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

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.

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. 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.