Stimulant Drugs of Abuse

Stimulants can be used medicinally for treatment of conditions such as narcolepsy and ADHD.  Stimulants are also used recreationally in a variety of forms, which will be the focus of this section. Stimulants produce a specific toxidrome referred to as the sympathomimetic toxidrome.  The sympathomimetic toxidrome is an exaggeration of the responses that would normally be produced in response to adrenergic stimuli. So you can consider "fight or flight" physiology as a baseline reference for what to expect in these patients.  

The sympathomimetic toxidrome affects several organ systems.  Cardiovascularly, you can expect to see patients with tachycardia and hypertension.  Central nervous system responses include dilated pupils, tremor, seizures, and psychosis.  Patients can become hyperthermic and diaphoretic.  Diaphoresis is an important clinical feature that helps in distinguishing the anticholinergic toxidrome from the sympathomimetic toxidrome.  Treatment differs between anticholinergic and sympathomimetic toxicity, so this is a critical physical exam finding to assess.  

Patient's abuse these drugs due to the euphoria experienced with consumption.  

Treatment of stimulant toxicity includes supportive care (intravenous fluids, etc.), temperature management, and management of seizures and agitation/psychosis. The drugs of choice in managing the toxic patient are benzodiazepines for both seizures and agitation. Antipsychotics can be helpful in managing agitation and psychosis.  

Amphetamines

Mechanism of Toxicity

Inhibits reuptake of norepinephrine

• Increases synaptic catecholamines

Inhibits reuptake of dopamine and serotonin

• Causes pleasurable/addictive effect

Methamphetamine or other synthetic amphetamines can be abused

Effects

• Euphoria

• Agitation/psychosis

• Chest pain

• Seizures

• Hyperthermia

Treatment

Supportive cares

Temperature management

Management of agitation/psychosis

• Benzodiazepines

• Antipsychotics

Cocaine

Mechanism of Toxicity

Inhibits reuptake of norepinephrine

• Increases synaptic catecholamines

Inhibits reuptake of dopamine and serotonin

• Causes pleasurable/addictive effect

Snorted in cocaine form

"Crack" form can be smoked

Effects

• Euphoria

• Agitation/psychosis

• Chest pain

• Seizures

• Hyperthermia

Treatment

Supportive cares

Temperature managementManagement of agitation/psychosis

• Benzodiazepines

• Antipsychotics

Avoid use of beta-blockers in cocaine induced acute coronary syndrome

• Cocaine use affects both alpha and beta receptors. Beta blockers cause unopposed alpha receptor effects, which results in coronary artery constriction and decreased myocardial oxygen delivery.

MDMA (methylenedioxymethamphetamine)

Mechanism of Toxicity

Inhibits serotonin reuptake

• Causes pleasurable/addictive effect

Street name: Molly, Ecstasy

Effects

• Euphoria

• Increases social interactions

• Tactile stimulation is enjoyed by users

• Serotonin syndrome

• Hyperthermia

• Agitation

• Renal failure

• Seizures

Treatment

Supportive cares

Temperature management

Management of agitation/psychosis

• Benzodiazepines

• Antipsychotics

Synthetic Cathinones

Mechanism of Toxicity

Inhibits reuptake of norepinephrine, epinephrine, and dopamine

"Bath salts"

Effects

• Euphoria

• Agitation/psychosis

• Seizures

• Hyperthermia

Treatment

Supportive cares

Temperature management

Management of agitation/psychosis

• Benzodiazepines

• Antipsychotics