Psychostimulants

Psychostimulants
 GPs and Psychostimulants
• GPs are increasingly likely to see
psychostimulant use

• Most commonly used illicit drug after

cannabis

• GPs are well placed to identify, manage

and minimise health problems that can
arise from psychostimulant use.

Psychostimulants
 Psychostimulants Defined
• The term ‘psychostimulant’ describes a diverse range
of naturally occurring and synthetically produced
drugs

• Also known as Amphetamine Type Stimulants (ATSs)

• Main effect – stimulates CNS activity

• Includes many commonly used substances/drugs

• Each drug varies in strength and effect, although each

has features in common

• Most people have used a psychostimulant in the last

24 hours!
Psychostimulants
 Psychostimulants May Be….
1. Synthesised Compounds

Pharmaceuticals Illicitly produced

Pseudoephedrine Amphetamine sulphate i.e. speed
Dexamphetamine Methamphetamine
Diethylpropion (Tenuate®) e.g. ice, meth, crystal
Amphetamine-type substances
Methylphenidate (Ritalin®)
e.g. MDMA (Ecstasy), PMA, MDA
etc.

2. Naturally Occurring Compounds

Tobacco (nicotine) Caffeine
Adrenaline Cocaine
Khat Guarana
Cocoa (chocolate) Others... Psychostimulants
 Psychostimulant Forms (1)
Common Chemical Appearance Cost ‘Route’
Form Composition Administered

Powder Amphetamine Fine to $50-100 Snorted,

also called sulphate or crystallised /gram swallowed,
speed, goey, methamphetamine coarse powder injected, shelved
whizz fast White-to yellow,
quick orange or pink

Crystal Methamphetamine ‘Crushed ice’ $50 Smoked, snorted,

also called hydrochloride large translucent /point swallowed,
ice to white crystals injected
crystal or coarse
meth powder
Shabu, glass

Psychostimulants
 Psychostimulant Forms (2)
Common Chemical Appearance Cost ‘Route’
Form Composition

‘Base’ Free-base form of Damp, sticky $30-50 / Injected,

also called methamphetamine gluggy powder, ‘point’ swallowed,
wax, paste, paste oily smoked,
point, pure yellow, red snorted
brown

‘Pills’ Dexamphetamine Tablets $30-40 / Injected,

methylphenidate tab (illicit swallowed
(Ritalin®), supply)
diethylpropion
(Tenuate®)

Psychostimulants
 Patterns of Use
• Use tends to:
– occur in social settings among diverse groups
of people
• Trends indicate psychostimulants are increasingly
injected
• Few patients will meet the criteria for dependence,
however:
– heavy users tend to use in a ‘binge’ pattern or a
‘run’ usually followed by a period of abstinence
– heavy users are frequently polydrug users, with
many using depressants to alleviate symptoms
associated with the ‘come down’.
Psychostimulants
 Pharmacology
• Variable chemical compositions result in
differences in pharmacological activity
across psychostimulant types
• Genetic differences in metabolism
• Half life of psychostimulants differ:
– amphetamine 12–36 hours
– methamphetamine 8–17 hours
– (ecstasy) MDMA 7–9 hours
– cocaine 45–90 minutes.
Psychostimulants
Synaptic Activity

Psychostimulants
 Meth/Amphetamine Effects:
Onset and Duration
Injection

Intranasal
Effect
Intensity

Swallowed

Amphetamine
1 min 3min 60 min 6 hours

Cocaine
1 min 3min 20 min 30 min
Duration of effect Psychostimulants
 Amphetamine Effects
Mild Moderate Toxic
Feel good Feel great
Alert Increased libido
Energy Increased
Confidence stamina
No need for sleep
Extreme agitation
Incoherence
Increased temperature
Crash Dehydration
Suspicion Thought disorder
Headache Violent aggression
Sleeplessness
Teeth grinding Stroke
Reduced appetite
Anxiety Heart attack
Dry mouth
Psychostimulants
 Psychostimulant Cycle of Use

Acquisition Cessation

Crash /
Administration
Withdrawal

Intoxication Intoxicated
behaviour
How and where can GPs
assist in reducing harms? Psychostimulants
Psychostimulants
Psychostimulants
Psychostimulants
 ‘Typical’ Pattern of Use
Using Stopping
High
Symptom Severity

