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Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Co-Occurring Disorders:
Integrated Dual Disorders Treatment
Integrated Dual Disorders Treatment Workbook
Chapter 4: Stimulants
INTRODUCTION
Cocaine, amphetamines, and other central nervous system stimulants increase alertness, enhance energy, decrease appetite, and induce a feeling of well-being or euphoria, but can be extremely addicting and lead to negative outcomes. In this chapter, the vignette of a young man who becomes dependent on cocaine illustrates a typical story of how stimulant abuse can affect the course of mental illness and treatment.
VIGNETTE
Jose is a 25-year-old Puerto Rican-American man who lives at home with his parents, younger sisters, and aunt. He speaks fluent English, but communicates in Spanish with family and friends. He was diagnosed with schizoaffective disorder, depressed type, and cocaine dependence when he was an 18 year old high school senior. At that time, after drinking alcohol and smoking crack cocaine, Jose became extremely depressed and heard voices telling him to kill himself. He was involuntarily hospitalized for a month and, when released, dropped out of school.
Jose was referred to the local mental health center, where he was assessed and assigned a case manager, who was Caucasian and did not speak Spanish. Jose was also referred to a substance abuse group, which he did not attend. He thought his case manager was OK "for a white guy" but made it clear that playing basketball and hanging out with his friends in the park was more important than going to the mental health center. He said that cocaine helped with his depression, and he didn't see his use as a problem.
With his case manager's help, Jose obtained disability income. He used his disability checks and also money he borrowed from his family to buy cocaine. His drug use created turmoil in the family. Jose spent most of his time in the park, smoking crack with his friends, or drinking in a bar down the street from his parents' apartment.
Constant auditory hallucinations and periodic depressions resulted in several hospitalizations. Jose's parents wanted him to return home to live with them when he left the hospital. They were sure that if they could stop him from using drugs that everything would be all right. Jose's father drank heavily, and he argued with Jose about cocaine use but not about his drinking.
Jose's case manager and psychiatrist were so worried about his illness and substance abuse that they pursued a representative payee. The payee made sure his money from the disability checks was spent on appropriate items and not available for cocaine, and Jose's cocaine use decreased. He wanted more money, however, and began to sell cocaine in the alley next to his favorite bar, which led to an arrest and three months in jail.
The assertive community treatment team worked with Jose using engagement techniques, motivational interviewing, skills training, monitored medication, and family interventions over the next five years. He was finally able to give up cocaine use. He met sober friends through a cousin and worked part-time for his uncle. His mother helps him with medications daily.
BASIC INFORMATION ABOUT STIMULANTS
Clinicians need to know basic information about stimulants, of which there are many types, including cocaine, amphetamines and other medications. Cocaine is a frequently abused street drug, especially in urban areas. It comes in various forms that are smoked, inhaled, and injected. Cocaine powder can be snorted or mixed with water and injected. When mixed with water and sodium bicarbonate, it becomes a solid "rock" that is smoked as "crack." The high is brief, lasting minutes to hours.
A variety of amphetamines (including methamphetamine) are also widely available. Amphetamines are usually taken orally or intravenously but can also be snorted or smoked. The amphetamine high lasts 12-24 hours. Other stimulants include prescribed and over-the-counter medications such as methylphenidate, a medication for attention deficit disorder; dexadrine, used for weight loss; and ephedrine, a component in many cold remedies. When these medications are used in higher amounts than recommended, they can have effects similar to cocaine and amphetamines. Caffeine is also a stimulant, and if used in very large amounts, can have similar effects.
INTOXICATION AND SHORT-TERM EFFECTS ON MENTAL ILLNESS
In small doses, stimulants increase alertness, enhance energy, suppress appetite, and induce a feeling of well-being or euphoria. The high wears off rapidly, however, and often leads to a cycle of depression and repeated use that goes on for many hours. At higher doses, symptoms of stimulant intoxication occur, including euphoria, hyperawareness, hypersexuality, hypervigilance, agitation, and sleeplessness. Thoughts typically race and speech becomes pressured. Anxiety, irritability, and psychosis can also occur. With very high doses, confusion and disorientation can occur, as well as seizures, strokes, and heart attacks. Inhalation and intravenous use are more likely to cause dangerous reactions, such as sudden death due to cardiac arrhythmias.
Even brief or occasional use of stimulants for a person with severe mental illness because use can induce or worsen psychiatric symptoms or precipitate major relapses. Episodes of mania or psychosis often are initiated by stimulant use, and depression is exacerbated by the cycle of stimulant use.
STIMULANT TOLERANCE AND WITHDRAWAL
The rapid onset of euphoria followed quickly by loss of action of stimulants in general and cocaine in particular make them highly addictive. Individuals often use the drug repeatedly to sustain the highs and avoid the lows. Repeated use produces tolerance, or diminished effects of the drug, and is followed by the use of larger amounts. This pattern can lead rapidly to addiction. While alcohol use typically transitions into addiction over years, people typically become addicted to cocaine within weeks or months.
