A 25-year-old man is brought to the emergency department by police for aggressive behavior. The patient is combative and shouts sexually aggressive remarks at the nursing staff. While obtaining the patient’s vitals, it is noted that he has markedly dilated pupils. His temperature is 98.2°F (36.8°C), pulse is 112/min, blood pressure is 130/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. Urine toxicology is obtained and sent off. Physical exam is notable for an energetic patient with dilated pupils and increased sweating. The patient spends the night in the emergency department. In the morning the patient is withdrawn and has a notable depressed affect. He apologizes for his behavior the previous night and states that he is concerned about his problem and wants help. Which of the following is appropriate management of this patient?

Referral to substance abuse treatment program

Motivational interviewing session

Discharge with outpatient follow-up

Psychiatric evaluation and assessment

A 28-year-old man is brought to the emergency department after he was found half dressed and incoherent in the middle of the road. In the emergency department he states that he has not slept for 36 hours and that he has incredible ideas that will make him a billionaire within a few months. He also states that secret agents from Russia are pursuing him and that he heard one of them speaking through the hospital intercom. His past medical history is significant only for a broken arm at age 13. On presentation, his temperature is 102.2°F (39°C), blood pressure is 139/88 mmHg, pulse is 112/min, and respirations are 17/min. Physical exam reveals pupillary dilation and psychomotor agitation. Which of the following mechanisms is most likely responsible for this patient's symptoms?

Increased biogenic amine release

N-methyl-D-aspartate receptor antagonist

Gamma-aminobutyric acid receptor agonist

A 22-year-old man presents to the emergency department with anxiety. The patient states that he is very anxious and has not been able to take his home anxiety medications. He is requesting to have his home medications administered. The patient has a past medical history of anxiety and depression. His current medications include clonazepam, amitriptyline, and lorazepam. Notably, the patient has multiple psychiatric providers who currently care for him. His temperature is 99.2°F (37.3°C), blood pressure is 130/85 mmHg, pulse is 112/min, respirations are 22/min, and oxygen saturation is 100% on room air. Physical exam is notable for an anxious, sweating, and tremulous young man who becomes more confused during his stay in the emergency department. Which of the following should be given to this patient?

Supportive therapy and monitoring

Stimulant use disorders — USMLE Lesson

Stimulants 101 - The Fast Lane

Core Mechanism: Primarily block reuptake of key monoamines, leading to ↑ synaptic levels.
- Dopamine (DA): Central to reward, motivation, and addiction.
- Norepinephrine (NE): Mediates sympathomimetic effects (↑ heart rate, blood pressure).
- Serotonin (5-HT): Influences mood and perception.
Key Agents & Nuances:
- Cocaine: Pure reuptake inhibitor (DA > NE > 5-HT).
- Amphetamines: Inhibit reuptake AND enhance presynaptic release of DA and NE.
- MDMA (Ecstasy): Similar to amphetamines but with greater 5-HT effects.

Stimulant-induced neurotransmitter reuptake inhibition

⭐ Cocaine is unique among stimulants for its additional local anesthetic and potent vasoconstrictive effects, achieved by blocking sodium channels. This vasoconstriction can lead to myocardial infarction and nasal septal perforation.

Clinical Picture - Highs and Crashes

Intoxication ("High")	Withdrawal ("Crash")
Psychiatric: * Euphoria, grandiosity * Psychomotor agitation * Anxiety, paranoia, psychosis * Tactile hallucinations (e.g., "cocaine bugs")	Psychiatric: * Severe depression ("crash") * Anhedonia, dysphoria * Suicidal ideation * Intense craving
Physical: * Sympathetic overdrive: ↑ HR, ↑ BP * Mydriasis (pupil dilation) * Diaphoresis, hyperthermia * Seizures, cardiac arrhythmias	Physical: * Fatigue, lethargy * Hypersomnia, vivid dreams * Increased appetite * Psychomotor retardation

Complications - The Body Under Siege

Cardiovascular:
- Acute Coronary Syndrome (vasospasm-induced MI).
- Aortic Dissection (from severe hypertension).
- Chronic use → Dilated Cardiomyopathy.
- Tachyarrhythmias, sudden cardiac death.
Neurological:
- Stroke (ischemic & hemorrhagic).
- Seizures (lowered threshold).
- Severe hyperthermia → rhabdomyolysis.
Psychiatric:
- Psychosis: Paranoid delusions, hallucinations (visual, tactile).
- Formication: Sensation of insects crawling on skin.

CT scan: Intracerebral hemorrhage from stimulant use

⭐ In stimulant-induced chest pain, avoid isolated beta-blockers. This can cause unopposed alpha-stimulation, worsening coronary vasospasm. Prioritize benzodiazepines.

Management - The Intervention Playbook

Acute Intoxication: Primarily supportive and symptom-directed.
- Agitation/Psychosis: Benzodiazepines (e.g., lorazepam).
- Hyperthermia (>40°C / 104°F): Rapid cooling measures.
- Severe Hypertension: Phentolamine, nitroprusside.
- Avoid pure beta-blockers (risk of unopposed alpha-stimulation).
Withdrawal: Supportive care is the mainstay.
- Focus on monitoring for depression and suicidal ideation.
Long-Term Treatment: Psychosocial interventions are first-line.
- Cognitive-Behavioral Therapy (CBT): Develops coping skills.
- Contingency Management: Uses motivational incentives (vouchers, prizes) to promote abstinence.

⭐ There are currently no FDA-approved medications for the treatment of stimulant use disorder. Management relies heavily on psychosocial support and symptomatic treatment.

High-Yield Points - ⚡ Biggest Takeaways

Stimulant intoxication mimics sympathetic overdrive: ↑ HR, ↑ BP, mydriasis, agitation, and potential for cardiac ischemia or seizures.

Withdrawal presents as a "crash" with severe depression, hypersomnia, fatigue, and intense craving.

Manage acute intoxication with benzodiazepines; avoid beta-blockers in cocaine toxicity due to risk of unopposed alpha-stimulation.

Chronic use can cause dilated cardiomyopathy, psychosis with tactile hallucinations (formication), and severe dental caries ("meth mouth").

The core mechanism is ↑ dopamine in the synaptic cleft.

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