9.4: Stimulant-Related Disorders
- Page ID
- 221737
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)- Identify stimulants and describe how they affect the brain and body
- Describe the diagnostic features and development of stimulant use disorder, stimulant intoxication, and stimulant withdrawal
Stimulants are drugs that tend to increase overall levels of neural activity. Many of these drugs act as agonists of the dopamine neurotransmitter system, meaning that these drugs increase dopamine levels in the brain. Dopamine activity is often associated with reward and craving; therefore, drugs that affect dopamine neurotransmission often have abuse liability. Drugs in this category include cocaine, amphetamines (including methamphetamine), cathinones (i.e., bath salts), MDMA (ecstasy), nicotine, and caffeine.
The use of stimulants in humans causes rapid weight loss; cardiovascular effects such as an increase in heart rate, respirations, and blood pressure; emotional or mental side effects such as paranoia, anxiety, and aggression; and a change in the survival pathway known as the reward/reinforcement pathway in our brain. An increase in energy, a reduced appetite, increased alertness and a boost in confidence are all additional side effects of stimulant use when introduced to the body.
Cocaine can be taken in multiple ways. While many users snort cocaine, intravenous injection and ingestion are also common. The freebase version of cocaine, known as crack, is a potent, smokable version of the drug. Like many other stimulants, cocaine agonizes the dopamine neurotransmitter system by blocking the reuptake of dopamine in the neuronal synapse. Cocaine’s most dangerous side effects include the following:- increased body temperature (high fever)
- irregular heart rate or rapid heart rate
- high Blood Pressure
- increased risk of heart attack
- strokes
- sudden death from cardiac arrest
- sudden aggression
- sudden extreme paranoia
- feeling, seeing, or hearing things that are not really there (hallucinations), including feeling like there are insects under the skin (this is called formication or coke bugs)
Dig Deeper: Crack Cocaine
Crack (Figure \(\PageIndex{1}\)) is often considered to be more addictive than cocaine itself because it is smokable and reaches the brain very quickly. Crack is often less expensive than other forms of cocaine; therefore, it tends to be a more accessible drug for individuals from impoverished segments of society. During the 1980s, many drug laws were rewritten to punish crack users more severely than cocaine users. This led to discriminatory sentencing with low-income, inner-city minority populations receiving the harshest punishments. The wisdom of these laws has recently been called into question, especially given research that suggests crack may not be more addictive than other forms of cocaine, as previously thought (Haasen & Krausz, 2001; Reinerman, 2007).
Amphetamines have a mechanism of action quite similar to cocaine in that they block the reuptake of dopamine in addition to stimulating its release (Figure \(\PageIndex{2}\)). While amphetamines are often abused, they are also commonly prescribed to children diagnosed with attention deficit hyperactivity disorder (ADHD). It may seem counterintuitive that stimulant medications are prescribed to treat a disorder that involves hyperactivity, but the therapeutic effect comes from increases in neurotransmitter activity within certain areas of the brain associated with impulse control.
In recent years, methamphetamine (meth) use has become increasingly widespread. Methamphetamine is a type of amphetamine that can be made from ingredients that are readily available (e.g., medications containing pseudoephedrine, a compound found in many over-the-counter cold and flu remedies). Despite recent changes in laws designed to make obtaining pseudoephedrine more difficult, methamphetamine continues to be an easily accessible and relatively inexpensive drug option (Shukla, Crump, & Chrisco, 2012).
The cocaine, amphetamine, cathinones, and MDMA users seek a euphoric high, feelings of intense elation and pleasure, especially in those users who take the drug via intravenous injection or smoking. Repeated use of these stimulants can have significant adverse consequences. Users can experience physical symptoms that include nausea, elevated blood pressure, and increased heart rate. In addition, these drugs can cause feelings of anxiety, hallucinations, and paranoia (Fiorentini et al., 2011). Normal brain functioning is altered after repeated use of these drugs. For example, repeated use can lead to overall depletion among the monoamine neurotransmitters (dopamine, norepinephrine, and serotonin). People may engage in compulsive use of these stimulant substances in part to try to re-establish normal levels of these neurotransmitters (Jayanthi & Ramamoorthy, 2005; Rothman, Blough, & Baumann, 2007).
Caffeine is another stimulant drug. While it is probably the most commonly used drug in the world, the potency of this particular drug pales in comparison to the other stimulant drugs described in this section. Generally, people use caffeine to maintain increased levels of alertness and arousal. Caffeine is found in many common medicines (such as weight loss drugs), beverages, foods, and even cosmetics (Herman & Herman, 2013). While caffeine may have some indirect effects on dopamine neurotransmission, its primary mechanism of action involves antagonizing adenosine activity (Porkka-Heiskanen, 2011).
