevery4hoursovera24hourperiod.
Becausetheconventionaldoseis10mg,dosesof150mgto1gwouldordinarilybehighlytoxictonaiveusers(Cho,1990).Thereis,
however,considerableindividualvariationintoxicityandoverdosefromstimulants.Althoughgeneralrangeshavebeenestablishedfor
lethaldosesandbloodlevels,reactionsareunpredictable(GoldandMiller,1997).

Thelethaldoseofcocainefor50percentofnoviceusers(LD50)is1.5grams.TheLD50forMAhasnotspecificallybeenestablished,
andthereissignificantindividualvariabilitytoitstoxicity.Forexample,dosesof30mgcanproduceseverereactions,yetdosesof400to
500mgarenotnecessarilyfatal.ReportedtissuelevelsofMAinfatalities,nonetheless,haverangedfrom1g/mLtoover14g/mL.
Reportedbloodlevelshavealsorangedfrom27g/mLtoonly0.6g/mL(Morietal.,1992).

Purity of the Drug

Thepurityofthestimulantusedalsoinfluencestherateandcompletenessofitsabsorptionandeffects.Thepurerthedrug,thegreaterthe
effects."Street"drugs,however,areseldomentirelypure.Thepurityofconfiscatedcocainehydrochlorideintendedfororalorintranasal
consumptiongenerallyrangesbetween20and80percentthepurityofintravenouscocainepreparationscanvarybetween7and100
percentandforfreebaseorcrackintendedforsmoking,from40to100percent(GoldandMiller,1997).MostseizedbatchesofMA
have40to70percentpurity(Burton,1991CSAT,1997).

Adulterantsareaddedtococainetoincreaseitsweightbycuttingorsubstitutinglessexpensivebutsimilartastingandactingproductsthat
willmaximizeprofitsforthedealerwhilestillsatisfyingthecustomer.Ingeneral,theadulterantsincocainedonotposeserioushealth
relatedproblems,althoughthesecannotbecompletelydiscounted(Schrank,1993).Cocaineismostoftencutwithmannitol,lactose,
quinine,glucose,orotherinertcompoundsforweight,andwithcaffeine,lidocaine,otherstimulants,anesthetics,orhallucinogensfor
tasteandeffect(Schrank,1993Gold,1997).

ThemanufacturingprocessesforillicitMAandiceareoftencrudeandcaninvolvemanyimpuritiesandcontaminantsthatdoposeserious
healthconsequences.Untilrecently,mostoftheMAsoldonthestreetwasmanufacturedfromphenyl2propanone(P2P),amethodof
synthesisinwhichleadacetateisusedasachemicalreagent.Thelargequantitiesofleadinthefinalproductcanresultinsymptomsof
hepatitis,nephritis,andencephalopathy(Allcottetal.,1987).TwooutbreaksofleadpoisoninginOregonin1977and1988involvinga
totalof14casesamongintravenousMAuserswereblamedontheleadacetateusedintheP2Pmanufacturingprocess.Testingrevealed
thepresenceof60percentleadbyweightinonecase(IrvineandChin,1991).

ThetypicalclandestinemanufacturingprocessforMAhaschangedoverthelast12yearsfromtheP2Pmethodtoanephedrinebased
methodand,morerecently,topseudoephedrineandphenylpropanolamineprocessing(CSAT,1997).Thedifferencebetweenthesetwo
primarysynthesismethodsisprimarilytheprecursorchemicalsused.

Thenewerandmorepopularephedrinemethod,whichaccountedfor89percentofproductionin1995,makesitsimplertosynthesize
MA,useslessstrictlycontrolledingredients,produceslessodorthanchemicalreactionsinvolvingP2P,andyieldsamorepotentand
psychoactiveformofMA(withahigherpercentageofthemoreactivedextrosteroisomer,ratherthanequalproportionsofdextroand
levostereoisomersproducedbytheP2Pmethod)(Burton,1991Cho,1990CSAT,1997DrugEnforcementAgency[DEA],1996).In
addition,dextroMAisthreetofourtimesmorepotenttothecentralnervoussystemthanlevoMA(SowderandBeschner,1993).
Therefore,theMAcurrentlybeingmanufacturedhasespeciallypotenteffects.

IllicitMAisalsolikelytocontainpotentiallytoxiccontaminantsfromunintendedreactionbyproductsandreagentresidualsaswellas
processingerrors.Manyclandestinelaboratoriesareoperatedbyuneducatedandunskilledchemistswhogetrecipesfromunpublished,
handwrittensourcesorthroughtheInternet.Aswithcocaine,mostofthecontaminantsareintentionalfillersusedtodiluteorcutthe
productandmayincludelactose,lidocaine,procaine,caffeine,quinine,orsodiumbicarbonate.

OtherimpuritiesinillicitMAcancausedangeroustoxicreactions.Someidentifiedcontaminantshavebeenshowntohavegreatpotency
forproducingseizuresinmice.Poisoningfromotherreagentsandorganicbyproducts,includingmercury,hasalsobeensuspectedbutnot
documented(Burton,1991).

Patterns of Use
Theeffectsofstimulantusealsoreflectthetemporalpatternofdrugadministrationandtheuser'sexperiencehistoryorchronicity.Users
describevariousmotivationsforinitialexperimentationwithcocaineorMA,includingadesireforheighteningasenseofwellbeingand
euphoria,increasingalertnessandenergy,boostingselfesteem,enhancingsexualdesireandresponsiveness,dispellingfatigue,improving
performance,losingweight,orconsumingmorealcoholwithoutfeelingintoxicated(HandoandHall,1997SowderandBeschner,1993).
Someusersonlyadministerstimulantsperiodically,althoughmostdiscoverthattolerancebuildsrapidlytomanyofthedesiredeffects,
particularlyeuphoria,sothatincreasingdosesareneededtoachievesimilareffects.

Althoughseriousmedical,psychological,andsocialconsequenceshavefollowedexperimentallowdoseuseofstimulants,twoother
patternsofselfadministrationareofgreaterconcern.ThefourtheditionofTheDiagnosticandStatisticalManualofMentalDisorders
(DSMIV)(AmericanPsychiatricPress,1994)characterizestheseas(1)episodicuse,separatedbyatleast2daysofnonuse,with
graduallyescalatingdosesandmorepotentroutesofadministrationthatoftenculminateinbingeuseand(2)daily,oralmostdaily,use
withnowidefluctuationsindose,butagradualescalation.Actually,compulsiveusersprobablyrepresentonly5to10percentofthetotal
numberofMAusersandanevensmallerpercentageofallusersofamphetamines(Cho,1990).

Becauseoftheirdifferentpharmacologicalproperties,MAuserstypicallyadministerthedrugonadailybasis,whereascrackcocaine
usersbingeonlargeamountsforashorterperiod,interspersedbyperiodsofnonuse(CSAT,1997KingandEllinwood,1997).Figure54
illustratesrapidlyescalatingandsustainedplasmalevelsattainedbydifferenttimepatternsofdrugadministrationduringcocaineandMA
binges.Anextremelycompulsivepatternofrapidlyrepeatedinjectionsorinhalationsisrequiredtosustainhighplasmalevelsofcocaine,
incontrasttoamphetamine/MA,whichhasalongerhalflife(EllinwoodandLee,1989).
 Table
Figure54:CommonSignsandSymptomsofAcuteStimulantIntoxication.

Thegreatestbehavioralpathologyandmostseriousmedicalconsequencesusuallyfollowcompulsivebingeingwithhighdosesofeither
smokedorinjectedMAorcocaine(EllinwoodandLee,1989).Thefollowingparagraphsdescribethesequenceofphasesthattypically
occurintheestablishmentofthishazardous,"hightransition"patternandsomeoftheiraccompanyingsideeffects(asdepictedin
EllinwoodandLee,1989KingandEllinwood,1997).Knowledgeofthesephasescanbeusefulforthemedicalpractitionerintakinga
substanceusehistoryandunderstandingwhateffectsarelikelytoaccompanyaparticularstageofacuteintoxication,withdrawal,ormore
chronicusepatterns.

Intoxication

Stimulant use phases

Initiation,singledosephase.Earlyuseofasingledoseofstimulantsresultsineuphoriaandincreasedenergythatcorrespond
closelytostimulantplasmalevels.Higherlevelsofeuphoriaareachievedbyinjectionorinhalationroutesofadministrationthat
evokearapidrisetopeakdrugconcentrations.Therushexperiencedbypersonswhoinhale(smoke)orinjectstimulantsis
profoundlyrewardingandreinforcing.Classicalconditioningtothecuesassociatedwithdrugusereputedlyoccursduringthis
initialphase.
Consolidation,dosefrequencyescalationphase.Astolerancedevelopstotheeuphorigeniceffects,userstendtoincrease
dosesandfrequencyofstimulantadministrationinanattempttorecapturetheoriginalandmostintenserushsensations.They
mayalsoswitchtherouteofadministrationtogetamorerapidresponse.Duringthisphase,intermittentconsumptionis
prolongedwiththediscoverythathigherdosesproducegreatereffects.
Maintenancephasewithbingeing.Highdoseandfrequentusepatternsoftenleadtoevenmorecompulsivebingeingovera
fewhourstodaysthatceasesonlywhentheuseristotallyexhaustedorthestimulantsupplyrunsout.Bingestypicallylast12to
18hours(butmaylast2to3daysorlonger)forcocaineusersandmuchlongerfrom3to15daysforMAusers.Thehighand
sustainedplasmalevelsachievedduringbingescanhaveconsiderablepathologicaleffects.Thebingeischaracterizedby
frequentmoodswingsasplasmalevelsofthestimulantfluctuate.Stereotypicbehaviorsandthinkingexcludeotherconcernsso
thattheuserfocusesexclusivelyoninternalsensationsandwithdrawsfromsocialactivitiesinpursuitofdirectpharmacological
effects.Almostallactivityisdirectedtoacquiringthedrugandconsumingit.Also,thesettingsinwhichdrugsareconsumedare
progressivelyrestricted.

"Crash" and withdrawal syndrome phases

Earlycrashphase.Thebingeterminateswitha"crash"thathasseveralsuccessivephasesthatfolloweachotherinrapid
successionoverarelativelybriefintervalafteracocainerun,butaremoreprolongedandpronouncedinMAuse.Dysphoria,
anxiety,andagitationbeginashorttimeaftercessationofstimulantuse,followedbyanintensedrugcravingthatoftenleadsto
recidivism.Usersmayexhibitarepetitivecycleofbingeing,withaninterveningcrash,overaperiodofseveralmonths.The
moreprotractedwithdrawalfromiceproducesaparticularlyirritableandjitterystatethatcoincideswiththeinitial"come
down"periodafterbingeuseandisadangeroustimebecausetheuserisshorttemperedandunpredictable.This"tweaking"
periodisexacerbatedbytheuser'sprolongedlackofsleep.Atthispoint,thetweakerisextremelyfrustratedbecausenodose
willreestablisheuphoria.Althoughnotapparentlyintoxicated,thetweakermayhaverapideyemovements,concisebutquivery
speech,andbrisk,somewhatjerkymovementsThetweaker'sthinkingseemsscatteredandsubjecttoparanoiddelusions.
Middlecrashphase.Anxietyandagitationarefollowedbyaperiodoffatigue,increasingdepression,andanhedoniawith
decreasedmentalandphysicalenergy.Anintensedesireforsleep,oftenaccompaniedbyinsomnia,usuallyreplacesthedrug
craving.Duringthispartofthecrash,usersmayusealcohol,benzodiazepines,oropiatestoinduceandprolongsleep.The
 middlecrashphaseterminateswithaperiodofprotractedsleep,oftenfor24to36hoursduringwhichtimeanyattemptat
therapyorotherinterventionisinappropriate.
Latecrashphase.Theperiodofhypersomnolenceinthelatecrashphaseisoftenfolloweduponwakeningbyintensehunger.
Protractedwithdrawal.Followingthecrashphase(orearlywithdrawal),theuserexperiencessymptomsthatareoppositeto
thoseofstimulantintoxication:fatigue,lossofphysicalandmentalenergy,depression,anhedonia,andalimitedinterestinhis
surroundings.Thesesymptomsmayincreaseinintensityoverthe12to96hoursimmediatelyfollowingthecrash,ortheymay
waxandwaneoverseveralweeks.Asevereandpersistingdepressioninthisphasecanresultinsuicidalideationorsuicide
attemptsandisamajorconcernfortheuser.Anhedoniaanddysphoriausuallydissipateovera6to18weekperiodforMA
users.Intheprotractedwithdrawalphase,periodsofdrugcravingmayreemerge.Thesecravingsareoftentriggeredby
conditionedenvironmentalcuesandcanonlybeextinguishedbysustainedabstinence.

