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«What Is a TIP?.........................3 Introduction...........................4 Effects of ...»

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Quick Guide

For Clinicians

Based on TIP 33

Treatment for Stimulant

Use Disorders


Why a Quick Guide?....................2

What Is a TIP?.........................3


Effects of Stimulants....................4

Forms and Routes of Administration......5

Stimulant Intoxication..................7

Stimulant Overdose.....................9 Stimulant Withdrawal.................10 Chronic Stimulant Abuse/Dependence...13 Associated Medical Complications.......14 Psychological/Psychiatric Complications...16 Treatment Strategies..................18 Treatment Issues for Special Groups.....26 Glossary.............................28 Quick Guide For Clinicians Based on TIP 33 Treatment for Stimulant Use Disorders This Quick Guide is based entirely on information contained in TIP 33, published in 1999. No additional research has been conducted to update this topic since publication of the original TIP.

2 Stimulant Use Disorders WHY A QUICK GUIDE?

The purpose of a Quick Guide is to provide busy clinicians with succinct, easily accessible information.

This Quick Guide is based on Treatment for Stimulant Use Disorders, number 33 in the Treatment Improvement Protocol (TIP) Series, published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. It will help substance abuse treatment providers assess clients and patients with problems related to stimulant abuse.

The Quick Guide has been formatted for ease of use. A glossary of terms is located on page 28.

Please refer to TIP 33 for more in-depth information on the topics in this Quick Guide.

What Is a TIP? 3 WHAT IS A TIP?

The TIP Series was launched in 1991. TIPs are aimed at disseminating consensus-based, fieldtested guidelines on current topics to substance abuse treatment providers.

TIP 33, Treatment for Stimulant Use Disorders Addresses stimulant use, its effect on the brain, z abuse and dependence, and the general effects of stimulants Presents research about effective approaches z to treatment and their practical applications Explains medical aspects of stimulant use z disorders, overdose, and treatment of psychological and medical complications Discusses treatment issues for special groups z and settings Includes worksheets for use by clients.

z To order a copy of TIP 33 and other related products, see the inside back cover of this Quick Guide.

4 Stimulant Use Disorders


Stimulant use and its consequences have contributed significantly to the decay of communities throughout the United States. The problems of cocaine use in the 1960s and 1970s grew to become major medical, legislative, and law enforcement issues in the 1990s. More recently, methamphetamine (MA) abuse has risen dramatically and resulted in policymakers, legal officials, and service providers focusing on the personal and societal effects of this drug.

This Quick Guide, based on TIP 33, provides basic information about the nature and treatment of stimulant use disorders. It reviews current knowledge about treating the medical, psychiatric, and substance abuse/dependence problems associated with the use of two high-profile stimulants: cocaine and MA.

–  –  –

The higher the dose of the stimulant, the more dopamine released (and the greater the euphoria).

This “rush” quickly fades to dejection (the “crash”) as dopamine levels decrease.

The user may then begin a cycle of taking more of the stimulant, producing another rush and subsequent crash. The pattern of repeated dosing, known as bingeing, can continue for days; the user may not eat or sleep and may lapse into severe depression, followed by worsening paranoia, belligerence, and aggression, a period known as tweaking. The user stops bingeing when stimulants are unavailable or when collapse occurs.


Cocaine Cocaine powder is

–  –  –

aluminum foil and inhaled, or smoked in marijuana or tobacco cigarettes.

Routes of Administration Snorting—Causes stimulants to reach the brain z

–  –  –

Intravenous injection—Produces a rush in 15 to z 30 seconds Smoking—Produces an almost immediate effect z and is the most intense high, which may lead to equally intense lows during withdrawal, when cravings for the drug may be extreme.

(For more information, see TIP 33, pages 13–26.)


