Methamphetamine Withdrawal Management in the Emergency Department
Critical First Point: Methamphetamine Withdrawal is Not Life-Threatening
Methamphetamine withdrawal, unlike alcohol or benzodiazepine withdrawal, does not cause seizures, delirium tremens, or life-threatening autonomic instability—management is entirely supportive and symptom-directed. 1, 2
Clinical Presentation and Assessment
Expected Withdrawal Timeline and Symptoms
Acute withdrawal symptoms typically emerge within 24 hours of last use and peak at 7–10 days, manifesting as profound fatigue, hypersomnia (sleeping 12–20 hours daily), depression, anhedonia, intense drug cravings, increased appetite, and psychomotor retardation. 1, 2
Psychiatric symptoms during withdrawal include anxiety, paranoia, irritability, and—in severe cases—transient psychotic symptoms (auditory/visual hallucinations, delusions) that usually resolve within 1 week but may persist longer in chronic users. 1, 2
Distinguish intoxication from withdrawal: Patients presenting with agitation, tachycardia, hypertension, hyperthermia, mydriasis, and psychomotor agitation are intoxicated, not withdrawing; true withdrawal presents with opposite features (lethargy, hypersomnia, bradycardia, hypotension). 2
Key Assessment Elements
Obtain last use timing to determine whether the patient is intoxicated (within 12–24 hours) or entering withdrawal (>24 hours since last use). 2
Screen for co-occurring opioid use disorder because polysubstance use is common; if present, initiate buprenorphine using standard protocols (COWS ≥8, appropriate waiting periods). 3, 4, 5
Assess for acute medical complications of methamphetamine use: rhabdomyolysis (check CK, creatinine), acute coronary syndrome (ECG, troponin), intracranial hemorrhage (neurologic exam, consider CT if severe headache or focal deficits), acute kidney injury, and hyperthermia. 6, 7, 2
ED Management Protocol
Supportive Care (First-Line for All Patients)
Provide a quiet, low-stimulation environment with dimmed lights and minimal noise to reduce agitation and paranoia. 1
Ensure adequate hydration and nutrition because withdrawal causes profound fatigue and increased appetite; offer oral fluids and food. 1
Allow extended sleep periods (patients may sleep 12–20 hours) as hypersomnia is the hallmark of methamphetamine withdrawal and is therapeutic, not a complication. 1
Pharmacologic Management (Symptom-Targeted)
For Agitation and Psychotic Symptoms
Administer benzodiazepines as first-line agents for agitation: lorazepam 1–2 mg IV/IM or diazepam 5–10 mg IV/PO, repeated every 15–30 minutes as needed until calm. 1, 2
Add antipsychotics for persistent agitation or psychosis after benzodiazepines: haloperidol 5 mg IM/IV or olanzapine 10 mg IM, with caution for QTc prolongation and extrapyramidal symptoms. 1, 2
Avoid physical restraints unless absolutely necessary for imminent harm; prioritize verbal de-escalation and chemical sedation. 5, 1
For Depression and Anhedonia
Do not prescribe stimulants or dopamine agonists (e.g., bupropion, modafinil) in the ED, as evidence does not support their use and they may worsen cravings. 1, 2
Consider mirtazapine 15–30 mg PO at bedtime for patients with severe insomnia, anxiety, and poor appetite during withdrawal, as it addresses multiple symptoms. 8, 1
For Insomnia (If Not Hypersomnic)
- Prescribe trazodone 50–100 mg PO at bedtime for patients with difficulty sleeping after the initial hypersomnic phase resolves. 8, 1
Adjunctive Medications
Ascorbic acid (vitamin C) 1000 mg PO daily may reduce methamphetamine toxicity by acidifying urine and enhancing renal clearance, though evidence is limited. 1
Thiamine, folate, and multivitamin supplementation should be provided to address common nutritional deficiencies in chronic users. 1
Disposition and Discharge Planning
Criteria for Admission
Admit patients with: severe agitation unresponsive to ED sedation, persistent psychotic symptoms, suicidal ideation, acute medical complications (rhabdomyolysis, AKI, intracranial hemorrhage, acute coronary syndrome), or inability to care for self due to profound withdrawal symptoms. 1, 7, 2
Consider inpatient addiction treatment for patients with severe methamphetamine use disorder who desire treatment, as intensive outpatient programs (3–5 visits weekly for ≥3 months) are the standard of care. 6, 7
Discharge Instructions for Stable Patients
Provide non-judgmental counseling and acknowledge addiction as a chronic medical condition, as patients report feeling stigmatized in the ED and avoid care due to anticipated negative interactions. 5
Link to outpatient addiction treatment by providing specific referrals (names, phone numbers, appointment dates) rather than generic advice, as patients desire concrete connections to resources. 5, 1
Prescribe symptomatic medications for home use: trazodone 50–100 mg PO nightly for insomnia, mirtazapine 15–30 mg PO nightly for depression/insomnia/appetite, and ibuprofen 400–600 mg PO every 6 hours for myalgias. 8, 1
Educate on harm reduction: Warn that tolerance drops rapidly during withdrawal, increasing overdose risk if use resumes; provide information on safer use practices and naloxone if co-using opioids. 5, 2
Screen for hepatitis C and HIV and offer testing or referral, as injection methamphetamine use carries transmission risk. 3, 4
Management of Co-Occurring Opioid Use Disorder
Buprenorphine Initiation in Polysubstance Users
Initiate buprenorphine in the ED if the patient meets criteria (COWS ≥8, appropriate waiting period since last opioid use) regardless of concurrent methamphetamine use. 3, 4
Standard buprenorphine protocol applies: 4–8 mg SL initial dose, target 16 mg daily maintenance, prescribe 3–7 days supply at discharge, and provide naloxone kit. 3, 4
Do not delay buprenorphine due to methamphetamine use, as polysubstance users have higher mortality and benefit equally from opioid use disorder treatment. 3, 4, 5
Common Pitfalls to Avoid
Mistaking intoxication for withdrawal: Agitated, hypertensive, tachycardic patients are intoxicated and require sedation, not supportive withdrawal care. 2
Over-sedating during the hypersomnic phase: Patients sleeping 12–20 hours daily are experiencing normal withdrawal; do not administer stimulants or wake them unnecessarily. 1
Discharging patients with persistent psychosis or suicidal ideation: These symptoms require psychiatric admission, not ED discharge. 1, 2
Providing only verbal referrals: Patients need concrete, written referrals with contact information and scheduled appointments to successfully link to outpatient care. 5, 1
Judgmental or dismissive interactions: Patients anticipate stigma and respond with combativeness or avoidance; non-judgmental, empathetic communication improves engagement and outcomes. 5