Psych · Addiction psychiatry — stimulant and methamphetamine use
Stimulant and methamphetamine use
Also known as Methamphetamine use disorder · Crystal meth · Ice · Amphetamine-type stimulants · Stimulant use disorder · Methamphetamine-associated psychosis · MAP · ATS · Speed · Cocaine use disorder interface
Exam-exhaustive fellowship reference on stimulant and methamphetamine use — intoxication and withdrawal, methamphetamine-associated psychosis, cardiovascular risk, behavioural disturbance, psychosocial treatment (contingency management, CBT, Matrix), limited pharmacotherapy evidence, dual diagnosis and harm reduction. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Chest pain, severe hypertension, hyperthermia, seizure, focal neurology or rhabdomyolysis during stimulant intoxication — treat as medical emergency before psychiatric labelling
- Agitated delirium with fluctuating consciousness — exclude medical causes; do not assume pure behavioural disturbance
- Active suicidal intent in the crash/withdrawal phase or command hallucinations to harm — same-day senior review and documented safety plan
- Persistent psychosis days after last use with negative drug screen and family history of schizophrenia — dual formulation; do not force lifelong primary psychosis label on day one without timeline
- Injecting use with fever or soft-tissue infection — sepsis pathway and infectious diseases liaison
- Polysubstance collapse (meth + GHB, opioids, alcohol) — reverse opioids if indicated; observe for delayed respiratory depression
Meet the patient
A 26-year-old man is brought to the emergency department by police after a five-day ice run. He is convinced the neighbours are laser-mapping his flat, picks at his skin, and tells you there are insects burrowing under it. Pulse 128, blood pressure 172/104, temperature 38.1, and he cannot sit still.[7][17]
Before any psychiatric label, three questions decide whether he survives the night: is his heart safe, is his brain perfusing, and is he about to hurt himself or someone else? Methamphetamine-associated psychosis looks psychiatric, but the catecholamine storm is cardiovascular and the crash is suicidal.[6][9]
References20ShowHide
- [1]ASAM/AAAP Clinical Guideline Committee The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder J Addict Med, 2024.PMID 38669101
- [2]Ronsley C, Nolan S, Knight R, et al. Treatment of stimulant use disorder: A systematic review of reviews PLoS One, 2020.PMID 32555667
- [3]Trivedi MH, Walker R, Ling W, et al. Bupropion and Naltrexone in Methamphetamine Use Disorder N Engl J Med, 2021.PMID 33497547
- [4]Coffin PO, Santos GM, Hern J, et al. Effects of Mirtazapine for Methamphetamine Use Disorder Among Cisgender Men and Transgender Women Who Have Sex With Men: A Randomized Clinical Trial JAMA Psychiatry, 2020.PMID 31825466
- [5]Colfax GN, Santos GM, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial Arch Gen Psychiatry, 2011.PMID 22065532
- [6]Kevil CG, Goeders NE, Woolard MD, et al. Methamphetamine Use and Cardiovascular Disease Arterioscler Thromb Vasc Biol, 2019.PMID 31433698
- [7]McKetin R, Lubman DI, Baker AL, et al. Dose-related psychotic symptoms in chronic methamphetamine users: evidence from a prospective longitudinal study JAMA Psychiatry, 2013.PMID 23303471
- [8]McKetin R, Lubman DI, Najman JM, et al. Does methamphetamine use increase violent behaviour? Evidence from a prospective longitudinal study Addiction, 2014.PMID 24400972
- [9]McGregor C, Srisurapanont M, Jittiwutikarn J, et al. The nature, time course and severity of methamphetamine withdrawal Addiction, 2005.PMID 16128721
- [10]Rawson RA, Marinelli-Casey P, Anglin MD, et al. A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence Addiction, 2004.PMID 15139869
- [11]Dutra L, Stathopoulou G, Basden SL, et al. A meta-analytic review of psychosocial interventions for substance use disorders Am J Psychiatry, 2008.PMID 18198270
- [12]Pfund RA, Ginley MK, Boness CL, et al. Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria Clin Psychol (New York), 2024.PMID 38863566
- [13]Srisurapanont M, Likhitsathian S, Suttajit S, et al. Efficacy and dropout rates of antipsychotic medications for methamphetamine psychosis: A systematic review and network meta-analysis Drug Alcohol Depend, 2021.PMID 33385693
- [14]McKetin R, Dean OM, Turner A, et al. N-acetylcysteine (NAC) for methamphetamine dependence: A randomised controlled trial EClinicalMedicine, 2021.PMID 34308314
- [15]McKetin R, Shoptaw S, Saunders L, et al. Mirtazapine for Methamphetamine Use Disorder: A Randomized Clinical Trial JAMA Psychiatry, 2026.PMID 41920558
- [16]Sinclair JMA, Kalk NJ, Kaar SJ, et al. Evidence-based consensus guidelines for the pharmacological management of substance dependence: Recommendations from the British Association for Psychopharmacology J Psychopharmacol, 2026.PMID 41731947
- [17]Fries A, Christ M, Nickl H, et al. The Diagnosis and Treatment of Stimulant-Related Emergencies Dtsch Arztebl Int, 2025.PMID 40991352
- [18]Clay S, Wilkinson Z, Ginley M, et al. The reflections of health service providers on implementing contingency management for methamphetamine use disorder in Australia Drug Alcohol Rev, 2024.PMID 38704742
- [19]Khalili M, Sadeghirad B, Bach P, et al. Management of Amphetamine and Methamphetamine Use Disorders: A Systematic Review and Network Meta-analysis of Randomized Trials Int J Ment Health Addict, 2025.PMID 41394525
- [20]Amin-Esmaeili M, Farokhnia M, Mojtabai R, et al. Evaluating Reduced Use and Abstinence as Outcomes in Pharmacotherapy Trials for Stimulant Use Disorder: A Meta-Analysis of 12 Randomized Clinical Trials JAMA Psychiatry, 2026.PMID 42234418