What medications are suitable for a 38-year-old male (YOM) with methamphetamine (meth)-induced psychosis prior to discharge from the Emergency Department (ED)?

From the Guidelines

For a 38-year-old male with methamphetamine-induced psychosis being discharged from the ED, I recommend prescribing a short course of an atypical antipsychotic such as olanzapine 5-10 mg daily or risperidone 1-2 mg twice daily for 3-7 days, as supported by 1. These medications help manage acute psychotic symptoms like paranoia, hallucinations, and agitation while the methamphetamine clears from the system.

Key Considerations

• Benzodiazepines such as lorazepam 1-2 mg every 6-8 hours as needed can be added for severe agitation or insomnia, but limit to 3-5 days to prevent dependence, as suggested by 1.
• The patient should be discharged with a clear follow-up plan within 2-3 days with addiction services and mental health providers.
• Antipsychotics work by blocking dopamine receptors, counteracting the excessive dopamine release caused by methamphetamine.
• It's essential to note that these medications are for short-term symptom management only, and the definitive treatment requires addressing the underlying substance use disorder through comprehensive addiction treatment.

Medication Details

• Olanzapine: 5-10 mg daily for 3-7 days
• Risperidone: 1-2 mg twice daily for 3-7 days
• Lorazepam: 1-2 mg every 6-8 hours as needed for severe agitation or insomnia, limited to 3-5 days

Follow-up Care

• Schedule a follow-up appointment with addiction services and mental health providers within 2-3 days of discharge
• Ensure the patient has a clear understanding of their treatment plan and the importance of follow-up care

From the FDA Drug Label

In a 4-week placebo-controlled trial (n=115) which involved a dose range of olanzapine (5-20 mg/day, once daily, starting at 15 mg/day), olanzapine was superior to placebo in the reduction of Y-MRS total score The efficacy of oral olanzapine with concomitant lithium or valproate in the treatment of manic or mixed episodes was established in 2 controlled trials in patients who met the DSM-IV criteria for bipolar I disorder with manic or mixed episodes. In clinical trial and postmarketing experience, events of leukopenia/neutropenia have been reported temporally related to atypical antipsychotic agents, including quetiapine.

Medications for Meth-Induced Psychosis:

• Olanzapine: may be effective in reducing symptoms of psychosis, as evidenced by its efficacy in treating manic or mixed episodes in bipolar I disorder.
• Quetiapine: may also be considered, but its use requires careful monitoring of complete blood count (CBC) and thyroid function due to potential risks of leukopenia/neutropenia and hypothyroidism.

Key Considerations:

• Monitor patients for potential side effects and adjust treatment accordingly.
• Consider concomitant treatment with lithium or valproate for enhanced efficacy.
• Regularly assess the need for maintenance treatment and adjust the dose as needed. 2 3

From the Research

Medications for Meth-Induced Psychosis

When discharging a 38-year-old male with meth-induced psychosis from the emergency department, the following medications may be considered:

• Olanzapine: an antipsychotic medication that has been shown to be effective in managing methamphetamine-induced psychosis 4
• Quetiapine: an antipsychotic medication that has been found to be effective in reducing symptoms of psychosis, including hallucinations and delusions 5, 6
• Risperidone: an antipsychotic medication that has been shown to be effective in managing psychosis, although it may not be as effective as quetiapine in reducing hallucinations 5, 6
• Ziprasidone: an antipsychotic medication that has been found to be effective in reducing symptoms of psychosis, including hallucinations 6

Considerations for Medication Selection

When selecting a medication, the following factors should be considered:

• The patient's symptoms and diagnosis: quetiapine may be a good option for patients with hallucinations, while olanzapine may be a good option for patients with methamphetamine-induced psychosis 4, 6
• The patient's substance use history: substance use does not appear to influence the general magnitude of side effects of antipsychotic medication, but may affect the occurrence of specific side effects 7
• The patient's medical history and potential interactions with other medications: the patient's medical history and current medications should be carefully reviewed to minimize potential interactions and side effects.

Potential Side Effects

The potential side effects of these medications should also be considered:

• Olanzapine: may cause increased hip circumference and other metabolic side effects 5
• Quetiapine: may cause increased dream activity, reduced salivation, and gynecomastia in patients with substance use 7
• Risperidone: may cause galactorrhoea and other neurological side effects 5
• Ziprasidone: may cause fewer side effects compared to other antipsychotic medications, but may still cause some neurological and metabolic side effects 5, 6