Tolerance/Sensitization To Stimulant Effects

Chronicusersofstimulantsdeveloptolerancetomanyoftheinitialeffects,oftenafteronlyafewweeksofdruguse.Thismeansthata
higherdoseisrequiredtoachievethesameeffects,ormarkedlydiminishedeffectsareattainedifthesamedoseiscontinued(American
PsychiatricPress,1994).Mostnotably,tolerancedevelopsrapidlytotheeuphorogeniceffectsofstimulantsandistheostensiblecausefor
mostdoseescalationbystimulantusersalthoughdoseincreasesmayalsostemfromadesiretoexperiencemoreintenseeffects.
TolerancealsodevelopstotheanorecticeffectsofMAinhumansbecauseweightlossstopsafterseveralweeks.Tolerancealsoappears
todeveloptothecardiotoxiceffectsoflargedosesofMAthatmanyuserssurvive.Infact,manyoftheinitialsymptomsofstimulant
intoxicationdisappearwithchronicuse:Bloodpressuremaybenormal,andnauseaandvomitingareseldomseen.Thistoleranceisnot
theresultofincreasedMAmetabolismbecausechronicusersshowmetabolicpatternssimilartonaiveusers(Angrist,1994).

Interestingly,chronic,highdosestimulantusersmayalsobecomesensitizedtothedrug,auniquephenomenoncharacteristicof
psychomotorstimulants.Sensitizationisessentiallythereverseoftoleranceandproducesundesirableeffectswithlowerdosesofthedrug
thanwererequiredtoyieldthesesamereactionsinanearlierphaseoftheaddictionprocess.Thereappearstobesomesensitizationtothe
psychosisinducingeffectsofstimulantsinhumans.Afteronepsychoticepisodeisexperiencedfollowingchronic,highdoseuse,alower
minimaldoseofcocaineorMAmayinduceanotherpsychoticepisode,withmorerapidonsetfollowingdrugintakeandalongerduration
thantheinitialpsychosis.Manysensitizedstimulantusersexperienceanalmostimmediatereturnofparanoia,psychosis,andstereotyped
thinkingifdruguseisresumed(Angrist,1994CSAT,1997).Thesensitizationprocessinstimulantdependenceiselaboratedinthe
sectionontoxicpsychosisinthischapter.

Clinical Manifestations And Medical Management

Asalreadynoted,theintensityanddurationofacutemanifestationsofstimulantintoxicationcorrelategenerallywiththerateofriseand
theheightofpeakbloodlevelsreflectedinbrainconcentrations.Acuteintoxicationwithstimulantsresembleshypomaniaoramanicstate.
Inlowdoses,thelibidoisstimulatedandsexualperformanceisenhanced.Inhighdoses,spontaneousejaculationandorgasmcanoccur.
Withincreasingdoses,poorjudgment,indiscretions,sexualactingout,andotherbizarrebehaviorsormentalalterationsaremorelikelyto
beseen.Acutestimulantintoxicationcanresultinseizures,confusion,dystonias,respiratorydepression,chestpain,orcardiac
arrhythmias(GoldandMiller,1997)(seeFigure54).

Distinctive Characteristics Of MA Intoxication

Theremaybeapeculiarodorofammoniaorstaleurine,especiallyamonguserswhosmokeMAthathasbeencrudely
synthesizedinillicitlaboratories.Smokediceis,however,essentiallyodorless.
TheMAusermaypresentwithtachycardia(rapidheartrate),althoughnotusuallyaccompaniedbyarrhythmia(irregular
heartbeat).Comparedwithcocaineintoxication,MAintoxicationcausesfewerheart,pulmonary,andcirculatoryproblems,
especiallyforusersofnewerformsofephedrinebaseddextroMAthatstimulatetheheart,lungs,andbloodvesselstoalesser
degreethanolderformscontainingequalpartsoflevoanddextroMA(Inabaetal.,1993).
MAusersaremorelikelytoappearintheERasaresultoftraumafromfightingormotorvehicleaccidentsthanforphysical
complaints.
 Becauseofitslongerlastingeffects,MAabusemayleadtomorefrequentpsychiatricimpairment,morepotentcentralnervous
system(CNS)effects,andmoreoverdoses.ChronicabuseofMA(beyond2weeks)ismorehazardousthanchroniccocaine
abusebecauseofMA'ssustainedeffects.Moreover,druginducedpsychosesinMAusersarelikelytolastlongerthanthoseof
cocaineusersand,inaddition,maynotrespondasreadilytoavailabletreatments.
MAusersaremorelikelythancocaineuserstobesinglesubstanceratherthanpolysubstanceusers(althoughmanyalsouse
marijuana).
Stereotypedactivitypersistent,repetitive,andcompulsiveactivitysuchasvacuumingthesamepartoftheflooroverandover
again,poppingknucklesrepeatedly,pickingatscabs,ortakingapartandreassemblingmechanicaldevicesmayappearinMA
users.

Distinctive Characteristics Of Cocaine Intoxication

CocaineusersaremorelikelythanMAuserstopresentwithseriousandpotentiallylethalphysicalcomplications(e.g.,cardiac
arrhythmia,chestpains,cerebrovascularaccident[e.g.,strokes],toxicseizures,hypertensioncrises,hyperthermia).
CocaineusersarealsomorelikelythanMAuserstousemultiplesubstances,especiallyalcohol,benzodiazepines,oropiates.

Management of Stimulant Intoxication

AcuteMAintoxication,unlessdeliriumorpsychosisispresent,seldomcomestomedicalattention.Mostcocaineuserswhocometoan
ERwithdrugrelatedcomplaintshavenotusedthedrugforseveralhours,andpeakplasmalevelshavealreadysubsided,especiallyifthe
cocainewasinjectedorsmoked(Rowbotham,1993).

Uncomplicatedintoxicationrequiresonlyobservationandmonitoringinasubduedenvironmentuntilsymptomssubsideoverseveralhours.
Generalmeasuresincludemonitoringofvitalsignsforrisingpulserate,temperature,orbloodpressureprovidingaquietandcool
environmentthathelpstodiminishagitationandoverreactiontoexternalstimuliandcloseobservation.Physicalexertionandan
overheatedroomcanpotentiateadverseeffectsbecausestimulantsaffectthebody'sheatregulatingmechanismatthesametimethat
bloodvesselconstrictionconservesheat.Althoughverbalreassuranceisusuallysufficientforquietingthepatient,indicationsthat
agitationisescalatingandmovingtowardparanoiaandpotentialpsychosis,withincreasingriskforviolence,maywarrant
pharmacologicalintervention.Fastactingbenzodiazepinessuchaslorazepam(Ativan)ordiazepam(Valium)areusefulforcalmingan
anxious,agitatedpatient(Ellinwood,1975Weis,1997).

Stimulant Overdose
Toxic,fatal,orsubfatalsyndromesareseldomseeninchronic,highdose,intravenousstimulantusers,probablybecausetolerance
developsrapidly.Moststimulantoverdosefatalitiesoccurinneophytesorpersonswhoaccidentallyingestlargeamounts,suchas
"bodypackers"orchildren(Ellinwood,1975).(Bodypackersareindividualswhohaveswallowedwaterproofpacketsfilledwithcocaine,
usuallyinSouthAmerica,inanattempttoclearU.S.customsundetectedandthenpassthepacketsthroughthegastrointestinaltract.)It
shouldbenoted,however,thatthetoxicdoseforstimulantshasenormousvariabilityandappearstobeidiosyncraticandunpredictable,
withoutaknownrelationshiptobodyweight.Hence,theamountofcocaineorMAusedisnotareliablepredictorofthereaction(Weis,
1997).

Thesymptomsofasublethalstimulantoverdosemayincludedizziness,tremor,irritability,confusion,hostility,hallucinations,panic,
headache,skinflushing,chestpain,palpitations,cardiacarrhythmias,hypertension,vomiting,cramps,andexcessivesweating.Highdoses
ofstimulantsmaycausehighfever,cardiacarrhythmiasandarrest,irregularbreathing,seizures,andstroke.Agitatedstates
characterizedbyincreasedaggressivenessorpsychoticfeaturesmayalsooccurwithintoxication,particularlyforMA(Weis,1997).The
developmentofhyperpyrexia(excessivelyhighfever),severehypertension,convulsions,andcardiovascularcollapsesignalalife
threateningsituation(Ellinwood,1975).

Lethaldosesofstimulantsadministeredtolaboratorydogsbyinjectionorobservedinbodypackerswheningestedpacketsleakorbreak
produceapredictablesequenceofeventsculminatingingeneralizedconvulsionsanddeath.Heartrate,bloodpressure,cardiacoutput,and
bodytemperatureriserapidly,andatoxicdeliriumisobservedbeforegeneralizedandterminalseizuresbegin(Ellinwood,1975
Rowbotham,1993Wetli,1993).

Management of a Potentially Lethal Overdose

Stimulantuserswhopresentwithlifethreateningmedicalconditionsandtoxicdruglevelsshouldbetreatedwithstandardlifesaving
techniquesthatrespondtothepresentingsymptoms(Weis,1997).Acuteneurologicalsymptomssuchasseizuresorrapidlyelevatingvital
signsrequireimmediateintervention.Nondrugcausesofanysymptomsshouldbecarefullyruledout,andthepatientshouldalsobe
evaluatedformultiplesubstanceuse.Stimulantoverdosepatientsshouldbehospitalized,especiallyiftreatmentisthreatenedby
polysubstanceuse(Gold,1997).

Nospecificantidotesorantagoniststostimulantoverdoseareavailableunlikenaloxone(Narcan)foropiatesandthebenzodiazepine
antagonistflumazenil(Romazicon).However,thefollowingproceduresaresuggested:

Requestspecialistconsultationsasneeded.
Managehyperthermiabysedatingtoslowdownandstopagitatedmovementsandrapidlycoolingthepatientwithbodyicepacks,
mistandfantechniques,orcoolingblankets(Ellinwood,1975Gold,1997).Simplemeasuressuchaspreventingorcorrecting
elevatedbodytemperaturecanberemarkablyeffectiveinpreventingdeathfromcocainetoxicity(Rowbotham,1993).Although
dantrolene(Dantrium)canbeadministeredforveryseriousandescalating,uncontrolledhyperthermia(Weis,1997),suchdrugs
donotalwaysenhancethecoolingprocessforpatientswithlifethreateninghyperthermia(GoldfrankandHoffman,1993).
Ifrestraintsarerequiredtostartanintravenousadministration,usemeshtypeblanketsonlytransientlytoavoidinterfering
furtherwithheatloss.
Provideadequateventilationandoxygenation.
Uncontrolledhypertensioncanbemanagedbyintravenousadministrationofphentolamine(Regitine)ordopamine(Intropin).
Althoughclinicalexperiencesupportstheuseoflabetalol(Normodyne)fortreatinghypertension,nocontrolledexperimental
studiessupporttheefficacyofthisdrugasanalphaadrenergicblocker(itsbetaadrenergiceffectsaremorepotent).Rapidly
actingandeasilycontrolledantihypertensiveagentssuchasthevasodilatornitroprussideorthealphaadrenergicblocker
phentolamineareusuallypreferable(GoldfrankandHoffman,1993).
Treatseizureslikestatusepilepticuswithintravenousdiazepamorotherbenzodiazepine.Diazepamismosteffectiveif
administeredbeforeorshortlyaftercocaineingestionbutislesseffectiveafterseizuresbegin(Rowbotham,1993).
Phenobarbitolorphenytoin(Dilantin)maybeusedifdiazepamisineffective(Schrank,1993).Alternatively,25to50mgof
intravenouspentobarbitolcanbeadministeredtocontrolcocaineinducedseizures(Gold,1997).
Complaintsofchestpainwarrantevaluationforpossiblemyocardialischemiaandinfarction.Nitratesareindicatedforcocaine
inducedmyocardialischemiatoalleviatecoronaryvasoconstriction.Betaadrenergicblockerssuchaspropranolol(Inderal)
shouldnotbeusedbecausetheymayenhancevasospasm.Aspirinshouldbeadministered,unlesscontraindicated,toreduce
cocainemediatedplateletaggregation(GoldfrankandHoffman,1993).

