Chapter 235. Stimulants

1. What are the most commonly abused stimulants?

2. How are the acute cardiovascular complications of stimulants managed?

3. How are the acute psychiatric complications of stimulants managed?

4. What are the other medical sequelae of abused stimulants?

5. What factors should be considered when discharging a patient with complications of stimulants?

What Are the Most Commonly Abused Stimulants?

Cocaine is a naturally occurring plant alkaloid found in the leaves of the coca bush, Erythroxylon coca. Cocaine for illicit use comes in two major forms, the base and the salt. Cocaine base or “crack” is smoked, while cocaine salt or powder cocaine is snorted intranasally or dissolved for intravenous injection. Amphetamine and methamphetamine are synthetic stimulants that are typically abused by the oral or intravenous route. “Ice” is crystallized methamphetamine that can be smoked or used intranasally. “Ecstasy” or MDMA is 3,4-methylenedioxymethamphetamine, and it is usually abused by the oral route. MDMA has both hallucinogenic and stimulant properties. Over-the-counter stimulants include ephedrine, phenylephrine, and pseudoephedrine. Two additional plant-derived stimulants that may be encountered in clinical settings include ephedra or “ma-huang” (from the dried branches of Ephedraceae species) and khat (prepared from the Catha edulis plant) (Table 235-1).

Prescription stimulants include methylphenidate, methamphetamine, dextroamphetamine, mazindol, phenmetrazine, and phentermine. Prescribed stimulants may be used therapeutically for multiple conditions, including attention deficit disorder, narcolepsy, fatigue in multiple sclerosis, and refractory depression, as well as in palliative care. When prescribed stimulants such as methylphenidate or dextroamphetamine are abused by patients who have valid prescriptions for them, clinicians may see unintended side effects such as elevation in resting heart rate or other cardiovascular complications; this may be a clue to the prescriber that unauthorized dose escalation is occurring.