When an individual stops heavy use of stimulants, withdrawal commonly ensues. Withdrawal from stimulants occurs in three phases: The first phase is a "crash" with feelings of depression, agitation and intense craving. Within days, the individual experiences fatigue, low energy and decreased interest. Weeks to months later, in the third phase, the individual may experience episodic intense craving.
LONG-TERM EFFECTS
Addiction, by definition, involves increasing preoccupation with drug procurement and use. Long term addiction often leads to criminal behavior to obtain money for drugs, and potentially to involvement with the criminal justice system. The euphoria of stimulants also results in unsafe sexual behaviors.
Over the long term, repeated use and the development of tolerance predispose the user to more potent routes of administration, such as intravenous use (IV or injection), which dramatically increase the risk of blood-borne infections such as hepatitis and HIV. The viruses that cause hepatitis and AIDs are spread through contact with infected blood and sex fluids, which can occur when sharing a straw through which drugs are snorted, by sharing injection equipment, and by having unprotected sex. Providing clients with information about infectious diseases is extremely important (See Chapter 15).
Chronic abuse of stimulants is generally disastrous for persons with severe mental illness because it can produce or worsen most psychiatric symptoms. In the vignette above, Jose's paranoia, ideas of reference, depression, and suicidal thoughts have been intertwined since adolescence. Though he is unable to observe it, his team observes that his mental illness symptoms are less severe during periods of sobriety than during periods of active substance use. Even intermittent or moderate stimulant use can worsen symptoms of the mental illness.
POLYSUBSTANCE ABUSE
Polysubstance abuse refers to abuse of three or more substances in the same time frame. It is associated with antisocial personality characteristics, poor functioning, and a strong family history of substance abuse. Of the 50% of persons with severe mental illness who also have a substance use disorder, almost half abuse alcohol and other drugs together, and about one fourth abuse multiple drugs.
Demographically, cocaine users tend to be young, male, and dependent on multiple substances. Cocaine is commonly used with sedating substances including alcohol, opioids, cannabis, and sedative-hypnotic medications. People may use the sedating substances to manage agitation or withdrawal symptoms.
People who abuse substances often develop a "drug of choice," the substance that they prefer to use when they have the option. However, people who use one substance usually have tried and used others, and they may develop new addictions over time.
TREATMENT ISSUES
This chapter alludes to several effective techniques of treatment, like engagement, motivational interviewing, and family psychoeducation, which are discussed in subsequent chapters. Below we will discuss several salient aspects of this vignette, including the use of a payee and incarceration.
Jose initially did not believe that treatment could help him. Because his substance use was so destructive, his team pursued a representative payee. A judge agreed that Jose was unable to take care of his finances by himself and assigned a payee. Note that to a large degree this is a legal rather than a clinical issue. The law specifies that a person who is unable to manage his or her disability funds, for example someone who uses the money for drugs rather than food and housing, cannot receive disability payments directly, and the court must decide on who can be an appropriate payee.
When his access to money was limited by the payeeship, Jose reduced his drug use. However, he began to sell drugs and ended up in jail. Jose's team wanted to support his sobriety by managing his money and reducing his access to cocaine and alcohol, which seemed to help in the short run, but not in the long run. The use of protective payees and other forms of involuntary treatments is controversial. Most teams prefer to persuade clients to use voluntary money management.
People with dual disorders, like Jose, are particularly prone to arrest and incarceration for drug-related behaviors. Incarceration is often a negative experience for people with severe mental illness, who often receive inadequate treatment while incarcerated. Mental health providers should develop a relationship with court officers in order to divert people away from incarceration and into treatment, and with prison treatment providers to advocate for clients who are incarcerated. Efforts to divert people from jail often include court-ordered participation in treatment that might improve motivation for treatment and promote behavioral change. The close monitoring resulting from probation and court ordered treatment often improve motivation for accepting help.
Another interesting aspect of this vignette is Jose's Hispanic background. Many clients would like to work with a clinician who is from the same culture as they are. Often, this is simply impossible. It is critical, however, that clinicians make an effort to understand the culture in which any client lives and to use this information to inform their efforts. Interpreters may be necessary to communicate with clients who do not speak English, and special training can be helpful to make the best use of an interpreter.
Clients' culture, race, gender, sexual orientation, age cohort, family, and social network are important parts of their identities. Clinicians can be most effective if they understand what these issues are like for each client. In Jose's case, for example, understanding how he experiences his Hispanic heritage, his friendships, and his family are essential to helping him find a path to recovery.
Recommended reading
There are many good books on stimulant abuse. A short, readable, and scientifically accurate introduction that we like is Cocaine by Roger Weiss and Steven Mirin (Washington, DC, American Psychiatric Press, 1987).
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