While caffeine is generally considered a relatively safe drug, high blood levels of caffeine can result in insomnia, agitation, muscle twitching, nausea, irregular heartbeat, and even death (Reissig, Strain, & Griffiths, 2009; Wolt, Ganetsky, & Babu, 2012). In 2012, Kromann and Nielson reported on a case study of a 40-year-old woman who suffered significant ill effects from her use of caffeine. The woman used caffeine in the past to boost her mood and to provide energy, but over the course of several years, she increased her caffeine consumption to the point that she was consuming three liters of soda each day. Although she had been taking a prescription antidepressant, her symptoms of depression continued to worsen and she began to suffer physically, displaying significant warning signs of cardiovascular disease and diabetes. Upon admission to an outpatient clinic for treatment of mood disorders, she met all the diagnostic criteria for substance dependence and was advised to dramatically limit her caffeine intake. Once she was able to limit her use to less than 12 ounces of soda a day, both her mental and physical health gradually improved. Despite the prevalence of caffeine use and the large number of people who confess to suffering from caffeine addiction, this was the first published description of soda dependence appearing in scientific literature.
Nicotine is highly addictive, and the use of tobacco products is associated with increased risks of heart disease, stroke, and a variety of cancers. Nicotine exerts its effects through its interaction with acetylcholine receptors. Acetylcholine functions as a neurotransmitter in motor neurons. In the central nervous system, it plays a role in arousal and reward mechanisms. Nicotine is most commonly used in the form of tobacco products like cigarettes or chewing tobacco; therefore, there is a tremendous interest in developing effective smoking cessation techniques. To date, people have used a variety of nicotine replacement therapies in addition to various psychotherapeutic options in an attempt to discontinue their use of tobacco products. In general, smoking cessation programs may be effective in the short term, but it is unclear whether these effects persist (Cropley, Theadom, Pravettoni, & Webb, 2008; Levitt, Shaw, Wong, & Kaczorowski, 2007; Smedslund, Fisher, Boles, & Lichtenstein, 2004).
To learn more about some of the most commonly abused prescription and street drugs, check out the Commonly Abused Drugs Chart and the Commonly Abused Prescription Drugs Chart from the National Institute on Drug Abuse.
Stimulant-Related Disorders
Stimulant use disorder is a type of substance use disorder that involves the abuse of stimulants. Stimulants are the most widely used drugs in the world today; approximately 200 million Americans have used some type of stimulant in the past year alone. Caffeine and nicotine are the most popular stimulants used today, with roughly 400 million cups of coffee consumed daily and 36.5 million current cigarette smokers, according to a 2015 study conducted by the Centers for Disease Control and Prevention.
Stimulant disorders described in the DSM-5 include cocaine use disorder, amphetamine-use disorder, and tobacco-use disorder. While not listed as its own disorder, certain isolated conditions related to caffeine are recognized in the DSM-5’s “substance-related” section: caffeine intoxication, caffeine withdrawal, and other caffeine-induced disorders.
Diagnostic Criteria
A stimulant use disorder is diagnosed as a pattern of amphetamine-type substance, cocaine, or other stimulant use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
- The stimulant is often taken in larger amounts or over a longer period than was intended.
- There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.
- A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects.
- The craving, or a strong desire or urge to use the stimulant is present.
- Recurrent stimulant use results in a failure to fulfill major role obligations at work, school, or home.
- Stimulant use is continued despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant.
- Important social, occupational, or recreational activities are given up or reduced because of stimulant use.
- Stimulant use is recurrent in situations in which it is physically hazardous.
- Stimulant use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the stimulant.
- Tolerance is present, as defined by either of the following:
- a. a need for markedly increased amounts of the stimulant to achieve intoxication or desired effect
- b. a markedly diminished effect with continued use of the same amount of the stimulant
- Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.
- Withdrawal is manifested by either of the following:
- a. the characteristic withdrawal syndrome for the stimulant
- b. stimulant (or a closely related substance) used to relieve or avoid withdrawal symptoms
- Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy.
If a substance is used over a long period of time and the user becomes dependent upon it, a substance abuse issue begins to appear. Substance abuse may lead to substance dependence and with time, addiction. Both mental and physiological dependence requires the development of tolerance leading to withdrawal symptoms.
Stimulant intoxication is marked by clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; or impaired judgement) that developed during, or shortly after, use of a stimulant. Cocaine intoxication refers to the deleterious effects of cocaine on the body. These effects can develop over time with regular use or can be the result of acute intoxication due to a single intake of the substance.
Stimulant withdrawal is marked by the following diagnostic criteria:
A. The cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use occurs.
B. Dysphoric mood and two (or more) of the following physiological changes develop within a few hours to several days after Criterion A:
- Fatigue.
- Vivid, unpleasant dreams.
- Insomnia or hypersomnia.
- Increased appetite.
- Psychomotor retardation or agitation.
