4.3 Stimulants
Key Takeaways
- Apply I.D.1–4 to cocaine, methamphetamine, and prescription amphetamines: monoamine pharmacology, intoxication and overdose, crash versus withdrawal, and heart, stroke, psychosis, and social effects (ADC Candidate Guide, November 2022, checked 2026-09-20).
- Cocaine is a short-acting reuptake blocker; methamphetamine is a longer-acting releaser plus reuptake blocker; prescription amphetamine salts are related releasers used medically and nonmedically; methylphenidate is a reuptake blocker, not a classic amphetamine releaser.
- Crack and powder are the same cocaine molecule with different salt and route: smoked crack hits in seconds and collapses in minutes; snorted powder is slower and a bit longer; the crash is not the same clock as alcohol DTs.
- Overdose dangers are hyperthermia, arrhythmia, myocardial infarction, stroke, and seizures; stimulant psychosis (especially methamphetamine) can outlast the high; suicide risk rises in the crash.
- Independent OpenExamPrep teaching does not claim IC&RC approval or exact equivalence with IC&RC training.
Applying Domain I.D to stimulants
Domain I is 25% of the ADC exam. Task I.D.1–4 applied to stimulants means pharmacology (class and kinetics), intoxication and overdose, crash and withdrawal, and physiological, psychological, and social effects (ADC Candidate Guide, effective November 2022, checked 2026-09-20). This section is independent ADC study material by OpenExamPrep. OpenExamPrep does not claim IC&RC approval, partnership, or exact equivalence with IC&RC courseware. Nicotine appears with remaining substances in chapter 5; the exam still expects cocaine and amphetamine fluency here.
Northbridge's Dana Ellis meets Tasha Brooks, age 29. She snorted powder cocaine on weekends, then smoked crack for a faster rush, and for the last eight months has been on multi-day methamphetamine runs. She presents with dilated pupils, a raw forearm from picking, and a story that people in the vents are talking. Dana needs three drug stories, not one upper.
Pharmacology: cocaine versus methamphetamine versus prescription amphetamines
Cocaine blocks reuptake of dopamine, norepinephrine, and serotonin. The high is short because plasma half-life is on the order of about one hour. Crack is cocaine freebase smoked; powder is usually cocaine hydrochloride snorted or injected. Same molecule, different salt and route—not two unrelated drugs.
Methamphetamine is a releaser of dopamine and norepinephrine and also blocks reuptake. It is more neurotoxic in standard teaching, more psychotogenic, and far longer acting (often 8–12 hours, sometimes longer). Smoked or injected meth hits fast; oral meth is slower but still long.
Prescription amphetamines (mixed amphetamine salts, dextroamphetamine, lisdexamfetamine) are related releasers used for ADHD and narcolepsy and diverted for binge energy or weight loss. Methylphenidate is mainly a reuptake blocker, closer to cocaine's transporter story than to methamphetamine's vesicular release, but still a CNS stimulant with cardiovascular and misuse risk. Misuse of prescribed stimulants is not harmless because a doctor wrote the first bottle.
| Agent | Primary action | Typical duration of the high | Distinct counselor cue |
|---|---|---|---|
| Powder cocaine (HCl), snorted | Reuptake block | About 15–30 minutes | Short cycles of redosing; epistaxis |
| Crack cocaine, smoked | Same cocaine, faster brain delivery | Seconds to about 5–15 minutes | Intense rush, rapid collapse, compulsive recuse |
| Cocaine IV | Same cocaine | Brief, intense | Overlap with injection harms |
| Methamphetamine, smoked or IV | Release + reuptake block | Many hours | Tweaking, formication, longer psychosis |
| Methamphetamine, oral | Same | Often 6–12 hours | Day-long wakefulness |
| Amphetamine salts (prescribed or diverted) | Release (lisdexamfetamine is a prodrug) | Hours, dose-dependent | Crushing extended-release to snort |
| Methylphenidate | DAT/NET reuptake block | Hours | Not a meth releaser, still a stimulant |
Crack versus powder kinetics is an exam favorite. Smoking avoids first-pass delay and dumps drug on arterial blood to the brain in seconds. The rush is bigger; the crash is sooner; the person redoses. Snorted powder is slower, slightly longer, and still cardiotoxic. Injected powder can rival smoked speed. Tasha did not switch chemicals when she switched to crack; she switched route and time course.
