Unlike central nervous system (CNS) depressants, stimulants increase breathing, heart rate, blood pressure, and alertness - and can create euphoria and decrease inhibitions.
Prescribed stimulants include methylphenidate (Ritalin® and Concerta®) and amphetamines (Adderall® and Dexedrine®). These stimulants may be prescribed for a variety of health conditions (1).
For this section, we will only describe the effects of commonly used unprescribed substances - including caffeine, cocaine, amphetamines, and methampethamines.
Pharmacology is a branch of science that deals with the study of drugs and their actions on living systems - that is, the study of how drugs work in the body.
Stimulants may be prescribed for a variety of health conditions (1). For this section, we will only describe the effects of commonly used unprescribed substances.
Common unprescribed stimulants in pregnancy are caffeine, cocaine, and amphetamines.
Stimulants act by augmenting the action of catecholamines, either by increasing release, inhibiting reuptake, or both.
Effects of stimulants are increased breathing, heart rate, blood pressure, alertness, euphoria, dilated pupils, vasoconstriction, decreased inhibitions and anorexia.
Side effects can occur with normal or higher than normal doses and include palpitations, paranoia, restlessness, seizures, or decreased attention.
There is insufficient evidence to support tolerance with prolonged use.
Half-life varies depending on the substance; half-life for cocaine is 1 hour; caffeine is about 5 hours; most amphetamines are about 12 hours.
Stimulants are metabolized in the liver, and then eliminated via urine, with elimination times depending on urine pH (1).
How does caffeine keep us awake?
"Over 100,000 metric tons of caffeine are consumed around the world every year. That’s equivalent to the weight of 14 Eiffel Towers! Caffeine helps us feel alert, focused, and energetic, even if we haven’t had enough sleep — but it can also raise our blood pressure and make us feel anxious. So how does it keep us awake? Hanan Qasim shares the science behind the world’s most widely used drug."
There are no pharmacological treatments for dependence on stimulants, although there is emerging data about a few promising medications (2).
Individual or group therapy may be helpful when there is a desire to change patterns of stimulant use (3).
Similar to trends for other illicit substance use in pregnancy, people who use stimulants tend to decrease their use over the course of the pregnancy, which dramatically decreases risks (4, 5).
The Food and Drug administration places methamphetamine, cocaine and caffeine in pregnancy category C (1).
Stimulants have not been linked to congenital anomalies or placental previa (6, 7, 3, 9, 8, 4, 10, 11).
Stimulants may lower birth weights and gestational age at delivery, increasing the risk of small for gestational age (SGA) or low birth weight (LBW) and accompanying morbidity (3, 7, 45, 12, 13, 14, 8, 15).
Many studies find that these differences disappear when controlled for confounding factors related to socioeconomic status and access to prenatal care (16, 17), or that findings of decreased birth weight, while statistically significant, are still within normal range (4).
The evidence for a causal link with cocaine to placental abruption is of very poor quality and does not adequately control for confounding factors (18-24).
There is no evidence based neonatal withdrawal from stimulants.
Stimulants are present in the breastmilk of parents who use them, and infant exposure should be limited (25-27).
Abstinence from stimulants during lactation is recommended, but in the case of a relapse, waiting at least 24 hours after cocaine use and 48 hours after methamphetamine use to provide human milk is recommended (26, 28).
Low to moderate caffeine use is considered safe during pregnancy and breastfeeding, but high doses could result in lower birth weights and spontaneous abortion (27, 29, 30-32).
There is no evidence of increased risk of congenital anomalies with caffeine use. Safe doses during pregnancy and lactation are likely to be around 200 mg/day (30).
Stimulants are present in the breastmilk of parents who use them, and infant exposure should be limited (25-27).
Overdose from stimulants does not directly cause death. Deaths involving stimulants are usually related to vascular events such as myocardial infarction, cerebrovascular accident, or aneurism (33).
Avoid Dangerous Combinations
If you use these substances together you are at danger of overdosing or drug poisoning.
We care about your health and wellbeing. Please don't combine these substances.
NOTE: If you are using more than one of these medications at the same time you can work closely with your prescriber to maximize the positive therapeutic benefits of these drug combinations while being careful to minimize the risks of taking them together.
Caffeine withdrawal involves headaches, irritability, sleepiness, and constipation (34).
There is evidence for acute abstinence, or “crash”, from illicit stimulants. The crash from cocaine is usually reported to last 1-2 days and the crash from methamphetamine is reported to last 7-10 days.
Symptoms consistently reported in the literature are anhedonia, irritability, anxiety and paranoia, malaise, insomnia or hypersomnia, anorexia or hyperphagia, fatigue, and psychomotor retardation or agitation.
