About This Page
This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Intoxication causes tachycardia, hypertension, mydriasis, diaphoresis, agitation, hyperthermia, chest pain, and psychosis
- Acute agitation, hypertension, seizures, hyperthermia: benzodiazepines first-line
- Cocaine chest pain requires ACS evaluation; benzodiazepines and nitroglycerin are useful
- No FDA-approved medication; contingency management has strongest evidence
- Withdrawal causes fatigue, hypersomnia, increased appetite, depression, anhedonia, suicidality
Overview
Stimulant use disorder includes problematic cocaine, methamphetamine, prescription amphetamine, or similar use. Intoxication increases dopamine/norepinephrine/serotonin. Cocaine also blocks sodium channels and can cause coronary vasospasm, arrhythmias, MI, and stroke.
Epidemiology
Stimulant use causes ED visits for chest pain, agitation, psychosis, hyperthermia, trauma, and infectious/sexual risk. Methamphetamine is associated with dental disease, skin picking, cardiomyopathy, pulmonary hypertension, and neurocognitive impairment.
Clinical Features
Symptoms
Craving, binges, inability to cut down, risky use, tolerance
Euphoria, energy, decreased appetite, insomnia, anxiety, paranoia
Chest pain, severe headache, focal deficit, syncope, seizure, hyperthermia
Psychosis with persecutory delusions or formication
Withdrawal: hypersomnia, fatigue, dysphoria, suicidality
Signs
Tachycardia, hypertension, mydriasis, diaphoresis, tremor, agitation
Hyperthermia, rigidity, seizures, severe hypertension, arrhythmia, delirium
Nasal septal perforation with cocaine
Excoriations, dental disease, weight loss, injection marks
Investigations
First-line
Acute toxicity evaluationVitals/temp, mental status, glucose, ECG, troponin if chest pain, CK/renal function if agitation/hyperthermia
DSM-5-TR SUD assessmentSubstance type, route, frequency, binges, withdrawal, psychiatric symptoms, polysubstance use
Urine toxicologyCocaine metabolites/amphetamines; interpret clinically
Second-line
Chest pain workupECG, serial troponins, CXR, ACS pathway if concerning
NeuroimagingSevere headache, focal deficits, seizure, trauma, concern for hemorrhagic/ischemic stroke
Infectious screeningHIV, HBV/HCV, STIs, pregnancy test, vaccination
Specialist
Emergency/ICUHyperthermia, severe agitation, seizures, hypertensive emergency, ACS, stroke, rhabdomyolysis
Addiction treatmentContingency management, CBT, community reinforcement, comorbidity treatment
Management
ASAM/AAAP Stimulant Use Disorder Guideline and SAMHSA Treatment of Stimulant Use Disorders1
Acute intoxication
- ABCs, cooling, IV fluids, low-stimulation environment, monitoring
- Benzodiazepines first-line for agitation, seizures, severe anxiety, hypertension/tachycardia
- Antipsychotics may be added for persistent psychosis/agitation after benzodiazepines
2
Cocaine chest pain
- ECG and troponins; treat suspected ACS
- Benzodiazepines reduce sympathetic surge; nitroglycerin treats vasospasm/chest pain
- Calcium channel blockers for persistent vasospasm/hypertension; classic exams avoid pure beta-blocker monotherapy acutely
3
Long-term treatment
- Contingency management is best-supported
- CBT, community reinforcement, motivational interviewing
- No FDA-approved medication for cocaine or methamphetamine use disorder
Complications
- ACS/MI:
- Stroke:
- Hyperthermia/rhabdomyolysis:
- Psychosis:
- Cardiomyopathy:
- Suicide during withdrawal:
USMLE Step 2 CK Exam Tips
- 1Cocaine chest pain = ECG/troponins
- 2Benzodiazepines first-line for stimulant agitation/hypertension/seizures
- 3Formication is classic cocaine/meth clue
- 4No FDA-approved medication; contingency management
- 5Withdrawal causes depression/hypersomnia
- 6Young MI/stroke: ask cocaine/amphetamines
practicetest your knowledge on stimulant use disorder (cocaine, amphetamines)Apply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
open q-bank