Stimulant Use Disorder

Overview

Stimulant Use Disorder is classified as a substance-related and addictive disorder, and is characterized by patterns of prolonged use of amphetamine-type stimulants, cocaine, or other forms of stimulants. These stimulants may be obtained through a prescription for a comorbid disorder, such as ADHD or narcolepsy in the case of amphetamines, or be sourced from friends, relatives, or illegal markets. Various stimulants are consumed in several different forms, including intravenous injection, powders, pastes, and so on. The use of stimulants is associated with significant morbidity.

The sex-based differences in stimulant use disorders vary according to its type. The age of onset is also subject to considerable variance, and the disorder can develop as rapidly as within a week following first exposure to stimulants. Certain demographic, temperamental, biological, and environmental risk factors are associated with Stimulant Use Disorder. 

In terms of management, behavioral intervention is considered to be the most effective for both abstinence as well as prevention of relapse. Certain pharmacological interventions have also been proposed.

Signs and Symptoms

The signs and symptoms of stimulant use disorders are primarily concerned with the prolonged use of stimulants such as amphetamine-type substance or cocaine, along with symptoms such as: 

1. Dramatic behavioral changes such as extreme confidence and euphoria upon stimulant use
2. Chaotic behavior, aggression, and sexual dysfuntion due to long-term use
3. Rambling speech, headache, and tinnitus
4. Paranoia
5. Feeling like one is “hearing things” or “feeling things” in the absence of stimuli 
6. Depressive feelings, irritability, or being overly emotional 
7. Slowed heart rate (bradycardia)
8. Using stimulants in large quantities
9. Using stimulants for longer duration than intended 
10. A desire to cut down on stimulant use with unsuccessful efforts 
11. Spending a long time obtaining stimulant for use, using it, and recovering from its effects
12. Craving the use of the stimulant
13. Failure to complete occupational, academic, or social responsibilities due to stimulant use and effects
14. Interpersonal problems due to stimulant use 
15. Aggressive or violent behaviors after stimulant use 
16. Intense anxiety when high-doses are used
17. Giving up on hobbies and interests due to stimulant use
18. Using stimulants in physically dangerous or hazardous situations 
19. Continuing use of stimulants in spite of knowledge of potential psychological and physical risks
20. Feeling less intoxicated by continued use of the same amount of stimulant
21. Needing to increase quantity of stimulant used in order to feel intoxicated

Risk Factors

The sex-based prevalence is subject to change according to age of the demographic group as well as the type of stimulant in question. In the case of amphetamine-type stimulants, a female predominance is observed between ages 12-17, while an overall proportionate prevalence is observed. In terms of cocaine use, a male predominance is generally observed. The age of onset of Stimulant Use Disorder varies, but the prevalence of the disorder is higher among the 12-25 year old population bracket. 

Temperamental risk factors are often implicated in the etiology of the disorder. Individuals who show higher risk-taking behavior may be more predisposed to engaging in stimulant use and developing Stimulant Use Disorder. Deviant behavior, antisocial nature, higher risk taking in terms of sexual activity, and use of substance including alcohol use may precede the development of the disorder. Higher scores on psychoticism, or the existence of psychosis among an individual, have both been associated with a higher likelihood of Stimulant Use Disorder. 

Adolescents are considered to be more vulnerable to addiction, and this has been studied in the context of brain development and maturation that takes place during adolescence. Greater gray and white matter alterations have also been observed among adolescent populations in comparison to adult populations. Repeated exposure to stimulants may result in neurotoxic effects, and can impact dopaminergic and serotonergic systems. The gamma-aminobutyric acid system has also been associated with the use of amphetamine-type stimulants. 

Many environmental factors are associated with Stimulant Use Disorder. It is reported that individuals may engage in stimulant use behavior in order to control their weight through weight loss, or improve their performance in areas such as academics, sports, or in their occupational area. Unstable family environments and a family history of substance use are also factors implicated in the development of the disorder. 

