Stimulant and Designer Drug Use: Primary Care Management

 

Am Fam Physician. 2018 Jul 15;98(2):85-92.

  Patient information: See related handouts on what you should know about club drugs and what you should know about meth, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Approximately 10% of the U.S. population 12 years and older reported using illicit substances in 2015. This article reviews the clinical effects and treatment of persons who use cocaine, methamphetamines, 3,4-methylenedioxymethamphetamine (MDMA), synthetic cannabinoids, and synthetic cathinones (“bath salts”). Cocaine blocks the reuptake of the monoamine transporters dopamine, norepinephrine, and serotonin. Immediate clinical effects include increased energy and euphoria, as well as hypertension and arrhythmias. Acute myocardial infarction, seizures, hallucinations, hyperthermia, and movement disorders are among the possible adverse effects. Like cocaine, methamphetamine blocks reuptake of monoamine transporters, but also stimulates dopamine release and has a longer duration of action. Methamphetamine misuse is associated with severe dental problems. MDMA is a stimulant and psychedelic with a chemical structure similar to serotonin. Adverse effects include serotonin syndrome, hyponatremia, long-term memory impairment, and mood disorders. Synthetic cannabinoids can have a more intense and long-lasting effect than natural cannabis. Acute intoxication may cause severe cardiac and respiratory complications and seizures. Synthetic cathinones are marketed as cheap substitutes for other stimulants. Their effects are similar to those of other stimulants, and they are addictive. Psychosocial intervention is the main form of treatment for addiction to these substances. Promising therapies include disulfiram and substitution therapy for cocaine misuse disorders, and mirtazapine for methamphetamine use disorder.

Illicit drug use is among the top 10 preventable risk factors for years of healthy life lost in developed countries.1 Approximately 10% of the U.S. population 12 years and older reported current use of illicit substances in 2015.2 The risk of lifelong substance use disorder is multifactorial and includes genetics, environment, neurobiology, and earlier age of initiation of substance use. One-third of teenagers younger than 14 years who initiate substance use will develop substance use disorder in their lifetimes.3

WHAT IS NEW ON THIS TOPIC

The American Heart Association recommends that patients with non–ST-segment elevation acute coronary syndrome and a recent history of cocaine use be treated in the same manner as patients without cocaine-related acute coronary syndrome unless they exhibit signs of acute intoxication, in which case beta blockers should be avoided.

Methamphetamine misuse is associated with severe dental problems. A study of 571 methamphetamine users showed that 96% had dental caries and 58% had untreated tooth decay.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should consider screening adolescents for illicit drug use because of the high risk of developing substance use disorder in those who initiate use.

C

1316

The use of unopposed beta blockers should be avoided in patients with cocaine intoxication and non–ST-segment elevation acute coronary syndrome.

B

32

Psychosocial treatment may improve short-term adherence to treatment for cocaine and amphetamine (including MDMA) use disorders, and it may improve abstinence rates.

B

34

Patients with human immunodeficiency virus infection should be asked about MDMA use because of the potential for life-threatening interactions with protease inhibitors.

C

25


MDMA = 3,4-methylenedioxymethamphetamine.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should consider screening adolescents for illicit drug use because of the high risk of developing substance use disorder in those who initiate use.

C

1316

The use of unopposed beta blockers should be avoided in patients with cocaine intoxication and non–ST-segment elevation acute coronary syndrome.

B

32

Psychosocial treatment may improve short-term adherence to treatment for cocaine and amphetamine (including MDMA) use disorders, and it may improve abstinence rates.

B

34

Patients with human immunodeficiency virus infection should be asked about MDMA use because of the potential for life-threatening interactions with protease inhibitors.

C

25


MDMA = 3,4-methylenedioxymethamphetamine.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

This article expands on a practical framework for a

The Authors

show all author info

ANN E. KLEGA, MD, is the director of women's health and assistant program director at Florida Hospital Family Medicine Residency, Winter Park, and clinical assistant professor of family medicine at Florida State University College of Medicine, Tallahassee....

JENNIFER TICKAL KEEHBAUCH, MD, is an associate professor of family medicine at Loma Linda (Calif.) University School of Medicine and chief medical officer at Winter Park (Fla.) Memorial Hospital.

