Management of Substance Abuse

Initial Assessment and Sedation

• Verify vital signs, especially temperature, heart rate, and blood pressure, and assess the level of consciousness and agitation in patients with substance abuse, as recommended by the American Heart Association 1
• Administer benzodiazepines IV in titrated doses as the first line of treatment for sedation in patients with substance abuse, with careful monitoring to avoid respiratory depression, as suggested by the American College of Cardiology 1
• Use ketamine as an option for sedation via IM injection when IV access is difficult, such as in combative patients, as recommended by 2
• Start benzodiazepines with 2 mg IV midazolam in benzodiazepine-naïve patients, followed by 1 mg/h infusion if needed, as recommended by the American College of Emergency Physicians 3

Monitoring and Adjustment of Sedation

• Continuously monitor oxygen saturation, cardiac activity, blood pressure, and capnography (if available) in patients with substance abuse, as recommended by 2
• Adjust sedation by administering additional doses of benzodiazepines for persistent agitation, and consider vasodilators (nitrates, calcium channel blockers) for refractory hypertension, as recommended by the American Heart Association 1
• Monitor for psychiatric complications during withdrawal, as warned by the American Psychiatric Association 4

Treatment of Specific Complications

• Use rapid external cooling for hyperthermia in patients with substance abuse, as recommended by the American Heart Association 1
• Administer sodium bicarbonate or lidocaine to treat ventricular tachycardia or arrhythmias in patients with substance abuse, as recommended by the American Heart Association 1
• Use vasodilators (nitrates, calcium channel blockers) for coronary vasospasm in patients with substance abuse, as recommended by the American Heart Association 1, 5
• Use benzodiazepines, such as IV diazepam or lorazepam, as the first-line treatment for seizures in patients with substance abuse, as recommended by the Neurocritical Care Society 1

Contraindications and Precautions

• Avoid using non-selective beta-blockers in patients with acute substance intoxication, as they may potentiate coronary vasospasm due to unopposed alpha stimulation, as advised by the American College of Cardiology 5, 6
• Avoid prolonged physical restraint, as it may increase blood pressure, intracranial pressure, and promote bleeding, as recommended by 2
• Avoid using medications without evidence of efficacy, as cautioned by the American Medical Association 4

Psychosocial Support and Treatment

• Provide brief interventions (5-30 minutes) with individualized feedback, as recommended by the American Psychological Association 4
• Use Cognitive Behavioral Therapy for better retention, as stated by the American Psychological Association 4
• Use Contingency Management combined with Community Reinforcement Approach, which shows the strongest evidence for effectiveness, as recommended by the American Psychological Association 4
• Recommend Mutual help groups such as Narcotics Anonymous, as stated by the American Medical Association 4

Transportation and Communication

• Continuously monitor patients during transportation, and have emergency equipment and a prepared team available to handle complications, as recommended by 2
• Communicate with the receiving hospital prior to transportation to ensure proper care and management of patients with substance abuse, as recommended by 2