Substance abuse stimulants

King GR, Ellinwood EH Amphetamines and other stimulants, in Substance Abuse A Comprehensive Textbook, 3rd Edition. Edited by Lowinson JH, Ruiz P, Mill-man RB, et al. Baltimore, MD, Williams Wilkins, 1997, pp 207—233 Klawans HE, Margolin Dl Amphetamine-induced dopaminergic hypersensitivity in guinea pigs implications in psychosis and human movement disorders. Arch Gen Psychiatry 32 725—732, 1975... 

The association of substance abuse with emergency department (ED) visits in 21 different metropolitan areas in the United States is reported by the Drug Abuse Warning Network (DAWN). This survey tracks ED visits that are due to a condition induced by or related to drug use. Included in the data are ED visits associated with alcohol, alone and in combination with other substances of abuse, including cocaine, heroin, marijuana, and major stimulants. Figure 33-2 indicates the number of ED visits that are associated with illicit... 

A number of medications have been studied to alleviate symptoms of stimulant withdrawal and the intense craving that may accompany it, but inconsistent results across controlled trials preclude any recommendations for their routine use. Patients with stimulant use disorders should be referred to substance abuse treatment because of the high risk for continued use either during or immediately following stimulant withdrawal. 

Growth suppression or delay is a major concern for parents of children taking stimulants. However, the evidence of this side effect is not dear. At present, growth delay appears to be transient and to resolve by midadolescence, but more data are needed to firmly resolve this issue.10 Another concern is the risk of substance abuse with stimulant use. A diagnosis of ADHD alone increases the risk of substance abuse in adolescents and adults. However, stimulant use has not been shown to further increase this risk but actually may decrease this risk, provided ADHD is treated adequately.15... 

Educate the patient s parents and/or caregivers that behavioral therapy is not as effective as stimulant therapy. Educate parents regarding the issues of growth delay and substance abuse risks with stimulants. 

Controversy over substance abuse and growth delay with stimulant therapy. 

King GR and Ellinwood EH (1992) Amphetamines and other stimulants. In JH Lowinson and P Ruiz (eds), Substance Abuse A Comprehensive Textbook (pp. 247-266). Williams Wilkins, Baltimore. 

Wilens, T. E., Faraone, S. V., Biederman, J. and Gunawardene, S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse A meta-analytic review of the literature. Pediatrics 111 179-185, 2003. 

Reward Therapy. A similar (yet nonspecific) approach is to use a medication that stimulates the brain s reward centers. Reward medications usually do not work in quite the same way as the substance of abuse however, the net effect in the final common pathway (i.e., the reward centers) may be the same. For the most part, these reward centers are activated by either dopamine or endogenous opioid agonists. One common feature of most abused drugs is that they stimulate these reward centers. This lies at the heart of their addictive potential. Some attempts have been made to use medications that activate these reward centers in place of the abused substance. The hypothesis is that the addict will have less intense craving for his/her preferred substance of abuse in the presence of these other agents. This is, of course, a relatively nonspecific approach that could theoretically be used to treat the abuse of many different substances. It has not yet, however, demonstrated any utility in the treatment of substance abuse. 

Interference Therapy. This is conceptually the opposite of the replacement and reward therapies. Whereas replacement medications substitute for the abused drug by stimulating the same brain receptors, interference therapies block these receptors. When the substance abuser uses his/her drug of choice, its effects are blocked by the interference medication. As a result, the drug does not produce the same intensity of pleasurable effects. By reducing the pleasurable effects of drug use, the incentive for repeated use should decrease as well. 

Dopamine-Stimulating Medications. A variety of drugs that increase the availability of dopamine have been studied in cocaine addicts including L-DOPA, bupropion, amantadine, and methylphenidate. In small uncontrolled trials, these have shown some benefit, but definitive studies have yet to be performed. In addition, some dopamine-stimulating medications (in particular, the stimulants like methylphenidate or the amphetamines) are themselves subject to abuse, though, of note, this is typically not a problem when they are prescribed to patients who do not have a history of substance abuse such as, for example, in the treatment of attention deficit-hyperactivity disorder. 

Once chronic insomnia has developed, it hardly ever spontaneously resolves without treatment or intervention. The toll of chronic insomnia can be very high and the frustration it produces may precipitate a clinical depression or an anxiety disorder. Insomnia is also associated with decreased productivity in the workplace and more frequent use of medical services. Einally, substance abuse problems may result from the inappropriate use of alcohol or sedatives to induce sleep or caffeine and other stimulants to maintain alertness during the day. 

While stimulants are potentially abusable, recent evidence suggests that stimulant treatment substantially reduces the risk for substance abuse generated by ADHD cognitive and behavioral impairments (Bieder-man et al., 1999b). Moreover, another study has shown that the most commonly abused substance in ADHD adolescents and adults is marijuana and not stimulants (Biederman et ah, 1995b). Appropriate education and monitoring are crucial to the safe prescription of psychostimulants in adolescents and adults. 

Lambert, N. (2005). The contribution of childhood ADHD, conduct problems, and stimulant treatment to adolescent and adult tobacco and psychoactive substance abuse. Ethical Human Psychology and Psychiatry 7, 197-221. 

Taper oft antidepressants, stimulants, and caffeine it possible Treat substance abuse... 

Stimulants have a high potential for abuse and must be used with caution in anyone with a current or past history of substance abuse or alcoholism or in emotionally unstable patients... 

Untreated ADHD is a significant risk factor for substance abuse disorders in adolescents (36). In contrast, pharmacotherapy, that is stimulants, was associated with an 85% reduction in the risk of substance abuse disorders in youths with ADHD. Most authorities recommend complete assessment and diagnosis of both ADHD and any dual diagnoses before starting stimulant medication. 

Substance abuse and related disorders represent a major problem area facing the clinician. Despite the "war on drugs" they continue to be a widespread problem. At least 5 percent of Americans are alcoholic, and stimulant abuse is a serious problem among teenagers and young adults. Any solution to these problems will undoubtedly involve social and political factors in addition to clinical programs. This chapter focuses on the differing types of clinical syndromes related to each commonly abused substance and medications that may be useful as an adjunct to treatment. 

Medications play an important part in the treatment of ADD. Stimulants are the mainstay of the treatment of ADD methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert). These differ in their half-lives, with Ritalin having the shortest and Cylert the longest. A warning has recently been issued about Cylert because of reports of sometimes fatal liver toxicity. Thus, it is recommended that it be used only if methylphenidate and dextroamphetamine are ineffective. There is individual variability in resporise, so that a person who does not respond to one may respond well to another. Other medications can also be effective in the treatment of ADD and may be useful, especially in residual ADD, where substance abuse may be an issue. These include tricyclic antidepressants (especially desipramine and imi-pramine) SSRIs, bupropion, venlafaxine, and clonidine. There are reports of antipsy-chotics and lithium being helpful in selected cases, as well. 

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