Similar to the subjective feeling of hangover experienced after heavy alcohol use, this crash is generally mild and does not require medical intervention.
It is not comparable to the predictable, measurable withdrawal syndrome demonstrated by chronic alcohol, benzodiazepine, and opioid use.
However, that it is not medically dangerous does not mean that it is clinically insignificant. As one researcher put it, “There continues to be considerable uncertainty about whether amphetamines (in this review, amphetamine, dextroamphetamine, and methamphetamine) should be regarded as having a true withdrawal syndrome (i.e., a predictable set of symptoms which are reliably found across users).
Nonetheless, many users report symptoms which are clinically severe in that they may lead to subjective distress, premature termination of treatment, relapse to further drug use, and suicidal ideation and attempts.” (35).
There is no evidence for long term physiological withdrawal (36-45).
1. Wolters Kluwer. (2010). Nursing 2010 drug handbook. Ambler, PA: Lippincott, Williams, and Wilkins.
2. Kampman K. M. (2009). New medications for the treatment of cocaine dependence. Annali dell'Istituto superiore di sanita, 45(2), 109–115.
3. American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women (2011). Committee Opinion No. 479: Methamphetamine abuse in women of reproductive age. Obstetrics and gynecology, 117(3), 751–755. https://doi.org/10.1097/AOG.0b013e318214784e
4. Wright, T. E., Schuetter, R., Tellei, J., & Sauvage, L. (2015). Methamphetamines and pregnancy outcomes. Journal of addiction medicine, 9(2), 111–117. https://doi.org/10.1097/ADM.0000000000000101
5. Della Grotta, S., LaGasse, L. L., Arria, A. M., Derauf, C., Grant, P., Smith, L. M., Shah, R., Huestis, M., Liu, J., & Lester, B. M. (2010). Patterns of methamphetamine use during pregnancy: results from the Infant Development, Environment, and Lifestyle (IDEAL) Study. Maternal and child health journal, 14(4), 519–527. https://doi.org/10.1007/s10995-009-0491-0
6. Shah, R., Diaz, S. D., Arria, A., LaGasse, L. L., Derauf, C., Newman, E., Smith, L. M., Huestis, M. A., Haning, W., Strauss, A., Della Grotta, S., Dansereau, L. M., Roberts, M. B., Neal, C., & Lester, B. M. (2012). Prenatal methamphetamine exposure and short-term maternal and infant medical outcomes. American journal of perinatology, 29(5), 391–400. https://doi.org/10.1055/s-0032-1304818
7. Behnke, M., Smith, V. C., Committee on Substance Abuse, & Committee on Fetus and Newborn (2013). Prenatal substance abuse: short- and long-term effects on the exposed fetus. Pediatrics, 131(3), e1009–e1024. https://doi.org/10.1542/peds.2012-3931
8. Forray, A., & Foster, D. (2015). Substance Use in the Perinatal Period. Current psychiatry reports, 17(11), 91. https://doi.org/10.1007/s11920-015-0626-5
9. Good, M. M., Solt, I., Acuna, J. G., Rotmensch, S., & Kim, M. J. (2010). Methamphetamine use during pregnancy: maternal and neonatal implications. Obstetrics and gynecology, 116(2 Pt 1), 330–334. https://doi.org/10.1097/AOG.0b013e3181e67094
10. Huybrechts, K. F., Bröms, G., Christensen, L. B., Einarsdóttir, K., Engeland, A., Furu, K., Gissler, M., Hernandez-Diaz, S., Karlsson, P., Karlstad, Ø., Kieler, H., Lahesmaa-Korpinen, A. M., Mogun, H., Nørgaard, M., Reutfors, J., Sørensen, H. T., Zoega, H., & Bateman, B. T. (2018). Association Between Methylphenidate and Amphetamine Use in Pregnancy and Risk of Congenital Malformations: A Cohort Study From the International Pregnancy Safety Study Consortium. JAMA psychiatry, 75(2), 167–175. https://doi.org/10.1001/jamapsychiatry.2017.3644
11. Andrade C. (2018). Risk of Major Congenital Malformations Associated With the Use of Methylphenidate or Amphetamines in Pregnancy. The Journal of clinical psychiatry, 79(1), 18f12108. https://doi.org/10.4088/JCP.18f12108
12. Bada, H. S., Das, A., Bauer, C. R., Shankaran, S., Lester, B. M., Gard, C. C., Wright, L. L., Lagasse, L., & Higgins, R. (2005). Low birth weight and preterm births: etiologic fraction attributable to prenatal drug exposure. Journal of perinatology : official journal of the California Perinatal Association, 25(10), 631–637. https://doi.org/10.1038/sj.jp.7211378
