The Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edition (DSM-5) defines a SUD as a pattern of use of amphetamine-type substances, cocaine, or other stimulants leading to clinically significant impairment or distress, as manifested by at least two of the following 11 problems within a 12-month period: taking larger amounts, or over a longer period of time, than intended; persistent desire or unsuccessful efforts to cut down or control; a great deal of time spent in activities necessary to obtain, use, or recover; craving; use resulting in failure to fulfill major role obligations; continued use, despite recurrent social or interpersonal problems; giving up social, occupational, or recreational activities; recurrent use in physically hazardous situations; continued use despite persistent or recurrent physical or psychological problems; tolerance; and withdrawal symptoms, or avoidance of withdrawal symptoms, by continued use.
| TREATMENT | ||
PsychostimulantsCOCAINE ACUTE INTOXICATIONFirst ensure a patent airway, breathing, and circulation. With cocaine use, succinylcholine is relatively contraindicated in rapid sequence intubation; consider rocuronium (1 mg/kg IV) or another nondepolarizing agent as an alternative. If psychomotor agitation occurs, rule out hypoglycemia and hypoxemia first and then administer benzodiazepines (e.g., diazepam 10 mg IV and then 5-10 mg IV every 3-5 min until agitation controlled). Benzodiazepines are usually sufficient to address cardiovascular side effects. Severe or symptomatic hypertension can be treated with phentolamine, nitroglycerin, or nitroprusside. Hyperthermic pts should be cooled with the goal to achieve a core body temperature of <102°F. Evaluation of chest pain should exclude myocardial infarction. Many instances of cocaine-related mortality have been associated with concurrent use of other illicit drugs (particularly heroin), thus the physician must be prepared to institute effective emergency treatment for multiple drug toxicities. COAINE USE DISORDERSTreatment of cocaine use disorders requires the combined efforts of primary care physicians, psychiatrists, and psychosocial care providers. Early abstinence often complicated by depression and guilt, insomnia, and anorexia, which can last for months or years after use has stopped. Behavioral therapies are mainstay of treatment for stimulant-use disorders and show modest benefit. No approved medications exist for psychostimulant addiction. |
Section 15. Psychiatry and Substance Abuse