Amphetamine use is common in Australia, second only to cannabis. This presentation reviewed the history, epidemiology, and complications of amphetamine use and provided a case study. Acute complications include increased heart rate, blood pressure, arrhythmias, chest pain, agitation, psychosis, seizures, and hyperthermia. Chronic complications include increased risk of infections, stroke, heart disease, and mental health issues. Management involves monitoring vitals and giving benzodiazepines to treat agitation, seizures, and other complications.

1. Amphetamine-Related
Presentations to ED
Colleen Taylor CME 15th May 2014

3. What we will cover
A little bit of history
A little bit of epidemiology
Case study
Acute and chronic complications of amphetamine
use

4. What are Amphetamines?
Synthetic psychoactive drug
Phenylethylamine derivative
Stimulates the release of catacholamines and
inhibits reuptake of monoamines. Increase in
central + peripheral NA, DA and 5HT
Prescription formulations e.g. dexamphetamines,
methylphenidate (Ritalin)
Or illegal formulations: Ice, speed, tablets

6. History of Amphetamines
First synthesised in Germany in 1887 (1)
Used medically in 1930’s as stimulant for nasal
decongestion, which progressed to treatment for
narcolepsy, hyperemesis and hyperactivity in
children (2)
Widely used in WWII to improve concentration
and endurance
Rendered an illicit drug 1970’s (3)

8. How Common is
Amphetamine use?
Multiple sources state that amphetamines are the
second most common drug of abuse in Australia after
cannabis (1, 3, 4)
Lifetime use 7.7% in men vs 4.9% in women (1)
Study at RPH in 2005 showed 1.2% of all
attendances related to amphetamines, with high
acuity (66% triage 1-3) and 1/3 of all needing
psychiatric assessment (4)
Between 2006 and 2010, there were 2062 persons
with a primary diagnosis of amphetamine-related
psychosis in outpatient and inpatient services of
metropolitan hospitals in WA (5)

9. Case Study
34 year old man
PMH: Cluster B personality disorder, ? Bipolar
affective disorder
Long history of polysubstance abuse mainly
alcohol and methamphetamines
Abstained from amphetamine use for past 3
months, but took several amphetamine tables
orally the night before presenting to Charlies ED

10. Case Study
Complaining of sudden onset of severe left sided
chest pain, both dull and sharp. Radiated to the left
of the chest and through to the back
Associated with shortness of breath, sweating and
nausea
No cough, fever, haemoptysis
Had some numbness in all 4 limbs, which may have
been slightly worse in the left arm and leg than the
right
No weakness, no slurred speech or facial droop. No
headache
Recent flu-like illness 5/7 ago

11. Case Study
O/e:
- A = Patent
- B = RR 18 sats 89% RA, Clear chest, no chest wall
tenderness
- C = CRT <2, pulse 140, BP 141/60 (L), 147/85 (R),
CV I+II+O
- D = GCS 15, normal neuro examination with no
reduced sensation to light touch or pinprick
- E = Temp 37.6, Soft abdomen, no obvious track
marks

12. Case Study
Bloods:
- WCC 13.5, otherwise normal
- U+E normal
- LFT normal
- Troponin 34/23
CXR: normal
ECG: Sinus tachy with no ST changes
CT Aortogram: Normal

13. Case Study
Treatment:
- IV diazepam
- IV opiates
- Anti emetics
- Fluids
After period of observation, chest pain settled,
tachcardia settled, blood pressure reduced.
Diagnosis of acute amphetamine toxicity

14. Acute complications - CVS
Tachycardia
HTN
Dysrhythmias
Acute coronary syndrome
Acute cardiomyopathy
Acute pulmonary oedema

15. Acute Complications - CVS
Tachycardia and HTN
- Use titrated doses (2.5 -5mg) of IV
benzodiazepines
- If unresponsive, consider use of nitrites
- Beta-blockers are contra-indicated
Dysrhythmia's:
- Treat with benzodiazepines and conventional
measures
- Correct hypoxia, acidosis, electrolyte
disturbances

16. Acute Complications - CVS
Acute Coronary Syndrome
- Mechanism may be increased myocardial oxygen demand,
coronary artery spasm, platelet aggregation, and thrombus
formation secondary to elevated catacholamine levels (9)
- ACS diagnosed in 25% of patients presenting to the ED
with chest pain after methamphetamine use (6)
- The population attributable risk suggests that amphetamine
abuse is responsible for 0.2% of acute myocardial
infarction (6)
- Manage ACS conventionally but consider CT brain should
be performed prior to anticoagulation or angiography if
headache is a feature