13. Shankaran, S., Lester, B. M., Das, A., Bauer, C. R., Bada, H. S., Lagasse, L., & Higgins, R. (2007). Impact of maternal substance use during pregnancy on childhood outcome. Seminars in fetal & neonatal medicine, 12(2), 143–150. https://doi.org/10.1016/j.siny.2007.01.002
14. Nguyen, D., Smith, L. M., Lagasse, L. L., Derauf, C., Grant, P., Shah, R., Arria, A., Huestis, M. A., Haning, W., Strauss, A., Della Grotta, S., Liu, J., & Lester, B. M. (2010). Intrauterine growth of infants exposed to prenatal methamphetamine: results from the infant development, environment, and lifestyle study. The Journal of pediatrics, 157(2), 337–339. https://doi.org/10.1016/j.jpeds.2010.04.024
15. Gorman, M. C., Orme, K. S., Nguyen, N. T., Kent, E. J., 3rd, & Caughey, A. B. (2014). Outcomes in pregnancies complicated by methamphetamine use. American journal of obstetrics and gynecology, 211(4), 429.e1–429.e4297. https://doi.org/10.1016/j.ajog.2014.06.005
16. Richardson, G. A., & Day, N. L. (1994). Detrimental effects of prenatal cocaine exposure: illusion or reality?. Journal of the American Academy of Child and Adolescent Psychiatry, 33(1), 28–34. https://doi.org/10.1097/00004583-199401000-00005
17. Richardson, G. A., Hamel, S. C., Goldschmidt, L., & Day, N. L. (1999). Growth of infants prenatally exposed to cocaine/crack: comparison of a prenatal care and a no prenatal care sample. Pediatrics, 104(2), e18. https://doi.org/10.1542/peds.104.2.e18
18. Mastrogiannis, D. S., Decavalas, G. O., Verma, U., & Tejani, N. (1990). Perinatal outcome after recent cocaine usage. Obstetrics and gynecology, 76(1), 8–11.
19. Chasnoff, I. J., Burns, K. A., & Burns, W. J. (1987). Cocaine use in pregnancy: perinatal morbidity and mortality. Neurotoxicology and teratology, 9(4), 291–293. https://doi.org/10.1016/0892-0362(87)90017-1
20. Slutsker L. (1992). Risks associated with cocaine use during pregnancy. Obstetrics and gynecology, 79(5 ( Pt 1)), 778–789.
21. ACOG Practice Bulletin No. 102: management of stillbirth. (2009). Obstetrics and gynecology, 113(3), 748–761. https://doi.org/10.1097/AOG.0b013e31819e9ee2
22. Little, B. B., Snell, L. M., Trimmer, K. J., Ramin, S. M., Ghali, F., Blakely, C. A., & Garret, A. (1999). Peripartum cocaine use and adverse pregnancy outcome. American journal of human biology : the official journal of the Human Biology Council, 11(5), 598–602. https://doi.org/10.1002/(SICI)1520-6300(199909/10)11:5<598::AID-AJHB3>3.0.CO;2-L
23. Aghamohammadi, A., & Zafari, M. (2016). Crack abuse during pregnancy: maternal, fetal and neonatal complication. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians, 29(5), 795–797. https://doi.org/10.3109/14767058.2015.1018821
24. Hulse, G. K., Milne, E., English, D. R., & Holman, C. D. (1997). Assessing the relationship between maternal cocaine use and abruptio placentae. Addiction (Abingdon, England), 92(11), 1547–1551.
25. Cressman, A. M., Koren, G., Pupco, A., Kim, E., Ito, S., & Bozzo, P. (2012). Maternal cocaine use during breastfeeding. Canadian family physician Medecin de famille canadien, 58(11), 1218–1219.
26. Bartu, A., Dusci, L. J., & Ilett, K. F. (2009). Transfer of methylamphetamine and amphetamine into breast milk following recreational use of methylamphetamine. British journal of clinical pharmacology, 67(4), 455–459. https://doi.org/10.1111/j.1365-2125.2009.03366.x
27. 49La Leche League. (2006). What effect does the mother’s consumption of caffeine have on the breastfeeding infant?. Retrieved from: http://www.llli.org/faq/caffeine.html
28. 85 National Institute of Health US National Library of Medicine TOXNET (2018). LactMed Database. Retrieved from: https://toxnet.nlm.nih.gov/cgi-bin/sis/search2/f?./temp/~ViU0iT:1
29. Watkinson, B., & Fried, P. A. (1985). Maternal caffeine use before, during and after pregnancy and effects upon offspring. Neurobehavioral toxicology and teratology, 7(1), 9–17.
