Problematic cocaine or amphetamine-type stimulant use meeting >=2 of 11 DSM-5-TR criteria in 12 months.
Also known as: cocaine use disorder, methamphetamine use disorder, stimulant addiction
Overview
A pattern of amphetamine-type or cocaine use leading to clinically significant impairment or distress, with >=2 of 11 DSM-5-TR criteria in 12 months. Methamphetamine and cocaine deaths are rising sharply, often driven by fentanyl co-exposure.
Epidemiology
Past-year cocaine use ~2%; methamphetamine ~0.6% of US adults; substantial increase in stimulant-involved overdose deaths in last decade.
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Question 1PsychiatryMedium
A 28-year-old man presents to the ED with agitation, mydriasis, hypertension (170/100), tachycardia, diaphoresis, and visual hallucinations after a party. He insists "spiders are crawling on the walls." Toxicology is pending. Which of the following is the most likely cause?
APhencyclidine (PCP) intoxication
BAnticholinergic toxidrome from jimson weed
CCocaine or amphetamine intoxication
DAlcohol withdrawal delirium
Reveal answer & full explanation
Correct answer: C — Cocaine or amphetamine intoxication
APhencyclidine (PCP) intoxication
BAnticholinergic toxidrome from jimson weed
CCocaine or amphetamine intoxication✓
DAlcohol withdrawal delirium
Why Cocaine or amphetamine intoxication is correct
The picture is a classic sympathomimetic toxidrome: mydriasis, hypertension, tachycardia, hyperthermia, diaphoresis, and agitation
Tactile/visual hallucinations (formication, "bugs on the walls") are characteristic of stimulant intoxication
Onset after a recreational party setting fits cocaine or amphetamine use
Benzodiazepines (lorazepam) are first-line for the agitation, hypertension, tachycardia, and seizure risk
Avoid beta-blockers alone — unopposed alpha stimulation can worsen hypertension and coronary vasospasm
Why the others are wrong
Phencyclidine (PCP) intoxication — right-concept-wrong-agent; PCP causes vertical/rotary nystagmus, dissociation, and extreme violence rather than this pure adrenergic surge
Anticholinergic toxidrome from jimson weed — shares mydriasis, tachycardia, hypertension, and hallucinations, but anticholinergic poisoning produces hot dry flushed skin and urinary retention rather than the diaphoresis described here
Alcohol withdrawal delirium — overlaps agitation, autonomic hyperactivity, and visual hallucinations, but follows cessation in a physiologically dependent drinker roughly 48-96 hours after the last drink, not acute onset during a party
Additional high-yield points
Sympathomimetic vs anticholinergic toxidrome: both cause mydriasis, tachycardia, and hyperthermia, but sympathomimetics produce diaphoresis (wet skin) whereas anticholinergics produce dry skin and urinary retention
Formication (the sensation of insects crawling on skin) strongly suggests chronic stimulant use ("cocaine bugs")
Cocaine-associated chest pain warrants benzodiazepines and nitrates; give aspirin and treat as ACS if ischemia is present
Question 2PsychiatryMedium
A 29-year-old man is brought to the emergency department by police after he was found pacing outside a store shouting that people were following him. He is hypervigilant, diaphoretic, and intermittently agitated. Temperature is 38.6 C, heart rate 128/min, and blood pressure 168/102 mm Hg; pupils are dilated, skin is moist, and there are excoriated lesions on the arms with marked dental decay. He reports not sleeping or eating for two days. A partner who arrives reports that over the past year his use of a smoked stimulant has escalated to near-daily, that he has repeatedly tried and failed to cut down, and that he was fired after continuing to use despite warnings. A urine drug screen is positive for amphetamines. Which of the following is the most likely diagnosis?
AAmphetamine use disorder
BSerotonin toxicity syndrome
CPrimary psychotic disorder
DBipolar I disorder, manic
Reveal answer & full explanation
Correct answer: A — Amphetamine use disorder
AAmphetamine use disorder✓
BSerotonin toxicity syndrome
CPrimary psychotic disorder
DBipolar I disorder, manic
Why Amphetamine use disorder is correct
The collateral history establishes a problematic 12-month pattern: escalating near-daily use, repeated failed attempts to cut down, and continued use despite job loss — meeting DSM-5-TR criteria for a stimulant use disorder (>=2 of 11 criteria over 12 months), with the substance specified as amphetamine-type by the positive screen.
The acute picture is a classic sympathomimetic toxidrome confirming the agent: hyperthermia, tachycardia, hypertension, mydriasis, diaphoresis (moist skin), agitation, and paranoia from the mesolimbic dopamine surge of amphetamine.
Methamphetamine-specific clues reinforce chronic use: dental decay ("meth mouth"), excoriated skin from picking, and the days of anorexia and insomnia.
Why the others are wrong
Bipolar I disorder, manic — can mimic stimulant intoxication with decreased sleep and agitation, but it is diagnosed only when symptoms persist independent of substance use; the positive amphetamine screen, the autonomic toxidrome, and the documented problematic use pattern point to a substance-related disorder.
Primary psychotic disorder — implies persistent psychosis with a chronic course independent of intoxication; here psychosis arises acutely alongside a sympathomimetic toxidrome and a positive amphetamine screen, so it is stimulant-related rather than primary.
Serotonin toxicity syndrome — shares the hyperthermia, tachycardia, hypertension, and agitation, but it requires a serotonergic agent and is defined by inducible clonus, hyperreflexia, and lower-extremity-predominant rigidity, none of which are present, and it would not explain the 12-month pattern of escalating stimulant use.
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Sexual minority status (methamphetamine and chemsex)
Adolescent onset
Concurrent opioid or alcohol use
Access and environmental exposure
Pathophysiology
Cocaine blocks dopamine, norepinephrine, and serotonin reuptake; amphetamines also promote release from vesicles. Both produce intense mesolimbic dopaminergic surge driving reinforcement. Chronic use produces dopaminergic depletion and prefrontal dysfunction.
DSM-5-TR: Problematic pattern of stimulant use causing impairment/distress with >=2 of 11 criteria over 12 months. Specify substance (amphetamine-type vs cocaine). Severity by criterion count.
Labs
Urine drug screen (cocaine metabolite benzoylecgonine; amphetamines/methamphetamine)
ECG, troponin in chest pain
CBC, CMP, CK (rhabdomyolysis), UA
Pregnancy test
Imaging
Head CT for altered mental status, seizure, focal deficit (stroke risk elevated)
Echocardiogram if prolonged use (cardiomyopathy) or suspected endocarditis (IV use)
Diagnostic algorithm
Feature
Cocaine
Methamphetamine
Duration of effect
30-60 min
8-24 hours
Half-life
~1 h
~10-12 h
Route
IN, smoked (crack), IV
Smoked, IV, IN, PO
Characteristic complications
MI, septal perforation, crack lung
Meth mouth, skin picking, psychosis
Treatment of agitation
Benzodiazepines
Benzodiazepines
Cocaine vs methamphetamine — clinical features and complications.
Treatment
First-line
No FDA-approved pharmacotherapy for stimulant use disorder
Behavioral therapies are mainstay: contingency management (strongest evidence), cognitive behavioral therapy, community reinforcement approach, matrix model
Acute intoxication/agitation: benzodiazepines (lorazepam, diazepam) for agitation, HTN, tachycardia, seizures
AVOID beta-blockers in cocaine intoxication (unopposed alpha vasoconstriction) — use benzodiazepines, nitrates, CCBs
Cooling for hyperthermia; supportive care for rhabdomyolysis
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