This is part 2 of a series on the above article. In this post, we will begin looking at the stimulant class of drugs. Stimulants include: cocaine/crack, amphetamines; 3,4-metylene (amphetamine substitute); Ecstasy, ephedrine (famously in weight loss drugs), phenylpropanolamine (from cough/cold medicine), and methylphenidate (more commonly known as Ritalin). I had to look those chemical names up as I had no idea what those were. At the cellular level, these drugs “enhance transmission at the catecholaminergic (including dopaminergic) synapses and share some common pharmacological effects and adverse effects in excess.”
Clinically, this looks like “elation and increased alertness, with increased motor activity in the short and longer term (increased endurance)…. tremor, myoclonus [including tics, dystonias and choreas], [central rigidity, muscular vascoconstriction] and seizures (can be prolonged and fatal)…. the neuropsychiatric manifestations include restlessness, irritability, violence, and a psychotic state, which is often paranoid.” The vitals will also show the drugs in elevated temperature and blood pressure and cardiac arrhythmias. Suddenly stopping taking these drugs, like will happen when admitted acutely into the hospital, is not life threatening. But you’ll see “disturbances of sleep, low mood and anxiety, and a craving for the drug.” Rhabdomyolysis sometimes also occurs “in the more sick patients,” particularly with cocaine as it seems to have a direct toxic effect on skeletal muscles as well as in Ecstasy. Long term cocaine abusers will show cognitive deficits, brain atrophy (deterioration) which can persist even after quitting. Long term amphetamine abusers (and to a lesser degree the cocaine abusers as well) have psychosis with visual and auditory hallucinations and paranoia.
Stroke is the most common neurological condition superimposed on illicit stimulant drug users. In typical cocaine users, the stroke will occur within an hour of ingesting, most likely within 3 hours after ingesting, but could happen anytime in the next few days. This is due to the cardiac effects of the drugs– vasoconstriction, vasospasm– creating high blood pressure and a hemorrhagic stroke. Hemorrhages are more common in those that snort or inject cocaine. Chronic cocaine abusers are more likely to get a stroke, especially when they have consumed alcohol along with the stimulant. The spasms can also cause a thrombis to dislodge somewhere distant in the circulatory system causing a thrombitic stroke. The thrombitic stroke is more common in cocaine smokers. Amphetamine abusers will have their strokes within the first few hours after ingestion, “presenting with headache, an evolving focal deficit and impaired conscious level.” Hemorrhagic strokes are more common, but thombitic are more common with smoking crystal meth. Again, vasospasm is the culprit here.
The amphetamine users are also most likely to have a vasculitis type presentation, which is “a more diffuse neurological picture, often with subacute progressive time course, including headache, encephalopathy and/or bilateral clinical and radiological abnormalities (often [ischemic] as well as [hemorrhagic].”
The other stimulants are made to mimic amphetamine and have many of the same clinical features as mentioned above. There are a few differences, however. “Ecstasy […] has a hallucinogenic effect at low doses, but at higher doses has amphetamine-like stimulant effects. Toxicity may present with [fever], seizures, [low tone], and coma leading to rhabdomyolysis and/or death.” Phenylpropanolamine, pseudoephedrine (nasal decongestants and appetite suppressants) and ephedrine show an increased risk of hemorrhagic stroke. Ephedra alkaloids (in some Chinese herbal medicines) are associated with hemorrhagic strokes and seizures. Methylphenidate (Ritalin) can cause seizures and hemorrhagic strokes.
Those stimulants can be nasty! Stay tuned for the next episode on sedatives!