What are the signs and symptoms of stimulant abuse in a patient?

Signs of Stimulant Abuse

Stimulant abuse presents with characteristic sympathomimetic effects including psychomotor agitation, cardiovascular changes (tachyarrhythmias, hypertension), dilated pupils, hyperactivity, insomnia, decreased appetite, and psychiatric symptoms ranging from anxiety to frank psychosis. 1

Physical and Cardiovascular Signs

The physical manifestations of stimulant abuse are primarily sympathomimetic in nature:

• Cardiovascular effects include increased heart rate, elevated blood pressure (or paradoxically hypotension in severe cases), tachyarrhythmias, sweating, and flushed skin 1
• Pupillary changes with dilated pupils are characteristic 1
• Hyperactivity and restlessness with inability to remain still, tremors, and loss of coordination 1
• Decreased appetite leading to weight loss, which differs from therapeutic use where appetite suppression is dose-dependent 2
• Hyperthermia can occur, with life-threatening temperatures exceeding 104°F in severe overdose 1

Psychiatric and Behavioral Signs

Stimulant abuse produces distinct psychiatric manifestations that differ from therapeutic effects:

• Psychosis including hallucinations, paranoia, and confusion—stimulants are known psychotomimetics particularly in vulnerable individuals 2, 1
• Anxiety, hostility, and aggression that may escalate to suicidal or homicidal ideation 1
• Mood elevation and euphoria beyond therapeutic effects, particularly with non-oral routes of administration 2
• Psychomotor agitation and increased speech rate exceeding normal therapeutic responses 2

Route-Specific Abuse Patterns

The method of administration provides critical diagnostic clues:

• Crushing and snorting is the most common form of prescription stimulant abuse (75% of cases), particularly with short-acting formulations 3
• Intravenous injection produces more rapid onset and higher abuse potential compared to oral administration 2
• Oral abuse of short-acting agents (mixed amphetamine salts, methylphenidate) occurs in 79.8% of prescription stimulant abuse cases 3

Distinguishing Abuse from Therapeutic Use

Critical differentiators between therapeutic use and abuse include:

• Dose escalation beyond prescribed amounts and inability to control use despite harmful consequences 1
• Non-therapeutic administration routes such as snorting or injection rather than oral use 1, 3
• Drug-seeking behavior including diversion, obtaining prescriptions from multiple providers, or purchasing illicit stimulants 2
• Preference for short-acting formulations that provide rapid onset of euphoria rather than sustained therapeutic effect 3
• Concurrent substance use, as ADHD patients with stimulant abuse show elevated rates of cocaine (62.2%) and methamphetamine (4.8%) use 3

Withdrawal and Dependence Signs

Physical dependence manifests upon discontinuation:

• Dysphoric mood and depression following abrupt cessation 1
• Fatigue and psychomotor retardation or paradoxical agitation 1
• Sleep disturbances including vivid, unpleasant dreams, insomnia, or hypersomnia 1
• Increased appetite as rebound from chronic appetite suppression 1

Severe Complications

Life-threatening manifestations require immediate recognition:

• Cardiovascular emergencies including vasospasm, myocardial infarction, aortic dissection, or Takotsubo cardiomyopathy leading to sudden cardiac death 1
• Neurologic complications including seizures, cerebral vascular accidents, serotonin syndrome, and coma 1, 4
• Rhabdomyolysis associated with severe hyperthermia 1

Common Pitfalls

Avoid assuming all stimulant use in ADHD patients represents abuse—therapeutic use at prescribed doses produces expected cardiovascular changes (1-2 bpm heart rate increase, 1-4 mmHg blood pressure elevation) that are clinically insignificant 2. The key distinction is non-therapeutic intent, dose escalation, alternative routes of administration, and functional impairment from the drug-seeking behavior itself rather than from ADHD symptoms 1.