Psych · Addiction psychiatry — stimulant intoxication and withdrawal
Stimulant intoxication and withdrawal
Also known as Methamphetamine intoxication · Stimulant toxicity · Ice intoxication · Crystal meth crash · Amphetamine withdrawal · Cocaine intoxication · Methamphetamine-associated psychosis · MAP · Sympathomimetic toxidrome
Fellowship-depth atlas on stimulant intoxication and withdrawal as acute clinical states — medical toxicity (hyperthermia, ACS, rhabdomyolysis, stroke), behavioural disturbance, methamphetamine-associated psychosis, crash time course and suicide risk, supportive care, and the explicit absence of an approved anti-craving or substitution standard of care. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Hyperthermia, chest pain, severe hypertension, seizure, focal neurology or rising CK — medical emergency before psychiatric labelling
- Agitated delirium with fluctuating consciousness — exclude organic causes; do not assume pure behavioural disturbance
- Active suicidal intent in the crash phase (especially days 1–3) — same-day senior review and documented safety plan
- Restraint of a hyperthermic, agitated patient without cooling and medical monitoring — risk of death
- Polysubstance collapse (meth + GHB, opioids, alcohol) — reverse opioids if indicated; observe for delayed respiratory depression
- Persistent psychosis after confirmed abstinence — dual formulation; do not force lifelong primary psychosis label on day one without timeline
Meet the patient
A 30-year-old is brought in by ambulance mid-binge: agitated, paranoid, convinced the staff are actors, picking at his skin, pulse 132, blood pressure 188/110, temperature 39.2. He has been awake for four days. The emergency registrar asks psychiatry to review for "behavioural."[3][15]
Before any formulation, the questions that keep him alive are medical: is he cooking, is his heart ischaemic, is his muscle breaking down, and is he about to seize or stroke? The psychiatric label comes second, every time.[5][15]
References16ShowHide
- [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]McGregor C, Srisurapanont M, Jittiwutikarn J, et al. The nature, time course and severity of methamphetamine withdrawal Addiction, 2005.PMID 16128721
- [3]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
- [4]McKetin R, Lubman DI, Najman JM, et al. Does methamphetamine use increase violent behaviour? Evidence from a prospective longitudinal study Addiction, 2014.PMID 24400972
- [5]Kevil CG, Goeders NE, Woolard MD, et al. Methamphetamine Use and Cardiovascular Disease Arterioscler Thromb Vasc Biol, 2019.PMID 31433698
- [6]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
- [7]Ronsley C, Nolan S, Knight R, et al. Treatment of stimulant use disorder: A systematic review of reviews PLoS One, 2020.PMID 32555667
- [8]Trivedi MH, Walker R, Ling W, et al. Bupropion and Naltrexone in Methamphetamine Use Disorder N Engl J Med, 2021.PMID 33497547
- [9]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
- [10]Colfax GN, Santos GM, Das M, et al. Mirtazapine to reduce methamphetamine use: a randomized controlled trial Arch Gen Psychiatry, 2011.PMID 22065532
- [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]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
- [14]McKetin R, Dean OM, Turner A, et al. N-acetylcysteine (NAC) for methamphetamine dependence: A randomised controlled trial EClinicalMedicine, 2021.PMID 34308314
- [15]Fries A, Christ M, Nickl H, et al. The Diagnosis and Treatment of Stimulant-Related Emergencies Dtsch Arztebl Int, 2025.PMID 40991352
- [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