eMedicine Specialties > Psychiatry > Addiction
Amphetamine-Related Psychiatric Disorders: Treatment & Medication
Updated: Jan 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Initial treatment should include medically stabilizing the patient's condition by assessing his or her respiratory, circulatory, and neurologic systems. The offending substance may be eliminated by means of gastric lavage and acidification of the urine. Psychotropic medication can be used to stabilize an agitated patient with psychosis. Because most cases of amphetamine-related psychiatric disorders are self-limiting, removal of the amphetamines should suffice.
- Induced emesis, lavage, or charcoal may be helpful in the event of overdose.
- The excretion of amphetamines can be accelerated by the use of ammonium chloride, given either IV or orally (PO).
- Amphetamine intoxication can be treated with ammonium chloride, often found in OTC expectorants, such as ammonium chloride (Quelidrine), baby cough syrup, Romilar, and P-V-Tussin.
- The recommended dose to acidify the urine is ammonium chloride 500 mg every 2-3 hours.
- The ingredients in OTC cough syrups vary, and the clinician should become familiar with 1 or 2 stock items for use in the emergency department.
- Ammonium chloride (Quelidrine), an OTC expectorant, can be used in the absence of liver or kidney failure.
- Administer IV fluids to provide adequate hydration.
- If the patient is psychotic or if he or she is in danger of harming him or herself or others, a high-potency antipsychotic, such as haloperidol (Haldol), can be used. Exercise caution because of the potential for extrapyramidal symptoms, such as acute dystonic reactions, and neuroleptic malignant syndrome.
- Agitation also can be treated cautiously with benzodiazepines PO, IV, or intramuscularly (IM). Lorazepam (Ativan) and chlordiazepoxide (Librium) are commonly used.
- Administer naloxone (Narcan) in the event of concurrent opiate toxicity. Use caution to avoid precipitation of acute opioid withdrawal in a patient who has used high doses of opioid on a long-term basis.
- Beta-blockers, such as propranolol (Inderal), can be used in the event of elevated blood pressure and pulse. They also may be helpful with anxiety or panic.
- Psychiatric hospitalization may be necessary when psychosis, aggression, and suicidality cannot be controlled in a less restrictive environment.
Consultations
- Neurologist
- Internal medicine specialist
- Psychiatrist: Consult for inpatient substance abuse treatment or further psychiatric stabilization.
- Social services: Social services coordinate outpatient services, such as Alcoholics Anonymous and Narcotics Anonymous meetings and sober houses, and provide appointments. Some large metropolitan areas have groups that specifically focus on crystal methamphetamine abuse in the gay population.
Activity
Patients intoxicated with amphetamines are dangerous, and their activity should be limited (eg, no driving) until their symptoms have resolved.
Medication
Several psychiatric conditions can be associated with amphetamine intoxication and withdrawal, all of which may require different management strategies. However, amphetamine-related psychiatric disorders are typically self-limited and usually remit on their own.
Amphetamine-related psychiatric disorders occur most often during intoxication; therefore, treatment should focus on controlling medical and psychiatric symptoms while eliminating the offending substance. Medical therapy involves stabilizing agitation and minimizing psychosis. Gastric lavage directly removes the amphetamines before they have an opportunity to be absorbed. Medication and charcoal eliminate amphetamines from the gastrointestinal and circulatory systems.
If the induced disorders persist and interfere with the patient's social and occupational functioning, treatment should be related to the remaining psychiatric symptoms. Antidepressants, such as sertraline (Zoloft), fluoxetine (Prozac), paroxetine (Paxil), and citalopram (Celexa), can be used to treat depression. Antimanic agents, such as valproic acid (Depakote), carbamazepine (Tegretol), and lithium carbonate, can be used to treat mania. Anxiety can be treated with nonbenzodiazepine drugs, such as beta-blockers and antimanic agents.
Data from recent studies suggest typical antipsychotics (haloperidol thioridazine, Thorazine, etc) may increase amphetamine and cocaine cravings in patients with dual diagnoses of amphetamine and cocaine abuse. Typical antipsychotics should be used for acute stabilization with the intention of switching to an atypical antipsychotic drug (eg, risperidone, quetiapine, olanzapine, aripiprazole, and ziprasidone) for long-term use.
