The ‘meth’ epidemic: Managing acute psychosis, agitation, and suicide risk
Methamphetamine-induced psychosis is difficult to differentiate from a primary thought disorder, especially in patients who
show signs of both.
Medical-Surgical Consultation
Ensuring safety. Ms. A, age 41, is admitted to the trauma surgery service after a motor vehicle accident in which she was the driver. She has long-standing methamphetamine dependence and is severely agitated. Urine drug testing is positive for methamphetamine, marijuana, and alcohol. Her alcohol serum level of 165 mg/dL exceeds the legal threshold for intoxication.
Tibial and fibular fractures sustained in the car accident require open reduction and internal fixation. On the postsurgical floor 2 days later, Ms. A remains “extremely irritable, dysphoric, and suicidal,” according to the trauma surgery consultation. Staff is concerned about her boyfriend’s behavior: “We think he’s using drugs and might be bringing her drugs.”
Understanding Ms. A’s behavior requires us to consider a broad range of diagnostic contributors, including:
- untreated withdrawal from alcohol or other drugs
- delirium from ongoing effects of the trauma or corrective operation
- inadequate pain control, particularly given her history of substance dependence
- psychiatric comorbidity.
Management includes:
- monitoring for withdrawal and treating it if symptoms emerge
- identifying and minimizing medical factors contributing to confusion, and medicating agitation with psychotropics
- providing adequate analgesia, mindful that dosing may need to be aggressive—particularly if the abused substances include narcotics
- assessing for pre-existing and methamphetamine-induced psychiatric disorders.
If the patient is cognitively able to cooperate, perform a thorough suicide assessment and provide initial supportive and cognitive-behavioral therapy to target suicidal behavior. Consider one-to-one monitoring, depending on the potential for deliberate self-injury, and guard against impulsive actions occurring in a drug- or treatment-induced delirium that could endanger the patient or staff.
A one-to-one monitor also can watch for smuggled contraband. When hospitalized, patients who are chronic substance abusers are prone to continue using illicit substances smuggled in by associates, such as the boyfriend in this case. Consider further testing for illicit drugs if you suspect smuggling.
Acute Psychiatric Inpatient
Initial diagnosis and treatment planning. Miss G, age 23 and homeless, is admitted directly to the inpatient psychiatric unit from an urgent care clinic. She reports being “depressed and suicidal.” An intermittent methamphetamine abuser, she says she last used the drug the previous day.
Miss G reveals that she is on probation for forged checks and drug use. She believes she failed a random urinalysis given earlier in the day as a condition of her probation, and she fears being sent back to jail. Her history includes childhood sexual abuse and emotional abuse in a relationship that ended the previous year.
Take the long-term view. Emergency room physicians and psychiatrists often disagree about drug testing in the ED. Emergency medicine physicians argue that the yield is low and results do not affect short-term ED management. However, we believe that drug testing is essential during the initial evaluation and that, at a minimum, urine toxicology screening must be performed to aid diagnosis and subsequent treatment planning.
A positive toxicology screen provides nearly irrefutable evidence with which to confront a resistant patient who is likely to be involved with the criminal justice system. In a study by Perrone et al,28 the patient history combined with drug testing was most likely to identify substance abuse. Overreliance on either the history or testing alone was flawed.
Objective data. In our experience, patients with legal problems often deny drug abuse. A toxicology screen provides objective data on concomitant use of other substances abused by many methamphetamine users to temper methamphetamine-related insomnia, anxiety, and overstimulation. Hair testing, a promising tool being investigated, may allow more substance abuse to be detected and possibly determine the level of use.29
Physical examination shows multiple erythematous excoriations on her arms from repetitive picking at her skin, poor dentition, and cachexia. She reports multiple recent sexual partners without using condoms. She cannot remember when she last menstruated, and she doesn’t recall ever being tested for sexually transmitted disease.
As in any medical setting involving methamphetamine abusers, acute management of psychiatric inpatients includes careful attention to methamphetamine-related physical conditions—in Miss G’s case possible sexually transmitted diseases, pregnancy, cellulitis, and dental disease.
Mood and anxiety disorders. Methamphetamine users may present with depressive symptoms and suicidality.18,30 In a study of Taiwanese methamphetamine abusers who had recently quit the drug, depressive symptoms were common on cessation but often resolved without antidepressants within 2 to 3 weeks.30 Evidence on antidepressant use in the methamphetamine-dependent patient is limited, and the existing studies have yielded conflicting results (as we will detail in part 2 of this article).
For patients previously diagnosed with mood or anxiety disorders, do not restart psychotropics until you have considered how methamphetamine use is contributing to the immediate presentation. We recommend initial observation for several weeks before starting an antidepressant if there is no pre-methamphetamine history of mood or anxiety symptoms.