Address correspondence to Ann E. Klega, MD, Florida Hospital Family Medicine Residency Program, 133 Benmore Dr., Ste. 200, Winter Park, FL 32792 (e-mail: ann.klega.md@flhosp.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. U.S. Preventive Services Task Force. Final recommendation statement: drug use, illicit: screening. January 2008. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/drug-use-illicit-screening. Accessed April 10, 2018....

2. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2015 National Survey on Drug Use and Health. September 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf. Accessed April 10, 2018.

3. Sussman S, Lisha N, Griffiths M. Prevalence of the addictions: a problem of the majority or the minority? Eval Health Prof. 2011;34(1):3–56.

4. Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113–121.

5. National Institute on Drug Abuse. Cocaine. May 2016. https://www.drugabuse.gov/publications/research-reports/cocaine. Accessed March 7, 2017.

6. National Institute on Drug Abuse. Methamphetamine. September 2013. https://www.drugabuse.gov/publications/research-reports/methamphetamine. Accessed October 11, 2017.

7. Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), rohypnol, and ketamine. Am Fam Physician. 2004;69(11):2619–2626.

8. National Institute on Drug Abuse. MDMA (ecstasy/molly). October 2016. https://www.drugabuse.gov/publications/drugfacts/mdma-ecstasymolly. Accessed March 7, 2017.

9. Kemp AM, Clark MS, Dobbs T, Galli R, Sherman J, Cox R. Top 10 facts you need to know about synthetic cannabinoids: not so nice spice. Am J Med. 2016;129(3):240.e1–244.e1.

10. National Institute on Drug Abuse. Synthetic cathinones (“bath salts”). February 2018. https://www.drugabuse.gov/publications/drugfacts/synthetic-cathinones-bath-salts. Accessed March 7, 2017.

11. University of Illinois at Chicago; Survey Research Laboratory; Columbia University; National Center on Addiction and Substance Abuse. Missed Opportunity: National Survey of Primary Care Physicians and Patients on Substance Abuse. New York, NY: Center on Addiction and Substance Abuse; 2000.

12. American Academy of Family Physicians. Clinical preventive service recommendation: iIlicit drug use. https://www.aafp.org/patient-care/clinical-recommendations/all/illicit-drug-use.html. Accessed August 20, 2017.

13. Levy SJ, Williams JF; Committee on Substance Use and Prevention. Substance use screening, brief intervention, and referral to treatment. Pediatrics. 2016;138(1):e20161211.

14. Levenberg PB, Elster AB, eds. Guidelines for Adolescent Preventive Services (GAPS): Clinical Evaluation and Management Handbook. Chicago, Ill.: American Medical Association; 1995.

15. Hagan JF Jr., Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2017.

16. American College of Obstetricians and Gynecologists. Committee opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015;125(6):1529–1537.

17. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC: American Psychiatric Association; 2013.

18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2000.

19. Ries R, Miller SC, Saitz R, Fiellin DA, eds.; American Society of Addiction Medicine. The ASAM Principles of Addiction Medicine. 5th ed. Philadelphia, Pa.: Wolters Kluwer Health; 2014.

20. Caplan YH, Goldberger BA. Alternative specimens for workplace drug testing. J Anal Toxicol. 2001;25(5):396–399.

21. D'Apolito K. Breastfeeding and substance abuse. Clin Obstet Gynecol. 2013;56(1):202–211.

22. Concheiro M, Lendoiro E, de Castro A, et al. Bioanalysis for cocaine, opiates, methadone, and amphetamines exposure detection during pregnancy. Drug Test Anal. 2017;9(6):898–904.

23. Smith MJ, Thirthalli J, Abdallah AB, Murray RM, Cottler LB. Prevalence of psychotic symptoms in substance users: a comparison across substances. Compr Psychiatry. 2009;50(3):245–250.

24. Devlin RJ, Henry JA. Clinical review: major consequences of illicit drug consumption. Crit Care. 2008;12(1):202.

25. Lindsey WT, Stewart D, Childress D. Drug interactions between common illicit drugs and prescription therapies. Am J Drug Alcohol Abuse. 2012;38(4):334–343.

