CNS stimulants

stimulant intoxication medical complications

HEENT: pupillary dilation, h/a

pulmonary: hyperventilation, dyspnea, chest pain, wheezing, hemoptysis, pulmonary edema

CV: increased HR/BP, arrhythmia, ischemia, MI, cardiogenic shock

GI: anorexia, N/V

renal: diuresis, myoglobinuria, acute renal failure

body temp: fever, malignant, hyperthermia

other: rhabdomyolosis

psychiatric/behavioral manifestations of stimulant intoxication

initially: increased energy, alertness and socialbility, elation, euphoria, decreased need for sleep

higher doses/repeated use: anxiety, iritability, hypervigilance, suspiciousness, grandiosity, impaired judgement and psychosis (paranoid delusions, auditory + visual hallucinations, tactile including formication), excited delirium (rare)

h/a, tremor, hyperreflexia, muscle twitching, tics, myoclonus, seizures, ceberal hemmorage or infarct, cerebral edema

how do we treat stimulant intoxication

supportive tx

sx management including using psychotropic Rx if needed (benzos, antipsychotics)

preferred Tx for severe agitation, anxiety, psychosis for stimulant intoxication if psychotropic rx is needed

benzos preferred over antipsychotics

which antipsychotics are preferred for agitation/anxiety/psychosis Tx in stimulant intoxication

high potency- haloperidol, risperidone

Pros of benzos in stimulant intoxication over Antipsychotics

protect against CNS/CV toxicities of stimulants

APs may worsen sympathomimetic and CV effects, lower seizure threshold, increased hyperthermia risk, EPSE

List 3 forms of cocaine

powder coke

crack

freebase

powder coke components/form

water soluble salt form

very oily, white powder (bitter numbing taste)

often adulterated with lidocaine, benzene

mixed with H2O to create an acid

purpose of lidocaine/benzene in powder coke

numb nasal passages when sniffed

how is powder coke consumed

snorted or mixed with H2O to inject

what form is crack

base

how is crack consumed

smoked

how is crack made

boil or microwave cocaine powder with water and baking soda which cleaves HCl salt and forms on oil which is scraped to side of pan and dried to produce lumps (rocks)

how is freebase produced

produced from the salt by dissolving it in water and treating it with an alkaloid (ex: ammonia), removes HCl

how is freebase consumed

smoke

Onset, peak duration of smoking crack (base)

onset: 7-8s

peak: 1-5min

duration: 10-15min

onset, duration, peak of injecting powder cocaine (salt)

onset: 15s

peak: 3-5min

duration: 10-20min

onset, duration, peak of snorting cocaine powder (salt)

onset 3-5min

peak 15-20min

duration 30-60min

Sx of cocaine w/d

crash with depression, fatigue, anergia, anhedonia, impaired concentration, agitation, anxiety, insomnia, hypersomnia, cravings

timeline of sx of cocaine w/d

occur within hours to up to several days of abrupt cessation

resolves over 1-2 weeks

cravings may persist for weeks

how to Tx cocaine withdrawal

Sx management

largely supportive care

only give pharmacotherapy where clearly indicated (ex: agitated give BZD/AP) - no specific med approved

tolerance occurs to which effects of cocaine

euphoric effects but NOT anxiety/depression (these may worsen)

when does cocaine tolerance occur

months-yrs, even days with a binge

which cocaine route is more likely to cause dependance

smoke/injecting more than snorting

example of amphetamines that may be involved in stimulant use disorder

MDMA

methamphetamine

methylphenidate

amphetamine effects (moa)

act on sympathetic NS to cause the release of noradrenaline (stimulant effects), 5HT (emotional effects), DA (reward/addiction) and also inhibits reuptake

do amphetamines or cocaine effects last longer

amphetamines

MDMA properties

sympathomimetic and serotonergic

enactogenic-empathogenic

mild hallucinogenic

How is MDMA consumed

tablets are swallowed

MDMA may contain what else

caffeine, acetaminophen, heroin, ketamine, ephedrine, meth

onset/peak/duration of MDMA

onset 30min

peak in 1-3hr

duration 8hr

when does MDMA come down occur

3-6hr post ingestion

Sx of MDMA use

tranquil euphoria, emotional empathy, greater insight to personal problems, at peace with world

highlights senses

bruxism

traditional amphetamine like stimulant effects= increased endurance

higher doses/repeated use can see more moof, anxiety, panic, psychosis (flight of ideas, hallucinations, delirium)

list a serious ae of MDMA

hyponatremia, seizures, coma, death

hyponatremia can lead to what

seizures

explain how MDMA causes seizures

hyponatremia

increased CNS stim, cerebral edema, increasing ICP

how does MDMA cause hyponatremia

MDMA associated with transient increases in body temp, dry mouth, increased thirst, polydipsia

increased secretion of ADH

Sx of MDMA w/d

depression, anxiety, fatigue, impaired conc

when does MDMA w/d occur

few days

Tx of MDMA w/d

self limited, typically resolves without treatment

list the forms of methamphetamine

Powder

Base

Crystal

how is powder meth consumed

snorted or pressed into tablet to be swallowed or injected

how is base of meth consumed

swallowed or injected

how is crystal form of meth consumed

usually smoked w/ glass pipe

dissolved and injected aswell

most potent and popular form of meth

crystal

most common route of using meth

smoked

onset/duration of meth

effect in seconds, can last 12hrs or more

how long does meth crash last

1-3 days

typical meth ingredients

pseudophed + paint thinner + draino

meth intoxication sx

psychiatric and behavioral: overstimulation, euphoria, restlessness, insomnia, increased energy and talkativeness, heightened sense of well being, repetitive motor movements, rarely panic, psychotropic episodes

other CNS: tremor, anorexia, dilated pupils

CV: palpitations, increased or irregular HR, increased BP, chest pain

resp: increased RR

intense intoxication and escalated meth use sx

behavioral and psychiatric: intense exhiliration and euphoria, racing thoughts, feelings of increased physical and mental agility, talkativeness, excitation, panic, agitation, irritability, stimulant psychosis with paranoia, hallucinations, violence

other CNS: seizures, hemorrhagic stroke, hyperthermia, coma

CV: angina, MI, arrythmias, CV collapse, fainting, high or low BP

renal: rhabo and acute renal failure

long term meth use complications

sleep disorders, prominent insomnia

anxiety, agitation

anhedonia, depression

paranoia, prolonged amphetamine psychosis

wasting

cardiac complications- arrhythmias, MI, HF

infections (IV use), lead poisoning (adulterants)

dental decay

skin lesions from crank bugs

Meth w/d sx

sim to cocaine but more intense

psychosis, extreme dysphoria, depression, exhaustion, agitation, anxiety, insomnia

prolonged period of anhedonia and fatigue

meth induced psychosis Tx

abilify, HDL, QTP

agitation management in meth w/d

IV lorazepam and droperidol

meth induced high BP Tx

isradipine (CCB)

Tx for managing meth cravings

buprenorphine or pexacerfont

first line Tx in meth w/d for severe agitation, aggressiveness, psychosis

benzos

how to manage stimulant intoxication/OD

supportive Tx - providing hydration, food, safe place to rest

route of methylphenidate when misusing

tabs crushed and either snorted or dissolved in water to make IV injection bc poor oral F

methylphenidate effects

similar to but less intense than other amphetamines