Amphetamine Use
Disorders
Michael J. Mancino, M.D.
University of Arkansas for Medical Sciences
© AMSP 2011
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Substance Use/Problems %
Lifetime Substance Use → → →
• Alcohol:
Lifetime Problems
80
60
• Cannabinoids: 40
50
• Cocaine:
15
50
• Amphetamine: 10
60
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Why Problems Arise
• Mimic medical/psych dx
• ↑ symptoms
• Direct side effects
• Occur in patient populations
• Recent ↑ in use
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This Talk Will Review
• History/nature of amphetamines
• Epidemiology
• Problems
• Treatment
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History
• 1887- Amphetamine synthesized
• 1919 - Methamphetamine synthesized
• 1930’s – AMPH OTC bronchodilator
• 1937 – AMPH prescription only
• 1939 – WWII troops, factory workers
• 1959 – FDA bans inhalers
• 1970 - AMPH Schedule II
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Drug Classification
• Depressants:↑sleep, ETOH high, disinhibit
• Cannabinoids → ↓ drive, ↑ appetite
• Opioids → ↓ pain, ↓ cough
• Stimulants → ↑ energy/attention/activity
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Amphetamines
• Routes of use
– Oral
– Nasal
– Intravenous
• Amphetamine high short-lived
– Drug half-life = 12-13 hours
– Post high letdown
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Amphetamines
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Structure
Adrenaline
Amphetamine
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Structure → Function
• Adrenaline = Epinephrine
• “Fight or flight”
• Bind to sympathetic system
• Mobilize defense system
–↑ glucose
–Shift blood
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How Neurons Communicate
Neurotransmitters are:
1.Synthesized in cell
1
5
2.Released
6
3.Bound to post-synaptic receptors
2
4
4.Recycled by transporters
3
5.Broken down by enzymes
6.Bound to pre-synaptic receptors
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Effect of AMPH at the Synapse
DA
AMPH
DA-R
DA-T
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1. AMPH enters in exchange for DA
DA
AMPH
DA-R
DA-T
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2. AMPH enters pre-synaptic vesicles
DA
AMPH
DA-R
DA-T
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3. ↑ release of DA in pre-synapse
DA
AMPH
DA-R
DA-T
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4.↑ DA in pre-synapse and synapse
DA
AMPH
DA-R
DA-T
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Medical Uses
• Narcolepsy: sleep disorder
–Modafinil (Provigil)
–Armodafinil (Nuvigil)
• ADHD: developmental d/o
– Amph/d-amphetamine (Adderall)
– Methylphenidate (Ritalin)
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This Talk Will Review
 History/nature of amphetamines
• Epidemiology
• Problems
• Treatment
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Epidemiology
• US lifetime use 2009 ≈ 10%
–Highest rate age 26-34 (>12%)
–Rate males = females
–Rate 2X white > black
• Past month use ≈ 0.5 %
• Lifetime dependence ≈ 1.5 %
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Drug Dependence
• Presence of ≥ 3 in 12 months
– Tolerance
– Withdrawal
– Larger amounts
– Desire/attempts to cut down
– ↑ time spent
– Give up activities
– Ongoing use despite problems
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Drug Abuse
• Presence of ≥ 1 in 12 months
–Fulfill obligations
–Physically hazardous situations
–Legal consequences
–Interpersonal problems
Never dependent on this drug
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This Talk Will Review
 History/nature of amphetamines
 Epidemiology
• Problems
• Treatment
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Amphetamine Problems
• Medical
–Overdose
–Withdrawal
–Other
• Psychiatric
–Psychosis
–Anxiety/depression
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Overdose
Copyright © 2010 Meth Kills
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OD: Sympathetic Symptoms
• ↑ heart rate (> 100 beats/min)
• ↑blood pressure (>160 /110)
• ↑ respiratory rate (>30/min)
• ↑ temperature (>
0
102 F)
• Dilated pupils
• Seizures
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OD: Sympathetic Symptoms
• Chest pain / heart attack
• Stroke
• Arrhythmias = irregular heart beat
• Muscle rigidity → shock
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OD: Psychological Effects
• Restlessness • Higher doses →
–Suspiciousness
• Dizziness
–Stereotypy
• Irritable/violent
• Insomnia
–Bruxism
–Punding
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OD Treatment
• Basic life support (ABC’s)
• ↑ temp - dantroline (Dantrium): 1-2mg/kg
• Seizures (diazepam): 10mg IV
• ↑ BP- phentolamine (Regitine): 5-15mg
• Chest pains/heart attack
• Urine tox: ID other drugs
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Agitation Treatment
• Benzodiazepines
• Diazepam (Valium): 10-30mg PO, 2-10 mg IV
• Lorazepam (Ativan): 2-4 mg PO, IM, IV
• Hi potency antipsychotics (anticholinergic SE)
• Haloperidol (Haldol): 5-10 mg PO, IM, IV
• Risperidone (Risperdal): 2-4 mg PO
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Withdrawal
• Begins ≥ 2 hrs, peaks day 1-2
• Symptoms opposite intoxication
– Sleepy, depressed, ↓ concentration, ↑ appetite
– Craving
• Symptoms ↓ over 3-4 days
• ↓ concentration/↑ sad last ≥ 2 months
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Other Medical Problems
• Infection (contaminated needles)
–Endocarditis (heart valve inflammation)
–Skin abcesses
–HIV → AIDS
• Intranasal → holes in nasal septum
• Heart attack
• Stroke (hemorrhagic or ischemic)
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Psychiatric
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Stimulant Psychosis vs Schizophrenia
Stimulant Psychosis
Schizophrenia
• Labile mood
• Bland mood
• Develops rapidly
• Develops slowly
• Physical findings
• Rare findings
• Resolve days/wk
• Worsen with time
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Treatment
• History, physical & labs
• Hospitalization
• Monitor vitals
• Behavioral
• Antipsychotics
• Avoid benzodiazepines
• Drug rehab
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Anxiety
• Intoxication (mimic panic attacks)
– ↑ Heart rate, palpitations
– Nervousness, hyperventilation
• Obsessive-compulsive picture
– Take apart / reassemble mechanical objects
– High levels of use
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Depression
• Related to withdrawal
• “Atypical depression”
– Impaired mood
– Sleepiness
– Excessive appetite
• Cessation → mood swings wks/mos
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Treatment Depression/Anxiety
• Counseling
• Reassurance
• Medication rarely necessary
• Evaluate medical illness
– Heart attack, hyperthyroidism
• Rule out pre-existing disorders
– Major depression or anxiety
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This Talk Will Review
 History/nature of amphetamines
 Epidemiology
 Problems
• Treatment
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Rehabilitation Goals
• Drug free forever
• Interim goals to reduce
– Use
– HIV risk and other med issues
– Unemployment
– Crime
• Engage in treatment
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Rehabilitation Focus
• Engage in treatment
• Support abstinence
• Prevent/reduce relapse
• Life management skills
• Cope with anxiety/stress
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Rehab Tools
• Individual & group counseling
• Urine toxicology
• Psychosocial treatments
– Contingency management
– Motivational interviewing
– Cognitive behavioral therapy (CBT)
– Self help groups
• Vocational rehab
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Medications
• Other substance use disorders
–Alcohol
–Opiates
• No efficacious meds for AMPH
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Summary
• Amphetamine structure → action
• Amphetamine use common & serious
• Problems mimic med/psych problems
• Tx required for acute & chronic use
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