Cocaine is in another galaxy so the bulk of this subject is focused on stimulant/meth abuse. Meth or stimulants doesn’t have approved medication options for dependence or withdrawals but the side effects, particularly with cocaine and meth are horrible. ADHD stimulants don’t have major withdrawals, but mixing stimulants with a downer such as alcohol, heroin, or benzos can have major negative reactions. However, stimulants are frequently prescribed and abused so I’ll discuss the risks, issues, and treatment options.
Structures of Stimulants
The phenylethylamine structure is the backbone of epinephrine, norepinephrine, and dopamine as well as a variety of abused substances including all amphetamines, “bath salts”, the 2C series, and most “designer” drugs. In general, phenylethylamines increase norepinephrine, dopamine, and serotonin.
Common Substances
- Amphetamines (Adderall): Amphetamine is a central nervous (CNS) system stimulant that functions by increasing the amounts of dopamine, norepinephrine, and serotonin (to a lesser extent) in the synaptic cleft through a variety of mechanisms. (-NIH)
- Cocaine: A powerfully addictive stimulant drug made from the leaves of the coca plant native to South America.
- Crystal Methamphetamine: a form of the drug that looks like glass fragments or shiny, bluish-white rocks. It is chemically similar to amphetamine –DrugAbuse. Meth, or methamphetamine, is a powerfully addictive stimulant that is both long-lasting and toxic to the brain. Its chemistry is similar to speed (amphetamine), but meth has far more dangerous effects on the body’s central nervous system. –abovetheinfluence.
- Methamphetamine (Desoxyn): is a stimulant drug usually used as a white, bitter-tasting powder or a pill –DrugAbuse.
- Methylphenidate (Ritalin, Concerta): blocks the reuptake of two neurotransmitters, norepinephrine (NE) and dopamine, by presynaptic neurons. (-NIH)
Other: caffeine, tea, and energy drinks that primarily work on the adenosine receptors, NOT dopamine so less abuse potential. Designer drugs such as MDMA (methylenedioxymethamphetamine) also have a stimulant effect.
| Fluid Sizes/Tablet | Caffeine Amount |
|---|---|
| Coca Cola 12oz. | 34mg |
| Excedrin tablet | 65mg |
| Midol tablet | 60mg |
| Mountain Dew 12oz. | 55mg |
| Red Bull 8.3oz. | 80mg |
| Starbucks 12oz. | 260mg |
| Vivarin (caffeine tablets) | 200mg |
Various Signs and Symptoms
Amphetamines: increase heart rate and body temp, less appetite, energy, aggressiveness, invincibility -> (later when you calm down” anxiety, depression, and agitation.
- High Doses: teeth grinding, paranoia, brain damage, Parkinson-like/neurotoxicity symptoms, Tourettes, a great release of dopamine, glucose, and norepinephrine -> constrict peripheral.
Methamphetamine (ice is the smokable form of meth): S/E: hallucinations, formication, up to several days of non-sleep, brain damage, aggression, paranoia, and Parkinson’s disease. Crystal Meth usually lasts 8-24; much longer than cocaine. Meth users tend to be during the day, while cocaine users are in the evenings with multiple doses.
Cocaine: euphoria 30-60 minutes -> overtime, REDUCES DA x220 %, moderate-severe depression, anxiety, psychotics symptoms, heart damage, and lung damage if smoked. Reduce the SZ threshold. Causes death to neurons in the brain causes plaque buildup in arteries. Possible death r/t HA, CVA, respiratory failure. LETHAL Combinations:
- Cocaine + ETOH: increased the half-life of cocaine by 5x and is more toxic to the body with cardiac deaths 18-25x over cocaine use alone
- Cocaine + heroin (speedball): increase respiratory depression effects of heroin and all opioids, leading to an increased risk of death
Quick Notes About Meth
Some people think meth was only big in the ’60-the ’70s but never underestimate the influence and power of these drugs. They are horribly ADDICTIVE. The stimulant class is the worse culprit and people and dealers will do whatever to get a fix… ‘Swipe Left for Meth’ (detectives use dating apps to bust drug dealers). Another issue with stimulants is drug testing. Yes the same addictive illegal drug that’s being trafficked, has similar qualities (look at the chemical structure above) to the prescribed ADHD medications and possibly produces “false positives”.
Urine Rx screens are cheap and quick but the downside is that is how the results can be shady. At the same time, I have patients that take “pressed pills” that can have a number of substances in them, which can be true as well. Things can be truly innocent or guilty but that’s why it’s important to look at the bigger picture or the obvious signs of meth use:
This is why meth is tragic. You won’t see the effects at first and in the meantime, people will still inquire about or abused ADHD medications. Working in community mental health, we didn’t have access to good Rx testing resources. I think my job just grabbed any company with a pulse and said let’s wing everything.
You have to at least make sure they can test more than the drug classes or have reliable specificity and since we didn’t have any of those options, I mainly focused on cocaine-positive screens. It’s just not fair to punish the patient if the testing is faulty. Plus, I used hair and urine testing and the results would still sometimes be inconclusive/mixed. I will make a different post about Rx testing but the main point is how meth use can be insidious or take a while to see the obvious signs. Notice how the lady below had about 6-7 years to have noticeable changes:
Of course, depending on the usage, the symptoms of meth can be more extreme but I still recommend Rx testing to make sure everything is covered. Plus drug test companies, usually have reps to discuss the results and how they are interpreted but our tech decided to quit and the company left… I don’t know if many people are in my boat but if you don’t have the resources at least rule out cocaine.
What Happens if the Rx Testing is Reliable and Patient Test Positive for Meth?
“Meth” shouldn’t technically ever be positive. People may say it’s the medication but usually, the testing includes the ADHD medication and there’s a level. However, if the patients are taking unknown substances, taking someone else meds, have press pills, partying, etc. it shouldn’t be a dealbreaker but at least give them a warning that doing these activities has consequences and will affect prescribing their ADHD medication. Switching to long-acting ADHD meds may be a consideration, for example.
Lastly, I want to emphasize how important communication is in psych. I literally used to print the drug screens and highlight what drug was positive or how certain medication levels are too low. Usually, my patients will explain the discrepancy but it also encourages abstinence from risky behaviors. Trust me, people do act right when they see things are being monitored and will be held accountable.
What About Treatment?
With meth and cocaine, it’s somewhat similar, nothing is FDA approved and we are primarily treating complicated moods and cravings/withdrawals. Both of these addictions can cause extreme highs and lows so the main focus is mood stability and chronically treating the cravings. The cravings will cause most of the psych symptoms; agitation, restlessness, anger, fatigue, depression, anxiety, guilt…etc. I discussed my usual treatment with cocaine users but with any addictions, it goes back to mood, sleep, and addressing other conditions such as ADHD.
Most providers who aren’t comfortable with the area of substance abuse will sometimes ignore treating ADHD or using schedules. I try to tell them, you risk them relapsing. If the patient is trying, improving, and being honest, don’t make things more difficult and demanding especially if the goals and stipulations are not clear. Keep focusing on stability, staying sober, and mutual respect.
Additional Resources & Information
5 Manifestations of Methamphetamine Poisoning by Psychiatric Times
