Stimulant Use Disorder

Stimulant use disorder encompasses problematic patterns of use involving cocaine and amphetamine-type stimulants (ATS) including methamphetamine ('crystal meth', 'ice'), prescription amphetamines (Adderall, Vyvanse), methylphenidate (Ritalin, Concerta), MDMA ('ecstasy', 'molly'), synthetic cathinones ('bath salts'), and emerging novel psychoactive stimulants. DSM-5 criteria require ≥2 of 11 criteria within 12 months: taking larger amounts/longer than intended, persistent desire/unsuccessful efforts to cut down, time spent obtaining/using/recovering, craving, role failure, social/interpersonal problems, important activities given up, recurrent use in hazardous situations, continued use despite physical/psychological problems, tolerance, withdrawal. Severity: mild (2-3 criteria), moderate (4-5), severe (≥6).

Pharmacology: cocaine blocks reuptake of dopamine, norepinephrine, serotonin (DAT, NET, SERT) producing euphoria, energy, decreased fatigue, sympathetic activation; amphetamines additionally cause release of catecholamines (more sustained effect, longer half-life — methamphetamine 8-12 hours vs cocaine 1 hour); MDMA primarily releases serotonin causing prosocial empathogenic effects. Acute effects: euphoria, increased energy, decreased appetite, hyperalertness, talkativeness, sweating, mydriasis, hyperthermia, hypertension, tachycardia, arrhythmias, seizures, hyperthermia, agitation, paranoia, hallucinations, violence, stroke (hemorrhagic and ischemic), myocardial infarction, aortic dissection, acute kidney injury, rhabdomyolysis. Chronic use: weight loss, dental decay (meth mouth), dermatological lesions (excoriation), stimulant-induced psychotic disorder, mood disorders, anxiety, suicide risk, cardiovascular disease (cardiomyopathy, accelerated atherosclerosis), neurocognitive deficits, cerebrovascular disease.

Withdrawal syndrome (less medically dangerous than alcohol/opioid but psychologically severe): early phase 'crash' (24-48 hours) with intense fatigue, hypersomnia, increased appetite, dysphoria, irritability; intermediate phase (days 3-10) with prolonged sleep, depression, anhedonia, intense cravings, anxiety, paranoid thinking; protracted phase (weeks-months) with persistent dysphoria, anhedonia, anergia, cognitive impairment, drug cravings particularly with environmental cues. Treatment focuses on psychosocial interventions due to limited approved pharmacotherapy: contingency management (most effective, voucher-based or prize-based reinforcement for stimulant-negative urines), cognitive-behavioral therapy (CBT), community reinforcement approach (CRA), motivational interviewing/enhancement, matrix model (intensive outpatient combining CBT, family therapy, education), 12-step facilitation, narcotics anonymous, residential treatment for severe cases. Pharmacotherapy: no FDA-approved medications; off-label trials of bupropion (limited efficacy for methamphetamine), naltrexone, topiramate, modafinil, mirtazapine, ondansetron, lisdexamfetamine substitution (controversial), combination injectable naltrexone-bupropion (some efficacy in trials). Treatment of comorbid psychiatric disorders (depression, ADHD with non-stimulant alternatives, anxiety, PTSD), HIV/HCV testing and treatment, harm reduction, sexual health counseling, contingency management for retention. Long-term recovery requires sustained engagement, relapse prevention skills, addressing co-occurring conditions, social support, recovery housing.