This handout is for amphetamine / stimulant withdrawal hypertensive crisis (rebound htn + autonomic instability + tachy + diaphoresis + tremor + agitation/depression overlap 6-72 h after abrupt cessation of chronic stimulant therapy or use). Your care team identified this based on: abrupt cessation of chronic stimulant use (methamphetamine, amphetamine, mdma, prescription stimulant such as adderall/lisdexamfetamine/methylphenidate at high chronic doses) within last 6-72 h + sbp ≥180 / dbp ≥120 + autonomic instability features.
Other reasons your team may use this plan: htn + tachycardia + diaphoresis + tremor + agitation overlap with depressive features ("crash" phase) 6-72 h after stimulant cessation; prescription amphetamine derivative (adderall, vyvanse, ritalin) held during hospitalization, rehab admission, or perioperative period without taper plan → withdrawal htn crisis (preventable).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| lorazepam | 1-2 mg IV q5-10 min, repeat to effect | IV | PRN q5-10 min then scheduled | AHA 2008 Class I PMID 18391116 + AHA 2024 stimulant update — sympatholytic + reduces HTN + reduces tachy + treats agitation/anxiety/dysphoria; first-line in withdrawal HTN crisis (extends from active-use framework) |
| diazepam | 5-10 mg IV q5-10 min | IV | PRN | Longer half-life alternative to lorazepam; useful for sustained sympatholysis |
| nicardipine | 5 mg/h IV titrate q5-15 min by 2.5 mg/h, max 15 mg/h | IV | continuous infusion | AHA 2025 HTN emergency Class I — first-line non-dissection HTN crisis; predictable titration; vasodilation reverses alpha-driven vasoconstriction |
| phentolamine | 1-5 mg IV q5-15 min titrate | IV | PRN bolus | Pure alpha-blocker reverses rebound NE-driven alpha-vasoconstriction; rescue for unopposed alpha if concurrent β-blocker exposure error |
| nitroglycerin | 5-200 mcg/min IV titrate q3-5 min | IV | continuous | Vasodilator + coronary vasodilator; useful for demand ischemia or LV-failure overlay |
| verapamil | 5-10 mg IV slow push q15-30 min | IV | PRN | Negus Circulation 1994 — verapamil reverses cocaine vasospasm; framework extends to stimulant withdrawal |
| mirtazapine | 15-30 mg PO at bedtime | PO | nightly | Coffin JAMA Psychiatry 2020 PMID 32049330 — modest benefit in methamphetamine use disorder; addresses depression + insomnia + craving components of withdrawal |
| bupropion | 150 mg PO daily × 3 d → 300 mg PO daily | PO | daily | Trivedi NEJM 2021 PMID 33497547 — naltrexone-bupropion combo modest benefit in methamphetamine use disorder; bupropion alone helpful for depression component |
| naltrexone | 50 mg PO daily OR 380 mg IM monthly | PO or IM | daily or monthly | Trivedi 2021 — naltrexone-bupropion combination has modest benefit; consider after acute crisis resolution |
| AVOID isolated β-blocker without α-blockade or benzo first | AVOID | N/A | N/A | Lange NEJM 1989 PMID 2522592 + AHA 2008 PMID 18391116 — same unopposed-alpha pharmacological principle as cocaine + meth + clonidine withdrawal; isolated β-blockade leaves alpha-vasoconstriction unopposed |
| CONSIDER stimulant restart if clearly iatrogenic (prescription Adderall/Vyvanse/Ritalin held during OR, rehab, or hospitalization) | Restart at lower dose with planned taper over 1-2 weeks if discontinuation planned, or resume home dose if continuation planned | PO | per home schedule | For iatrogenic withdrawal, restart corrects the underlying cause; planned discontinuation needs supervised gradual taper coordinated with prescriber + perioperative protocol for future surgeries |
| CONTINGENCY MANAGEMENT for stimulant use disorder | Per program protocol | behavioral | per program | Connors Annu Rev Clin Psychol 2018 PMID 29494256 — strongest RCT evidence for StUD treatment; no FDA-approved MAT exists; evidence-based first-line non-pharmacologic intervention |
Plan: Amphetamine / stimulant withdrawal HTN crisis — benzodiazepine FIRST + nicardipine + phentolamine; AVOID isolated β-blocker; consider stimulant restart if iatrogenic; psychiatric care for depression + suicide risk; long-term contingency management for StUD
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Stimulant use disorder (StUD) treatment — CONTINGENCY MANAGEMENT has strongest RCT evidence (Connors Annu Rev Clin Psychol 2018 PMID 29494256); no FDA-approved MAT for StUD (mirtazapine + naltrexone-bupropion combo modest benefit per Trivedi NEJM 2021 PMID 33497547 + Coffin JAMA Psychiatry 2020 PMID 32049330); cardiology follow-up if MI/cardiomyopathy occurred; ECHO at 3-6 months to assess for chronic stimulant cardiomyopathy reversibility with abstinence (Schürer JACC 2017); BP regimen if persistent HTN; psychiatric care for depression component (high suicide risk during early abstinence — close follow-up); harm reduction; HIV/HCV screening; PrEP if applicable; support groups (NA/CA, SMART Recovery); IF prescription-stimulant iatrogenic withdrawal — coordinate with prescriber for supervised taper plan + advance-supply system + perioperative protocol
Guideline: 2025 ACC/AHA HTN Guideline (Whelton) + AHA 2024 stimulant cardiotoxicity (Manja Circulation 2024) + SAMHSA TIP 33 (2021) + Trivedi NEJM 2021 PMID 33497547 (naltrexone-bupropion for methamphetamine StUD)