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03. Stimulants Use: Course, Assessment, and Diagnosis

Published on December 1, 2021 Expired on April 1, 2025

Andrew Saxon, M.D.

Professor, Department of Psychiatry and Behavioral Sciences - University of Washington School of Medicine

Key Points

The course and prognosis for stimulant use disorder can vary widely.
Use DSM-5 criteria to make the diagnosis of stimulant use disorder.
Asses for other substance use and co-occurring psychiatric and medical disorders.
The use of other substances along with stimulant use is common.
Most psychiatric disorders and serious medical side effects commonly co-occur with stimulant use disorder.

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Slides and Transcript

Slide 1 of 19

Now that you understand some of the pharmacology and neurobiology of stimulants, we need to take a step back and talk clinically about how to assess and make a treatment plan when you have a patient with stimulant use disorder.

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The course and prognosis for stimulant disorder can vary widely with some individuals spontaneously remitting, some having a good response to treatment, and others showing an unremitting downhill course into a lifetime of disability.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

Stimulants Use: Course, Assessment, and Diagnosis Slide 2 of 19

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Slide 3 of 19

There are areas of the history that are very valuable to obtain in order to treat this disorder the best and that would include the number of years of use that the person has had of the stimulant, the amount and frequency of their use, the route of administration which can vary from oral to intranasal to smoking to intravenous.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Other substance use because very typically when people have a stimulant use disorder they may be using other substances. Psychiatric disorders are very common to occur with people who have stimulant use disorder and these can either be psychiatric disorders that are caused by the stimulant use or they can be independent psychiatric disorders. And the stimulants themselves are pretty toxic compounds when they're used excessively so that creates a lot of physical health problems as well.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

Stimulants Use: Course, Assessment, and Diagnosis Slide 4 of 19

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Slide 5 of 19

So we want to make a diagnosis of stimulant use disorder using the DSM-5 criteria. The DSM-5 criteria are 11 criteria. The first two criteria are the existence of tolerance or the presence of withdrawal.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Stimulants Use: Course, Assessment, and Diagnosis Slide 5 of 19

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And we haven't talked much about stimulant withdrawal but what typically happens because stimulants are so activating when the stimulants are stopped people don't feel any sense of reinforcement or reward and they feel like life is very bland but they also can be very fatigued, loss of energy and very irritable.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

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Slide 7 of 19

And in order to make a diagnosis, there are different levels of severity that's measured by the number of symptoms. So, two to three of the criteria would be a mild disorder, four to five would be moderate and six through 11 would be severe.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

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And the criteria can be broken down basically into two domains. One is loss of control over use and the other is beginning to develop dysfunctional behaviors because of the substances.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Slide 9 of 19

Loss of control over use is very common. The person might say, "I'm just going to snort one little bit of cocaine tonight just to get my energy up a little bit," and then they end up using several grams without having had that plan. Craving for stimulants is very common when people can't get that. Because they remember that the stimulant helped them feel good, helped their brain reward processes work properly or seem to work properly, they're constantly thinking about getting some of that so they can feel good.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Back to the area of dysfunction, people often have to spend a lot of time getting the stimulants. That means that people are giving up their other activities. They continue using it despite negative effects. So commonly stimulants, cause insomnia and people become sleep deprived yet they still continue using it. And when the substance use disorder gets so bad, people are not really able to do the things they need to do like work, go to school, do their childcare.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Slide 11 of 19

And then it's very common for these people to use stimulants when it's dangerous to do so and the typical thing would be driving under the influence, and finally, family problems start to occur because the person is focused on the drug use and not the people in their lives.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Frequently, other substance use along with stimulants is happening. We'll talk a bit about how that might be important for some of the pharmacotherapies which can target some of these other co-occurring substances.

References:

Darke, S., & Hall, W. (1995). Levels and correlates of polydrug use among heroin users and regular amphetamine users. Drug and Alcohol Dependence, 39(3), 231-235.

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Slide 13 of 19

And we mentioned the co-occurring psychiatric disorders, which can either be stimulant induced or primary, so that includes psychosis, depression, bipolar disorder, posttraumatic stress disorder, anxiety disorders and attention deficit hyperactivity disorder as a special case because the presence of attention deficit hyperactivity disorder may modify the pharmacotherapy treatment of stimulant disorder.

References:

Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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And then there could be very serious medical side effects. Seizures are common. Neurovascular damage is common. And cognitive impairment is common particularly with the amphetamine-like stimulants and part of that may be due to the cytotoxic effects of dopamine being in the cytoplasm. Oftentimes, the cognitive impairment improves with abstinence but not always.

References:

Lappin, J. M., Darke, S., & Farrell, M. (2017). Stroke and methamphetamine use in young adults: A review. Journal of Neurology, Neurosurgery & Psychiatry, 88(12), 1079-1091.
Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Slide 15 of 19

And then because the stimulants also block the reuptake of norepinephrine which is the main compound both in the brain and in the periphery stimulating our sympathetic nervous system, high blood pressure, occlusion of coronary arteries, and cardiac arrhythmias can happen.

References:

Paratz, E. D., Cunningham, N. J., & MacIsaac, A. I. (2016). The cardiac complications of methamphetamines. Heart, Lung and Circulation, 25(4), 325-332.
Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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And then of course, overdose can happen. It's often in combination with those other substances but basically what happens in overdose is that the brain just goes on overdrive, and the cardiovascular system goes on overdrive, and people just die of cardiovascular collapse from too much stimulant.

References:

Paratz, E. D., Cunningham, N. J., & MacIsaac, A. I. (2016). The cardiac complications of methamphetamines. Heart, Lung and Circulation, 25(4), 325-332.
Paulus, M. P., & Stewart, J. L. (2020). Neurobiology, clinical presentation, and treatment of methamphetamine use disorder. JAMA Psychiatry, 77(9), 959.

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Slide 17 of 19

So to summarize this section, the course and prognosis for stimulant disorder can vary widely. Use the DSM-5 criteria to make the diagnosis of stimulant use disorder and when possible, assess for other substance use, and co-occurring psychiatric and medical disorders.

Stimulants Use: Course, Assessment, and Diagnosis Slide 17 of 19

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Use of many other substances along with stimulants is common. Most psychiatric disorders especially ADHD and very serious medical side effects are very common to occur with people who have stimulant use disorder.

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Next Section

04. Overview of the Approach to Treatment

Learning Objectives:

After completing this activity, the learner will be able to:

Review the pathophysiology and clinical course of stimulant use disorder.
Discuss the appropriate use of psychotropic medications for the management of stimulant use disorder.
Cite specific strategies in the management of specific stimulant use disorders, such as methamphetamine and cocaine use disorders.

Original Release Date: 12/01/2021

Review and Re-release Date: 03/01/2024

Expiration Date: 04/01/2025

Expert: Andrew Saxon, M.D.

Medical Editor: Melissa Mariano, M.D

Relevant Financial Disclosures:

The following planners, faculty, and reviewers have the following relevant financial relationships with commercial interests to disclose:

Dr. Saxon has disclosed the following relationships:

Indivior, Inc.: Advisory board
UpToDate, Inc.: Section Editor
Indivior, Inc.: Advisory board
UpToDate, Inc.: Editor

All of the relevant financial relationships listed for these individuals have been mitigated.

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