Psychiatry/Behavioral · PANCE / PANRE

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

Cocaine vs methamphetamine — clinical features and complications.

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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