Central Nervous System (CNS) Stimulant Use Disorders

Cocaine and amphetamines are readily available in the United States. The patterns of use and abuse of and dependence on cocaine and amphetamines are similar because both are CNS stimulants with similar psychoactive and sympathomimetic effects.

In the United States, cocaine is available in two forms: as cocaine hydrochloride powder, which is typically snorted, and as cocaine alkaloid crystal ("crack"), which is typically smoked. Cocaine has an extremely rapid onset of action (when snorted or smoked) and a short half-life, requiring frequent dosing to remain "high."

In the United States, an amphetamine (dextroamphetamine) and methylphenidate are available in pill form by prescription for the treatment of obesity, narcolepsy, and attention-deficit/hyperactivity disorder. Various forms of amphetamine are used illicitly including a very pure form of methamphetamine, called crystal methamphetamine, which can be snorted or smoked. Amphetamines have a longer half-life than cocaine and hence are taken less frequently.

Clinical Manifestations

Cocaine or amphetamine intoxication is characterized by

1. Maladaptive behavioral changes (e.g., euphoria or hypervigilance);
2. Tachycardia or bradycardia;
3. Pupillary dilatation;
4. Hyper- or hypotension;
5. Perspiration or chills;
6. Nausea or vomiting;
7. Weight loss;
8. Psychomotor agitation or retardation;
9. Muscular weakness, respiratory depression, chest pain, cardiac dysrhythmias;
10. Confusion, seizures, dyskinesia, or coma.

Cocaine intoxication can cause tactile hallucinations ("coke bugs"). Both cocaine and amphetamine intoxication can lead to agitation, impaired judgement, and transient psychosis (e.g., paranoia, visual hallucinations). Cocaine and amphetamine dependence is defined by the criteria outlined above for substance dependence.

Withdrawal of cocaine or amphetamines leads to fatigue, depression, nightmares, headache, profuse sweating, muscle cramps, and hunger. Withdrawal symptoms peak in 2 to 4 days.

Management

Withdrawal from amphetamines or other (CNS) stimulants is self-limited and usually does not require inpatient detoxification. Psychosis from amphetamine intoxication or withdrawal is generally self- limited, requiring only observation in a safe environment. Antipsychotic medications can be used for agitation.

Ultimately, the goal is rehabilitation. Narcotics Anonymous, treatment of comorbid psychopathology, drugs to reduce craving, and family therapy are the essential features of cocaine rehabilitation.

1. Cocaine and amphetamines are CNS stimulants. 2. CNS stimulants can cause transient psychosis (e.g., "coke bugs" or paranoia). 3. Withdrawal symptoms (fatigue, depression, nightmares, etc.) peak in 2 to 4 days. 4. Withdrawal from CNS stimulants is self-limited.