Usestandardtreatmentsforarrhythmias,includingphenytoin.Atrialarrhythmiasthatdonotrespondtocoolingandsedationmayrequire
cautioususeofcalciumchannelblockersormixedalpha/betaadrenergicblockerssuchasverapamil(Calan),esmolol(Brevibloc),and
labetalol(GoldfrankandHoffman,1993).Lidocainemaybecontraindicatedforventriculararrhythmiasthatbeginimmediatelyafter
cocaineuseasaresponsetocatecholamineexcessbutisappropriateforventriculararrhythmiasthatindicateanischemicmyocardium.
Sodiumbicarbonatehasprovenusefulforcocaineinducedwidecomplexarrhythmias(GoldfrankandHoffman,1993).Alsonotethat
managementofacutepsychiatricmanifestationsofcocaineintoxicationbysedationappearstohaveasalutaryeffectonemerging
cardiovascularcomplications.

Ingeneral,phenothiazines,especiallychlorpromazine(Thorazine,Mellerial),arecontraindicatedbecausethesedrugslowertheseizure
threshold(Gold,1997).Haloperidol(Haldol)hasnotprovenefficaciousinpreclinicalstudiesinprotectingagainstcocaineinduced
seizuresorfatalities,butitmayhaveutilityforMAinducedpsychoses.Theseriousdifficultiesencounteredinusinghaloperidolfor
sedativehypnoticwithdrawalinhumanswhenagitationandhyperthermiaarepresentmayalsoapplytoitsuseforacutelyagitatedor
psychoticstimulantuserswhoalreadyhavedeficitsinthermoregulatorycontrol.Haloperidolmayprecipitateorexacerbateacutedystonic
reactionsassociatedwithcocaineuse(GoldfrankandHoffman,1993).
Manifestations of Stimulant Withdrawal/Abstinence
Acharacteristicwithdrawaltypesyndromeusuallydevelopswithinhourstodaysaftercessationofprolongedandheavystimulantuse.
Thesymptomscanfollowlongtermuseormuchshorterbinges.Although"cocaineblues"weredescribedasearlyastheturnofthe
century(GawinandKleber,1986),morerecentinvestigatorsnotethatstimulantwithdrawalismuchlessdefinitivethanwithdrawalfrom
opiatesoralcoholandhasnotbeensowellstudied(LagoandKosten,1994WestandGossop,1994).(SeeFigure55forsomecommon
signsofstimulantwithdrawal.)

Table
Figure55:CommonSignsandSymptomsofStimulantWithdrawal/AbstinenceSyndrome.

Somecliniciansdistinguishbetweenstimulantwithdrawalsymptomsfollowingaseveraldaybingeandcomplaintsthatcharacterize
withdrawalaftermorechronichighdoseuse.Stimulantuserswhohavebingedfor2to3daysaredysphoric,exhausted,andsleepfor24
to48hours.Cocaineusersinthiscategorycommonlyusealcohol,marijuana,benzodiazepines,orheroinwithcocainetoreduce
irritability.Followingmorechronicandregularstimulantuse,withdrawalsymptomsthatsubsideover2to4daysincludedysphoria,
irritability,difficultysleeping,andintensedreaming(CSAT,1995d).

OthercliniciansemphasizedifferencesinseveritybetweenwithdrawalfromcocaineandwithdrawalfromMA.Asubstantialnumberof
personswithcocainedependencehavenoclinicallyevidentwithdrawalsymptoms.Fortheminorityofcocaineuserswhodocomplain,
symptomsbeginwithinhourstodaysofthelastdose,thecrashlastsfor3to4days,withdrawalpersistsfrom1to10weeks,withwaxing
andwaningofthedrugcraving.Themoodstateofthecocaineusermayreturntonormalafterseveraldaystoamonth.

Withdrawalsymptomsseemtobemostsevereintheinitialdaysfollowingcessationofuse(CornishandO'Brien,1996GoldandMiller,
1997).AlthoughtherearenophysicalmanifestationsofawithdrawalsyndromewhenMAuseisstopped,thereareseveralsymptomsthat
occurwhenachronicuserstopstakingthedrug(NationalInstituteonDrugAbuse[NIDA],1998a).Symptomsbegin12to24hoursafter
bingeuseisterminatedandmaypersistfor1to2weeks.Theclientinitiallyfeelsdepressedandanxious,withanintensecravingforMA.

Thisphaseisfollowedbyfatigueandsleepiness,althoughthismaybemixedwithinsomnia.Uponawakeningafterprolongedsleep,the
clientmaybeveryhungry,andtheremaybepersistinganhedoniaanddysphoria.Othersymptomsincludeparanoiaandaggression.
DepressionappearstobemoresevereandprolongedfollowingMAuseandiscorrelatedwithdurationofuseandsizeofthedoses(Gold
andMiller,1997GawinandEllinwood,1988).

Management of Stimulant Withdrawal

Stimulantwithdrawalisnotmedicallylifethreateningand,unlikealcoholorbarbituratewithdrawal,doesnotrequirepharmaceutical
intervention.Althoughnoconsistentphysiologicaldisruptionsrequiringgradualwithdrawalhavebeenobserved,somemedicationsmaybe
usedtoattenuatesymptomsandprovidesupport.

Thegreatestriskfromthedistinctivestimulantabstinencesyndromeisofdoingharmtoselforothers.Becausewithdrawalrelated
dysphoriaanddepressioncanbeparticularlysevereinstimulantusers,riskofsuicideisintensified,andsensitivemanagementisessential.
Cocaineinduceddepressionusuallydissipatesfairlyrapidlyinamatterofhours.Thedepressionisagitatedandoftenrelatedtoactual
situationsresultingfromdruguse(e.g.,theclientisdisturbedthatallofhismoneyhasbeen"blown"onthecocainebingeorthat
interpersonalrelationshipsarejeopardizedbyhiscontinuingdrugdependence).

However,withdrawalassociateddepressionfollowinghighdoseMAuseismoreprolonged.Duringthetweakingphaseofwithdrawal,
thehighdoseMAuserbeginsarocky,jitteryreactioncharacterizedbyagitatedparanoia,extremefrustration,andthereturnofintense
drugcravings.Suicidalideationmaybehigh,andviolenceiseasilyprovoked.

Tweakingeffectsafterpersistentbingeingoniceareparticularlydangerous.Clientsmaymisinterpretcaretakers'gesturesandturn
againstthem.Restraintsandsedationinasecurefacilitymaybenecessary.Althoughstressreductiontechniquesandotherapproachesto
preventingharmshouldbeusedstandardly,medicalpersonnelcanalsousebenzodiazepines(e.g.,diazepam)tocontrolagitationand
tachycardia(seefurtherdiscussionofviolenceasaspecialissue).

Forclientswithpreexistingdiagnosedorunrecognizedclinicaldepression,cocaineworsenssymptomatology.Theseindividualsaremost
likelytoexperiencedeepeningdysphoriaand/orparanoiaaftercocaineuse.Treatmentwithselectiveserotoninreuptakeinhibitors
(SSRIs)maybeofuse(Gold,1997).

Continuingagitationandpersistentinabilitytofallasleepduringthetweakingstagemayalsobetreatedsymptomaticallybyusingthe
antidepressanttrazodone(Desyrel),whosedopaminergicpropertieshelptosedatetheclient.Benadrylisalsousedforitssedating
propertiesandforitseffectsonthedermatologicproblemsthatoftenaccompanyMAuse(e.g.,itchingandhypersensitivityoftheskin).
However,cautionshouldbeexercisedinusinganymedicationswithhighabuse/dependencepotential.Ingeneral,prescriptionsshouldnot
bewrittenforuseoutsidethetreatmentfacilitybecauseuseorresaleofthesedrugsisverytemptingtothispopulation.

Afterthetweakingstage,MAabstainersusually"crash"andsleepseveraldaysatatime,dependingonthedoseanddurationofthebinge.
Thishypersomnolencemayinterferewithassessmentofmentalstatusandpotentialfordangerousbehavior.Hence,clientsshouldbe
evaluatedimmediatelyafterwakeningfromthisprolongedsleepforpersistingdysphoriaandotherpsychiatricsymptomsofanxietyand
depression(Weis,1997).Duringthishypersomnolentstate,anduntilsleepdeprivationisovercome,activeparticipationintherapyor
followupofareferraltoatreatmentprogrambystimulantusersisnotarealisticexpectation.

Drugcravingduringstimulantwithdrawalhasbeentreatedwithavarietyofmedications(e.g.,bromocriptine,amantadine)without
demonstratedefficacyinalleviatingsymptoms,gettingclients"clean,"orpreventingrelapse.

"Cocainedreams"mayoccurduringthisperiodoraslateas8or9monthsafterterminationofstimulantuseduringaprotracted
abstinencephase.Theyusuallyentailvividrecallofactuallyusingandexperiencingthehigh.Theclientmayactuallysweatand
experienceothersymptomsofintoxicationwhiledreaming.Theseintensedreams,whichmaysometimescontainvignettesinwhichthe
druguserlosesordropsasupplyorrefusestosmokecrack/ice,canbeusedtherapeuticallytoconvinceclientsthattheyaremaking
progressintreatmentbymakingasubconsciouschoicenottouse.Otherwise,thedreamsmayenhancedrugcravingsandintensifya
vulnerabilityforrelapse.Thesedreamsareprimarilyexperiencedbyusersofinjectedcocaine/MAandsmokedcrackorice.

Becausestimulantusersfrequentlyselfmedicatewithdrawalsymptomswithalcohol,benzodiazepines,oropiates,theremaybesymptoms
ofwithdrawalfromthesedrugsiftheyhavebeenusedcontinuouslyorathighdoses.Theserequirespecificmanagementandtitrationof
substitutedosesorothermeansofalleviatingsymptoms.

Manifestations of Chronic Stimulant Use Disorders

Althoughfatalitiesfromstimulantoverdoseoracutemyocardialinfarctionfollowingadministrationofcocainebyinexperiencedusers
havebeendocumented,andothermedicalandpsychiatriccomplicationshavebeenobservedatalldoselevelsandroutesofadministration
amongnaiveusers,themajorityofseriousstimulantinducedmedicalandpsychologicalcomplicationsfollowschronic,highdoseuse.

Becausetolerancedevelopsrapidlytothesubjectiveandcardiovasculareffectsofstimulants,thespecificationofcomplicationsfollowing
chronicuseiscomplex(Rowbotham,1993).However,cocainetoxicityaffectsnearlyeveryorgansystem,withthemostdramaticchanges
foundinthecardiovascularsystem,thebrain,theliver,andthepulmonarysystem(Majewska,1996).Althoughtherearesomeminor
differencesbetweenthesequelaeofchronicMAandcocaineuse,theincidenceofsuchsideeffectsaschestpain,seizures,paranoid
reactions,andsuicidalthoughtsisaboutthesameforbothdrugs.ChronicMAusersappeartohavemoreheadaches,severedepression,
andhallucinationsthancounterpartcocaineusers,buttheevidencefromcommunitysamplesisnotdefinitive(CSAT,1997).

Figure56summarizessomeofthemorecommonsymptomsandpotentiallyseriouscomplaintspresentedbychronicstimulantusers.The
followingsectioncontainsadetaileddescriptionofstimulantinducedmedicalandpsychiatriccomplicationswithlimitedcommentsabout
managementoftheseconditions.SchrankspecifiesmoredetailedERproceduresforrespondingtosomeofthemorefrequentlyseen
complications(Schrank,1993).Figure57showsthedistinctiveindicatorsofchronicMAuseandchroniccocaineuse.

Table
Figure56:CommonSymptomsofChronicStimulantAbuse/Dependence.
 Table
Figure57:DistinctiveIndicatorsofChronicAbuseofCocaineVersusMA.

Identification and Management of Medical Complications

Cardiovascular System Effects

CardiotoxicitystemmingfromcatecholamineexcessisobservedinbothcocaineandMAusers.Althoughthecardiaceffectsaremore
profoundforMAusersbecausethisdrugresultsinevengreaterelevationofcatecholaminesthancocaine,theincidenceoffatalities
followingmyocardialinfarctionhasbeenlessfrequentuntiltherecentincreaseininhaling(smoking)orinjectingMA(Cho,1990Cooket
al.,1993CSAT,1997).