Thought disorder
Agitation Exhaustion Anhedonia
Insomnia Depression Lack energy
Suspicion Oversleeping Anxiety Flat mood
Increased energy
Overeating Sleepless Emotionally fragile
Feel good
Low No craving High craving Episodic craving to cues

-7 0 2 5 15 20 25 30+

Days
Pead, et al. (1996, p. 37) Psychostimulants
 Assessment Points
• Occupation

• Age

• Social activities

• AOD History

– patterns of use, drug type, route, other drug use

• Physical health (e.g. stability of weight)

• Mental health (emotional lability, psychosis / paranoia)

• Current level of intoxication / evidence of withdrawal

• Laboratory investigations.
Psychostimulants
 Psychostimulants
Psychostimulants
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
 Psychostimulants
Psychostimulants
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Management of Toxic Reactions
Priorities are:

• maintain airway, circulation, breathing

• control elevated body temperature

(hydration, cold water, ice)

• control seizures (IV diazepam)

• manage psychotic symptoms (antipsychotics)

• reassurance, support, comfort, minimal stimulation.

Treatment depends on patient’s condition on presentation.

Psychostimulants
 Case Study

Rory, a 24 year old student, presents with persistent

headache, lethargy, and unexplained weight loss. He is
‘burning the candle at both ends’, working (in a bar) and
studying, and states that ‘life is pretty hectic’ at present.
Speed helps him get things done.

Describe a brief intervention for Rory.

Psychostimulants
 Psychostimulant Withdrawal
Crash Peak symptoms Residual symptoms
(Days 1–3) (Days 2–10) (from 1–8 weeks)
 exhaustion  dysphoria  episodic craving
 depression  lack energy  insomnia
 oversleeping  increased appetite
 no cravings  generalised aches Fluctuating:
and pains  irritability
 re-emergence of  agitation
mild psychotic  restlessness
features, including:  dysphoria
misperceptions  lethargy
paranoid ideation  amotivation
hallucinations
anxiety.
 sleeplessness
 high craving
From Pead et al. (1996, p. 84) Psychostimulants
 Withdrawal Treatment
• Immediate withdrawal treatment
– setting (home withdrawal, outpatient, or inpatient)
– supportive environment, information and
reassurance
– provide ongoing monitoring
– pharmacotherapies for symptomatic relief
– plan long term management strategies
• Planning for prolonged withdrawal
– anticipate it will be prolonged
(i.e. affecting sleep, mood, cravings)
– plan for lapse and relapse
– pharmacotherapies (short and long term)
– prepare harm reduction strategies.
Psychostimulants
 Pharmacotherapies
For Psychostimulant Withdrawal
• Aim to decrease discomfort
• Benzodiazepines
– assist sleep or reduce anxiety and agitation
– avoid long term prescribing
• Antidepressants
– tricyclic antidepressants are generally not
helpful
– SSRI’s may be helpful but symptoms generally
resolve within a week of withdrawal
• Antipsychotics
– available research shows limited efficacy.
Psychostimulants
 Case Study
Kylie, a 33 year old lawyer, recently discovered she
was pregnant. She has an active work and social life,
and consequently, tends to eat poorly. The pregnancy
was unplanned. She is concerned about the health of
her baby, and her lifestyle that precludes regular eating
habits.

How would you incorporate an AOD history into

your consultation?
What triggers may lead you to suspect
psychostimulant use?
Psychostimulants
 Cocaine
• Alkaloid from plant leaf of Erythroxylon coca
• Known as coke, charlie, snow, okey doke
• Sold in ‘lines’
• CNS stimulant with local anaesthetic actions
• Also stimulates SNS
• Blocks reuptake of dopamine, noradrenaline and
serotonin.

Cocaine Crack Crack in vials

Psychostimulants
 Cocaine: Patterns of Use
People who use cocaine tend to:
– be middle class, well educated professionals
who snort
– be injecting polydrug users, occasionally using
‘speedballs’
– use alcohol to enhance cocaine effects
Patterns:
– usually injected or snorted, occasionally smoked
– ‘binge’ or a ‘run’
– bingeing patterns arise from rapid
neuroadaptation.

