What is the recommended management for methamphetamine (meth) intoxication?

Management of Methamphetamine Intoxication

Benzodiazepines alone or in combination with nitroglycerin are the first-line treatment for methamphetamine intoxication, as they effectively manage agitation, hypertension, tachycardia, and psychosis while avoiding the risks of beta-blockers. 1

Initial Assessment and Stabilization

• Immediately assess airway, breathing, circulation, and neurological status 1
• Obtain ECG to evaluate for cardiac ischemia, arrhythmias, or other cardiovascular complications 1
• Consider cardiac biomarkers such as troponin to assess for myocardial injury 1
• Provide intravenous hydration and oxygen supplementation as needed 2

Primary Pharmacological Management

• Administer benzodiazepines as first-line therapy for:
  • Agitation and psychosis 1
  • Hypertension and tachycardia 1
  • Seizures 2
• Consider combining benzodiazepines with nitroglycerin for better control of hypertension and tachycardia 3, 1
• For chest pain with suspected coronary vasospasm, use:
  • Sublingual nitroglycerin 1
  • Intravenous calcium channel blockers 1

Medications to Avoid

• AVOID BETA-BLOCKERS in patients with signs of acute methamphetamine intoxication (euphoria, tachycardia, hypertension) as they may worsen coronary vasospasm through unopposed alpha-adrenergic stimulation 3, 1, 4
• Immediate-release nifedipine should be avoided in the absence of beta-blocker therapy as it can cause reflex tachycardia 4

Management of Specific Complications

Cardiovascular Complications

• For chest pain and ECG changes, manage as non-ST-elevation acute coronary syndrome but avoid beta-blockers 1
• For hypertensive crisis, consider calcium channel blockers rather than beta-blockers 1, 4
• Monitor for cardiac arrhythmias and treat according to standard protocols (avoiding beta-blockers) 5

Hyperthermia

• Aggressive cooling measures for hyperthermia 2
• Continue benzodiazepines to reduce muscle activity and heat production 2

Rhabdomyolysis

• Aggressive IV fluid administration 6
• Monitor creatine kinase, renal function, and electrolytes 6

Monitoring and Supportive Care

• Patients with ECG changes and normal cardiac biomarkers should be observed in a monitored setting for 24 hours 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
• For patients with continued production of toxicity from long-acting stimulants, extended monitoring may be necessary 6

Special Considerations and Pitfalls

• Beta-blockers should be strictly avoided during acute intoxication but can be used in patients with a history of methamphetamine use without signs of acute intoxication 1
• Methamphetamine-related cardiac complications can occur even with normal coronary arteries due to vasospasm 1
• Patients with severe agitation may require physical restraints temporarily while pharmacological management takes effect 6
• Risk of stroke, cardiac arrhythmia, and intracranial hemorrhage necessitates close neurological and cardiovascular monitoring 2, 5