Author: Charles Frank

Amphetamine Withdrawal Symptoms

Use of amphetamine-containing diet pills has resulted in pulmonary arterial hypertension (Garg et al., 2017). Cardiovascular complications are a leading cause of death among people who use MA. Hypertension, aortic dissection, acute coronary syndromes, pulmonary hypertension, and cardiomyopathy (heart muscle dysfunction) are frequently observed (Paratz et al., 2016; Paulus & Stewart, 2020). Hypertension and tachycardia are common and largely attributable to acute catecholamine release (Richards & Laurin, 2020). Vasoconstriction also triggered by catecholamine release can cause acute coronary syndromes and stroke. Damage to cardiac and vascular tissue, such as the endothelial cells, by molecular mechanisms triggered by MA causes aortic dissection, dilated cardiomyopathy, arrythmia, and pulmonary hypertension (Kevil et al., 2019).

Withdrawal syndromes should be thought of as a direct effect of a withdrawal from excessive dopaminergic activity throughout the body. A binge terminates with acute withdrawal, often called a “crash” (Lerner & Klein, 2019). Acute withdrawal is characterized by dysphoria, anxiety, and agitation and can begin a short time after cessation of stimulant use (Lerner & Klein, 2019).

Patients should be monitored 3-4 times daily for symptoms and complications. The Alcohol Withdrawal Scale (AWS, p.49) should be administered every four hours for at least three days, or longer if withdrawal symptoms persist. A patient’s score on the AWS should be used to select an appropriate management plan from below. Alcohol withdrawal symptoms appear within 6-24 hours after stopping alcohol, are most severe after 36 – 72 hours and last for 2 – 10 days.

1. As the efficiency of the delivery system increases, so does the intensity of both the pleasurable and the adverse effects.
2. Although serious medical, psychological, and social consequences have followed experimental low-dose use of stimulants, two other patterns of self-administration are of greater concern.
3. Stimulants are a class of psychoactive drugs that when used stimulate the body, which results in increased activity and alertness.
4. Cocaethylene appears to prolong the duration of cocaine-related increases in blood pressure and, in turn, to increase the likelihood of small-vessel cerebral infarct or intracerebral hemorrhage.

Hallucinations may stop within 24 to 48 hours of cessation of substance use, and paranoia and altered perceptions of reality decrease over the next week to 15 days. Clinicians also report that drug-induced psychosis dissipates more quickly for cocaine use—usually in 1 to 3 days—compared with up to 2 to 3 weeks for MA use. Long-term use can lead to stimulant use disorder, tolerance, and, upon cessation of use, withdrawal (UNODC, 2019b). This is also true for prescription stimulants, which are Schedule IIN drugs (DEA, Diversion Control Division, n.d.).

However, different routes of use may lead to higher concentrations in the blood, indicating a greater effect and greater potential for overdose. The incidence and severity of stimulant-induced side effects and overdose potential are also dose related. As the dose increases, the profile of side effects progresses from mild excitement to more intense reactions (NIDA, 2016a). Because tolerance develops rapidly to the desired euphoric effects, people using stimulants nearly always escalate dose size and frequency of drug use in pursuit of the vanishing rush.

Management of mild opioid withdrawal

Common psychological complications of stimulant use disorders include psychosis, depression, hypervigilance, and anxiety. Common medical complications of stimulant use disorders are cardiovascular conditions, respiratory problems, cerebrovascular events, muscular and renal dysfunction, gastrointestinal problems, infections including HIV/AIDS, and hepatitis C. During withdrawal, the patient’s mental state should be monitored to detect complications such as psychosis, depression and anxiety.

If the protocol in Table 11 does not adequately control alcohol withdrawal symptoms, provide additional diazepam (up to 120mg in 24 hours). Patients should drink at least 2-3 litres of water per day during stimulant withdrawal. Multivitamin supplements containing B group vitamins and vitamin C are recommended. Symptomatic medications should be offered as required for aches, anxiety and other symptoms.

6. WITHDRAWAL MANAGEMENT FOR ALCOHOL DEPENDENCE

Identified anxiety, phobias, ADHD, and antisocial personality disorder typically precede chronic cocaine use, whereas alcohol use disorder, depression, and paranoia generally follow stimulant use. For MA use, people appear more likely to have non-substance-induced, preexisting lifetime depressive, anxiety, or psychotic disorders than to have MA-induced depressive, anxiety, or psychotic disorders (Salo et al., 2011). Assessment of acute versus chronic stimulant-induced psychosis may be difficult and will likely require patients to engage in multiple treatment sessions. Patients should be evaluated after they have been able to sleep and regain some level of normal life functioning to differentiate between acute and chronic stimulant-induced psychosis.

