Stimulants (also called as central nervous system stimulant, psychostimulant, or colloquially an upper) are a class of psychoactive drugs that increase alertness. They are used for various purposes, such as enhancing attention, motivation, cognition, mood, and physical activity. Some stimulants occur in nature while others are synthetic. Common stimulants include caffeine, nicotine, cocaine, amphetamine, methamphetamine, methylphenidate, and modafinil. Some stimulants are subject to governmental regulation or prohibition because they can have adverse side effects including addiction, drug tolerance, drug withdrawal, psychosis, anxiety, insomnia, cardiovascular disease, and neurotoxicity. The misuse or abuse of stimulants can have serious adverse health and social consequences, such as overdose, substance dependence, crime, and violent behavior.
Stimulants increase activity in the sympathetic nervous system. They often increase synaptic concentrations of excitatory neurotransmitters, particularly norepinephrine and dopamine. Other stimulants work by binding to the receptors of excitatory neurotransmitters (e.g., nicotine) or by blocking the activity of endogenous agents that promote sleep (e.g., caffeine). Stimulants can affect various functions, including arousal, attention, the reward system, learning, memory, and emotion. Effects range from mild stimulation to euphoria, depending on the specific drug, dose, route of administration, and inter-individual characteristics.
Stimulants have a long history of use, both for medical and non-medical purposes. Archeological evidence from Peru shows that cocaine use dates back as far as 8000 B.C.E. Stimulants have been used to treat various conditions, such as narcolepsy, attention deficit hyperactivity disorder (ADHD), obesity, depression, and fatigue. They have also been used as recreational drugs, performance-enhancing substances, cognitive enhancers, and to promote aggression of combatants in wartime.
Definition Stimulant is an overarching term that covers many drugs including those that increase the activity of the central nervous system and the body, drugs that are pleasurable and invigorating, or drugs that have sympathomimetic effects. Sympathomimetic effects are those effects that mimic or copy the actions of the sympathetic nervous system. The sympathetic nervous system is a part of the nervous system that prepares the body for action, such as increasing the heart rate, blood pressure, and breathing rate. Stimulants can activate the same receptors as the natural chemicals released by the sympathetic nervous system (namely epinephrine and norepinephrine) and cause similar effects.
Psychostimulant refers to a subset of substances within the stimulant drug class that act at the dopamine transporter (DAT), a protein that normally clears dopamine from the synaptic cleft. Amphetamine, methylphenidate, cocaine, and modafinil are examples of psychostimulants that promote arousal and affect task performance in a dose-dependent manner. Psychostimulants act at DAT by inhibiting dopamine reuptake or by initiating transporter-mediated dopamine efflux (i.e., reverse transport), thereby producing indirect dopamine agonist effects in the central nervous system. The DAT-mediated actions of psychostimulants contrast with other central nervous system stimulants that can overlap in behavioural effects, such as caffeine, a drug that promotes wakefulness primarily through antagonism of adenosine receptors.
Effects Acute Stimulants in low doses, such as those prescribed to treat attention deficit hyperactivity disorder (ADHD), increase ability to focus, vigor, sociability, wakefulness, libido and may elevate mood or cause euphoria. However, in higher doses, stimulants may actually decrease the ability to focus, a principle of the Yerkes–Dodson law.
Many, but not all, stimulants have ergogenic effects; that is, they enhance physical performance. Drugs such as ephedrine, pseudoephedrine, amphetamine, and methylphenidate have well documented ergogenic effects, while cocaine has the opposite effect.
Neurocognitive enhancing effects of stimulants, specifically modafinil, amphetamine, and methylphenidate have been reported in healthy adolescents by some studies, and is a commonly cited reason among illicit drug users for use, particularly among college students in the context of studying. Still, results of these studies is inconclusive: assessing the potential overall neurocognitive benefits of stimulants among healthy youth is challenging due to the diversity within the population, the variability in cognitive task characteristics, and the absence of replication of studies. Research on the cognitive enhancement effects of modafinil in healthy non-sleep-deprived individuals has yielded mixed results, with some studies suggesting modest improvements in attention and executive functions while others show no significant benefits or even a decline in cognitive functions.
In some cases, psychiatric phenomena may emerge such as stimulant psychosis, paranoia, and suicidal ideation. Acute toxicity has been reportedly associated with hyperhidrosis, panic attacks, severe anxiety, mydriasis, paranoia, aggressive behavior, psychosis, rhabdomyolysis, and punding. The violent and aggressive behavior associated with acute stimulant toxicity may partially be driven by paranoia. Most drugs classified as stimulants are sympathomimetic, meaning that they stimulate the sympathetic branch of the autonomic nervous system. This stimulation leads to effects such as mydriasis (dilation of the pupils), increased heart rate, blood pressure, respiratory rate and body temperature. When these changes become pathological, they are called arrhythmia, hypertension, and hyperthermia, and may lead to rhabdomyolysis, stroke, cardiac arrest, or seizures. However, given the complexity of the mechanisms that underlie these potentially fatal outcomes of acute stimulant toxicity, it is impossible to determine what dose may be lethal.