30. Temple, J. L., Bernard, C., Lipshultz, S. E., Czachor, J. D., Westphal, J. A., & Mestre, M. A. (2017). The Safety of Ingested Caffeine: A Comprehensive Review. Frontiers in psychiatry, 8, 80. https://doi.org/10.3389/fpsyt.2017.00080
31. Gaskins, A. J., Rich-Edwards, J. W., Williams, P. L., Toth, T. L., Missmer, S. A., & Chavarro, J. E. (2018). Pre-pregnancy caffeine and caffeinated beverage intake and risk of spontaneous abortion. European journal of nutrition, 57(1), 107–117. https://doi.org/10.1007/s00394-016-1301-2
32. Peacock, A., Hutchinson, D., Wilson, J., McCormack, C., Bruno, R., Olsson, C. A., Allsop, S., Elliott, E., Burns, L., & Mattick, R. P. (2018). Adherence to the Caffeine Intake Guideline during Pregnancy and Birth Outcomes: A Prospective Cohort Study. Nutrients, 10(3), 319. https://doi.org/10.3390/nu10030319
33. Winslow, B. T., Voorhees, K. I., & Pehl, K. A. (2007). Methamphetamine abuse. American family physician, 76(8), 1169–1174.
34. Juliano, L. M., & Griffiths, R. R. (2004). A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features. Psychopharmacology, 176(1), 1–29. https://doi.org/10.1007/s00213-004-2000-x
35. Gossop M. (2009). Review: limited evidence to support pharmacological therapy for amphetamine withdrawal. Evidence-based mental health, 12(4), 122. https://doi.org/10.1136/ebmh.12.4.122
36. Kampman, K. M., Volpicelli, J. R., McGinnis, D. E., Alterman, A. I., Weinrieb, R. M., D'Angelo, L., & Epperson, L. E. (1998). Reliability and validity of the Cocaine Selective Severity Assessment. Addictive behaviors, 23(4), 449–461. https://doi.org/10.1016/s0306-4603(98)00011-2
37. Mendelson, J. H., & Mello, N. K. (1996). Management of cocaine abuse and dependence. The New England journal of medicine, 334(15), 965–972. https://doi.org/10.1056/NEJM199604113341507
38. Walsh, S. L., Stoops, W. W., Moody, D. E., Lin, S. N., & Bigelow, G. E. (2009). Repeated dosing with oral cocaine in humans: assessment of direct effects, withdrawal, and pharmacokinetics. Experimental and clinical psychopharmacology, 17(4), 205–216. https://doi.org/10.1037/a0016469
39. Cantwell, B., & McBride, A. J. (1998). Self detoxication by amphetamine dependent patients: a pilot study. Drug and alcohol dependence, 49(2), 157–163. https://doi.org/10.1016/s0376-8716(97)00160-9
40. McGregor, C., Srisurapanont, M., Jittiwutikarn, J., Laobhripatr, S., Wongtan, T., & White, J. M. (2005). The nature, time course and severity of methamphetamine withdrawal. Addiction (Abingdon, England), 100(9), 1320–1329. https://doi.org/10.1111/j.1360-0443.2005.01160.x
41. McGregor, C., Srisurapanont, M., Mitchell, A., Longo, M. C., Cahill, S., & White, J. M. (2008). Psychometric evaluation of the Amphetamine Cessation Symptom Assessment. Journal of substance abuse treatment, 34(4), 443–449. https://doi.org/10.1016/j.jsat.2007.05.007
42. Mancino, M. J., Gentry, B. W., Feldman, Z., Mendelson, J., & Oliveto, A. (2011). Characterizing methamphetamine withdrawal in recently abstinent methamphetamine users: a pilot field study. The American journal of drug and alcohol abuse, 37(2), 131–136. https://doi.org/10.3109/00952990.2010.543998
43. Newton, T. F., De La Garza, R., 2nd, Kalechstein, A. D., Tziortzis, D., & Jacobsen, C. A. (2009). Theories of addiction: methamphetamine users' explanations for continuing drug use and relapse. The American journal on addictions, 18(4), 294–300. https://doi.org/10.1080/10550490902925920
44. Pennay, A. E., & Lee, N. K. (2011). Putting the call out for more research: the poor evidence base for treating methamphetamine withdrawal. Drug and alcohol review, 30(2), 216–222. https://doi.org/10.1111/j.1465-3362.2010.00240.x
45. Zorick, T., Nestor, L., Miotto, K., Sugar, C., Hellemann, G., Scanlon, G., Rawson, R., & London, E. D. (2010). Withdrawal symptoms in abstinent methamphetamine-dependent subjects. Addiction (Abingdon, England), 105(10), 1809–1818. https://doi.org/10.1111/j.1360-0443.2010.03066.x