It is not recommended to increase the dose when symptoms worsen; instead, persist with the current dose until symptoms abate, then continue with the dose reduction schedule. Codeine phosphate alleviates opioid withdrawal symptoms and reduces cravings. The dose of buprenorphine given must be reviewed on daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects. The greater the amount of opioid used by the patient, the larger the dose of buprenorphine required to control symptoms. Symptoms that are not satisfactorily reduced by buprenorphine can be managed with symptomatic treatment as required (see Table 3). Symptomatic treatment (see Table 3) and supportive care are usually sufficient for management of mild opioid withdrawal.

At birth, infants exposed to stimulants may manifest symptoms suggestive of withdrawal. As with other newborns with substance exposure, implementation of the Eat Sleep Console model of caring for the mother and infant as a dyad, focusing on nonpharmacologic care and treatment of the newborn, has produced positive results (Dodds et al., 2019). The most common presenting symptoms are lethargy, sleepiness, and poor feeding. Stimulant-exposed infants may have difficulty being consoled (Anbalagan & Mendez, 2021); the action of consoling can increase crying because of damage to the infant’s nervous system. The interaction between this and the stimulant-affected mother’s low frustration tolerance (due to protracted withdrawal) can interfere with bonding and create negative feedback, psychologically and neurologically.

2. STANDARD CARE FOR WITHDRAWAL MANAGEMENT

People who use stimulants will frequently self-medicate withdrawal symptoms with alcohol, benzodiazepines, or opioids. Patients may experience symptoms of withdrawal from these other substances if such use was regular or at high doses. These withdrawal symptoms require specific management and may potentially require a medication titration schedule to alleviate symptoms and prevent an acute medical event. The intensity and duration of acute manifestations of stimulant intoxication correlate generally with the rate of rise and the height of peak blood levels reflected in brain concentrations. In low doses, the libido (sexual drive) is stimulated; sexual desire and sexual response are enhanced (Ciccarone, 2011). Agitated states featuring increased paranoia, fear of persecution, or other psychotic symptoms may also occur with intoxication, particularly for MA (UNODC, 2019b).

Dosing patterns of MA vary by individual and pattern of use and can range broadly from 50 mg to 2,000 mg per day (Cunha-Oliveira et al., 2013). People with chronic MA use may binge in doses up to 5,000 mg per day (Cunha-Oliveira et al., 2013). Low-to-moderate doses of MA that range from 5 to 30 mg can induce arousal, euphoric mood, cardiac stimulation, and acute improvements in attention and psychomotor skills (Cruickshank & Dyer, 2009).

Opportunities for wound assessment and care should be a standard part of outreach, prevention, and harm-reduction services for people who use drugs. People who use stimulants and present with life-threatening medical conditions (e.g., arrhythmias, compromised airways, seizure) and lethal drug levels should be treated with standard life-saving techniques that respond to the presenting symptoms (NIDA, 2018b; Vasan & Olango, 2020). Acute neurologic symptoms, such as seizures or rapidly elevating vital signs, require immediate intervention. Non-drug-induced causes of any symptoms should be carefully ruled out, and the patient should also be evaluated for polysubstance use. Stimulant overdose—as well as acute intoxication and withdrawal—can be managed in hospital settings to help address medical complications and prevent symptoms from increasing in severity (UNODC, 2019b). All of these factors not only mediate drug effects, but also influence the person’s susceptibility to an SUD and are an important part of screening and history taking (American Society of Addiction Medicine, 2015a).

Offer accurate, realistic information about drugs and withdrawal symptoms to help alleviate anxiety and fears. Professional monitoring proves to be a key component of successful detox from stimulants for many people. Psychological symptoms of stimulant withdrawal can be difficult to cope with alone, and having encouraging support throughout the challenges often makes a big difference for recovering users. Researchers have established that cocaethylene, the ethyl ester of benzoylecgonine, forms in the liver when a person uses these two substances together. The person may experience more intense pleasure than if using either substance alone, but he or she is also exposed to the combined toxicities of cocaine and the even more potent cocaethylene (da Silva Maia et al., 2017; A. W. Jones, 2019; Liu et al., 2018).

Stimulant about Benzodiazepine withdrawals, the symptoms and how long they last

People who use large amounts of stimulants, particularly methamphetamine, can develop psychotic symptoms such as paranoia, disordered thoughts and hallucinations. These symptoms can be managed using anti-psychotic medications and will usually resolve within a week of ceasing stimulant use. The severity of benzodiazepine withdrawal symptoms can fluctuate markedly and withdrawal scales are not recommended for monitoring withdrawal. Rather, the healthcare worker should regularly (every 3-4 hours) speak with the patient and ask about physical and psychological symptoms. All opioid dependent patients who have withdrawn from opioids should be advised that they are at increased risk of overdose due to reduced opioid tolerance. Should they use opioids, they must use a smaller amount than usual to reduce the risk of overdose.