Stimulants,especiallycocaine,havebeenlinkedtovirtuallyeveryformofheartdisease,includingdifferentformsofarrhythmias,
coronaryvasospasm,myocardialischemia,myocardialinfarction,andcardiomyopathy(CornishandO'Brien,1996Gold,1997).Case
reportsoffatalitiesfrommyocardialinfarctionandtachyarrhythmiasdocumenttheiroccurrenceatalldoselevelsandroutesof
administrationinotherwisehealthyyoungadultswithouttheusualcoronaryriskfactors,butpreexistingcoronaryarterydiseasecan
exacerbatetheresponseandincreasethelikelihoodofsuddendeath,ascanhyperthermiaandagitation(EllinwoodandLee,1989Gold,
1997Schrank,1993).Tachycardia,hypertension,rupturedbloodvessels,arrhythmias,andarterioscleroticlesionstypicallyprecede
myocardialischemiaandinfarction(Majewska,1996).Withpromptmedicalintervention,patientsgenerallysurvivestimulantinduced
cardiomyopathywithheartfailure(CSAT,1997).Thereissomecontroversyaboutoptimalpharmacologicapproachestotreating
arrhythmiasandothercardiaceffects.Lidocainewaspreviouslyusedbutmaybecontraindicatedforventriculararrhythmiasbecauseit
lowerstheseizurethreshold(GoldfrankandHoffman,1993).However,certaincalciumchannelblockers(e.g.,Nifedipine,diltiazem,
verapamil)seempromising(Gold,1997Schrank,1993).

Respiratory/Pulmonary Effects
Cocainecracksmokersfrequentlyseekmedicalattentionfordifficultiesinbreathing(dyspnea)orseverechestpain.Thismayresultfrom
cocaineinducedpulmonaryhemorrhage,lungdamage,pneumonia,pulmonaryedema,asthma,pneumothorax,pneumomediastinum,or
pneumopericardium(CornishandO'Brien,1996Gold,1997).Pulmonarybarotraumamayresultfromspasmiccoughingfollowingsmoke
inhalationoroddmechanismsofdrugdelivery(mouthtomouthinhalation),withsuddenincreasesinairwaypressurethatresultin
alveolarruptureandtheinductionoffreeairintothepleuralcavity,mediastinum,orsubcutaneoustissues.Theamountoffreeairis
usuallysmallandresolvesspontaneouslyunderobservation.Thepossibilityofesophagealruptureshouldbeconsideredin
pneumomediastinumifvomitingispresent(Schrank,1993).Cocainecanalsocausesuddendeathbyrespiratoryfailurefromdruginduced
inhibitionofthemedullarycentersinthebrain(Gold,1997).

Tracheobronchitiswithcoughisafrequentaccompanimentofcracksmoking,asarelobarandnonlobarpneumonias.Bronchospasmis
anothercomplaintofthesesmokers,usuallyinclientswithahistoryofasthma(Schrank,1993).Cracklungisanewsyndromethat
manifestswithsymptomsofpneumoniaseverechestpainsandbreathingproblemswithhighfeverbutnosubstantiatinglungXray
evidence.Theconditiondoesnotrespondtostandardtreatment,althoughantiinflammatorydrugsmayrelievesymptoms.Clientswith
cracklungmaysufferfromoxygenstarvationorlossofbloodwithpotentiallyfatalresults(Gold,1997).

PulmonaryedemahasbeenobservedinbothcocaineandMAfatalitiesandattributedvariouslytodeepinhalationaggravationof
preexistingconditions(Nestoretal.,1989)andgranulomasformedinresponsetoadulterantsaddedtothedrugs(CSAT,1997).Chronic
obstructivelungdiseaseinMAusersisthoughttoresultfromthrombosisofsmallpulmonaryvesselswithgradualreductionofpulmonary
vascularbed,pulmonaryfibrosis,andgranulomaformation(CSAT,1997).

Cerebrovascular Complications
Anincreasingamountofresearchhasrecentlyfocusedonneurologicalimpairmentsapparentlyresultingfromhighdoseandchronicuse
ofstimulants,particularlybymorerapidroutesofadministration.Someofthemoredevastatingcerebrovascularconsequencesofcocaine
andMAusehavebeenknownforyearsseizures,ischemicstrokes,andsubarachnoidandintracerebralhemorrhages.Otherneurological
complicationsincludeopticneuropathy,globalbrainischemia,andedemafollowingmyocardialinfarction.Newerbrainimaging
techniquesnowdemonstratevariousdegreesofpreviouslyundetectedandunsuspectedcerebralatrophyandbrainlesionsinmanychronic
cocaineusers(CornishandO'Brien,1996Schrank,1993Majewska,1996).

Seizuresareawellknowncomplicationofcocaineuse,occurringalmostimmediatelyafteranyofthemorerapiddeliveryroutes,butnot
alwaysdoserelated.Chronicusemaysensitize(kindle)anindividual'sresponse,butthisisnotdefinitivelyproven(Daras,1996Gold,
1997).Mostcocaineinducedseizuresareofshortdurationandleavenoresidualeffects,althoughprolongedseizurescanbecatastrophic
(seeearlierreferencesunderoverdosemanagement)(Schrank,1993CornishandO'Brien,1996).

Cerebralhemorrhageandischemicstrokesarerelativelyrareeventsforstimulantusersbutoccurmorefrequentlywithusersofcrack
andice.Atleasthalfofthosewhosufferbrainhemorrhageshavesuchunderlyingabnormalitiesasarteriovenousmalformationsand
cerebralaneurysms.Stimulantinducedhypertensionprobablyleadstoruptureoftheseabnormalitiesthatwillalsorequiresurgical
interventiontocorrect.Cocaineinducedhypertensionandvasospasmseemtobeassociatedwithothercases.

Thetoxicroleofsimultaneousalcoholandcocaineusethatproducescocaethylene(seelaterdiscussion)isalsounderinvestigation
(Schrank,1993Daras,1996).AnotherunresolvedissueiswhetherCNSvasculitisisacausalfactorMAinducednecrotizingvasculitis
hasbeendocumentedsince1970(Milleretal.,1993).Cocaineusingclientswhocomplainofheadachewhileintoxicatedshouldbe
evaluatedforpossibleintracranialhemorrhage(EllinwoodandLee,1989Daras,1996).

Therecentlydocumentedneurologicaldeficienciesfoundinchroniccocaineusers,particularlyinthebasalgangliaandfrontalcortex,are
similartothosefoundinavarietyofneurological/psychiatricdisorders,includingbipolardisorder,schizophrenia,andfrontallobe
degenerationfromseizures,stroke,orinjurythatisaccompaniedbydementia,apathy,depression,andsocialdisinhibition(Majewska,
1996).Animalstudieshaveconfirmedsimilarenduring,possiblypermanent,CNSchanges,associatedwithrepeatedhighdosesofMA.
NeurotoxicityatanearlyagemaypredisposestimulantuserstoprematureonsetofmovementdisorderssuchasParkinson'sdiseaseand
otherdystonicorchoreoathetoiddisordersinvolvingundulating,involuntary,wholebodymovementsthatmayappearattheendofa
prolongedbingeinchronicusersandarenotrelatedtouseofneurolepticmedications(CSAT,1997GoldandMiller,1997).

Anarrayofcognitivedeficitsisalsoobservedincocaineandotherstimulantusersthatalsocharacterizesbrainaginganddementiaand
mayindicateprematurebrainagingorpossiblecerebralatrophyinthesedrugdependentindividuals.Theseincludeproblemsinattention,
concentration,problemsolving,abstraction,arithmeticperformance,newlearning,andshorttermmemory(Majewska,1996Cornishand
O'Brien,1996Gold,1997).Unfortunately,manyofthestudiesdocumentingthesedeficitslackadequatedataonrespondents'premorbid
performance(Daras,1996).

Muscular and Renal Toxicity

CocaineandMAmaybedirectmuscletoxinsbecauseacuterhabdomyolysisaconditionthatdestroysskeletalmusclehasbeen
diagnosedinuserswhodidnothaveanyofthepreviouslyassociatedriskfactors(i.e.,hyperthermia,agitation,seizures,hypotension,toxic
deliriumorcoma,oracuterenalfailure).Musclenecrosismayoccurafteranyrouteofdrugadministration,andthepresenceof
rhabdomyolysisshouldbeconsideredinstimulantintoxicatedclients,particularlythosecomplainingofmyalgiaormuscletenderness.One
studyfoundthatonefourthofclientspresentingwithcocainerelatedcomplaintshadevidenceofmild,usuallyasymptomatic,
rhabdomyolysisdefinedaselevatedcreatinekinaselevelsthatwerefivetimeshigherthannormal(GoldfrankandHoffman,1993
Schrank,1993).

Althoughmildcasesofrhabdomyolysismaynotleadtorenalcomplications,renalinsultandfailureisadistinctpossibilityforpatients
withconcomitanthyperthermia,seizures,delirium,orcoma(Schrank,1993).Renalfailurefromrhabdomyolysishasbeenreportedasan
outcomeofcocaineandMAuse(ScandlingandSpital,1982).Accompanyinghepaticdamageisrareandprobablyanidiosyncratic
response(CSAT,1997).

Gastrointestinal Complaints
Abdominalpain,nausea,andvomitingareexperiencedbysomestimulantusers,probablyindicatingmildintestinalischemia.Severe
bowelinfarctionwithelevatedwhitebloodcellcounts,metabolicacidosis,andshockhavealsobeenobserved.Occasionally,severe
abdominalpain,bowelobstruction,orsuddenonsetofseizuresareindicativeofleakageorruptureofpacketsofcocaineingestedby
"bodypackers"(Schrank,1993).Anotherobservedsyndrome,"cocainecolitis,"manifestsasabdominalpainalongwithdiarrheaand
bloodystools,probablyindicatingdiffusegastrointestinalhemorrhageandtissuenecrosis(GoldfrankandHoffman,1993).

Infections
Asalreadynoted,intravenousinjectionofcocaineorMAisassociatedwithavarietyofinfectiousdiseases.Unsterileparaphernaliaare
particularlylikelytoresultinbloodbornetransmissionofHIV/AIDSandhepatitisB,C,andD.Associatedmalnutritioninchronicusers
furtherlowersresistancetoinfection.Injectioncocaineusersareatgreaterriskofinfectiousendocarditisthanotherparenteraldrug
users(Daras,1996).

Disinhibitionandtheinitialaphrodisiaceffectsofstimulantsareassociatedwithparticipationinhighriskandunprotectedsexualactivity.
Vigorousandprolongedsexualactivityoranalintercourseislikelytodamagetissuesorprotectivecondomsandtherebyincreasethe
likelihoodoftransmittingsexuallycontracteddiseases(CornishandO'Brien,1996).

Effects on Reproductive Function And Fetus/Newborn

Useofstimulantsbypregnantwomenhasbeenrelatedtopoorobstetricaloutcomesandadverseeffectsforthedevelopingfetus,the
newbornandtheolderchild.Anincreasedincidenceofpreecalmpsia,spontaneousabortions,andabruptioplacentaehasbeenobserved
amongcocaineusingpregnantwomen.Toxiceffectsalsoresultinfetalcerebralinfarctionsaswellaslowbirthweightforgestational
ageandsmallheadcircumference.RecentstudiesinseveralseparatelocationshavefoundsimilarratesofthesecomplicationsinMA
andcocaineusingwomenandtheirprenatallyexposedoffspring(CSAT,1997OroandDixon,1987).

Newbornsexposedtostimulantsinthewombmayhavepoorfeedingandsleeppatterns,tremor,andhypertonia.Difficultiesinconsoling
these"jittery"babiesmayinhibitclosebondingwiththeirmothersandcontributetodevelopmentalproblems(Gold,1997).Despiteaspate
ofarticlesoutliningprobablebehavioralandcognitivedeficienciesinprenatallystimulantexposedchildren,morerecentmetaanalyses
haveonlyconfirmedlowerbirthweightcomparedwithcontrols,butnoclearlyattributableeffectsonthefetus,infant,orchild(Rabin
andLittle,1994CornishandO'Brien,1996).

Amajorproblemwithmostoftheearlierstudiesisthatpolysubstanceuseamongpregnantwomenisubiquitous,sothatattributionof
prenatalexposureeffectstoanysingledrugisverydifficult.Additionalmethodologicalconfoundswereintroducedbydifferencesin
mothers'nutritionalstatus,prenatalcare,socioeconomiclevel,andtrimesterofmaternaldruguse,aswellasafailuretoaccountforthe
impactofthehomeenvironmentinpredictingIQ(CSAT,1997CornishandO'Brien,1996).Essentially,thelongtermeffectsof
maternalstimulantuseonoffspringarenotknown.