Intoxication, overdose, heart, and stroke
Intoxication: mydriasis, tachycardia, hypertension, pressured speech, bruxism, delayed sleep, appetite suppression, confidence, and risk-taking. Overdose / severe toxicity is a sympathomimetic emergency: hyperthermia, tachyarrhythmia, myocardial ischemia or infarction, hypertensive crisis, hemorrhagic or ischemic stroke, seizures, and rhabdomyolysis. Cocaine's sodium-channel effects add arrhythmia and sudden death even in young people. Methamphetamine cardiomyopathy and hemorrhagic stroke appear in counselor case conferences for a reason.
Dana's moves: emergency medical activation for chest pain, focal weakness, seizure, or a temperature that is cooking the client. Quiet, cooler space if it does not delay EMS. No cold-water dunking folklore, no walking off 104°F, no pocket alprazolam from another client. Hospital teams may use benzodiazepines for stimulant agitation; that is not a lobby protocol.
Crash versus withdrawal, and psychosis
The crash is the immediate trough after a binge: exhaustion, hypersomnia, hunger, vivid dreams, and a depressive plunge that can last hours to a couple of days. Suicide risk can spike here. Withdrawal (sometimes called the protracted phase) is longer dysphoria, anhedonia, craving, and sleep disturbance over days to weeks as dopamine systems reset. It is miserable and relapse-promoting. It is not alcohol-pattern DTs or CIWA-Ar seizures. Do not load alcohol-withdrawal benzodiazepines because Tasha slept 18 hours and looks flattened.
Stimulant psychosis is more common and often more persistent with methamphetamine than with cocaine: paranoia, ideas of reference, auditory or visual hallucinations, and formication (bugs under the skin) that drives picking. Insight may be partial. Psychosis can outlast intoxication by days and, with heavy methamphetamine use, can become a more lasting psychotic disorder. Treat it as a psychiatric-medical overlap, not as a character flaw, and do not argue delusions as if they were a motivational-interviewing opportunity while she is terrified.
Physiological effects: dental decay from dry mouth, bruxism, and neglected hygiene (not a unique acid in meth); weight loss; skin infections; HIV and hepatitis C from injection or sex while high; obstetric complications. Psychological effects: anxiety, depression in the crash, aggression, and psychosis. Social effects: job loss from absenteeism and paranoia, legal charges, housing loss, child-welfare cases, and relationship violence during runs.
Stimulant traps
- Treating crack and powder as unrelated molecules rather than route-and-kinetics variants of cocaine.
- Equating methamphetamine's many-hour clock with cocaine's one-hour clock.
- Calling the crash delirium tremens or scoring CIWA-Ar as if Tasha were in alcohol withdrawal.
- Walking off hyperthermia, chest pain, or a new droop on one side of the face.
- Dismissing methamphetamine psychosis as only intoxication that must vanish when the urine screen fades.
- Treating diverted ADHD amphetamines as harmless because they began as prescriptions.
Tasha used to snort powder cocaine and now smokes crack because the rush is bigger. Which kinetics statement should Dana teach?
During a methamphetamine run Tasha develops crushing chest pressure, a temperature of 104°F, and new weakness on one side of her face. Which cluster names the overdose dangers Dana must not walk off?
After a 72-hour cocaine and crack binge Tasha sleeps 18 hours, then says she wishes she were dead. Two weeks later she is still anhedonic and craving. Which comparison of crash, withdrawal, and psychosis is most accurate?