What is the management for a methamphetamine (meth) overdose?

Methamphetamine Overdose Management

Immediate Stabilization and Assessment

Administer benzodiazepines as first-line therapy for all patients presenting with methamphetamine overdose to manage agitation, hypertension, tachycardia, and psychosis. 1

Initial Evaluation

• Rapidly assess airway, breathing, circulation, and neurological status upon presentation 1
• Obtain an immediate ECG to evaluate for cardiac ischemia, arrhythmias, or other cardiovascular complications 1
• Check cardiac biomarkers (troponin) to assess for myocardial injury 1
• Monitor for acute behavioral disturbance, which occurs in approximately 78% of presentations and is the most common clinical manifestation 2

Primary Pharmacological Management

Benzodiazepines (First-Line)

Benzodiazepines alone or combined with nitroglycerin are the cornerstone of treatment for sympathomimetic toxidrome from methamphetamine. 1

• Use benzodiazepines to control agitation, hypertension, tachycardia, and psychosis 1
• Oral sedation successfully manages acute behavioral disturbance in approximately 61% of patients, with parenteral sedation reserved for those who fail oral therapy 2
• Benzodiazepines can be combined with nitroglycerin for better control of hypertension and tachycardia 1

Management of Chest Pain and Cardiovascular Complications

• Administer sublingual nitroglycerin or intravenous calcium channel blockers as first-line therapy for chest pain with suspected coronary vasospasm 1
• Strictly avoid pure beta-blockers in acute methamphetamine intoxication, as they worsen coronary vasospasm through unopposed alpha-adrenergic stimulation 1
• If combined alpha-beta blockers are needed for severe hypertension, use with extreme caution 1
• Manage patients with chest pain and ECG changes as non-ST-elevation acute coronary syndrome (NSTE-ACS) but avoid beta-blockers 1

Monitoring and Observation

Duration of Observation

• Observe patients with ECG changes and normal cardiac biomarkers 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
• The median length of stay for methamphetamine presentations is approximately 14 hours 2

Complications to Monitor

• Rhabdomyolysis occurs in approximately 30% of presentations 2
• Acute kidney injury develops in approximately 13% of presentations 2
• Monitor for tachycardia (56% of cases), hypertension (42% of cases), and hyperthermia (5% of cases) 2
• Rare but serious complications include seizures, intracranial hemorrhage, myocardial infarction, and out-of-hospital cardiac arrest 2

Critical Pitfalls to Avoid

Beta-Blocker Contraindication

The most important pitfall is administering beta-blockers during acute intoxication. 1

• Beta-blockers potentiate coronary vasospasm by allowing unopposed alpha-adrenergic stimulation 1
• This contraindication applies only to patients with signs of acute intoxication (euphoria, tachycardia, hypertension) 1
• Patients with a history of methamphetamine use but without signs of acute intoxication can receive standard therapies including beta-blockers if indicated 1

Vasospasm Recognition

• Methamphetamine-related cardiac complications can occur even with normal coronary arteries due to vasospasm 1
• Do not assume normal coronary anatomy excludes cardiac risk 1

Disposition

• The majority (84%) of patients are managed solely within the emergency department and discharged home 2
• Approximately 11% require mental health admission 2
• Most patients can be managed conservatively in the emergency department without requiring intensive care 3, 2