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stimulant
Betty Rachma
stimulant
substances that induce a number of
characteristic symptoms, (alertness with
increased vigilance, a sense of well-being,
and euphoria)
classified by the US Drug Enforcement
Agency (DEA)
DEA classification
Schedule I
Schedule II
Schedule III
Schedule IV
Schedule V
DEA classification
Schedule I
Schedule II
Schedule III
Schedule IV
Aminoxaphen Cathinone
Fenethylline
Methcathinone
Mephedrone
Methylaminore
x
Amphetamine
variants
Cocaine
Dextroampheta
mine
Lisdexamfetam
ine dimesylate
Methampheta
mine Methylphenidat
e Phenmetrazine
Biphetamine
Benzphetamin
e Chlorphentermi
ne
Clortermine
Phendimetrazi
ne tartrate
Armodafinil
Diethylpropion
hydrochloride
Fencamfamin
Fenproporex
Mazindol
Mefenorex
Modafinil
Norpseudoeph
edrine
Pemoline
Phentermine
Pipradrol
Sibutramine
Schedule V
pyrovalerone
Clinical Presentation
Physical
Mental status
examination
(during
stimulant
intoxication)
Mental status
examination
(during
stimulant
withdrawal)
Behavior - Sedated
Psychomotor activity - Decreased
Mood or affect - Depressed or irritable
Speech - Decreased production
Thought processes or content - suicidal ideation and drug
craving. Homicidal ideation; paranoia
Insight or judgment - Variable
Orientation - May be normal or close to normal
Memory - Likely impaired due to sleep deprivation,
associated fatigue, decreased attention and irritability
Diagnostic Considerations
Workup
Drug screens for amphetamines. Urine drug screens may be useful for
excluding other substances.
Routine evaluations (ECG and electrolyte evaluation).
Treatment & Management
Activated charcoal should be prescribed in a case of acute overdose.
Otherwise the treatment should target specific signs and symptoms
Consultation a psychiatrist
Patient and Family Education
Supportive therapy
Establish and maintain ABCs.
Decontamination with gastric lavage
Monitor vital signs and hydrate with intravenous fluids.
Withdrawal related insomnia may be treated with trazodone (75-200 mg),
hydroxyzine (25-50 mg), or diphenhydramine (50-100 mg) at bedtime.
Benzodiazepines should be avoided unless the patient is also in detox from
alcohol/benzodiazepines/opiates.
Neuroleptics may be used for the symptomatic treatment of psychosis.
Physical restraints may be required in certain cases.
an antidepressant is recommended for persistent (> a week) depressive
symptoms at a level of moderate or severe or associated with suicidal
ideation/attempts.
Amphetamine-Related
Psychiatric Disorders
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IVTR):
Pathophisiology
epidemiology
USA: dependence/abuse rise significantly during this
period, from 164,000 in 2002 to 257,000 in 2005
Drug Abuse Warning Network (DAWN), 2005:10% of all
drug-related hospital emergency department visits were
stimulant-related. 26% of all drug-related deaths in
Oklahoma City were due to methamphetamine,
people aged 20-39 years who are inclined to abuse
amphetamine derivatives at rave parties and dance
clubs.
Clinical presentation
occurred when the patient was not exposed
to amphetamines?
had a psychiatric disorder/symptoms
similar in relation to any other drug?
provides information about the
patient's in utero exposure to
medications, illicit drugs, alcohol,
pathogens, and trauma.
When?
How often?
How much?
intoxicated or in withdrawal?
attend rave parties?
recently increased his or her use or
started to binge?
Clinical presentation
intoxication
DSM-IV-TR
the patient has recently used an amphetamine or related substance
Clinically significant maladaptive behavioral or psychological changes developed
Such as:
Euphoria or affective blunting
Changes in sociability
Hypervigilance
Interpersonal sensitivity
Anxiety, tension, or anger
Stereotyped behaviors
Impaired judgment
Impaired social or occupational functioning
Clinical presentation
withdrawal
DSM-IV-TR:
The patient has recently ceased or reduced heavy or prolonged use of amphetamines
or related substances.
A dysphoric mood and 2 or more of the following physiologic changes develop ed:
Fatigue
Vivid, unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor retardation or agitation
A complete mental status examination (hallucinations, delusions, suicide and/or
homicide, orientation, memory, and judgment)
The aforementioned symptoms cause clinically significant distress or impairment in
terms of social, occupational, or other important areas of functioning.
The symptoms are not due to a general medical condition, and another mental
disorder does not account for them better than amphetamine withdrawal does.
Differential diagnosis
Work up
Laboratory test:
Finger-stick blood glucose test
CBC determination
Determination of electrolyte levels, including magnesium, amylase,
albumin, total protein, uric acid, BUN, alkaline phosphatase, and
bilirubin levels
Urinalysis
Stat urine or serum toxicology screening
Blood test for an alcohol levelif the patient appears intoxicated
HIV and rapid plasma reagin (RPR) tests
Imaging Studies neurologic impairments (+), CT / MRI: evaluating for
subarachnoid and intracranial hemorrhage
Other Tests
ECG cardiac involvement.
EEG seizure disorder.
brief psychotic rating scale (BPRS), Beck Depression Scale,
violence and suicide assessment
neuropsychological testing assess levels of psychosocial and
neurologic function to guide treatment
projective testing, such as the Rorschach test and the Thematic
Apperception Test, can help in clarifying thought disorders.
During amphetamine intoxication, MMSEcognitive change.
Treatment medical
Consultations:
Neurologist
Internal medicine specialist
Psychiatrist substance abuse treatment or further psychiatric
stabilization.
Social services: Social services coordinate outpatient services
Activity:Patients intoxicated with amphetamines are dangerous, and their
activity should be limited (eg, no driving) until their symptoms have resolved.
Follow up
Further Inpatient Care
observation (mania, severe depression, psychosis, delirium, or if he or she
is suicidal or homicidal)
delirium placed in a quiet, cool (not cold), dimly lit (not dark) room and, if
uncontrollable, placed in restraints.
Further Outpatient Care
Monitoring closely for recurring
Psychiatric follow-up care should occur within, at most, 2 weeks of the initial
evaluation ensure compliance.
consider a follow-up examination with a neurologist and an internist
complications of amphetamine abuse in the specific patient
complication
Psychosis
Depression
Anxiety disorder
Sleep disturbance
Memory impairment
Medical complications
Neurologic complications
Abuse of another or several substances
Psychosocial impairment
Affect dysregulation and aggression
Patient Education
Instruct the patient to abstain from alcohol and illicit drugs, especially
because dual diagnosis is a real issue. The only effective treatment is
abstinence.
Patients should be in a support group.
psychosocial counseling.
Hospitalize (suicidal or homicidal)
substance abuse counseling.
The family must be educated about the patient's addiction and its dangers
Thank you