What is the treatment for methamphetamine (meth) intoxication in the Emergency Department (ED)?

Treatment of Methamphetamine Intoxication in the Emergency Department

Benzodiazepines are the first-line treatment for methamphetamine intoxication in the emergency department, particularly for managing agitation and autonomic hyperactivity, with additional supportive care based on specific clinical manifestations. 1

Initial Management

• Benzodiazepines: Lorazepam or diazepam should be administered as first-line agents for agitation and autonomic hyperactivity 1

  • These medications effectively reduce sympathetic overstimulation
  • Can be given orally for mild-moderate agitation or parenterally for severe agitation
  • May require repeat dosing, particularly with lorazepam 2

• Cardiovascular Management:

  • For hypertension and tachycardia: Calcium channel blockers (e.g., diltiazem) or nitrates are preferred 1
  • For chest pain with ECG changes: Administer nitrates and calcium channel blockers 1
  • For coronary vasospasm: Use nitrates and calcium channel blockers 1
  • For chest pain with ST-segment elevation: Give sublingual nitroglycerin or calcium channel blockers; consider coronary angiography for persistent symptoms 1

• Important Contraindication: Beta-blockers (including labetalol) are contraindicated as they may worsen coronary vasoconstriction 1

Supportive Care

• Fluid Management: Administer IV fluids for dehydration and to prevent rhabdomyolysis 1
• Monitoring: Continuous ECG monitoring is essential 1
• Temperature Management: Active cooling for hyperthermia (occurs in approximately 5% of cases) 3
• Laboratory Monitoring: Check for rhabdomyolysis and acute kidney injury, which occur in approximately 30% and 13% of presentations, respectively 3

Clinical Considerations

1. Acute Behavioral Disturbance:

   • Present in approximately 78% of methamphetamine intoxication cases 3
   • Oral sedation alone is effective in about 61% of patients with behavioral disturbances 3
   • Parenteral sedation is required in more severe cases

2. Alternative Sedation Options:

   • While benzodiazepines are first-line, research suggests droperidol may produce more rapid and profound sedation than lorazepam for methamphetamine toxicity 2
   • Droperidol is less likely to require repeat dosing compared to lorazepam 2

3. Disposition:

   • Most patients (approximately 84%) can be managed solely within the ED 3
   • Median length of stay is approximately 14 hours 3
   • About 11% of cases require mental health admission 3

Complications to Monitor

• Rhabdomyolysis (30% of presentations) 3
• Acute kidney injury (13% of presentations) 3
• Less common but serious complications: seizures, intracranial bleeds, and myocardial infarction 3

Treatment Pitfalls to Avoid

1. Never use beta-blockers (including labetalol) as they can worsen coronary vasoconstriction in the setting of methamphetamine intoxication 1

2. Don't underestimate fluid requirements - aggressive hydration is often needed to prevent rhabdomyolysis and acute kidney injury 1, 3

3. Don't discharge prematurely - patients require adequate observation time for symptom resolution, with median ED stays of 14 hours 3

4. Don't overlook psychiatric evaluation once the acute intoxication resolves, as many patients may have underlying psychiatric conditions requiring treatment 4