Chronic,highdosestimulantusealsoaffectsreproductiveandsexualfunctioninginbothmalesandfemales.Menreportgynecomastia
(developmentofbreasts),lossofsexualinterest,impotence,anddifficultyinmaintaininganerectionorejaculating.Womenhave
derangementsofthemenstrualcycle,includingamenorrheaandinfertility,aswellasgreaterdifficultyinachievingorgasm(Gold,1997).
Femalestimulantuserswhohaveirregularornomenstrualperiodsoftenthinktheycannotgetpregnant,althoughtheyarenotalways
infertileandcanhaveunwantedpregnancies.Testingforpregnancyandregularuseofbirthcontrolshouldbeencouraged.

HIV/AIDS and Hepatitis

IncreasedHIVandhepatitisBandCtransmissionarelikelyconsequencesofincreasedstimulantuse,particularlyinindividualswho
injectintravenouslyandshareequipment.InfectionwithHIVandotherinfectiousdiseasesisspreadamonginjectiondrugusersprimarily
throughthereuseofcontaminatedsyringes,needles,orotherparaphernaliabymorethanoneperson.InnearlyonethirdofAmericans
infectedwithHIV,injectiondruguseisariskfactor,makingsubstanceabusethefastestgrowingvectorforthespreadofHIVinthe
nation(NIDA,1998a).

ResearchalsoindicatesthatMAandrelatedpsychomotorstimulantscanincreaselibidoinusers,incontrasttoopiates,whichactually
decreaselibido.However,longtermcocaineusemaybeassociatedwithdecreasedsexualfunctioning,atleastinmen(Rawsonetal.,
1998b).Inaddition,theuseofMAseemstobeassociatedwithroughersex,whichmayleadtobleedingandabrasions.Thecombination
ofinjectionandsexualrisksmayresultinHIVbecomingagreaterproblemamongMAusersthanamongopiateandothersubstance
users,somethingthatalreadyseemstobehappeninginCalifornia(NIDA,1998a).

Identification and Management of Psychological Complications

Toxic Psychosis
InitiallydescribedbyYoungandScovillein1938,amphetaminepsychosisisausuallybriefandspontaneouslyremittingparanoidstatethat
isfrequentlyaccompaniedbyintense,fearevokingdelusionsandhallucinations,butwithclearconsciousnessandarelativelyintact
formalthoughtprocess(Angrist,1994).Stimulantinducedpsychosisoccurswhiletheuserisintoxicated,notinwithdrawalafterdrug
cessation(Tinklenberg,1975).Theconditionisnotrareoridiosyncratic,buttypicallyfollowschronic,highdoseadministrationof
amphetamines,MA,orcocaine.However,thisdruginducedpsychosisismoreprevalentamongamphetamineandMAusersthanthose
whousecocaine,probablybecausetheshorthalflifeofcocainemakesitdifficulttoaccumulateandsustainhighplasmalevelsofthat
drug(Angrist,1994KingandEllinwood,1997).Nonetheless,theconditionhasbeenreportedafteracuteintoxicationinrelativelynaive
usersandoccasionallyafterlowdoses.

Originalreportsoftheconditiondescribedathresholddoseforelicitingapsychoticresponseaschronicadministrationof50mg
amphetaminedaily,butatleast10caseshavebeendocumentedatlowerdoses,andtherearealsocasestudiesofpsychoticreactionsafter
asingledose(usuallyhigh)oronlybriefexposuretothedrug(Angrist,1994).Becausestudiesofstimulantusershavefoundasurprising
prevalenceofcoexisting,oftenpremorbid,psychiatricdisorders(onefourthofparticipantsinonestudyhadpreexistingschizophrenia),
lowdosesofstimulantsmayactuallyprecipitatelatentschizophreniainsomeuserswhosepsychosisisthenmistakenlydiagnosedas
stimulantinduced(Angrist,1994).

Amphetamine-induced psychosis

Severalinvestigatorsclaimthatatoxicparanoidreactionorpsychosis,usuallyaccompaniedbydelusionsand/orhallucinations,isa
probablecomplicationofhighdoseMAuse.Amphetamineinducedpsychosishasbeeninvestigatedprospectivelyunderexperimental
conditionsinatleasttwostudiesinvolvingfewerthan50clients.Griffithandcolleaguessuccessfullyelicitedpsychoticsymptomsin25of
31experiencedusersafterhighdoseadministrationofMAandobservedthat22ofthe25werefranklypsychotic(Griffithetal.,1972).
Bellevokedsimilaramphetamineinducedpsychosisin11of13subjects(Bell,1973)theremaining2werefoundtohavepreexisting
schizophrenia(Angrist,1994).Surveysofchroniccocaineusersintreatmenthavealsofoundthatonehalftotwothirdshadparanoid
experiencesthatwerenottrivial(Angrist,1994).

However,therearemethodologicalproblemswitheachoftheinvestigativeapproachestostudyingstimulantinducedpsychosisthatmake
thefindingslessthancompelling.Whenthisconditionisstudiedprospectively,thedrugexperiencedvolunteerswhomustbeusedfor
ethicalreasonshaveunknown(unobserved)sensitivityandtolerancetostimulantsthenumbersare,ofnecessity,quitesmallfordrawing
definitiveconclusions,andatleastsomeoftheparticipantshavemanagedtocontinuedruguse,evenunderrigorouslaboratoryconditions.
Datafromcasereportshaveotherdrawbacks:Thepremorbidhistoryofdruguseandpsychiatricstatusisunknownandmaynotbe
accuratelyreportedbyrespondents(Angrist,1994CSAT,1997).

Development of toxic psychosis

Someresearchersandcliniciansdescribethedevelopmentofstimulantinducedpsychosisasanevolvingprocess.Panelmembersdepicted
MAusersashavingbriefandtransientpsychoticepisodesbeforeafullblownpsychosisemergesaftermoreextensivechronicuse.MA
usersoftenrecognizetheseearlypsychoticeffectsandtrytostavethemoffbyselfmedicatingwithalcoholordecreasingdruguse.In
severalarticles,EllinwoodandcolleaguesdescribetheevolutionofMAinducedpsychosisasprogressivelyabnormalbehaviors
beginningatmoderatelyhighdoseswithintensefeelingsofcuriosityabouttheenvironmentandpatternsofexplorationthatresult,for
example,inexaminingthepunctuationperiodsinamagazinetextforevidenceofasecretcode(Ellinwoodetal.,1973).

Thisfirstenthusiasmabout"discoveries"movesovertimeandincreasingdosesfrom"watchingtheworld"tofeelingsofbeingwatched.
Behaviorsbecomemorefixedandstereotyped,culminatingwithintensesuspiciousnessand,inpsychoticreactions,paranoiddelusionsthat
misinterpretenvironmentalcues.Visualhallucinationsmaybeoverreactionstobarelyglimpsedandrecognizableobjectsintheclient's
peripheralvisionauditoryhallucinationssimilarlybeginwithhearingsimplenoises.Inlaterstagesofthepsychosis,theclientlosesall
contactwithrealityandhasdelusionsofpersecution.Ifheisexhaustedafteraprolongedbinge,thehyperreactivitytostimuliand
confusioncanleadtopanic,suddenviolence,evenhomicide(KingandEllinwood,1997).

Manifestations of toxic psychosis

TheDSMIV(AmericanPsychiatricPress,1994)distinguishesbetweencocaineintoxicationwith"perceptualdisturbances"andcocaine
inducedpsychoticdisorderwitheitherdelusionsorhallucinations(dependingonwhichistheprominentfeature).Intheformer,thedrug
userhasintactrealitytestingandisawarethatauditory,visual,ortactilehallucinationsaresubstanceinduced,notactualrepresentations
ofexternalreality.Anothercommonmanifestation,beforeparanoiaisrampantandasdeteriorationdevelops,isstereotypypersistent,
repetitiveactssuchasdisassemblingandreassemblingradiosorothersmallgadgetsthatseemstooffersomerelieffromagitationand
anxiety.Eventhoughtheclientseemstoknowthatthebehaviorismeaningless,stoppingitresultsinirritabilityandfrustration(Kingand
Ellinwood,1997Tinklenberg,1975).Aschronic,highdosestimulantconsumptioncontinues,mostusersalsowithdrawfromallsocial
interactionsandinitiateotherbizarrebehaviorsbeforetheintensivedruguseculminatesinparanoidreactionsorpsychosiswithoutany
insightintoactivities.

Symptomsofstimulantinducedtoxicpsychosisusuallyabatespontaneouslywithinaweek(CSAT,1997).Hallucinationsstopwithin24to
48hoursofabstinence,andparanoiaanddelusionsdecreaseoverthenextweekto15days.Theclientmaysleepafterthefirst24hours
foraslongas3days,withextensivedreamingduringthisphase(Ellinwood,1975).Cliniciansalsoreportthatdruginducedpsychosis
dissipatesmorequicklyforcocaineusersusuallyin1to3dayscomparedwithupto2to3weeksforMAusers.Usersoficeare
reputedtohavethemostintenseandpersistentpsychoses(SowderandBeschner,1993).

Toxicstimulantpsychosiscanhavetypicalandatypicalpresentations.Casereviewshaveestablishedthatapproximately80percentof
thesepsychoticclientsexperienceparanoiddelusions60to70percenthavehallucinations12percenthavetactilehallucinations(e.g.,
cocainebugscrawlingontheskin)olfactoryhallucinationsarepresentinfewerthan10percentandabout7percentbecomedisoriented.
Hyperactivityandexcitationareusuallypresent(Tinklenberg,1975Ellinwood,1975Angrist,1994).Theclientisgenerallyorientedand
hasintactmemoryandanappropriatelevelofconsciousness.Clientsrememberthepsychoticepisodeswithremarkableclarity
(Tinklenberg,1975Ellinwood,1975).Thoughtdisorder,ifpresent,isusuallymildandtransient(CSAT,1997).

Afewclientsareconfusedusuallydeliriousfromhighdosestowhichtheyhavenotdevelopedtolerancebizarre,usuallyautoerotic,
sexualbehaviorispresentinsome,andothershavedestructiveoutburstsormakeunmotivatedassaults.Oneinvestigatorfoundno
differencesinsymptomsbetweenrelativelynaiveandchronicamphetamineuserswithpsychoticreactions,butothersclaimthat
individualswhobingeonhighdosesoverafewdayshavemoredelusionsanddisorganizedhallucinationsandparanoidideationthan
chronicuserswhohavemoresystematicdelusions.Intravenousdrugadministrationcausednochangeinsymptoms,butmorerapid
progressiontopsychosis(Angrist,1994CSAT,1997).

The role of drug sensitization

Severalissuespertainingtostimulantinducedpsychosisremainunresolved.Thereissomedisagreementabouttheroleofdrug
sensitization(kindling)inprecipitatingmorefrequenttoxicpsychoticreactionsatsmallerthanpreviouslyrequireddosesandsoonerafter
druguseisreinitiatedfollowingaperiodofabstinence.Thereisalsodisagreementabouttheroleofsensitizationindeepeningthe
depressionexperiencedafterwithdrawal.Themechanismsforthis"reversetolerance"arenotfullyunderstood.Althoughanimal
experimentshaveshownthatdaily,intermittentdosingwithstimulantsresultsinsensitization,studiesofamphetamineinducedpsychosis
inhumanshaveyieldedmoreambiguousresults(CSAT,1997).However,a1991surveybySatelandcolleaguesof50cocainedependent
clientsconsecutivelyadmittedtoatreatmentprogramfoundthattwothirds(68percent)hadexperiencedparanoidpsychosiswhile
intoxicatedandduringtheimmediatepostdrugcrash(Sateletal.,1991).

Thereportedcharacteristicsofthisparanoiawereconsistentwithasensitizationprocess.Allofthosewithaparanoidreactionhad,on
average,yearsofbingeusebeforeparanoidsymptomsgraduallyemerged.Anxietygraduallyintensifiedduringbingesbeforefrank
paranoiddelusionswereexperienced.Onceparanoiaemerged,everysubsequentbingeproducedintensifiedreactions(despiteuseof
anxiolyticstreetdrugsbyhalfofthegrouptoameliorateparanoidreactions),andtheonsetofthesedelusionsafterstartingarun
acceleratedovertime.Halfofthosewhohadexperiencedparanoidpsychosisacknowledgedengaginginbizarrebehaviorsuchashiding
orcompulsively"checkingup"onthingsnearlytwofifthshadsecuredweaponstoprotectthemselvesfromimaginedassailants.This
paranoiapersistedforanaverageof12hours,withneartotalresolutionin97percentofcasesbeforeawakeningafterthepostbingecrash
(GawinandKhalsaDenison,1996).

