What is the management approach for a methamphetamine overdose?

Management of Methamphetamine Overdose

The management of methamphetamine overdose should follow similar principles to cocaine-induced toxicity, focusing on treating cardiovascular complications with nitrates and calcium channel blockers as first-line agents, while avoiding beta-blockers that could worsen coronary vasospasm. 1

Initial Assessment and Stabilization

• Assess airway, breathing, circulation, and neurological status immediately 1
• Monitor vital signs including temperature, as hyperthermia (>38°C) occurs in approximately 5% of cases and may require active cooling 2
• Obtain ECG to evaluate for cardiac ischemia, arrhythmias, or other cardiovascular complications 1
• Consider cardiac biomarkers (preferably troponin) to assess for myocardial injury 1

Management of Cardiovascular Complications

• For chest pain with suspected coronary vasospasm:

  • Administer sublingual nitroglycerin or intravenous calcium channel blockers (e.g., diltiazem 20 mg IV) as first-line therapy 1
  • Avoid pure beta-blockers as they may worsen coronary vasospasm by allowing unopposed alpha-adrenergic stimulation 1
  • If combined alpha-beta blockers (e.g., labetalol) are needed for severe hypertension, use with caution 1

• For persistent chest pain with ST-segment elevation:

  • Consider coronary angiography if available 1
  • If angiography is unavailable and ST-elevation persists with clinical symptoms consistent with MI, consider fibrinolytic therapy in the absence of contraindications 1

Management of Acute Behavioral Disturbance

• Acute behavioral disturbance is the most common presentation (78% of cases) 2
  • Attempt verbal de-escalation first
  • Oral sedation is effective in approximately 61% of cases 2
  • For severe agitation, consider parenteral sedation with benzodiazepines 2
  • Maintain a calm environment and minimize stimulation 2

Monitoring and Supportive Care

• Monitor for and treat complications:

  • Rhabdomyolysis (occurs in approximately 30% of cases) - provide IV fluids 2
  • Acute kidney injury (occurs in approximately 13% of cases) - maintain adequate hydration 2
  • Hyperthermia - implement active cooling measures if temperature exceeds 39°C 2
  • Seizures - treat with benzodiazepines 2

• For patients with ECG changes and normal cardiac biomarkers:

  • Observe in a monitored setting for 24 hours, as most complications occur within this timeframe 1
  • A shorter observation period of 9-12 hours with serial troponin measurements at 3,6, and 9 hours may be appropriate in select cases 1

Disposition

• Most patients (approximately 84%) can be managed solely within the ED 2
• Median length of stay is approximately 14 hours 2
• Consider psychiatric evaluation for patients with persistent behavioral disturbances or suicidal ideation 2

Special Considerations and Pitfalls

• Avoid beta-blockers in acute methamphetamine intoxication - this is a critical pitfall as they may worsen coronary vasospasm 1
• Be aware that methamphetamine use is increasingly associated with opioid co-use, which may complicate the clinical presentation and management 3, 4
• Patients may not recognize symptoms of "overamping" (methamphetamine overdose) and rarely seek medical attention for psychological effects 5
• Fatal acute methamphetamine overdose is less common than with opioids, but deaths have increased 180% from 2015 to 2019 3
• Methamphetamine-related cardiac complications can occur even with normal coronary arteries due to vasospasm 1

Follow-up Recommendations

• Provide education about harm reduction strategies including hydration and adequate rest 5
• Screen for polysubstance use, particularly opioids, as co-use is increasingly common 3, 4
• Assess for risk factors that may complicate recovery including housing instability, lack of insurance, and comorbidities such as HIV/AIDS, hepatitis, and depression 3