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Introduction

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Jimsonweed. Jimsonweed seed pod with dried seeds. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

 

The authors thank and acknowledge Matthew D. Sztajnkrycer, MD, PhD, FACEP, for his contributions to prior editions of this chapter.

Clinical Summary

Amphetamine toxicity may occur from abuse of prescription amphetamines, use of supplements, or use of illicit forms of the drugs. Routes of administration include ingestion, insufflation (“snorting”), parenteral injection, and smoking. Phenylethylamine is the backbone structure of amphetamines as a class, and supplements may be labeled as such. “Ice” refers to a pure preparation of methamphetamine hydrochloride in a large crystalline form. Designer amphetamines include 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) and synthetic cathinones (ingredients in “bath salts”). While the central nervous system (CNS) targets of these compounds are serotonergic and dopaminergic pathways, the clinical presentation is typically a sympathomimetic toxidrome. The structure of the compound determines if the drug has more hallucinogenic effects.

FIGURE 17.1

Amphetamine Bulk Supplements. This packet was brought with a patient who exhibited a severe sympathomimetic toxidrome after ingesting the entire packet. Note the “serving” size of 500 mg with 200 “servings” per container. (Photo contributor: Saralyn R. Williams, MD.)

Although clinically indistinguishable from cocaine toxicity, the duration of effects is appreciably longer. The most common cardiovascular manifestations are tachycardia and hypertension, although myocardial ischemia has been reported. CNS toxicity is the primary reason most amphetamine users are brought for medical care. Presentations may range from increased anxiety to life-threatening agitated delirium with hyperthermia. Visual and tactile hallucinations and psychoses are common. Poor dentition is seen among chronic methamphetamine users (“meth mouth”).

FIGURE 17.2

“Ice” Methamphetamine. An example of the “ice” form of amphetamines with a pipe. (Photo contributor: US Drug Enforcement Administration.)

FIGURE 17.3

Ecstasy. Examples of the candy-like appearance of ecstasy tablets. (Photo contributor: US Drug Enforcement Administration.)

FIGURE 17.4

Early “Meth Mouth.” “Meth mouth,” the extensive and accelerated dental caries associated with chronic methamphetamine abuse. (Photo contributor: R. Jason Thurman, MD.)

Management and Disposition

Treatment focuses on the signs and symptoms of toxicity. As with other causes of sympathomimetic toxicity, initial management includes control of the agitation to prevent other complications (eg, rhabdomyolysis). Benzodiazepines are the first-line therapy for agitation; large repeated doses may be required. Severe hyperthermia requires evaporative cooling techniques. Hypertonic sodium may be useful for MDMA-associated cerebral edema and seizures.

Pearls

  1. In addition to the medical complications associated with chronic methamphetamine use, ...

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