For the purposes of this discussion, specific treatment of amphetamine toxicity is reviewed. For further information, please refer to the articles on Depression, Substance-Induced Mood Disorder, Depressed Type, Bipolar Affective Disorder, Schizophrenia, Anxiety Disorders, and Sleeping Disorders.
Antipsychotics
Clinicians should select a high-potency antipsychotic that is available in tablet, liquid, and IM forms for administration in emergency situations. Antipsychotics help control psychotic symptoms and provide rapid tranquilization of the agitated and psychotic patient.
Haloperidol (Haldol)
Provides rapid sedation of agitated anxious patient; available PO and IM, allowing for flexible, emergency administration.
Adult
2-5 mg PO/IV/IM
Pediatric
0.5-2 mg PO/IV/IM
May increase TCA serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathy-like syndrome associated with concurrent administration of lithium
Documented hypersensitivity; narrow-angle glaucoma; bone-marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe cardiovascular disease and in patients receiving anticonvulsants, anticoagulants, or rifampin; may increase prolactin levels; may cause extrapyramidal symptoms of muscle rigidity, inability to walk or talk, akathisia, and dystonia (opisthotonos and oculogyric crisis); extrapyramidal symptoms readily treated with benztropine mesylate (Cogentin), diphenhydramine (Benadryl) PO/IV/IM, or trihexyphenidyl (Artane)
Thiothixene (Navane)
Blocks postsynaptic blockade of CNS dopamine receptors, inhibiting dopamine-mediated effects. PO and IM forms allow for rapid tranquilization.
Adult
5-20 mg PO/IM single dose or divided throughout day
Pediatric
2.5-10 mg PO/IM single dose or divided throughout day
Decreases effects of guanethidine; increases toxicity of CNS depressants, anticholinergics, and alcohol
Documented hypersensitivity; lactation; circulatory collapse; comatose; CNS depression by any cause; blood dyscrasias
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Increases prolactin levels; increases photosensitivity; caution in cardiovascular disease and history of convulsions or state of alcohol withdrawal (may precipitate seizures); may cause extrapyramidal symptoms of muscle rigidity, inability to walk or talk, akathisia, and dystonia (opisthotonos and oculogyric crisis); extrapyramidal symptoms readily treated with benztropine mesylate (Cogentin), diphenhydramine (Benadryl) PO/IV/IM, or trihexyphenidyl (Artane)
Benzodiazepines
These drugs are primarily used to sedate agitated patients. Availability in PO, IV, and IM forms allowing the drug to be used in emergency situations. Caution must be used in the violent, aggressive patient because benzodiazepines may cause disinhibition.
Lorazepam (Ativan)
Provides rapid onset and efficacy in sedating aggressive patient; flexible administration in emergency situation.
Adult
5-10 mg PO/IV/IM single dose or divided over 24 h
Pediatric
1-5 mg PO/IV/IM single dose or divided throughout day
Toxicity of benzodiazepines in CNS increases with concurrent alcohol, phenothiazines, barbiturates, or MAOIs
Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Because of concern of sedation in elderly and debilitated patients, initial doses should be 2 mg; caution in renal or liver failure; paradoxical excitement can occur, resulting in rage behavior; should be used with caution in patients who are depressed and at risk of suicide
Chlordiazepoxide (Librium, Libritabs, Mitran)
Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing activity of gamma-aminobutyric acid (GABA) activity, major inhibitory neurotransmitter.
Adult
25-50 mg PO and repeat in 2-4 h if necessary
Pediatric
Not established
Coadministration with alcohols, phenothiazines, barbiturates, and MAOIs increases CNS toxicity; cisapride can significantly increase levels
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients receiving other CNS depressants or with low albumin levels or hepatic failure
Opiate antagonists
These drugs inhibit the action of opiates.
Naloxone (Narcan)
Used to treat concurrent opiate toxicity. Consider in patients with altered mental status due to opiate overdose. Poorly absorbed PO route and should be administered IM or IV. Available in IV, IM, and SC forms. Use caution to avoid precipitating acute opioid withdrawal in patient using opioids long term.