Physiological Signs/Symptoms of Intoxication z Dilated pupils Profuse sweating, chills z High blood pressure (hypertension) z Increased heart rate (tachycardia), palpitations z (arrhythmia), chest pain, or slow heart rate (bradycardia) Elevated temperature (hyperthermia) z Suppressed appetite z Teeth grinding z Insomnia or little need for sleep z

–  –  –

Seizures (mostly in cocaine users) z Confusion z Respiratory depression.

z 8 Stimulant Use Disorders Psychological/Behavioral Signs and Symptoms of Intoxication z Euphoria, heightened sense of well-being Increased energy, giddiness, sense of enhanced z mental acuity and performance Agitation, restlessness, irritability z

–  –  –

Be given fast-acting benzodiazepines (lorazepam z or diazepam) to calm them (if anxious or agitated).

(For more information, see TIP 33, pages 79–88.)


Stimulant overdoses are seldom fatal to chronic, high-dose users.

Fatal overdoses mostly occur in new users or persons who accidentally ingest large amounts, such as children or bodypackers (smugglers) whose swallowed packets of cocaine accidently break.

The amount needed to produce a toxic dose varies widely and is not related to body weight. Toxic doses cause high fevers, cardiac arrhythmias and arrests, irregular breathing, seizures, and strokes.

Lethal doses cause a rapid rise in heart rate, blood pressure, cardiac output, and body temperature followed by delirium, then generalized, terminal seizures. No antidotes or antagonists are available.

Very high fever, severe hypertension, convulsions, and cardiovascular collapse signal a life-threatening situation. Lifesaving measures should be used immediately.

10 Stimulant Use Disorders


Stimulant withdrawal is not medically life threatening and does not require pharmaceutical intervention. However, users may become suicidal or violent.

Withdrawal symptoms develop hours to days after heavy use stops. Stimulant users with withdrawal symptoms may self-medicate with alcohol, benzodiazepines, or opioids and may have symptoms of withdrawal from these drugs.

Withdrawal-related depression can be severe, and sensitive management is essential. Cocaineinduced depression usually dissipates in a few hours. Depression after high-dose MA use lasts longer.

Users with preexisting clinical depression become more depressed during withdrawal, and treatment with selective serotonin reuptake inhibitors may help. Persistent agitation and insomnia may be treated symptomatically with the antidepressant trazodone.

Physiological Signs/Symptoms of Stimulant Withdrawal z Rocky, jittery reactions with agitated paranoia

–  –  –

Intense drug cravings z Weight loss, gaunt appearance, anorexia z Dehydration z Fatigue, lethargy, lack of energy z Dulled senses z Psychomotor lethargy and retardation—may be z preceded by agitation Hunger z

–  –  –

Insomnia followed by hypersomnia.

z Common Psychological/Behavioral Signs/Symptoms of Withdrawal z Dysphoric mood, which may become clinical depression, suicidal thoughts Persistent and intense drug cravings z Anxiety, irritability z Impaired memory z Loss of interest in pleasurable activities z (anhedonia) Withdrawal from social interactions z Intense and vivid drug-related dreams.

z (For more information, see TIP 33, pages 91–93.) 12 Stimulant Use Disorders Reducing the Risk for Violence Individuals withdrawing from stimulants often are paranoid, aggressive, and violent. A staff member should

–  –  –

cious environment with little stimuli. Make the door accessible, but do not let the client get between the interviewer and the door.

Ask simple questions, tolerate repetitive replies, z and remain nonconfrontational.

Acknowledge agitation and the potential for z

–  –  –


DEPENDENCE Physiological Signs/Symptoms z Extreme fatigue, physical and mental exhaustion, disrupted sleep patterns Nutritional disorders (extreme weight loss, z

–  –  –

Muscle pain/tenderness z Cardiovascular damage z Hypertension z Difficulty breathing z Involuntary movement disorders z Impaired sexual performance and reproductive z functioning Cerebrovascular damage z Gastrointestinal complaints.

z 14 Stimulant Use Disorders Psychological/Behavioral Signs/Symptoms z Paranoia with misinterpretation of environmental cues, psychosis with delusions, hallucinations Acute anxiety, apprehension, fears of impending z

–  –  –

(For more information, see TIP 33, pages 93 and 94.)