SimilarresultsarereportedbyBradyandcolleaguesaftera1991studyofanother55cocainedependentclientsintreatment53percent
hadexperiencedcocainepsychosis,mostwithlessdrugandincreasingfrequencyovertimeandwithmorerapidonsetforthemajority
(Bradyetal.,1991).Itseemsclearthatsensitizationtothepsychosisinducingeffectsofcocainedoesoccur,althoughtheevidencefor
sensitizationwithamphetaminesissomewhatlessclear(Angrist,1994).

Stress-induced psychosis

Theroleofstressorother"triggers"suchasalcoholuseorinsomniainprecipitatingthereturnofpsychoticsymptomsthatwereinitially
inducedbystimulantsisalsocontroversial.

Someinvestigatorshavereportedthatstresscanevokethereturnofpsychoticsymptoms(delusions,hallucinations,paranoia,suicidal
thoughts)withoutfurtheramphetamineorMAuseandafterlongperiodsofabstinence(NIDA,1998aSowderandBeschner,1993Spotts
andSpotts,1980).

However,Angristquestionstheaccuracyofsuchreportsofspontaneousorstressinducedpsychosisfollowingamphetaminepsychosis
becausethereportedcaseswerenotcarefullymonitoredwithurinetoxicologiestoruleoutcontinuingsubstanceuseorexaminedforthe
possibilityofsimultaneousdevelopmentofanotherpsychiatricdisorder(Angrist,1994).

Duration of toxic psychosis

Thedurationoftoxicstimulantpsychosisisanotherissueinsomedispute.Typically,uncomplicatedpsychosisinducedbystimulants
resolvesrapidlyunlessmoreofthedrugistaken.However,severalJapaneseinvestigators(i.e.,Tatesu,1964Nakatani,1990Iwanamiet
al.,1994[ascitedinAngrist,1994])havereportedpersistingpsychosesinchronicstimulantusersforupto1yearafterabstinencewhen
amphetaminemetaboliteswerenolongerpresent.

AngristarguesthatWesterninvestigatorsdonotseeprolongedpsychosesveryfrequently,andthepersistingpsychosesobservedinJapan
mayactuallybecaseswherestimulantsprecipitatedlatentschizophrenia(orbipolardisorder),orthedisorderwaspresentbut
undiagnosedbeforeamphetamineusebegan(Angrist,1994).Heconcludesthatthepotentialforamphetaminetocauselongstanding
psychosismaybeacomplicationforsomeindividuals.Thisconclusionis,however,unprovenbecausethepremorbidstateofclientsin
reportedstudieshasnotbeenknownandbecausecontinuedsubstanceusehasnotbeenruledoutbyurinetoxicologymonitoring.

Treatment of toxic psychosis

Treatmentoftheclientwhopresentswithtoxicstimulantpsychosisentailsrapid,systematicvisualassessment,continuedobservationand
monitoring,andsymptommanagement.Allunnecessarystimulationshouldbereduced,butcompletesensorydeprivationshouldbeavoided
byprovidingquietroomswithmoderatelightingandsufficientspaceandinsistingonsubduedtalkingwithoutanyrapidorunexpected
movements.Theclinicianshouldreassuretheclientthattheconditionisdruginducedandwillsubside(Tinklenberg,1975).Restraints
mayberequiredinitiallytogaincontroloftheclient,butshouldbecheckedfrequentlytoensurethatrisktoextremitiesisminimized,that
respirationisnotcompromised,andthatheatlossisnotinhibited.Agitationshouldbecontrolledpromptlybysedationwithparenteral
benzodiazepinesusuallydiazepam.

Differentialdiagnosisofacuteconfusionalstatesmustbeinstitutedimmediately.Considerationshouldbegiventothepossibilityofhead
injury,intracranialhemorrhage,orthyrotoxicosis.Informationfromsignificantothersishelpful,andtoxicologytestingisalsousefulto
confirmadiagnosis(Schrank,1993).

Acutestimulantinducedpsychosisshouldgenerallybemanagedinahospitalpsychiatricdepartmentorsimilarfacility.Minorpsychotic
episodeswithlowgradesymptomsthatrespondreadilytoneurolepticmedicationsmay,onsomeoccasions,bemanagedinawellstaffed,
freestandingchemicaldependencyunitifsufficientpersonnelwithtrainingandexperienceintreatingdualdiagnosisarereadily
available.Urinetestingisrecommendedtoconfirmadiagnosisofdruginducedpsychosisbecausethesyndromecancloselymimicother
psychoticdisorderssuchasschizophrenia,hypomania,depression,obsessivecompulsivereactions,orcatatonia.However,anegative
urinereportdoesnotnecessarilymeanthatstimulantswerenotpresent(Ellinwood,1975Tinklenberg,1975).Thecriteriaforplacement
shouldreflectthepersistenceofthecondition,thecompetenceandtrainingofpersonnel,andthedrugtaken.MAuserswhohave
accumulatedhighplasmalevelsfromlongerbingesandlargerdosesofstimulantswithlongerhalflivesareparticularlypronetoviolence
duringpsychosistheirparanoiamakesthemsuspiciousofattemptstomedicatethem,theyarelikelytobecomeaggressive,andtheydon't
complywithmedicationinstructionsafterreleasefromthehospital.

Thecriteriaforcontinuedhospitalizationorinpatientcareduringpsychosisareperceivedriskorthreatstoselfandothers,aswellas
elevatedvitalsigns,severesuicidalideation,persistenceofpsychologicalorcognitiveimpairmentsbeyondtheusualtimeforspontaneous
resolution,andseverityofanymedicalproblemssuchasseriousheartdisease,ahistoryofinfarcts,concomitantalcohol,barbiturateor
opiatedependence,ordiabetesandsimilarconditionsthatrequirecarefulmonitoring(Tinklenberg,1975).Releaseshouldnotbe
considereduntilthemedicalcrisisisresolvedoruntilthepatienthasbeenstabilizedpsychologicallyfor24hoursandisabletoselfcalm
withoutcontinuinguseofneuroleptics.Buspironehydrochloride(Buspar)isusedexperimentallyinHawaiitotreatlowgraderesidual
psychosisandisanecdotallyeffectivewhengiveninlargerthanusualdoses(over60mg).Itisrelativelysafe,althoughnotadvisableif
theclienthasahistoryofbenzodiazepineabuse.

Aggression and Violence

Amajorperceivedproblemassociatedwithamphetamine/MAabuseisthepotentialforsuddenandintenseviolence(MiczekandTidey,
1989).MAhasbeenassociatedwithcrimeandcombativebehavior(SowderandBeschner,1993).Anecdotalreportsbylawenforcement
officials,psychiatrists,anddrugusersthemselves,aswellassomesurveys,linkstimulantstoaggressionandunprovokedassaults.Users
havecommittedmurdersandotherviolentactswhileintoxicatedwithamphetamines.Nonetheless,theeffectsofstimulantsonaggression
andviolencearecomplexandparadoxical.Therearesharplydifferingopinionsaboutthenatureandextentoftheproblem(Kingand
Ellinwood,1997MiczekandTidey,1989).

Ina1987reviewofclinicalobservationsandsurveyresults,Miczekfounddifferingrepresentationsofamphetamineeffects(Miczek,
1987).Somesurveysfoundthatsizeableproportionsofprisonpopulationsandjuveniledelinquentscommitcrimesofviolencewhile
intoxicatedbyamphetamines,butotherstudiesidentifiedonlyrarecasesandsmallpercentagesofjuveniledelinquentsandhostilepersons
whowereamphetamineusers.Thereliabilityofthesestudieswasunfortunatelycompromisedbythelackofmatchedsamplesand
relianceonverbalselfreportscontainingquestionableinformationaboutdoseandfrequencyofdrugadministration.Itmaybethatintense
violentactsaremoreprominentamongchronichighdoseusers,butnoreportslinkedamphetaminestoahighincidenceofexcessively
violentbehaviororotheroffensivesocialbehavior(MiczekandTidey,1989).

Althoughwellcontrolledexperimentalstudiesofstimulantassociatedaggressionorviolenceinhumansarescarce,theconclusionsare
similarlyambivalent.Earlystudiesofcocaineoramphetaminesdidnotfocusonthisaspectornoteanyincreasedaggressionasa
behavioralsideeffect.Infact,lowdoses(10to30mg)ofparticularstimulants(i.e.,Ritalin)havewellknownandcarefullystudied
beneficialeffectsonchildren5to14yearsoldwhoarediagnosedwithattentiondeficit/hyperactivitydisorder(AD/HD)whichmanifests
asaggressive,destructive,irritable,hyperactivebehavior.Animalstudiesofmice,rats,squirrels,monkeys,andcatshaveexamined
aggressioninducedbyisolation,pain,andbrainstimulationincombinationwithamphetamines,withmixedresults.
Themostimportantdeterminantsofaggressionanddefensiveresponsesseemtobesituation,species,priorexperiencewiththese
behaviors,dosage,andchronicityofthestimulus.Forexample,asubstantialincreaseinaggressivebehaviorcanbeevokedif
amphetaminesareadministeredtoanimalsthatarerepeatedlyconfrontinganintruder.Mostimportantly,theremaybeabiphasicdose
effectonaggressivebehaviorinsomeanimals:Aggressioncanbeenhancedatlowdosesandalsoathigherdoses,uptoapointatwhich
stereotypyandsocialwithdrawalinterfere(MiczekandTidey,1989KingandEllinwood,1997).

Otherresearchmoreclearlyconfirmstheeffectofamphetaminesonhumanaggression.ArecentJapanesestudyascertainedthatMA
usersscoredhigherontestsofverbalandphysicalaggressivenessandonimpulsivenessthaneitheralcoholicornormalcontrolgroups
(Mukasa,1990[citedinSowderandBeschner,1993]).Anearlierinvestigatorfoundthatparticipantsinataskthatenabledthemto
rewardcompetitorswithmoneyorpunishthemwithwhitenoiseincreasedtheiraggressivenessafter5and10mgdosesofamphetamines,
whereascaffeinereducedthefrequencyofthisaggressivebehavior(Chereketal.,1986[citedinKingandEllinwood,1997]).

Probablythemostusefulexplanationofamphetamineeffectsonviolenceisofferedbyresearcherswhoclaimthatstimulantsdohavea
specific,butcomplexassociationwithviolentbehavior.Chronic,moderatetohighdoseMAuse,especiallyifthedrugisinjectedorused
byanotherrapidrouteofadministration,oftenresultsinassaultivebehaviorandotherformsofviolenceinthecontextofaninteractionof
behavioralandpsychologicaleffects(e.g.,hyperactivity,agitation,emotionallability,andparanoiddelusionalthinking)combinedwith
personalityfactorsandsocialenvironment(KingandEllinwood,1997).Inotherwords,certainindividualswhoareregularlyusinghigh
dosesofamphetaminemaybepronetointenseviolence,especiallyifexperiencingparanoiddelusions,butitisnotknownhowfrequently
thisoccursorwhatcircumstances/personalitycharacteristicspromotethisreaction(MiczekandTidey,1989).

Prevention of aggressive behavior

TheConsensusPanelnotesthatthecombinationoflowimpulsecontrol,paranoia,poorjudgment,andgrandiosityexperiencedbythe
chronicMAuser,especiallyduringapsychoticorprepsychoticepisode,isanaturalsetupforviolence.Similarly,thecombinationofa
longactingdrugandasustainedhighbecauseofMA'sreadyavailabilityandlowcostresultsinamoresevere/intensewithdrawal
reactionandaccompanyingsusceptibilitytowardviolence.Thetweakerwhoisreadytocrashafterbingeingonicedoesnotneed
provocationtoreactaggressively,butconfrontationincreasesthelikelihoodofaviolentreaction.

Becausedruginducedpsychosesapparentlyincreasethepotentialforviolenceinresponsetoperceivedpersecutionandparanoia,sound
behavioralmanagementtechniquestopreventthisnegativeanddangerousresponseareessential.ThetechniqueslistedinFigure58have
beendemonstratedtobeusefulandshouldbeadoptedbyERpersonnelaswellasemergencymedicaltechniciansandpolice.

Box
Figure58:RecommendedApproachesforReducingtheRiskofViolence.Keeptheclientintouchwithrealityby
identifyingyourself,usingtheclient'sname,andanticipatingconcerns.Placethe(more...)

