History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors include: history of stimulant use, criminal lifestyle, poly-substance use, history of drug smuggling, history of involvement with illicit drug manufacture.

compulsive stimulant use despite negative consequences

Defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) as a pattern of stimulant use leading to clinically significant impairment or distress, defined by the presence of at least 2 of 11 symptoms during a 12-month period.[1]

hypervigilance

Commonly occurs after acute use.

hyperarousal

Commonly occurs after acute use.

anxiety

Commonly occurs after acute use.

hallucinations

Commonly occurs after acute use. Patients may recognise hallucinations as a drug effect.[1] Psychotic symptoms due to methamphetamine may sometimes last for months or years after cessation of substance use.[58]

chest pain

Typical or atypical anterior cardiac chest pain is seen. Also, pleuritic chest pain is common as a result of acute smoking or snorting.

Important to rule out heart disease including pulmonary artery hypertension and valvular abnormalities.

paranoia

More often seen with binge use of methamphetamine. Psychotic symptoms due to methamphetamine may sometimes last for months or years after cessation of substance use.[58]

increased BP

Commonly occurs after acute use.[56] Also seen as a result of longer-term use. 

Is a sign of increased sympathetic nervous system activity.[59][60]

dilated pupils

Commonly occurs after acute use.

Is a sign of increased sympathetic nervous system activity.

tachycardia

Reported with acute use.[56]

skin picking, skin lesions, excoriations

Often from picking/scratching at the skin to remove imagined insects. Occurs after acute use and worsens with longer-term use.

dental decay, gum disease

Common with chronic use.[61]

Tend to see unusual dental wear from grinding and increased decay and gum disease from dry mouth and direct stimulant effects.[59][60]

trismus, bruxism

May occur as a result of acute and longer-term use.

uncommon

dyspnoea

Occurs with acute toxicity or chronic morbidities such as pulmonary hypertension or valvular abnormalities.

hyperthermia

Commonly occurs after hours of use.

Is a sign of increased central nervous system serotonergic and dopaminergic stimulation, sympathetic nervous system activity, and direct muscle toxicity.

Low likelihood of occurrence, but associated with life-threatening overdoses.

Other diagnostic factors

common

guarded/suspicious behaviour

Commonly occurs after acute use.

euphoria

Commonly occurs after acute use of methamphetamine.

alertness

Commonly occurs after acute use.

increased concentration

Commonly occurs after acute use.

headache

Associated with acute and longer-term use.

irritability

More often occurs with longer-term use and after bingeing.

aggression

More often occurs with longer-term use and as part of drug-seeking behaviours, but may occur acutely as well.

nausea, vomiting

May occur as a result of acute use.

depression

Common with longer-term use, and with withdrawal. Depression associated with withdrawal usually resolves within 1 week.[1]

anorexia

Waning appetite and resulting weight loss occur as a result of longer-term use.

increased motor activity

Commonly occurs after acute use.

anhedonia

Occurs with withdrawal of amfetamine/methamphetamine.

uncommon

haemoptysis

Occurs as a result of airway damage or pulmonary embolus after smoking or injecting methamphetamine.

pacing

Occurs after acute use.

cardiac arrhythmias

Have been reported with acute high exposures.[56]

vasculitis

Reported with heavy longer-term use.[56]

cerebral haemorrhage

Rarely reported with acute use.[56]

Risk factors

strong

Adverse childhood events

History of adverse childhood events including physical and sexual abuse, neglect, family conflict, or violence predispose to the development of substance use disorders.[36][37][38]​​​[39][40]​​ Early-life trauma predicts earlier age at first use of methamphetamine.[41]

history of previous stimulant use

Increases the chances that acute or chronic toxicity explains a current clinical event.

selling/producing drugs, or other criminal justice system involvement

Manufacturing and distribution of methamphetamine is associated with use. Additionally, longer-term use of methamphetamine leads to a lowered violence threshold.

poly-substance use

Amfetamine use disorder is associated with other comorbid substance use disorders/harmful substance use, such as alcohol, opioids, gamma-hydroxybutyrate (GHB), cocaine, ketamine, and marijuana, often in a club or party environment.

history of body packing, body stuffing, or 'parachuting'

Body packing involves transport of methamphetamine packets in the gastrointestinal tract across national boundaries to avoid law-enforcement detection.[42]

Body stuffing involves rapid, unplanned ingestion of drug, often immediately preceding a law-enforcement encounter.[42]

Parachuting involves ingesting a large amount of methamphetamine in a plastic bag with holes punched to provide slow release.[42]

history of illicit manufacturing or distribution

Illicit manufacturing and distribution of methamphetamine is associated with methamphetamine use.

Frequently associated with chemical explosions and burns.

weak

history of a mental health disorder

Comorbid psychiatric disorders such as bipolar disorder, ADHD, major depression, anxiety disorders, personality disorders, and post-traumatic stress disorder are risk factors.[36][43][44][45]​​​ Psychiatric comorbidity in methamphetamine use disorder is complex, given the overlap in symptoms (e.g., psychosis and depression) and presence of shared risk factors (e.g., adverse childhood events; see below).[27][28]​​​ Psychiatric comorbidity may adversely affect treatment success.[46][47]

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