Adult
0.4-2 mg IV/IM/SC/ET
Pediatric
Not established
Decreases analgesic effects of narcotics
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease; naloxone may precipitate withdrawal symptoms in patients addicted to opiates
Beta-blockers
Propranolol (Inderal) is useful in patients who are agitated, anxious, and hyperarousable because of amphetamines. They are temporarily used until the amphetamine is eliminated from the patient's system. For some patients, anxiety can be prolonged, and nonaddictive beta-blockers may be helpful.
Propranolol (Inderal)
Antihypertensive agent useful in psychiatry to treat anxiety and impulse control. Often well tolerated with minimal effect on hemodynamics of blood pressure and pulse.
Adult
Immediate control of anxiety: 40 mg PO 1 dose
Persistent anxiety: 10 mg PO hs to 40 mg bid as initial dose, reaching maintenance dose not to exceed 120-240 mg qd
Pediatric
Acute anxiety: 0.5 mg/kg PO 1 dose
Persistent anxiety: 1 mg/kg PO per dosage schedule (0.5 mg/kg bid)
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity; may increase toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines
Toxicity of benzodiazepines in CNS increases with concurrent alcohol, phenothiazines, barbiturates, or MAOIs; cardiogenic shock; sinus bradycardia; bronchial asthma; heart failure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Not indicated for hypertensive emergencies; use with caution in impaired renal or liver function; may reduce intraocular pressure and should be used with caution in glaucoma because withdrawal can cause rebound increase in intraocular pressure
Expectorants
Expectorants are used to acidify the urine and increase amphetamine excretion when intoxication from amphetamines has resulted in psychiatric and medical complications. These agents are available in PO form, and the patient must be able to swallow or receive a nasogastric tube.
Ammonium chloride (Quelidrine)
Commonly used as OTC expectorant; acidifies urine at high doses. Safe and easy to use.
Adult
Acidification of urine: 500 mg PO/IV q2-4h
As expectorant: 300 mg PO/IV q2-4h
Pediatric
Not established
May reduce aspirin, chlorpropamide, ephedrine, methadone, pseudoephedrine, spirolactone, and para aminosalicylic acid
Documented hypersensitivity; severe hepatic and renal dysfunction; primary respiratory acidosis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic and renal impairment
Adsorbents
These agents, given through a nasogastric tube into the stomach, absorb intentionally and accidentally ingested substances to prevent their further absorption into the systemic circulation.
Activated charcoal suspension (Actidose-aqua, Inst-Aqua, Liquid-Char)
Bottles and tubes. Use long after amphetamine ingestion can reduce systemic levels by adsorbing amphetamines recirculating through gastric mucosa.
Adult
Bottle: 25-50 mg PO; dose depends on size of patient
Tube: 15-50 mg PO; dose depends on size of patient
Pediatric
Bottle: 25-50 mg PO; dose depends on size of patient; should begin with 15 mg in children and increase to 50 mg in adolescents; safe and well tolerated
Tube: 15-50 mg; dose depends on size of patient; should begin with 15 mg in children and increase to 50 mg in adolescents; safe and well tolerated
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix charcoal with sherbet, milk, or ice cream (decreases adsorptive properties)
Documented hypersensitivity; poisoning or overdosage of mineral acids and alkalies
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Not effective in ethanol, methanol, or iron-salt poisoning; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns black
More on Amphetamine-Related Psychiatric Disorders |
| Overview: Amphetamine-Related Psychiatric Disorders |
| Differential Diagnoses & Workup: Amphetamine-Related Psychiatric Disorders |
 Treatment & Medication: Amphetamine-Related Psychiatric Disorders |
| Follow-up: Amphetamine-Related Psychiatric Disorders |
| References |
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Further Reading
Keywords
amphetamine-induced psychotic disorders, amphetamine-induced psychosis, amphetamine, amphetamine derivatives, methamphetamine, dextroamphetamine, 3, 4-methylenedioxymethamphetamine, MDMA, cathinone, methcathinone, ecstasy, XTC, methamphetamine, crystal meth, crystal methamphetamine, ice, khat, Catha edulis Forsk, Qat tree, psychosis, delusions, hallucinations, depression, bipolar affective disorder, schizophrenia, sleep disorders, delirium, para -methoxyamphetamine, PMA, 2, 5-dimethoxy-4-bromo-amphetamine, DOB, 3, 4-methylenedioxyamphetamine, MDA