People who inject tend to use more often, use

greater quantities than snorters, and are at
greater risk of harm. Psychostimulants
 Cocaine: Pharmacology

• Blocks reuptake of
– dopamine (DA)
– noradrenaline
– serotonin
• DA thought to be responsible for reinforcing
effects
• Interaction between cocaine and alcohol can
produce toxic, if not fatal, effects.

Psychostimulants
 Cocaine: Metabolism

• Rapid onset of action (2–8 minutes respectively)

• Peak blood levels occur in 5–30 minutes
• Action is brief:
– half-life of 15–30 minutes if injected
– half-life of up to 30 minutes if snorted
• Metabolised by liver, 1–2% excreted unchanged in urine
• Inactive metabolites can be detected in:
– blood or urine for 24–36 hours after use
– hair for weeks to months after use.

Psychostimulants
 Cocaine: Acute Effects
 Desired  Acute low dose  Acute high dose

(Overdose)
 Euphoria  Local anaesthesia  Stereotyped,
 Sociable/gregarious,  Dilated pupils repetitive behaviour
talkative  Vasoconstriction  Anxiety, panic
 Confidence, control,  Increased respiration,  Aggression, hostility
energy pulse, BP,  Cardiovascular
 Reduced need for temperature events (e.g.
sleep arrythmias, MI)
 Temporary increase  Neurological events
in functional activity/ (CVA, seizures,
efficiency blurred vision,
dizziness, headache)
 Psychological events
(hallucinations,
confusion)
 Stomach pain,
nausea
Psychostimulants
 Cocaine: Chronic Effects
• Insomnia
• Depression, anxiety
• Aggression, violence
• Loss of appetite, concomitant weight loss
• Muscle twitching
• Psychosis – paranoid delusions, hallucinations
• Loss of libido / impotence
• Heightened reflexes
• Increased pulse rate.
Psychostimulants
Cocaine: Symptoms of Withdrawal
• Dysphoria (rather than depression) which may
persist (up to 10 weeks). Plus at least two of:
– fatigue
– insomnia / hypersomnia
– psychomotor agitation
– craving
– increased appetite
– vivid unpleasant dreams
• Withdrawal tends to peak 2–4 days following
cessation of use.
Psychostimulants
Cocaine: Withdrawal Management
• Non-stimulating/non-threatening environment
• Possible suicide precautions
• To date, no effective pharmacotherapies for
withdrawal management
• Prescribed medications:
– short term use of benzodiazepines
(anxiety, agitation, promote sleep)
– antidepressants (SSRIs; though continued
cocaine use may precipitate toxic
reactions).
Psychostimulants
 Cocaine:
Problems Associated with Use
Physical Psychosocial
• Nasal – e.g. rhinorrhoea, • Interpersonal
epistaxis, ulcers, sinusitis, (relationship discord,
perforated nasal septum, paranoia – irrational
risk of HCV transmission jealousy, alienation)
through sharing snorting and • Occupational
injecting equipment (absenteeism, job or
• IDU – e.g. systemic / local productivity loss)
infections, vein problems • Financial
(abscess, cellulitis, phlebitis), • Legal.
bacterial endocarditis,
BBV transmission
• Cardiovascular complications
• Death. Psychostimulants
Psychostimulant Interventions (1)
• Be non-judgmental, do not insist on abstinence
• Engage and retain patient in treatment
• Understand patient’s treatment goals
• Tailor intervention to suit patient, including level and
intensity of referrals
• Offer flexible service delivery, consistent with a
patient’s changing goals and needs
• Provide psychosocial support
• Address concurrent mental health needs; e.g. anxiety,
bipolar, or attention deficit disorders are common with
cocaine use.
Psychostimulants
Psychostimulant Interventions (2)
• Behavioural and psychosocial therapies produce
better results than pharmacotherapies

• Cognitive-Behavioural Therapy (CBT) helps the

patient develop problem solving skills and
strategies to:
– identify high-risk situations
– identify functional drug use
– deal with cravings

• CBT is more effective and longer lasting than less

intensive strategies.

Psychostimulants