Co-Occurring Disorders Among People With Stimulant Use Disorders

Stimulantusershaveasurprisingnumberofcoorpreexistingdisordersthatcanmakedifferentialdiagnosischallengingorcomplicate
treatment.Recently,investigatorshavebecomemoreinterestedintheimplicationsofpremorbidconditionsaspotentialindicatorsof
vulnerabilitytostimulantdependence.Majewskapointsouttheneedformoreresearchtoestablishtheepidemiologicalrelationships
betweenpreexistingneurologicaldeficitsresultingfromgenetic,developmental,traumatic,orneurotoxicfactorsandvulnerabilitytodrug
addiction(Majewska,1996).Morespecifically,preclinicalstudiesandsomesurveysseemtoindicatethatneurologicaldeficitsassociated
withAD/HD,neuroanatomicalabnormalities,leadpoisoning,alcoholism,posttraumaticbrainlesions,andposttraumaticstressdisorder
(PTSD)maybecorrelatedwithincreasedvulnerabilitytostimulantaddiction.Anotherinvestigator(Bauer,1996)listsanothersetof
conditionsordisordersthatfrequentlycooccurwithcocaineusedisordersandnotesthatthesecorrelatesrepresentpotentialconfoundsto
researchregardingthesequelaeofcocaineabuseanddependenceaswellaspotentialriskfactorsfordevelopingthosedisorders.These
includeantisocialpersonalitydisorder,depression,otherDSMAxisIdisorders,polysubstanceuse,aggression,afamilyhistoryof
alcoholismorothersubstanceusedisorders,prescribedpsychoactivemedications,seizures,headinjury,HIV/AIDS,andothermajor
medicalproblems.

Thefollowingsectionsdescribesomeofthemostcommonlyidentifiedpremorbidandcooccurringdisordersamongstimulantusers,with
somecommentsontreatmentprecautions.

Polysubstance Use
Concomitantuseofavarietyofotherlicitandillicitpsychoactivesubstancesisacommoncorrelateofstimulantuse.Thesesubstances
arefrequentlyusedtoattenuateaversivesymptomsexperiencedintheposteuphoricphaseofuse(Weis,1997)ormaybeadministeredto
prolongorcounterparticulareffectsofstimulantintoxication.Differentcombinationsofsubstancesareusedtotitratemoodstatesor
effects(CSAT,1997).

Cocaineuserstendtopreferalcohol,marijuana,oropiates.ThereisgenerallylessalcoholusebutmoremarijuanauseamongMAusers
thancocaineusers(CSAT,1997).Cigarettesmokingisalmostubiquitousamongstimulantusers,usuallytorelieveperceivedstress.
Speedballingsimultaneoususeofopioidsandcocaineorotherstimulantsisstillprevalentinmanyplacesbecausethecombinationis
perceivedtosmooththeeffectsofeachdrug.Someclientswhoaretakingprescribedneurolepticsforpsychiatricproblemstake
stimulantstocounteractthesedatingpropertiesoftheseantipsychoticmedications(Weis,1997).

Variousreportsindicatethat62to90percentofcocaineusersconcurrentlydrinkalcoholtoprolongthehighandattenuateunpleasant
agitationandsleeplessnessthatemergeattheendofabinge(Gold,1997GoldandMiller,1997).However,thecombinationofcocaine
andalcoholappearstobeparticularlydangerous.Researchershaveestablishedthatcocaethylene,anethylesterofbenzoylecgonine,is
formedintheliverwhenthesetwosubstancesareusedtogetherandthatthismetaboliteisparticularlytoxictotheliver.Asubstanceuser
whocombinescocaineandalcoholmayexperiencemoreintensepleasurefromtheexperiencethanusingeithersubstancealone,butis
alsoexposedtothecombinedtoxicitiesofcocaineandtheevenmorepotentcocaethylene(Gold,1997CornishandO'Brien,1996).
MendelsonandcolleaguesfoundthatacombinationofingestedalcoholandinjectedMAincreasedusers'perceptionofintoxicationas
wellascardiacresponses,withpotentialformoreseriouscardiovascularconsequences(Mendelsonetal.,1995).Yamamuraand
colleaguesfoundthecombinationaggravatedbothsomaticandmentaldisorders(Yamamuraetal.,1992).Becausecocaethylenehasa
longerhalflife(2hours)thancocaine(38to60minutes),thecumulativeandadditiveeffectsfoundinthecombinationincreasethe
incidenceoflethalheartattacksandstroke(18timeshigherriskofsuddendeaththanwithcocainealone).

Cocaethyleneappearstoprolongthedurationofcocainerelatedincreasesinbloodpressureand,inturn,toincreasethelikelihoodof
smallvesselintercerebralinfarcts.Inaddition,cocaethyleneincreasestheriskofpanicandanxietyattacksthatchroniccocaineusers
experience,especiallythosethatpersistforsometime.Thereissomeindicationthatcocaethyleneproducesgreaterirritabilityandmore
persistentwithdrawalcomplaints(GoldandMiller,1997).Theroleofcocaethyleneinevokingviolenceandintensifyingagitationisalso
beinginvestigated(Schrank,1993).

Concomitantuseofbenzodiazepinesandcocainetobluntdysphoriceffectsisalsocommon.Thiscombinationmayenhancerespiratory
depressionandprolongalteredmentalstates,butdecreaseriskofseizuresespeciallyifdiazepamistakenbeforecocaineisused
(Schrank,1993).

Thepopularityofmarijuanaamongstimulantusersisexplainedbyitspharmacologicproperties.Becausemarijuanainducesvasodilation
ofnasalmucosa,itattenuatesthevasoconstrictionofcocainesothatabsorptionisincreased.Smokingmarijuanabeforesnortingcocaine
decreasesthetimetopeakeuphoriceffects,decreasesdysphoriceffects,andincreasespeakcocainelevelsapparentlybyincreasing
bioavailability(Gold,1997).

Psychiatric Disorders
Itisbelievedthatmoststimulantusershaveconcurrentpsychiatricdisorders.A1991surveyofnearly300treatmentseekingcocaine
usersfoundthatmorethan70percenthadalifetimehistoryofpsychiatricdisorderssuchasalcoholism,majordepression,bipolar
disorder,anhedonia,anxiety,phobias,antisocialpersonality,andchildhoodAD/HD(RounsavilleandCarroll,1991).Atleastfourother
earlierstudiesfoundsimilarcomorbidityofcocainewithmostofthesesamepsychiatricdiagnosesinadditiontoPTSD(Majewska,1996).
Asmanyashalfofsurveyedcocaineusersintreatmenthavelifetimediagnosesofdepression20to25percenthavecyclicmood
disordersandsizeablepercentagesoftheseclientsreportborderlineorantisocialpersonality,PTSD,orresidualAD/HD(Gold,1997).
Thesepsychiatricdisordersaremorecommonamongstimulantusersthaninthegeneralpopulation(Weis,1997).

Identifiedanxiety,phobias,AD/HD,andantisocialpersonalitydisordertypicallyprecedecocainedependence,whereasalcoholism,
depression,andparanoiagenerallyfollowstimulantuse.Althoughthesymptomsofstimulantinducedpsychosiscloselymimicthoseof
schizophrenia,andheavyuseofcocaine/amphetaminesmayprecipitatelatentschizophrenia,thetwodisordersarenotcloselycorrelated
(Majewska,1996).Panicattacksareanothercorrelateofcocaineuse.Riskforthisproblemmayincreasebecauseofsensitizationto
cocaine(Gold,1997).

Differentiatingcomorbidpsychiatricdisordersfromstimulantrelateddisorderscanbechallenging.Acuteorchronicstimulant
intoxicationcanelicitsymptomsofanxietythatareindistinguishablefromphobias,obsessivecompulsiveness,panic,andgeneralized
anxiety.Theparallelsbetweensymptomsofstimulantinducedpsychosisandschizophreniaarewellknown.Withdrawalfromstimulants
cancausedepressionthatisindistinguishablefrommajordepressionfromothercauses(GoldandMiller,1997).Itcantakeatleasta
monthofabstinencefromallstimulantusetodifferentiatestimulantinduceddysphoria,depression,paranoia,oranxietyfromatrue
psychiatricdisorder.

Theprognosisforsubstanceusedisordersisworsenedbythepresenceofotheruntreatedpsychiatricdisorders(orsubstanceuse
disorders).Clientswithcomorbidpsychiatricanddrugdependencedisordersneedtohavebothtreatedthepsychiatricproblemsusually
improvewithabstinence.Antidepressantandneurolepticmedicationswithlowanticholinergicandsedativepropertiesarepreferredin
ordertoavoidanotheraddiction.Sedativehypnoticsandbenzodiazepinesmustbeusedwithcautioninhighriskpopulations(Goldand
Miller,1997).

Medical Conditions
Anypreexistingacuteorchronicphysicalconditionsarealsolikelytobecomplicatedandexacerbatedbythestressofstimulant
intoxicationandwithdrawal.Particularlydangerouscoexistingmedicalconditionsincludeanyhistoryofseizures,coronaryheartdisease,
cardiacorthyroidproblems,hypertension,orrespiratoryandpulmonarydisease.Hypertension,renalfailure,anddiabetesmellitus,which
areriskfactorsforstroke,canbeexacerbatedifcocaine/crackissmoked(CornishandO'Brien,1996).

Clientswhoarealreadytakingmedicationsforothermedicalconditionsmaybeatspecialriskifstimulantsaremixedwith,forexample,
antidepressants,medicationsforhighbloodpressure,orantipsychotics.Theeffectsofsuchdruginteractionsmaybedifficulttopredict.

CrackorMAusingmothersmaybeidentifiedduringprenatalcareorinthedeliveryroomthroughpregnancyordeliverycomplications,
positiveurinetoxicologies,oracknowledgedhistoriesofsubstanceuse.Newbornswhowereexposedtostimulantsinuteromaymanifest
neurobehavioralproblemsthatarelessobviousanddangerousthanthoseseeninopiateoralcoholexposedcounterparts.Thesymptomsof
stimulantexposureinnewbornsarelikelytobetransientandnotrequiredirectintervention.However,theyoungbabiesaretypically
irritable,tremulous,lethargic,emotionallylabile,andsomnolent.Theymayhaveapronouncedstartlereaction,CNSinstability,and
prolongedandinconsolablecrying.Afewhavesignsofvasculardisruptionsand,rarely,congenitalmalformations,particularlyofthe
heart,gastrointestinaltract,orskeletalsystem.Riskofsuddeninfantdeathsyndromemaybeheightenedslightly.

Managementisprimarilybycloseobservationinaquietnurseryenvironment,gentlehandling,carefulattentiontofeedinghabits,and
promotingpositivebondingwiththemother.Moreinformationaboutassessing,diagnosing,andmanagingthestimulantexposedneonate
canbefoundinTIP5,ImprovingTreatmentforDrugExposedInfants(CSAT,1993).

Traumatic Injury
Patientsappearinginhospitalemergencydepartmentsfollowingmildtoseveretraumasmaybestimulantuserswhohavebeeninvolvedin
fightsoraccidentsofvarioustypes.TheincidenceofbrokenhandsafterfightingseemstobeparticularlyhighamongMAusers.TIP16,
AlcoholandOtherDrugScreeningofHospitalizedTraumaPatients(CSAT,1995b),providesrelevantinformationregardinghowto
identifyandmanagetraumapatientswithacuteorchronicsubstanceusedisorders,includingstimulantabuse.Severalwidelyused
screeninginstrumentsthatcanhelphospitalpersonneldeterminesubstanceusestatusofconscioustraumapatientsaredescribed,asare
laboratoryteststodeterminesubstanceusestatusofanyindividualwithpotentialsymptomsofsubstanceuse,abuse,ordependence.

Assessment and Diagnosis

DiagnosiscanbebasedonestablishedDSMIVcriteriaforamphetamineorcocaineabuse/dependenceandotherlistedcomposites
(AmericanPsychiatricPress,1994).Fortreatmentreimbursement,thediagnosismayalsoneedtoreflectcriteriaaccordingtothe
InternationalClassificationofDiseases(AmericanMedicalAssociation,1997).Arrivingatadiagnosisissimplifiedbyhavinginformation
availablefromarelevantandaccurateclienthistory,aurinetoxicologyscreenorsimilarlaboratorytests,andclinicalobservationsof
physicalsignsandmentalstatus.

History
Anappropriatesubstanceusehistoryshouldincludethesubstance(s)andmedicationsusedduringthelast30daysthespecific
substance(s)orcombinationstypicallyusedwiththeusualdose,frequency,androuteofadministrationthedurationofuseandthetime
andamountoflastuse,aswellaswhenthesymptomsorcomplaintsdevelopedandhowtheyhaveprogressed.Iftheclienthasbeen
bingeing,abriefdescriptionofthisandpreviousepisodesishelpful.Inaddition,thehistoryshouldincludeinformationaboutanyprevious
seizures,deliriumtremens,heartandpulmonaryproblems,paranoidreactions(withorwithoutdelusionsandhallucinations),andother
seriousmedicalandpsychologicalconditionsandpsychiatricdiagnoses,aswellasallcurrentmedicationstheclientistaking.Although
peoplewithstimulantusedisordersarenotaslikelyasthosewithothertypesofsubstanceusedisorders(i.e.,alcoholics)tohaveagenetic
componentorfamilialhistory,informationaboutothersubstanceabuseorpsychiatricproblemsinthefamilycanbeenlightening.