Cardiovascular system effects—Every form of z heart disease; fatal reactions occur at all dose levels in otherwise healthy young adults Respiratory/pulmonary effects—Hemorrhage, z pneumonia, pulmonary edema, bronchospasm, asthma, or pneumothorax; death from respiratory failure or “crack” lung syndrome (symptoms of pneumonia without evidence of it on lung x-rays) Neurological complications—Seizures, strokes, z and hemorrhages; cerebral atrophy and brain lesions; neurological deficiencies similar to those found in persons with neurological/ psychiatric disorders; cognitive deficits (problems with attention, concentration, Associated Medical Complications 15 problemsolving,


thinking, math, new learning, and short-term memory) Muscular and renal toxicity—Consider rhabdoz myolysis, a condition that destroys skeletal muscle and may cause kidney failure, when clients complain of muscle tenderness Gastrointestinal complaints—Abdominal pain, z nausea, and vomiting; severe bowel infarction;

“cocaine colitis” (abdominal pain and bloody diarrhea)

Infections—With intravenous (IV) injection:

z human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS);

hepatitis B; hepatitis C; infectious endocarditis Reproductive function and fetal/neonatal z effects—Low birth weight relative to gestational age, poor feeding and sleep patterns, tremor, and hypertonia; jitteriness leading to difficulties with mothers and babies bonding. Preeclampsia;

spontaneous abortion; abruptio placentae.

Males may develop breasts, lose sexual interest, and become impotent. Women may have irregular menstrual cycles or amenorrhea leading to an erroneous belief that they cannot become pregnant, although many are infertile.

(For more information, see TIP 33, pages 94–99.) 16 Stimulant Use Disorders



Toxic Psychosis MA users sometimes have brief psychotic episodes before a full-blown psychosis emerges.

Abnormal behaviors can progress into psychotic symptoms of paranoia, delusions, and hallucinations. If a client is exhausted after a prolonged binge, hyperreactivity to stimuli and confusion may lead to panic, violence, and in extreme cases homicide.

A common early sign of paranoia is the performance of repetitive acts that seem to relieve the user’s agitation and anxiety. As high-dose stimulant use continues, most users withdraw from all social interactions and initiate other bizarre behaviors before the intensive drug use culminates in paranoid reactions or psychosis.

Symptoms of psychosis usually abate spontaneously within a few weeks of abstinence.

Hallucinations stop within 24 to 48 hours, and paranoia and delusions decrease over the next week to 15 days. Clients may sleep for as long as 3 days, dreaming extensively. Psychosis may dissipate more rapidly in cocaine users—in 1 to 3 days—than in MA users—up to 3 weeks. Ice users Psychological/Psychiatric Complications 17 reportedly have the most intense and persistent psychoses.

Urine testing is recommended to confirm diagnosis because drug-induced psychosis can mimic other psychiatric disorders.

Treatment of toxic psychosis—Rapid, systematic visual assessment and continued observation, monitoring, and symptom management in a hospital psychiatric department or similar facility are recommended.

Minor psychotic episodes that respond to neuroleptic medications may be managed in a freestanding chemical dependence unit as long as it is well staffed by appropriately trained personnel.

MA users ending a binge are prone to violence.

Their paranoia makes them suspicious of medication. Staff should not release these individuals until their medical crisis is resolved or until they have been psychologically stable for 24 hours and are able to calm down without using neuroleptics.

Coexisting Disorders Most stimulant users have concurrent psychiatric disorders. As many as half of surveyed cocaine users in treatment have lifetime diagnoses of depression; 20 to 25 percent have cyclical mood 18 Stimulant Use Disorders disorders; and sizable percentages have borderline or antisocial personality, posttraumatic stress, or attention deficit/hyperactivity disorders. These disorders are more common among stimulant users than the general population.

A month of abstinence from all stimulant use is required to differentiate psychiatric disorders from stimulant-related disorders.

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