Stimulant intoxication and withdrawal — MAP, toxicity, and anti-craving vacuum (MEQ)

(i) Immediate medical and behavioural priorities. Treat as medical-psychiatric emergency: ABC, serial vitals (temperature, HR, BP), oxygen/glucose as needed, ECG and serial troponin given borderline value and catecholamine strain, IV fluids and CK monitoring for rhabdomyolysis, cooling measures if hyperthermia escalates per ED protocol. Low-stimulus environment, de-escalation, oral sedation first if needed under local rapid-tranquillisation policy; avoid unnecessary restraint that worsens hyperthermia. Do not start "stimulant OAT."[4]

(ii) MAP formulation and acute treatment. Persecutory delusions and auditory hallucinations with clear consciousness temporally linked to a heavy binge favour methamphetamine-associated psychosis / substance-induced psychotic disorder rather than proven lifelong primary schizophrenia on day one — but dual formulation remains open if symptoms persist after abstinence. Dose-related psychosis association supports this framing. If psychosis is dangerous or persists after medical screen, use a time-limited antipsychotic (e.g. oral olanzapine 5–10 mg if safe to take orally, local protocol overriding) and reassess within days; network meta-analysis supports antipsychotic efficacy signals in MAP. Avoid indefinite high-dose polypharmacy without review.[3][5]

(iii) Crash course and suicide plan. Expect early crash with fatigue/hypersomnia, peak dysphoria/anhedonia/irritability/craving around day 2, improvement over about 1–2 weeks with residual sleep/mood symptoms possible (McGregor). Day-2 tearfulness and passive suicidal ideation sit in the high-yield safety window: observation level, means restriction, structured MSE for suicide, family contact, crisis plan — not "he's just sleeping it off" discharge without review.[2]

(iv) No approved anti-craving standard; first-line ongoing care. ASAM/AAAP frames psychosocial treatments first-line; there is no FDA-approved standard pharmacotherapy analogous to methadone/buprenorphine for stimulants. Do not invent substitution therapy. After stabilisation, recommend contingency management (strongest psychosocial signal) plus CBT/CRA/Matrix-style structured AOD care, dual-diagnosis follow-up, and honest discussion that agents such as mirtazapine or ADAPT-2 naltrexone XR + bupropion XL are selected specialist options, not mandatory acute standards.[1][6]

(v) Disposition and harm reduction. Medical clearance criteria, psych observation or short admission if suicide/MAP risk high, then community mental health + AOD shared care with early review. Harm reduction: safer-use advice without moralising, wound care, STI/HIV testing pathways, take-home naloxone if opioid co-use, housing/peer support, written crisis contacts. Document dynamic violence risk during heavy use periods for handover if forensic/custody issues arise.[1][3]