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Stimulant Abuse, Cocaine and Mental Illness

[Download the NAMI stimulants fact sheet.]

The term “stimulant” refers to a number of different substances—both legal and illegal—originally found in various plants including the coca (cocaine) and the ephedra plants (ephedrine, amphetamine). Both legal stimulants (e.g., amphetamines [Dexedrine, Adderall], methylphenidate [Ritalin]) and illegal amphetamines (e.g., cocaine, crack or illegally obtained prescription medications) are highly addictive substances. Most people are aware of the dangers that cocaine poses, yet approximately 14 million people across the globe will use this drug each year.

Many people are prescribed stimulant medications and use them responsibly and without experiencing significant adverse effects. In spite of this, prescription stimulants remain a frequently abused substance: over 900,000 Americans will use these medications for non-medical purposes on a monthly basis. While some people may try it a single time, people who frequently abuse stimulants are likely to experience consequences of their stimulant use. Someone who has difficulty stopping his habit, gets sick, injured, or arrested due to stimulant use—or who experiences problems at work, school, or at home due to being intoxicated—may be dependent on stimulants.

What happens when a person abuses stimulants?

A person uses stimulants may begin to feel “high.” This can involve peaceful feelings—such as being happy or relaxed—which are most likely related to the drug’s interactions with certain chemicals in the brain (including dopamineandnorepinephrine). People with mental illness may be more likely to also experience concerning symptoms such as severe mood changes (irritability, depression), psychotic symptoms (paranoia, hallucinations), as well as anxiety (panic attacks) and insomnia. People abusing high doses of stimulants, such as cocaine, are at risk of acute medical complications including heart attacks, seizures and strokes. Studies have shown that cocaine abuse is associated with more patients requiring emergency room care than with any other illegal drug in America.

People who regularly abuse stimulants may become addicted (e.g., their body becomes physically dependent on the substance). An addicted person who abruptly stops using stimulants will experience stimulant withdrawal—a group of symptoms causing intense physical and psychological distress. Stimulant withdrawal generally begins within hours of one’s last use but can take longer if a person had been abusing a longer-acting stimulant drug. In most cases, stimulant withdrawal is not a medical emergency and consists of uncomfortable symptoms such as depressed mood, anxiety, sleepiness, abnormal movements (i.e., tremors) and muscle pain. Some people may experience acute suicidal thoughts or behaviors which would likely require emergent psychiatric evaluation. Other people may be at risk for cardiovascular complications which could require medical intervention.

Many people seek assistance in stopping their stimulant abuse. This may include inpatient detoxification which can involve admission to a hospital—either a general hospital or a detoxification facility—although this is rarely medically necessary. The specifics of detoxification are largely beyond the scope of this review and there is no medication that has been definitively shown to treat stimulant withdrawal.

What is the relationship between stimulant abuse and mental illness?

The relationship between stimulant abuse and mental illness is complex, and the treatment of both together is more complicated than the treatment of either condition alone. Certain groups of people with mental illness—including males and individuals of lower socioeconomic status—are at increased risk of abusing stimulants. Scientific data is clear that regular stimulant abuse is linked with increased risk of legal troubles and jail time, difficulties at school and at work, as well as abuse of other drugs. When used together with other drugs—including alcohol and opiates—the risk of unintentional lethal overdose is greatly increased.

Stimulant abuse results in a worse prognosis for a person with mental illness. It is particularly dangerous in patients with bipolar disorder and schizophrenia, as these drugs are often associated with worsening symptoms of mania and psychosis. People who are actively using are less likely to follow through with their treatment plans (e.g., adhering to their medication regimens and keeping appointments) which leads to more psychiatric hospitalizations and other adverse outcomes. Active users are similarly less likely to receive adequate medical care and are more likely to experience severe medical complications and early death. People with mental illness who abuse stimulants and cocaine are also at increased risk of impulsive and potentially violent acts. Perhaps most concerning is that people who abuse cocaine are more likely to both attempt suicide and to die from their suicide attempts.

People with mental illness and active stimulant abuse are less likely to achieve lasting sobriety. They may be more likely to experience severe complications of their substance abuse, to end up in legal trouble from their substance use and to become physically dependent on these drugs.

What is the relationship between stimulant abuse and medical illness?

The potential health benefits of controlled stimulant use are largely beyond the scope of this review. However, it should be noted that controlled use of stimulants have been shown to be helpful in certain specific psychiatric and medical illnesses (e.g., ADHD and narcolepsy) although stimulant use in these situations should be at the direction of one’s physicians.

Many people use stimulant drugs by oral ingestion or intranasal methods (e.g., by “snorting” or “blowing” the drugs). Other people may use these drugs intravenously—injecting the drugs into their veins. This method of drug abuse carries specific health risks due to the use of shared, dirty needles. Intravenous drug use remains the second most common means of contracting HIV/AIDS in America and the most common means of contracting hepatitis C, a potentially deadly liver disease. While using clean needles is much safer, people who inject drugs into their body are at risk of strokes, blood vessel disease and developing severe infections (including endocarditis and tuberculosis).

Some people may not be familiar with the significant risk of fatal overdose that accompanies stimulant abuse. Stimulant overdose is a life-threatening emergency that happens when a person uses too much, and it can result in death by seizure, stroke or heart attack. This can happen to people who use any kind of stimulant and regardless of whether they swallow, snort, or inject the drug.

What treatments are available for people with stimulant abuse and dependency?

For people with severe stimulant abuse, the first step is safely coming down off of the drug. After this is achieved, many options exist for people who are newly sober or who are trying to avoid relapse. These can include inpatient rehabilitation centers or supportive housing (e.g., sober houses, group homes, residential treatment facilities). Other people may choose to return home to their friends and family who can be helpful in encouraging the newly-sober individuals to continue their efforts.

Some people find therapy to be a helpful part of maintaining their sobriety. This can include self-help groups such as Narcotics Anonymousor SMART Recovery. Individual therapy can also be useful and some people will find that cognitive behavioral therapy is an important part of their treatment plan. Another form of therapy called “motivational interviewing”—an interactive, patient-centered model of treatment focused on finding inspiration for behavioral change—has been found to be effective in helping people to stop abusing stimulants. These and other tools can be useful as a significant majority of people will relapse at some point in their lives, even if they are eventually able to achieve long-lasting sobriety.

There is no medication that can cure stimulant abuse. A number of different medications—including a “cocaine vaccine”—have been studied in the treatment of stimulant abuse and the specifics of each should be discussed with one’s prescribing physicians and rest of their treatment team. It should be noted that at the current time, no medication has been approved by the US-FDA for the treatment of stimulant abuse. For people who also abuse other drugs such as opiates or alcohol, medical treatment of these addictions can be very helpful in treating co-existing stimulant abuse.

Family, friends and others can be most helpful in providing empathic and non-judgmental support of their loved one. With this support and effective psychiatric treatment, many people with opiate abuse and mental illness will be able to actively participate in their recovery journey.

Reviewed by Ken Duckworth, M.D., and Jacob L. Freedman, M.D., March 2013

[Download the NAMI stimulants fact sheet.]

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