Chronic Assessment of the effects of stimulants is relevant given the large population currently taking stimulants. A 2022 meta-analysis with a sample size of just under four million people found no association between the use of prescription stimulants and the development of cardiovascular disease in any age group. A review of a year long period of prescription stimulant use in those with attention deficit hyperactivity disorder (ADHD) found that cardiovascular side effects were limited to transient increases in blood pressure only. However, a 2024 systematic review of the evidence found that stimulants overall improve ADHD symptoms and broadband behavioral measures in children and adolescents, though they carry risks of side effects like appetite suppression and other adverse events. Initiation of stimulant treatment in those with ADHD in early childhood appears to carry benefits into adulthood in social and cognitive functioning, and appears to be relatively safe.
Abuse of prescription stimulants (not following physician instruction) or of illicit stimulants carries many negative health risks. Abuse of cocaine, depending upon route of administration, increases risk of cardiorespiratory disease, stroke, and sepsis. Some effects are dependent upon the route of administration, with intravenous use associated with the transmission of many disease such as hepatitis C, HIV/AIDS, and potential medical emergencies such as infection, thrombosis, or pseudoaneurysm, while inhalation may be associated with increased lower respiratory tract infection, lung cancer, and pathological restricting of lung tissue. Cocaine may also increase risk for autoimmune disease and damage nasal cartilage. Abuse of methamphetamine produces similar effects as well as marked degeneration of dopaminergic neurons, resulting in an increased risk for Parkinson's disease.
Medical uses Stimulants are widely used throughout the world as prescription medicines as well as without a prescription (either legally or illicitly) as performance-enhancing or recreational drugs. Stimulants produce a noticeable crash or comedown at the end of their effects. In the US, the most frequently prescribed stimulants as of 2013 were lisdexamfetamine (Vyvanse), methylphenidate (Ritalin), and amphetamine (Adderall). It was estimated in 2015 that the percentage of the world population that had used cocaine during a year was 0.4%. For the category "amphetamines and prescription stimulants" (with "amphetamines" including amphetamine and methamphetamine) the value was 0.7%, and for MDMA 0.4%.
Stimulants have been used in medicine for many conditions including obesity, sleep disorders, mood disorders, impulse-control disorders, asthma, nasal congestion and, in case of cocaine, as local anesthetics. Drugs used to treat obesity are called anorectics and generally include drugs that follow the general definition of a stimulant, but other drugs such as cannabinoid receptor antagonists also belong to this group. Eugeroics are used in management of sleep disorders characterized by excessive daytime sleepiness, such as narcolepsy, and include stimulants such as modafinil and pitolisant. Stimulants are used in impulse control disorders such as ADHD and off-label in mood disorders such as major depressive disorder to increase energy, focus, and elevate mood. Stimulants such as epinephrine, theophylline, and salbutamol orally have been used to treat asthma, but inhaled adrenergic drugs are now preferred due to less systemic side effects. Pseudoephedrine is used to relieve nasal or sinus congestion caused by the common cold, sinusitis, allergic rhinitis, and other respiratory allergies; it is also used to relieve ear congestion caused by ear inflammation or infection.Bicopoulos D, editor. AusDI: Drug information for the healthcare professional, 2nd edition. Castle Hill: Pharmaceutical Care Information Services; 2002.
Depression Stimulants were one of the first classes of drugs to be used in the treatment of major depressive disorder, beginning after the introduction of the amphetamines in the 1930s. However, they were largely abandoned for treatment of depression following the introduction of conventional antidepressants in the 1950s. Subsequent to this, there has been a resurgence in interest in stimulants for depression in recent years.
Stimulants produce a fast-acting and pronounced but transient and short-lived mood lift. In relation to this, they are minimally effective in the treatment of depression when administered continuously. In addition, tolerance to the mood-lifting effects of amphetamine has led to dose escalation and dependence. Although the efficacy for depression with continuous administration is modest, it may still reach statistical significance over placebo and provide benefits similar in magnitude to those of conventional antidepressants. The reasons for the short-term mood-improving effects of stimulants are unclear, but may relate to rapid tolerance. Tolerance to the effects of stimulants has been studied and characterized both in animals and humans. Stimulant withdrawal is remarkably similar in its symptoms to those of major depressive disorder.
Chemistry
Classifying stimulants is difficult, because of the large number of classes the drugs occupy, and the fact that they may belong to multiple classes; for example, ecstasy can be classified as a substituted methylenedioxyphenethylamine, a substituted amphetamine and consequently, a substituted phenethylamine.
Major stimulant classes include phenethylamines and their daughter class substituted amphetamines.
Amphetamines (class)