The Diagnosis and Treatment of Stimulant-Related Emergencies

Stimulants are the most commonly used illegal drugs in Germany, with a lifetime prevalence of 1.2-6.1%. In Germany, cocaine and amphetamines are the most commonly used illegal stimulants. Their use is on the rise and associated with significant morbidity, mortality, and crime. We present an overview of the management of stimulant-related disorders.

This review is based on publications retrieved from a selective search in scientific databases and AI-supported platforms, with consideration of pertinent guidelines, reviews, meta-analyses, and original papers.

Even in younger persons, stimulant use increases the risk of medical and neurological emergencies such as rhabdomyolysis (for amphetamines: 30.5%, 95% confidence interval [22.6; 38.5]) and stroke (for amphetamines: OR: 4.95 [3.24; 7.55]; for cocaine: OR: 2.33 [1.74; 3.11]). Stimulant intoxication manifests itself with agitation, aggression, or psychotic symptoms. There can also be long-term psychosis, depression, and cognitive impairment. Symptomatic acute treatment may be needed for dehydration, hyperthermia, and agitated states. Agitated patients need de-escalating communication and stimulus shielding and can be adequately treated with benzodiazepines or antipsychotic drugs in 70-90% of cases. The standard treatment for stimulant dependence is withdrawal treatment for several weeks, followed by rehabilitation therapy for several months. No type of pharmacotherapy has yet been approved for this. Cognitive behavioral therapy, contingency management, and exercise have been found to stabilize abstinence.

Stimulant-related emergencies pose a therapeutic challenge because of their varied and unpredictable course and the limited available evidence on abstinence-maintaining treatment. Symptom-oriented treatment in acute situations, supplemented by a multimodal treatment strategy to promote abstinence, is recommended.