Key clinical syndromes

• Acute stimulant intoxication: agitation, tachycardia, hypertension, mydriasis, diaphoresis and increased energy.
• Severe toxidrome: hyperthermia, seizures, rhabdomyolysis, arrhythmia, acute coronary syndromes and stroke.
• Stimulant-induced psychosis: paranoia, hallucinations, disordered thought—may be transient or reveal underlying psychotic vulnerability.
• Withdrawal: profound fatigue, hypersomnolence, depressed mood, increased appetite and cravings.

Initial approach — safety first

1. Stabilise ABCs; ensure rapid access to airway and circulatory support.
2. Apply continuous monitoring: ECG, SpO₂, temperature and frequent vital signs.
3. Remove environmental stressors: quiet room, minimise stimulation and ensure staff safety.
4. Use de-escalation techniques and involve security only if risk cannot be managed clinically.

Investigations — essentials

• Immediate: ECG, capillary glucose, pulse oximetry, arterial blood gas where indicated.
• Blood: CBC, electrolytes, renal & liver function, CK, troponin (if chest pain), coagulation profile.
• Urine drug screen / serum toxicology if available (interpret with caution for NPS limitations).
• CT/MRI head for focal deficits or head trauma; chest imaging for pulmonary concerns.

Acute management — pharmacologic & non-pharmacologic

• Benzodiazepines: first-line for severe agitation, sympathomimetic effects and seizures (e.g., lorazepam titrated to effect).
• Antipsychotics: consider when psychosis persists despite sedation or when benzodiazepines are insufficient—use lowest effective dose and monitor QTc; olanzapine or haloperidol are commonly used.
• Hyperthermia management: immediate cooling (external cooling, cold IV fluids), treat seizures and monitor for multiorgan complications; ICU early for refractory hyperthermia.
• Cardiac care: ACS evaluation per protocol; manage severe hypertension with short-acting agents avoiding beta-blocker monotherapy in acute cocaine intoxication without benzodiazepine cover.
• Rhabdomyolysis: aggressive IV fluids, monitor CK and renal function, nephrology consultation if oliguria or rising creatinine.

Managing stimulant-induced psychosis

• Prioritise safety and use non-pharmacological calming measures where possible.
• Benzodiazepines can reduce agitation and distress; antipsychotics are used for persistent psychosis or danger to self/others.
• Most cases resolve over days—reassess the need for ongoing antipsychotic treatment and consider psychiatric follow-up to evaluate for primary psychotic disorders.

Special considerations — cardiovascular and neurologic risks

• Acute coronary syndromes can occur even in younger patients—consider serial troponins and cardiology input.
• Ischaemic or haemorrhagic stroke risk increases with stimulant use—neuroimaging and stroke team involvement for focal signs.
• Avoid beta-blocker monotherapy in suspected acute cocaine intoxication; use benzodiazepines and nitrates for chest pain initially, and consult cardiology for further management.

Withdrawal and longer-term management

• Withdrawal is usually managed supportively: rest, sleep hygiene, nutritional support and monitoring for depression or suicidality.
• Refer to specialist addiction services for psychosocial treatments—contingency management has the strongest evidence for stimulant use disorder treatment.
• Consider integrated care for co-occurring mental illness; monitor for persistent psychosis or mood disorders requiring psychiatric treatment.

Pharmacotherapy — current status

There is no universally approved medication for stimulant dependence. Some agents (bupropion, modafinil, topiramate, naltrexone) show mixed results; pharmacotherapy should be considered only in specialist settings or clinical trials.

Key takeaways

• Adopt a syndrome-based, safety-first approach when the stimulant is unknown—treat hyperthermia, seizures, cardiac and renal complications aggressively.
• Benzodiazepines are first-line for severe agitation and sympathomimetic effects; antipsychotics used for persistent psychosis with monitoring.
• Refer to specialist addiction services for evidence-based psychosocial treatments, especially contingency management for stimulant use disorder.
• Ensure multidisciplinary follow-up (cardiology, nephrology, psychiatry, addiction medicine) where organ complications or persistent psychiatric symptoms occur.