Management of Methamphetamine Intoxication

Primary Management

Benzodiazepines are first-line therapy for agitation, hypertension, tachycardia, and psychosis in acute methamphetamine intoxication, as recommended by the American College of Medical Toxicology 1, 2
Avoid beta-blockers completely in acute intoxication, as they may worsen coronary vasospasm through unopposed alpha-adrenergic stimulation, according to the American Heart Association 1, 2
Nitroglycerin or calcium channel blockers should be used for chest pain with suspected coronary vasospasm, as suggested by the American College of Cardiology 1

Achieving adequate urinary acidification requires extremely high doses of ascorbic acid (12 g per day or more frequent administration every 4 hours) to maintain urine pH below 6.0, as stated by the Infectious Diseases Society of America 3
Standard doses of ascorbic acid (up to 4 g per day) show no significant effect on mean urinary pH, according to the Clinical Infectious Diseases journal 3

Immediate priorities in methamphetamine overdose include assessing core temperature, administering benzodiazepines, and obtaining an ECG, as recommended by the American College of Medical Toxicology 1, 2
If severe hyperthermia (>40°C) with continued agitation, consider immediate intubation with paralysis using nondepolarizing agents and initiate aggressive cooling measures, as suggested by the American Heart Association 2
For cardiovascular complications, use sublingual nitroglycerin or IV calcium channel blockers for chest pain and monitor cardiac biomarkers, according to the American College of Cardiology 1

No FDA-approved pharmacotherapy exists for methamphetamine use disorder, and behavioral therapies remain the evidence-based treatment approach, as stated by the American Psychiatric Association 4

Do not delay definitive treatment while attempting urinary acidification strategies, as recommended by the American College of Medical Toxicology 1, 2
Do not use ascorbic acid thinking it will enhance elimination, as the doses required are impractical and potentially nephrotoxic, according to the Infectious Diseases Society of America 3
Do not use beta-blockers even if combined alpha-beta blockers, as they worsen outcomes, as stated by the American Heart Association 1, 2