FormostpatientspresentinginanER,thesubstanceandmedicalhistorywill,ofnecessity,bebriefandfocusonthepotentialcausesfor
theobservedsymptomsandcomplaintsandanypotentialmedicalorpsychologicalproblemsthatarelikelytocomplicatemanagementand
thepatient'sresponse.Stabilizethepatientmedicallybeforetryingtotakeahistoryandassesspotentialdangertoselforothersbeware
ofexaggerationordismissalbythepatientofhissymptomsandconditionandusesignificantothers,wheneverpossible,tovalidatehis
history.Insituationswherethepatientisdelirious,psychotic,orunabletorespond,informationfromaccompanyingfriendsorsignificant
othersabouttheantecedentsoftheproblemisparticularlyimportant.Sometimes,thesubstancehistorymustawaitsymptomatic
management.

Thehistorymaybesupplementedbyavarietyofscreeninginstrumentsconstructedtoascertainsubstanceusedisorders,althoughthese
arenotnotablyreliableifusedwithacutelypsychoticorintoxicatedindividuals.Anumberofthesescreeninginstrumentsaredescribedin
detailinTIP16,AlcoholandOtherDrugScreeningofHospitalizedTraumaPatients(CSAT,1995b).

Urine Toxicology
Aurinescreenortoxicologytestmaybeusedtoidentifywhichsubstancestheclienthasusedrecently.Thistestingisvitaltoconfirm
clinicians'personalassessmentsandobservations.SomeERshavebedsideorpatientsideurineimmunoassaytestingkits(dipsticktests)
thatcanbeusedforaquickturnaroundwithoutwaitingonmoreformalassays.Thesecanbevalidatedbyadditionallaboratorystudies
thatrequire6to8hoursorlongerforprocessinginahospitalsetting.

TheresultsofeitherdipstickorEnzymeMultipliedImmunoassayTechnique(EMIT)testsareappropriatetouseformedicalpurposes,
butcannotbeusedforcriminalprosecutionbecausenochainofcustodyisestablished.Alternativetechniquesfordeterminingsubstance
useareanalysesofhair,blood,sweat,ortissuesamples.Ingeneral,however,urinehasbecomethestandardmethodofdetermining
substanceuseinanindividual,andtestsarereadilyavailableinthemedicalsettingwhereothertypesoftestingarenot.Urinescreensare
lessexpensivethandrawingbloodsamplesfortestingorotheralternatives.Bothqualitativeandquantitativeurineassaysareusually
neededtoverifyuseandtime/amounttaken.Repeatedassaysmaybeusedtotrackeliminationofstimulantsfromthesystemiflarge
amountshavebeendetected.

Becausenostandardsetofsubstancesistestedinaurinesubstancescreen,medicalpersonnelshouldmakecertainthatassaysfor
suspectedsubstancesareincluded.Also,notoxicologyscreencandeterminewithcertaintythatanyparticularsubstanceorany
substancesatallwasingested.Thedetectionlimitationsmaybetoobroadorthespecificsubstancemayhavebeencompletely
metabolizedbeforeaurinespecimenwascollected.Apositivereportwillnotnecessarilyindicatewhenthesubstancewaslastused:
Metabolitesforsomesubstancesaredetectablefordaysorweeksafterlastuse,buttakesometimeaftersubstanceadministrationtobe
detectableinurine(CSAT,1995b).

Stimulantscanbedetectedinurineforapproximately24to48hoursfollowinguseand,maximally,for3daysafterasingledoseand7to
12daysfollowingrepeatedhighdoses(AmericanPsychiatricPress,1994).Cocaineisexcretedmorerapidlyandismoredifficultto
detectinurinesamplesthanMA.However,anEMITtestcandetectbenzoylecgonine,aninactivecocainemetabolite,inurineforupto
72hoursafterlastingestion(Weis,1997).Benzoylecgoninehasbeenfoundinurineaslateas22daysafterlastcocaineintoxicationin
threeasymptomaticclientswithsubstantialhistoriesofcocaineuse(GoldfrankandHoffman,1993).Manyprescriptionandoverthe
counterdrugs(e.g.,dietaids,coldremedies)containphenylpropanolamineorephedrinethatmayyieldpositiveEMITorRIAtestsfor
amphetamines.Aprocedurethatdoesnothavecrossreactivitytophenylpropanolamineorephedrinewillbeneededtoconfirmthat
amphetaminewasconsumed(HawksandChiang,1986).

Physical Signs and Mental Status

Dataacquiredfrommonitoringvitalsigns(temperature,bloodpressure,pulserate,respirationrate)canbeusedtodocumentphysical
indicators.Inaddition,observationsofphysicalmanifestationslistedforacuteorchronicusersandfromthewithdrawalstagecanbe
documented.Similarly,avarietyofinstrumentsexiststodeterminementalstatus,althoughobservationaldataregardingpsychologicaland
mentalstatusmaybeadequate.

Differential Diagnosis
Inthediagnosticprocess,otherdisordersandconditionswithsimilaroridenticalpresentationsmustbeconsideredtoruleoutorinclude
them.Asalreadynoted,manystimulantusershavecoexistingmentalillnessessuchasbipolardisorders,borderlinepersonality,andsoon.
Similarly,thecauseofaheartattackorseizuremustbedeterminedforoptimalcontinuingcareandmedicalmanagement.

Beforeadifferentialdiagnosisofacoexistingpsychiatricdisorder(dualdiagnosis)canbemade,theclientmustbeabstinentforsome
periodoftime,atleast3to4weeks.Thesyndromeandsymptomspresentedcanbetreatedmeanwhile,andadiagnosisofpsychotic
disorder,nototherwisespecified(NOS),canbegiven.Moreinformationregardingthediagnosticprocessforclientswithsymptomsthat
indicatecoexistingsubstanceuseandmooddisorderscanbefoundinTIP9,AssessmentandTreatmentofPatientsWithCoexistingMental
IllnessandAlcoholandOtherDrugAbuse(CSAT,1994a).

Newformsofbrainimagingtechniquesofferapromisingapproachformakingadifferentialdiagnosisifcurrentresearchdeterminesthat
thesetechniquesareusefulfordistinguishingamongdruginducedandotherformsofpsychosis.

Developing Linkages Between Treatment Programs and Medical Facilities

BecausetheERmaybethestimulantuser'sfirstpointofcontactwiththemedicalsystemandpotentialtreatment,attentionneedstobe
giventoestablishingandsupportingacontinuumofcareinwhichappropriatelinkagesamongallnecessaryservicesandprogramsfor
substanceusersarerepresented.Althoughtheburdenofdevelopingandencouragingtheselinkagesamongtreatmentcomponentscannot
falltohospitalstaffalone,anditwouldbeunrealistictoexpectthis,cooperationandenlightenedselfinterestareencouraged.Ifnot
hookeduptothetreatmentsystem,cocaineandMAusersarelikelytoreturnrepeatedlytotheERandotherpartsofthehospitalforcare
ofmoreandmoreserioushealthandmentalhealthproblems.Stimulantabuse/dependence,asallsubstanceusedisorders,isalifelong,
relapsingconditionthatrequiresongoingmanagementandsupport.

Hence,treatmentprogramsshouldtakeprimaryresponsibilityfordevelopinglinkageswithhospitals,usingseveralapproaches.Themost
exemplaryapproachandthatmostlikelytosucceedistohaveasubstanceabusetreatmentcounselorortrainednurse/socialworkervisit
thehospitalandothermedicalfacilitiesregularlyinordertoidentify,screen,encourage,andfollowupclientswhohavestimulantrelated
andothersubstanceuseproblemsandneedaccesstotheongoingtreatmentcontinuum.Afacetofacevisitbyanoutreachspecialistis
particularlyeffectiveinsupportingthecrisisprecipitatedmotivationtoentertreatment,especiallyifthepotentialclientishospitalizedfor
somelengthoftime.Becauseacrisiscreatesaninterventionopportunity,clientsmaybeunusuallyreceptivetoconsideringlifestyle
alternativesandtheneedforlongertermtreatment.
Italsomayberealisticforhospitalstafftohandoutalistofavailabletreatmentfacilitiesforstimulantuseand/orothersubstanceuse
disordersthatisdevelopedandprovidedbythesubstanceusedisordertreatmentstaff.However,itisnotverylikelythatclientsincrisis
willfollowupthesuggestedreferral,especiallyiftheyareintheearlystagesofcrashing(andterriblysleepy)orparanoid.

Someeducationalliteraturemightalsobehelpfulparticularlyregardingwithdrawalsymptoms,druginducedpsychoses,andmedical
complicationsiftheclientorasignificantotheriswillingtoreadit.Becauseitisimperativefordoctorsandothermedicalstafftoknow
abouttheaddictionprocessinordertounderstandclientstheyseeeveryday,crosstraininginthefieldofsubstanceusedisordertreatment
isvitalforlearningaboutandactivelysupportingthedevelopmentanduseoflinkagesandreferralmechanisms.Itisbelievedthatatleast
onefourthofthosetreatedinhospitalshassometypeofsubstanceuserelatedproblem.

Motivationforchangeisoftendifficulttodetermineinthesubstanceuser.Healthproblemsmay,however,bethemotivationtomovethe
individualfromcontemplationtoaction(Prochaskaetal.,1992).Healthcarepersonnelworkingwithapatienthospitalizedforanacute
drugepisodemaycapitalizeonthefactthatthesituationwassoacutefromdrugusethathehadtobehospitalized.

Hospitalsoftendealwithapopulationknownas"frequentflyers,"thatis,personswithfrequent,revolvingadmissionstohospitalERsor
inpatienthospitalbedsbecauseofmedicalorpsychiatriccomplicationsresultingfromtheirsubstanceuse.Thefinancialburdenscanbe
severeforthepatientand,inthecaseofthoselackinginsurance,thehospital'scostsofcaremaybeunrecoverable.Acollaborative
arrangementbetweenthehospitalandalocaltreatmentfacilitycanallowfordoortodoordrugtreatment.

Obtaining Consent for Treatment

Inobtainingtheclient'sconsentfortreatment,gatheringinformationfromothersabouthishistoryofsubstanceuse,makingreferralsfor
continuingcare,orseekingreimbursementfrominsurancecarriers,hospitalstaffmustbefamiliarwiththeprovisionsofspecialFederal
andStatelawsandregulationsforprotectionofclients'confidentialityassetforthin42U.S.C.290dd2(1992)andC.F.R.Part2.
Intoxicatedorpsychoticclientsmayhavediminishedcapacityforprovidinginformedconsenttotreatment.Ifconsentisobtained,even
temporarily,fromarelative,thismaybeconsidereda"disclosureofidentifyinginformation"andsubjecttoFederalguidelines.In
referringaclientfromahospitaltoanothertreatmentprogramandmakinganappointment,staffarealsomakingadisclosureandwill
ordinarilyneedawrittenconsentformfromtheclientcontainingspecifiedinformation(seeFigure59).

Box
Figure59:ClientConsentForm:RequiredItems.Nameorgeneraldescriptionoftheprogram(s)makingthedisclosure
NameortitleoftheindividualororganizationthatwillreceivethedisclosureNameofthe(more...)

Specialexceptions,however,applytoinformationneededinamedicalemergencythatcanbeprovidedtomedicalpersonnelwhoneed
healthortreatmentrelatedfactsaboutaclientinordertotreathislifethreateningcondition.However,thetreatmentprogramthatis,
forexample,providingthisinformationtoahospitalbeforetransferringtheclientforemergencycare,mustdocumentspecificdatainhis
recordregardingthenatureoftheemergency,whatinformationwasreleased,thenameofthepersonmakingthedisclosure,andthedate
andtime.Additionalinformationaboutconsent,confidentiality,andothertypesofcommunicationsgovernedbyFederalregulationsis
presentedinTIP19,DetoxificationFromAlcoholandOtherDrugs,(CSAT,1995d).

Publication Details

Copyright
Copyright Notice

Publisher
Substance Abuse and Mental Health Services Administration (US), Rockville (MD)
NLM Citation

Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);
1999. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 5Medical Aspects of Stimulant Use Disorders.