Approach to stimulant use, intoxication, and overdose: Clinical sciences

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Introduction 0:00–1:12

Stimulants refers to a broad class of medications, supplements, and illicit substances that have sympathomimetic effects on the central nervous system.
In general, they can cause increased alertness and wakefulness, elevated mood, enhance cognitive functions like focus and concentration, increase energy levels, and reduce the need for sleep.
Common types of stimulants include amphetamines like dextroamphetamine, methamphetamine, and methylenedioxymethamphetamine, also known as MDMA or ecstasy; as well as cocaine, and caffeine.
While pharmaceutical formulations of stimulants are commonly prescribed for the treatment of ADHD and narcolepsy, substances like methamphetamine and cocaine are manufactured and used illicitly for their similar sympathomimetic properties.
Caffeine, on the other hand, is the most widely consumed stimulant in the form of coffee or tea for its desired effects of alertness and heightened focus.
Regardless of the type and purpose of use, large amounts of these substances can lead to intoxication, overdose, and chronic dependance.
Alright, when a patient presents with a chief concern suggesting stimulant use, your first step is to perform an ABCDE assessment to determine if they are stable or unstable.

Unstable Patient 1:12–4:09

If the patient is unstable, stabilize the airway, breathing, and circulation right away. This may require supplemental oxygen or even endotracheal intubation and mechanical ventilation.
Next, obtain IV access and consider starting IV fluids. Put your patient on continuous vital sign monitoring, including temperature, pulse, blood pressure, pulse oximetry, respiratory rate, and cardiac telemetry.
Additionally, consider using cooling blankets for patients with hyperthermia, and sedation for those with severe agitation.
Here’s a clinical pearl to keep in mind! When evaluating unstable patients with suspected ingestion of stimulants, always consider the possibility of overdose.
Overdose is characterized by the ingestion of large amounts of a substance leading to hemodynamic instability, respiratory depression or failure, altered mental status, or severe psychosis.
Once you’ve initiated acute management, obtain a focused history and physical exam and order a urine or serum toxicology screen.
If the patient is unable to provide adequate history, obtain it from a family member or a friend accompanying the patient.
On history, you can expect to find recent use of stimulants sometimes with signs of psychosis, like hallucinations, shortly following the ingestion.
It is also helpful to ask about previous use of similar substances or multiple substances to get an idea of chronic use or dependance.
Keep in mind, the clinical course can differ based on increased physiologic tolerance to these substances. Now, physical exam will likely reveal altered mental status, hypertension, dilated pupils, hyperthermia, and skin flushing.
You might also see severe acne, pustules, or erythematous cutaneous macules, and in cases of nasal inhalation, nasal septal erythema or perforation.
With these findings, think stimulant overdose, which is a medical emergency. Here is a clinical pearl!
Substance overdose in most cases is a clinical diagnosis. A toxicology screening can help you identify which substances have been used.
However, you should never wait for the tox screen results to start treatment. The management of stimulant overdose is mostly providing supportive care.
This includes providing supplemental oxygen or mechanical ventilation if the patient is intubated, blood pressure control, evaluating for end-organ damage from elevated blood pressure, and sedation for severe agitation or active psychosis.
Alright, now that we’ve addressed unstable patients, let’s return to the ABCDE assessment and look at the stable ones. Your next step is to obtain a focused history and physical exam along with a urine tox screen.

Stable Patient 4:09–6:01

These individuals will have a history of recent or chronic use of stimulants. Patients with recent use might report chest pain or angina, perspiration, chills, nausea or vomiting, as well as signs of psychosis like hallucinations, or even euphoria.
On exam, you might see altered mental status, mildly elevated blood pressure and heart rate, dilated pupils, skin flushing, epistaxis or hemoptysis, skin excoriations, or nasal septal erythema or even perforation.
If you see these findings, suspect stimulant use or intoxication. Keep in mind, chronic use patients might not have these signs especially if they have not used recently.
To confirm your diagnosis, assess the DSM-5 diagnostic criteria. Time for another clinical pearl!
Some of the physical exam findings are specific to various stimulants. These are not included in the DSM-5 criteria.
For example, cocaine is a vasoconstrictor. Nasal inhalation of cocaine can damage nasal blood vessels leading to epistaxis or hemoptysis.
However, chronic use of cocaine may result in ischemic necrosis, erythema, or perforation of the nasal septum. On the flip side, methamphetamines lead to dehydration which causes excess production of oil and sebum by the skin.
They also raise body temperature leading to excessive sweating. Those intoxicated with methamphetamines are prone to repetitive skin picking leading to skin excoriations.
Going back to DSM-5 criteria, let’s discuss stimulant intoxication. These patients must have a history of recent use of stimulants, mood or behavioral problems due to substance use, and one or more symptoms of intoxication with a stimulant.

Stimulant intoxication 6:01–7:04

Intoxication symptoms include mydriasis, psychomotor agitation or retardation, chills or perspiration, chest pain or arrhythmia, hypertension or hypotension, as well as dystonia, dyskinesias, weight loss, nausea, vomiting, respiratory depression, muscular weakness, altered mental status, or in severe cases seizures or even coma.
If the patient meets these criteria, diagnose stimulant intoxication. The management includes providing supportive care like supplemental oxygen and IV fluids to help them through acute intoxication.
You should also consider referring the patient to substance rehabilitation and psychotherapy. Alright, let’s move on to stimulant use disorder.

Stimulant use disorder 7:04–8:14

Patients with stimulant use disorder show similar symptoms to those with stimulant intoxication but have a history of chronic use over a longer time.
To be formally diagnosed with stimulant disorder, patients must have two or more of the following findings observed within the past twelve months.
These findings include tolerance; withdrawal symptoms; craving to use; using more than intended; difficulty stopping or reducing use; spending significant time devoted to substance use; use despite acknowledging health problems due to the substance; use despite social, occupational, or other adverse consequences; neglecting other responsibilities or activities due to substance use; or engaging in risky or dangerous behaviors and situations due to substance use.
If the criteria are met, diagnose stimulant use disorder. Management involves supportive care for any acute symptoms of recent use and the initiation of psychotherapy for long-term care.
Alright, as a quick recap... Stimulants are substances that cause sympathomimetic symptoms and can lead to overdose, intoxication, and chronic use.

Review 8:14–9:01

Stimulant overdose is considered a medical emergency as patients are often hemodynamically unstable and require urgent supportive care.
When it comes to stable patients, stimulant intoxication refers to acute use. Treat these patients with supportive care and refer them to substance rehabilitation and psychotherapy.
Lastly, stimulant use disorder refers to chronic use and built-up dependence on the substance over the last twelve months that affect daily life and function.
Management includes supportive care and a referral for psychotherapy.