17. Acute complications - CVS
Aortic dissection
- Amphetamine abuse is significantly associated
with aortic dissection. In one study odds ratio =
3.33, 95% CI = 2.37-4.69, P < .0001 (7)
- Another study suggests 20% of all patients with
aortic dissection under the age of 50 years are
due to amphetamine misuse (8)

18. Acute Complications -
Neurological
Agitation/Aggressive behaviour
Psychosis
Movement disorders
Seizures
Intra-cerebral haemorrhage

19. Acute Complications -
Neurological
Agitation/behavioral disturbance
- Mild: PO diazepam 10-20mg +/-olanzapine
wafer. Consider review of benzodiazepines after
more than 60mg required
- Moderate/severe/refusing PO meds: IV
benzodiazepines +/- droperidol. If failing to
respond, consider IM olanzapine

20. Acute Complications -
Neurological
Movement disorders
- Increased muscle tone or repetitive movements e.g.
bruxism/choreoathetoid movement
- Treat with PO/VIV benzodiazepines
Seizures
- Treat with PO/VIV benzodiazepines
- Consider barbituates as a second line agent
- Correct reversible causes as per normal seizures

21. Acute Complications -
Neurological
Intra-cerebral haemorrhage
- Headache should be considered as a red flag in
amphetamine users; early CT is a priority
- Many factors could be involved including
vasospasm, cerebral vasculitis, enhanced
platelet aggregation, cardioembolism, and
hypertensive surges. Around 40% of patients
have pre-existing lesions (10)

22. Acute Complications -
Other
Hyperthermia
- Temperature >38.5°C: continuous core-temperature
monitoring, IV benzodiazepines and passive cooling with
tepid sponging/cool spray/fluids
- Temperature >39.5°C: Consider intubation and ventilation
for rapid active cooling. Paralysis if intubated.
Hyponatraemia
- If >120mmol, no seizures/change in GCS, manage
conservatively with fluid restriction. If any of above,
consider 3% hypertonic saline
- Think about glucose and K+ abnormalities

23. Acute Complications -
Others
Rhabdomyolysis
Dirty hit
Foreign body embolus

25. Chronic complications
Increased risk of septic emboli e.g. endocarditis,
lung/brain abscesses
Increased risk of stroke
Increased risk of cardiovascular disease
including cardiomyopathy
Increased mental health issues
Poor socioeconomic outcomes

26. Conclusions
Amphetamine use is common
Look for features of amphetamine toxicity
including tachycardia, HTN, sweating and
agitation
Headache, chest pain and hyperthermia are all
red flags and should be thoroughly assessed and
managed
If in doubt, give benzodiazepines!

27. References
1. Greene, SL, Kerr F and Braitberg, G. Review article:
Amphetamines and related drugs of abuse. EMA 2008; 20:
391-402
2. http://www.cesar.umd.edu/cesar/drugs/amphetamines.pd.
Accessed 14/05/2014.
3. Ellatt EC, Montgomery S, Nemiki T, Noguchi T.
Misrepresention of stimulant street drugs: a decade of
experience in an analysis program. J. Toxicol. Clin. Toxicol
1986; 24: 441–50.
4. Gray SD, Fatovich, DM, McCoubrie DL and Daly, FF.
Amphetamine-related presentations to an inner-city tertiary
emergency department: a prospective evaluation. Med J Aust
2007; 186 (7): 336-339
5. http://drugaware.com.au/Drug-
Information/Amphetamines/Amphets-And-The-Ed.aspx.
Accessed 14/05/2014.

28. 6. Turnipseed SD, Richards JR, Kirk JD,Diercks DB, Amsterdam EA.
Frequency of acute coronary syndrome in patients presenting to the
emergency department with chest pain after methamphetamine use.
J Emerg Med. 2003;24(4):369-373.
7. Westover AN and Nakonezny PA. Aortic dissection in young adults
who abuse amphetamines. Am Heart J. 2010 Aug; 160(2):315-21.
doi: 10.1016/j.ahj.2010.05.021.
8. Wako, E., LeDoux, D., Mitsumori, L. and Aldea, G. S. (2007), The
Emerging Epidemic of Methamphetamine-Induced Aortic Dissections.
Journal of Cardiac Surgery, 22: 390–393. doi: 10.1111/j.1540-
8191.2007.00432.x
9. Nolan J and Ghuran A. The cardiac complications of recreational
drug use. West J Med. Dec 2000; 173(6): 412–415.
10. Pozzi M, Roccataglitan D and Sterzi R. Drug abuse and intracranial
haemorrhage, Neurol Sc. 2008; 29 (issue 2): 269-270