Managing acute stimulant intoxication in ambulatory settings: a protocol-driven case report

Background: Stimulant use and overdose (known as overamping) are rising across the United States, placing strain on the healthcare system. Harm reduction strategies and behavioral interventions for overamping are more effectively implemented in ambulatory settings, which also prevents costly emergency room utilization for this vulnerable population. However, clinical guidance for ambulatory overamping management is lacking.Objective: To address this gap, we developed a protocol for patient-centered ambulatory care and present two cases demonstrating its implementation.Methods: The protocol was developed by substance use disorder clinician and pharmacy experts. We incorporated evidence for the management of acute stimulant intoxication, clinical expertise, and implementation considerations in protocol development. The protocol was reviewed by a third-party pharmacist with expertise in psychosis treatment and stimulant use disorders. We describe protocol implementation and outcomes for two cases.Results: The protocol was implemented in patients that presented with signs of overamping and consented to treatment. First-line treatment was behavioral intervention, including environmental modifications to reduce external stimuli, remaining present, addressing acute needs, and verbal de-escalation. Second-line treatment was pharmacotherapy, including benzodiazepines followed by antipsychotics. Two cases are presented, both treated initially with behavioral measures and later pharmacotherapy. Long-term follow-up demonstrates continued care and management of stimulant use.Conclusion: Protocol-driven ambulatory care of overamping has the potential to provide patient-centered compassionate care that ensures patient follow-up and promotes continued treatment.