C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
Note: Amphetamine, cocaine, or other stimulant withdrawal can only occur in the presence of a moderate or severe amphetamine, cocaine, or other stimulant use disorder. For example, cocaine withdrawal happens when a person who uses a lot of cocaine stops using cocaine. It can also happen when a person who uses a lot of cocaine starts using less cocaine than they did before. When a person who is used to using cocaine stops right away, they will go through what is called a “crash” along with many of other cocaine withdrawal symptoms, like
- paranoia
- depression
- exhaustion (feeling very tired)
- anxiety
- itching
- mood swings (quick changes in emotions
- irritability (feeling easily annoyed)
- fatigue (feeling tired), sleeping many hours
- insomnia (trouble sleeping)
- a very strong craving for more cocaine
- nausea and vomiting
Withdrawal symptoms can last for days, weeks, months, and on rare occasions, years, depending on the frequency and dosages used by the individual. Unless intensive medical and psychological treatment is sought after, there is a very high likelihood of relapse among the user.
Tobacco-Related Disorders
Tobacco use disorder, as described in the DSM-5, is a problematic pattern of tobacco use leading to clinically significant impairment or distress, as manifested by at least two of the 11 symptoms listed in the diagnostic criteria above.
Nicotine dependence is a state of dependence upon nicotine. Nicotine dependence is a chronic, relapsing disease defined as a compulsive craving to use the drug, despite harmful social consequences. Tolerance is another component of drug dependence. Nicotine dependence develops over time as a person continues to use nicotine. Nicotine dependence is a serious public health concern due to it being one of the leading causes of avoidable deaths worldwide.
First-time nicotine users develop a dependence about 32% of the time. There are approximately 976 million smokers in the world. There is an increased frequency of nicotine dependence in people with anxiety disorders. Nicotine is a parasympathomimetic stimulant that attaches to nicotinic acetylcholine receptors in the brain. Neuroplasticity within the brain’s reward system occurs as a result of long-term nicotine use, leading to nicotine dependence. There are genetic risk factors for developing dependence. For instance, genetic markers for a specific type of nicotinic receptor (the α5-α3-β4 nicotine receptors) have been linked to increased risk for dependence. Evidence-based medicine can double or triple a smoker’s chances of quitting successfully.
Caffeine-Related Disorders
Consumption of one to one-and-a-half grams (1,000–1,500 mg) per day is associated with a condition known as caffeinism. Caffeinism usually combines caffeine dependency with a wide range of unpleasant symptoms including nervousness, irritability, restlessness, insomnia, headaches, and palpitations after caffeine use.
Caffeine overdose can result in a state of central nervous system over-stimulation known as caffeine intoxication, a clinically significant temporary condition that develops during, or shortly after, the consumption of caffeine. This syndrome typically occurs only after ingestion of large amounts of caffeine, well over the amounts found in typical caffeinated beverages and caffeine tablets (e.g., more than 400–500 mg at a time).
Caffeine intoxication may be diagnosed if five (or more) of the following symptoms develop after recent consumption of caffeine: restlessness, nervousness, excitement, insomnia, flushed face, diuresis (increased production of urine), gastrointestinal disturbance, muscle twitching, rambling flow of thought and speech, tachycardia (increased heart rate) or cardiac arrhythmia, periods of inexhaustibility, and psychomotor agitation.
euphoric high: feelings of intense elation and pleasure from drug use
methamphetamine: type of amphetamine that can be made from pseudoephedrine, an over-the-counter drug; widely manufactured and abused
stimulant: drug that tends to increase overall levels of neural activity; includes caffeine, nicotine, amphetamines, and cocaine
stimulant intoxication: clinically significant problematic behavioral or psychological changes that develop during, or shortly after, the use of a stimulant
stimulant withdrawal: marked by significant behavioral and psychological changes following the cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use
stimulant use disorder: a type of substance use disorder that involves the abuse of stimulants
- Compton, W. M., Han, B., Blanco, C., Johnson, K., & Jones, C. M. (2018). Prevalence and Correlates of Prescription Stimulant Use, Misuse, Use Disorders, and Motivations for Misuse Among Adults in the United States. The American journal of psychiatry, 175(8), 741–755. https://doi.org/10.1176/appi.ajp.2018.17091048↵
- 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 5—Medical Aspects of Stimulant Use Disorders. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64323/↵
- Modification, adaptation, and original content. Authored by: Bob Hoople for Lumen Learning. Provided by: Lumen Learning. License: CC BY-SA: Attribution-ShareAlike
- Substance Use and Abuse. Authored by: OpenStax College. Located at: http://cnx.org/contents/Sr8Ev5Og@5.49:fOU1RGxh@6/Substance-Use-and-Abuse. License: CC BY: Attribution. License Terms: Download for free at http://cnx.org/contents/4abf04bf-93a...fd46e68cc@5.48
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- Treatment for Stimulant Use Disorder. Provided by: Center for Substance Abuse Treatment. Located at: https://www.ncbi.nlm.nih.gov/books/NBK64323/. License: Public Domain: No Known Copyright