Stimulant Use Disorder
Problematic cocaine or amphetamine-type stimulant use meeting >=2 of 11 DSM-5-TR criteria in 12 months.
Also known as: cocaine use disorder, methamphetamine use disorder, stimulant addiction
Overview
A pattern of amphetamine-type or cocaine use leading to clinically significant impairment or distress, with >=2 of 11 DSM-5-TR criteria in 12 months. Methamphetamine and cocaine deaths are rising sharply, often driven by fentanyl co-exposure.
Epidemiology
Past-year cocaine use ~2%; methamphetamine ~0.6% of US adults; substantial increase in stimulant-involved overdose deaths in last decade.
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Risk factors
- Family history of SUD
- Comorbid mood, anxiety, ADHD, PTSD
- Sexual minority status (methamphetamine and chemsex)
- Adolescent onset
- Concurrent opioid or alcohol use
- Access and environmental exposure
Pathophysiology
Cocaine blocks dopamine, norepinephrine, and serotonin reuptake; amphetamines also promote release from vesicles. Both produce intense mesolimbic dopaminergic surge driving reinforcement. Chronic use produces dopaminergic depletion and prefrontal dysfunction.
Clinical presentation
Symptoms
- Intoxication: euphoria, hypervigilance, increased energy, anorexia, tachycardia, hypertension, mydriasis, sweating, hyperthermia, tremor, paranoia, psychosis, seizures
- Severe: arrhythmia, MI, stroke, hyperthermia, rhabdomyolysis, excited delirium
- Withdrawal ('crash'): dysphoria, fatigue, hypersomnia, increased appetite, vivid unpleasant dreams, anhedonia — peaks days 1-3, gradual improvement
Signs / physical exam
- Sympathomimetic toxidrome: tachycardia, hypertension, hyperthermia, diaphoresis, mydriasis, agitation
- Methamphetamine: dental decay ('meth mouth'), excoriated skin from picking, weight loss
- Cocaine: nasal septal perforation (insufflation), pulmonary hemorrhage (crack lung)
- Cardiac: chest pain, arrhythmia
Differential diagnosis
- Primary psychotic disorder — Persistent psychosis beyond intoxication; chronic course
- Bipolar mania — Distinguish by independent history and persistence of symptoms with abstinence
- Hyperthyroidism, pheochromocytoma — Sustained tachycardia, HTN, suppressed TSH or elevated metanephrines
- Anticholinergic toxicity — Dry skin, urinary retention, ileus — distinct from sympathomimetic toxidrome
- Serotonin syndrome / NMS — Recent medication exposure, hyperreflexia/clonus vs rigidity
Diagnostic workup
Diagnostic criteria
DSM-5-TR: Problematic pattern of stimulant use causing impairment/distress with >=2 of 11 criteria over 12 months. Specify substance (amphetamine-type vs cocaine). Severity by criterion count.
Labs
- Urine drug screen (cocaine metabolite benzoylecgonine; amphetamines/methamphetamine)
- ECG, troponin in chest pain
- CBC, CMP, CK (rhabdomyolysis), UA
- Pregnancy test
Imaging
- Head CT for altered mental status, seizure, focal deficit (stroke risk elevated)
- Echocardiogram if prolonged use (cardiomyopathy) or suspected endocarditis (IV use)
Diagnostic algorithm
| Feature | Cocaine | Methamphetamine |
|---|---|---|
| Duration of effect | 30-60 min | 8-24 hours |
| Half-life | ~1 h | ~10-12 h |
| Route | IN, smoked (crack), IV | Smoked, IV, IN, PO |
| Characteristic complications | MI, septal perforation, crack lung | Meth mouth, skin picking, psychosis |
| Treatment of agitation | Benzodiazepines | Benzodiazepines |
Treatment
First-line
- No FDA-approved pharmacotherapy for stimulant use disorder
- Behavioral therapies are mainstay: contingency management (strongest evidence), cognitive behavioral therapy, community reinforcement approach, matrix model
- Acute intoxication/agitation: benzodiazepines (lorazepam, diazepam) for agitation, HTN, tachycardia, seizures
- AVOID beta-blockers in cocaine intoxication (unopposed alpha vasoconstriction) — use benzodiazepines, nitrates, CCBs
- Cooling for hyperthermia; supportive care for rhabdomyolysis
Second-line / adjunct
- Off-label pharmacotherapy with modest evidence: bupropion + naltrexone combination (methamphetamine), topiramate, mirtazapine (methamphetamine + MSM), modafinil
- Treat comorbid psychiatric illness
- Harm reduction: education, fentanyl test strips, naloxone given co-use
- Residential treatment for severe disease
Complications
- Cardiovascular: MI, arrhythmia, aortic dissection, sudden death, cardiomyopathy, accelerated atherosclerosis
- CNS: hemorrhagic and ischemic stroke, seizures, intracranial hemorrhage from HTN surges
- Psychiatric: stimulant-induced psychosis, mood/anxiety symptoms, suicidality
- Pulmonary: crack lung, pulmonary hypertension
- Infectious: HIV/HCV from IV use; STIs from chemsex
- Pregnancy: placental abruption, preterm birth, IUGR
- Overdose with fentanyl contamination
PANCE pearls
- Cocaine-associated chest pain: avoid beta-blockers (unopposed alpha vasoconstriction worsens coronary spasm); use benzodiazepines + nitrates + aspirin; CCB or phentolamine for refractory HTN.
- Stimulant-induced psychosis can persist for weeks after cessation, especially methamphetamine; consider short-course atypical antipsychotic.
- Contingency management has the strongest evidence base — financial incentives for stimulant-negative urines reliably reduce use.
- Co-use of opioids (intentional or via fentanyl contamination) is driving stimulant overdose deaths — distribute naloxone and fentanyl test strips.
References
- ASAM 2024 — ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder (2024)
- SAMHSA TIP 33 — SAMHSA TIP 33: Treatment for Stimulant Use Disorders
- NIDA — NIDA Research Reports: Cocaine and Methamphetamine
- DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
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