26. Winslow BT, Voorhees KI, Pehl KA. Methamphetamine abuse. Am Fam Physician. 2007;76(8):1169–1174.

27. Michael White C. How MDMA's pharmacology and pharmacokinetics drive desired effects and harms. J Clin Pharmacol. 2014;54(3):245–252.

28. Weaver MF, Hopper JA, Gunderson EW. Designer drugs 2015: assessment and management. Addict Sci Clin Pract. 2015;10:8.

29. Miotto K, Striebel J, Cho AK, Wang C. Clinical and pharmacological aspects of bath salt use: a review of the literature and case reports. Drug Alcohol Depend. 2013;132(1–2):1–12.

30. Rastegar DA, Fingerhood MI, eds. The American Society of Addiction Medicine Handbook of Addiction Medicine. New York, NY: Oxford University Press; 2016.

31. Qureshi AI, Suri MF, Guterman LR, Hopkins LN. Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: data from the Third National Health and Nutrition Examination Survey. Circulation. 2001;103(4):502–506.

32. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in Circulation. 2014;130(25):e433–e434]. Circulation. 2014;130(25):e344–e426.

33. Richards JR, Garber D, Laurin EG, et al. Treatment of cocaine cardiovascular toxicity: a systematic review. Clin Toxicol (Phila). 2016;54(5):345–364.

34. Minozzi S, Saulle R, De Crescenzo F, Amato L. Psychosocial interventions for psychostimulant misuse. Cochrane Database Syst Rev. 2016;(9):CD011866.

35. Pani PP, Trogu E, Vacca R, Amato L, Vecchi S, Davoli M. Disulfiram for the treatment of cocaine dependence. Cochrane Database Syst Rev. 2010;(1):CD007024.

36. Minozzi S, Cinquini M, Amato L, et al. Anticonvulsants for cocaine dependence. Cochrane Database Syst Rev. 2015;(4):CD006754.

37. Minozzi S, Amato L, Pani PP, et al. Dopamine agonists for the treatment of cocaine dependence. Cochrane Database Syst Rev. 2015;(5):CD003352.

38. Indave BI, Minozzi S, Pani PP, Amato L. Antipsychotic medications for cocaine dependence. Cochrane Database Syst Rev. 2016;(3):CD006306.

39. Gates S, Smith LA, Foxcroft DR. Auricular acupuncture for cocaine dependence. Cochrane Database Syst Rev. 2006;(1):CD005192.

40. Pani PP, Trogu E, Vecchi S, Amato L. Antidepressants for cocaine dependence and problematic cocaine use. Cochrane Database Syst Rev. 2011;(12):CD002950.

41. Castells X, Cunill R, Pérez-Mañá C, Vidal X, Capellà D. Psychostimulant drugs for cocaine dependence. Cochrane Database Syst Rev. 2016;(9):CD007380.

42. National Institute on Drug Abuse. High rates of dental and gum disease occur among methamphetamine users. November 23, 2015. https://www.drugabuse.gov/news-events/news-releases/2015/11/high-rates-dental-gum-disease-occur-among-methamphetamine-users. Accessed February 6, 2017.

43. Colfax GN, Santos GM, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial. Arch Gen Psychiatry. 2011;68(11):1168–1175.

44. Elkashef AM, Rawson RA, Anderson AL, et al. Bupropion for the treatment of methamphetamine dependence. Neuropsychopharmacology. 2008;33(5):1162–1170.

45. National Institute on Drug Abuse. Synthetic cannabinoids (K2/spice). February 2018. https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids. Accessed February 14, 2017.

46. Mills B, Yepes A, Nugent K. Synthetic cannabinoids. Am J Med Sci. 2015;350(1):59–62.

47. Gates PJ, Sabioni P, Copeland J, Le Foll B, Gowing L. Psychosocial interventions for cannabis use disorder. Cochrane Database Syst Rev. 2016;(5):CD005336.

48. Marshall K, Gowing L, Ali R, Le Foll B. Pharmacotherapies for cannabis dependence. Cochrane Database Syst Rev. 2014;(12):CD008940.

49. Baumann MH, Partilla JS, Lehner KR, et al. Powerful cocaine-like actions of 3,4-methylenedioxypyrovalerone (MDPV), a principal constituent of psychoactive ‘bath salts’ products. Neuropsychopharmacology. 2013;38(4):552–562.

 

 

Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article