Why an “unspecified” label is used

Use this label when clinical features indicate stimulant-related harm but the exact agent cannot be ascertained at presentation due to absent history, mixed intoxication, or novel psychoactive substances not detectable on routine screens. It remains a working diagnosis prompting immediate, safety-focused care.

Typical clinical presentations

• Acute intoxication: agitation, tachycardia, hypertension, diaphoresis, dilated pupils, mydriasis.
• Severe presentations: hyperthermia, rhabdomyolysis, seizures, acute coronary syndrome, stroke.
• Psychiatric: stimulant-induced psychosis (paranoia, hallucinations), severe anxiety, suicidal ideation.
• Withdrawal: fatigue, increased appetite, hypersomnolence, depression and strong drug craving.

Assessment — immediate priorities

1. Stabilise ABCs: airway protection for reduced consciousness, oxygen for hypoxia, IV access and cardiac monitoring if unstable.
2. Rapid observations: temperature (for hyperthermia), HR, BP, RR, SpO₂, GCS.
3. Focused exam: note pupils, agitation level, neuromotor signs, skin findings, signs of trauma or injection use.
4. Collateral information from friends, paramedics or scene (containers, pills) — even small details help target management.

Differential diagnoses to consider

• Other toxidromes: anticholinergic, serotonergic, opioid (look for mixed presentations).
• Primary psychiatric disorders (first-episode psychosis) — distinguish by timeline and drug exposure.
• Acute medical causes: sepsis, thyroid storm, withdrawal from other substances, intracranial events.

Investigations — essential & targeted

• Immediate: ECG, capillary glucose, pulse oximetry, arterial blood gas if respiratory compromise suspected.
• Bloods: CBC, electrolytes, renal & liver function, CK, coagulation, troponin if chest pain, serum osmolality.
• Toxicology: urine drug screen and serum testing where available (note limitations for NPS).
• CT head for head injury, focal neurology or prolonged altered consciousness; consider chest imaging if aspiration or pulmonary complications suspected.

Acute management — key principles

Treat the physiological complications first, control severe agitation safely, and prevent complications such as hyperthermia and rhabdomyolysis.

• Agitation / psychosis: calm environment, verbal de-escalation and then benzodiazepines (e.g., lorazepam) as first-line pharmacologic treatment. Avoid high-dose antipsychotics as first-line in severe stimulant hyperactivity without specialist input; use antipsychotics (e.g., haloperidol or olanzapine) when psychosis persists after sedation or for severe agitation—monitor for QTc prolongation.
• Hyperthermia: aggressive cooling, IV fluids, treat seizures and consider ICU involvement for severe cases.
• Cardiovascular complications: treat chest pain per ACS protocols and consult cardiology; control severe hypertension with short-acting agents.
• Seizures: treat promptly with benzodiazepines followed by second-line antiseizure agents if needed.
• Rhabdomyolysis: IV fluids, monitor CK and renal function; alkalinisation and nephrology input when indicated.

Managing stimulant-induced psychosis

• Assess for safety risk; use least-restrictive measures first (de-escalation, quiet room, reassurance).
• Benzodiazepines are first-line for severe agitation; use antipsychotics for persistent psychosis or high-risk behaviour, at the lowest effective dose and with monitoring.
• Plan re-assessment—many cases of substance-induced psychosis resolve within days; longer-term antipsychotic treatment reserved for persistent psychosis that suggests primary psychotic disorder.

Withdrawal management and follow-up

• Withdrawal typically features hypersomnolence, increased appetite, depressed mood and intense craving; treat supportively with sleep hygiene, short-term monitoring and safety planning for suicidality.
• Provide psychosocial support and refer to addiction services for contingency management, CBT and relapse prevention programs (evidence supports contingency management for stimulant use disorder).
• Treat comorbid depression or suicidality according to standard psychiatric protocols and involve mental health teams early when needed.

Pharmacotherapy — current evidence & options

• No universally approved medication for stimulant use disorder; some agents (bupropion, modafinil, topiramate) have mixed evidence and may be considered in specialist settings.
• Psychostimulant substitution and experimental pharmacotherapies are under investigation—refer to specialist addiction services and clinical trials where appropriate.

Key takeaways

• When the specific stimulant is unknown, manage by clinical syndrome—focus on airway, haemodynamic stability, controlling agitation and preventing complications.
• Benzodiazepines are first-line for severe agitation; antipsychotics reserved for persistent psychosis or high-risk behaviours with monitoring.
• Monitor for hyperthermia, rhabdomyolysis, cardiac ischemia and seizures—treat aggressively and involve ICU where needed.
• Refer to specialist addiction services for evidence-based psychosocial treatments (contingency management, CBT) and consider specialist pharmacotherapy trials when indicated.