Significant comorbidities are considered to occur, especially with other substance use disorders including alcohol use disorder and cannabis-related disorders. Posttraumatic stress disorder, antisocial personality disorder, ADHD, and gambling disorder are common co-occurrences. Cardiopulmonary issues, as well as medical problems may be experienced. 

Diagnosis

A comprehensive diagnostic process for Stimulant Use Disorder is likely to include a variety of laboratory tests in order to detect the type of stimulant used. Urine tests are likely to be carried out, as traces of cocaine use are typically present for 1-3 days, and the traces of prolonged use may be present for 7-12 days. Liver function tests, electroencephalographic tests, as well as hair sample tests may be carried out. Additionally, physical factors such as weight loss, poor hygiene, and malnutrition may be looked out for. A thorough history is also required to be taken. 

The DSM-5 provides the following diagnostic criteria for Stimulant Use Disorder: 

1. 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:
   

1. The stimulant is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control stimulant use.
3. A great deal of time is spent in activities necessary to obtain the stimulant, use the stimulant, or recover from its effects.
4. Craving, or a strong desire or urge to use the stimulant.
5. Recurrent stimulant use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued stimulant use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the stimulant.
7. Important social, occupational, or recreational activities are given up or reduced because of stimulant use.
8. Recurrent stimulant use in situations in which it is physically hazardous.
9. 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.
10. Tolerance, as defined by either of the following:

1. A need for markedly increased amounts of the stimulant to achieve intoxication or desired effect.
2. A markedly diminished effect with continued use of the same amount of the stimulant.

Note: This criterion is not considered to be met for those taking stimulant medications solely under appropriate medical supervision, such as medications for attention-deficit/hyperactivity disorder or narcolepsy

11. Withdrawal, as manifested by either of the following:

1. The characteristic withdrawal syndrome for the stimulant (refer to Criteria A and B of the criteria set for stimulant withdrawal).
2. The stimulant (or a closely related substance) is taken 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.

Specifications are made on the basis of whether the use of stimulants is carried out in an environment where the activity is restricted, as well as on the basis of severity.

Treatment

Behavioral intervention is considered to be the first priority of treatment in the case of Stimulant Use Disorder. While no medication has received formal approval for Stimulant Use Disorder, certain drugs have been proposed for pharmacological intervention. 

There has been significant empirical support for the efficacy of Contingency Management, also known as motivational incentives, in the management of Stimulant Use Disorder. The process works by incentivizing abstinence from stimulant use, and typically provides a desired item in return in order to positively reinforce the abstinence behavior. Secondly, the Community Reinforcement Approach puts together various behavioral skill trainings in order to create an environment that facilitates drug abstinence rather than use, by providing job counseling, marital therapy, relapse prevention, and more. Cognitive Behavioral Therapy, or talk therapy, has also shown considerable effectiveness in providing support to individuals by providing adequate skills and cognitive restructuring that encourages drug abstinence as well as prevents relapse. 

Certain techniques have also been proposed to facilitate rehabilitation on a more individualistic level, including exercise therapy, twelve-step facilitation, and mindfulness. 

Pharmacological intervention has also been proposed, owing to the abnormalities in neurochemical and hormonal systems that result from long-term stimulant use. Anticonvulsants, antidepressants, and opioid antagonists are largely the most used classes of drugs that have shown efficacy in managing these abnormalities. Topiramate, naltrexone, bupropion, and modafnil are some such medications. It is important to take into account possible underlying comorbidities before considering pharmacological approaches to treatment. 

Specialist

Primary healthcare providers are likely to diagnose and assess Stimulant Use Disorder. On the basis of type and severity of the presentation, as well as possible comorbidities, individuals may be referred to psychiatrists, clinical psychologists, or therapists that can carry out appropriate psychosocial intervention. Support groups may also facilitate the rehabilitation process. In severe cases, hospitalization may be required.