Screening and assessment of stimulant use

Ask all new patients routinely and others (adolescents and adults) opportunistically and periodically about stimulant use, as part of a general screen for disorders of substance use and gambling; these disorders are common (and often co-exist) and people are reluctant to disclose them, often due to fear of stigma. Screening and assessment of substance use and addictive behaviours outlines history-taking (including use of the ASSIST-Lite tool), examination, and investigations that should be considered in a broad review of substance use and addictive behaviour.

Core features of the assessment should identify:

  • how much, how often and how stimulants are used
  • features of toxicity; see Risk assessment for stimulant drug poisoning
  • any other harms experienced
  • severity of dependence and withdrawal on previous attempts to reduce or stop using
  • psychiatric symptoms including psychosis, anxiety, depression; difficulties with emotional regulation (eg as can occur with personality disorder), suicide risk, and features of attention deficit hyperactivity disorder (and whether symptoms preceded use)
  • potential drug interactions, which can complicate intoxication or withdrawal presentation (eg serotonin toxicity)
  • likelihood of pregnancy
  • what changes the patient is interested in making to their use and how they prioritise them; see Brief interventions for discussion of motivational interviewing.

Withdrawal from stimulants is not usually complicated; however, the risk of agitation and violence is increased if a patient uses large amounts of stimulants, has pre-existing psychiatric symptoms or uses more than one substance (polysubstance useGrigg, 2018). Time course of stimulant withdrawal symptoms illustrates 4 phases of withdrawal. Strong cravings and mood symptoms can persist for longer than with some other substances (eg alcohol or opioids).

Table 1. Time course of stimulant withdrawal symptomsGrigg, 2018

Phase

Physical symptoms

Psychological symptoms

Days 1 to 3 (comedown or crash phase)

exhaustion, low energy

increased sleep

increased appetite

restlessness

depression, anxiety

irritability

paranoia

amotivation

anhedonia

suicidal ideas or behaviour

Days 2 to 10 (withdrawal phase)

strong cravings

sleep difficulties, nightmares

aches, pains, stiffness

headaches

increased appetite

strong urge to use

depression, anxiety

mood swings

poor concentration, confusion

paranoia

easily upset

Days 7 to 28 (persisting symptoms)

strong cravings

sleep difficulties, nightmares

strong urge to use

mood swings

anxiety

boredom

Months 1 to 3

cravings persist

sleep and activity levels return to normal

general health improves

urge to use persists

mood improves

Specific questionnaires can be useful in assessing the extent of stimulant use, including the Amphetamine Withdrawal Questionnaire (AWQ) and the Severity of Dependence Scale (SDS); both are available at the National Centre for Education and Training on Addiction website. The S-check app can be used by patients to track their use of crystalline metamfetamine (‘ice’).

Examination of a patient who uses stimulants should include assessment of the person’s mental state, and a physical examination including a comprehensive systems review, to look for harms outlined in Potential harms of stimulant use. Consider the need for investigations to assess for: