Stimulant Intoxication is a substance-related disorder caused by recent use of amphetamine-type substances, cocaine, or other stimulants resulting in clinically significant behavioural, psychological, or physiological changes that develop during or shortly after substance use.

Stimulant intoxication may present with cardiovascular, neurological, psychiatric, and metabolic complications depending on the type of stimulant used, dose, route of administration, and individual factors.

Epidemiology

• Stimulant intoxication is associated with the misuse of substances such as cocaine, amphetamines, methamphetamine, and other stimulant drugs

• It contributes significantly to emergency department presentations due to agitation, psychosis, cardiovascular complications, and seizures

• Stimulant use disorders are associated with increased risks of mental health disorders, infectious diseases, and social impairment

Risk Factors

• History of stimulant use disorder

• Previous substance use disorders

• Peer influence and social environment

• Coexisting psychiatric disorders

• Easy access to stimulant substances

• High-dose or repeated stimulant use

• Use of multiple substances simultaneously

• Stressful life events

Pathophysiology

Stimulants increase activity of the central nervous system primarily by enhancing catecholamine neurotransmission, particularly dopamine, norepinephrine, and serotonin. Increased sympathetic activity results in cardiovascular stimulation, elevated alertness, agitation, anxiety, psychosis, and, in severe cases, seizures, hyperthermia, cardiovascular collapse, or coma.

Clinical Presentation

Clinical manifestations vary depending on the stimulant used, amount consumed, and duration of exposure.

Cardiovascular Features

• Increased heart rate

• Decreased heart rate in some cases

• Elevated blood pressure

• Reduced blood pressure in severe cases

• Chest pain

• Cardiac arrhythmias

Neurological and Psychiatric Features

• Psychomotor agitation

• Restlessness

• Anxiety

• Irritability

• Confusion

• Paranoia

• Hallucinations

• Psychosis

• Seizures

• Reduced consciousness or coma

Other Features

• Pupillary dilation

• Sweating

• Chills

• Nausea or vomiting

• Weight loss

• Muscle weakness

• Respiratory depression in severe toxicity

Diagnostic Criteria (DSM-5)

Diagnosis requires:

• Recent use of an amphetamine-type substance, cocaine, or another stimulant

• Clinically significant behavioural or psychological changes developing during or shortly after stimulant use

• Evidence of impairment in functioning

The condition is manifested by at least two of the following signs or symptoms:

• Increase or decrease in heart rate

• Pupillary dilation

• Increased or decreased blood pressure

• Perspiration or chills

• Nausea or vomiting

• Evidence of weight loss

• Psychomotor agitation or retardation

• Muscular weakness

• Respiratory depression

• Chest pain or cardiac arrhythmias

• Confusion

• Seizures

• Coma

Symptoms should not be better explained by another medical condition or another substance.

Differential Diagnosis

• Anxiety disorders

• Panic attacks

• Acute psychosis

• Schizophrenia

• Alcohol intoxication

• Opioid intoxication

• Sedative-hypnotic intoxication

• Hyperthyroidism

• Hypoglycaemia

• Delirium due to medical illness

• Epileptic seizure

Investigations

Investigations depend on clinical severity and suspected complications.

Laboratory

Investigations

• Blood glucose

• Full blood count

• Serum electrolytes

• Renal function tests

• Liver function tests where indicated

• Creatine kinase if rhabdomyolysis is suspected

• Toxicology screening where available

• Cardiac enzymes if myocardial injury is suspected

Additional Assessment

• Electrocardiogram for chest pain, arrhythmias, or significant stimulant exposure

• Continuous monitoring of vital signs in severe cases

• Assessment of body temperature

• Mental status examination

• Suicide risk assessment where indicated

Management

Treatment Goals

• Stabilize airway, breathing, and circulation

• Control agitation and behavioural disturbance

• Treat psychosis and complications

• Prevent cardiovascular and neurological complications

Non-Pharmacological Management

• Provide a calm and low-stimulation environment

• Assess and maintain airway, breathing, and circulation

• Monitor vital signs including temperature and oxygen saturation

• Provide reassurance and supportive care

• Manage dehydration and electrolyte abnormalities

• Assess for suicidal behaviour or risk of harm to others

• Provide counselling and referral for substance use treatment after stabilization

Pharmacological Management

Treatment is mainly supportive and directed at the symptoms experienced by the patient.

Agitation or Aggressive Behaviour

If the patient presents with severe agitation or aggressive and disruptive behaviour, manage according to the protocol for aggressive and disruptive behaviours.

Psychosis Associated with Stimulant Intoxication

Chlorpromazine 100–1000 mg orally in divided doses per day. Maximum dose 1000 mg per day.

OR

Haloperidol 1.5–6 mg orally in divided doses per day. Maximum dose 20 mg per day.

Notes

• Treatment should be individualized according to clinical presentation

• Monitor for adverse effects including sedation, extrapyramidal symptoms, and cardiovascular effects

• Address the underlying stimulant use disorder after acute intoxication has resolved

Referral Criteria

Refer to the next level of care if:

• Severe agitation requiring intensive management

• Psychosis not responding to initial treatment

• Seizures

• Chest pain or suspected acute coronary syndrome

• Cardiac arrhythmias

• Severe hypertension

• Hyperthermia

• Reduced consciousness or coma

• Suicidal ideation or severe behavioural disturbance

• Recurrent stimulant intoxication

• Suspected stimulant use disorder requiring specialist treatment

Complications

• Acute psychosis

• Cardiovascular complications

• Myocardial infarction

• Cardiac arrhythmias

• Stroke

• Seizures

• Hyperthermia

• Rhabdomyolysis

• Acute kidney injury

• Suicidal behaviour

• Death

Prevention

• Public education regarding stimulant-related harms

• Early identification of stimulant misuse

• Screening for substance use disorders

• Access to counselling and rehabilitation services

• Treatment of underlying psychiatric disorders

• Harm reduction education

Prognosis

Prognosis depends on the severity of intoxication, type of stimulant used, presence of complications, and access to treatment. Most acute symptoms improve with supportive care, but recurrent intoxication increases the risk of psychiatric, cardiovascular, and social complications.

Patient Education

• Stimulant intoxication can cause serious medical and psychiatric complications

• Avoid mixing stimulants with alcohol or other substances

• Seek urgent medical care for chest pain, seizures, severe agitation, confusion, or loss of consciousness

• Substance use disorders are treatable conditions requiring ongoing support

• Counselling and rehabilitation reduce the risk of relapse