Clinical Approach to Acute Recreational Drug Intoxication in the Emergency Setting: A Practical Guide Based on Swiss Experience

Acute intoxications related to recreational drug use represent an increasing challenge for emergency departments (EDs). Worldwide, more than 600,000 deaths are attributable each year to illicit drug consumption, and in Switzerland approximately 190 deaths related to recreational drug use were reported in 2023. Most patients present after the use of recreational drugs such as stimulants (cocaine and amphetamines), opioids, cannabis or hallucinogens, with stimulants representing the majority of acute presentations in European emergency departments. In recent years, a sharp progression of amphetamine-like substance consumption derived from khat has been observed. Clinical presentations range from agitation, psychosis, seizures, and hyperthermia to respiratory depression, multi-organ failure and cardiac arrest. Emergency physicians are frequently the first to provide care, yet management is often complicated by the coexistence of multiple substances, the emergence of new psychoactive compounds, and the limited availability of toxicological testing in the acute setting. This narrative review summarises the current evidence and recommendations relevant for clinical practice. It is based on a literature search conducted in PubMed, EMBASE, Cochrane Library, but also grey literature such as MonAM, Infodrog and Tox Info Suisse regarding the specific Swiss context. The review highlights the recognition of typical toxidromes: stimulants causing sympathomimetic effects; opioids with mainly respiratory depression; hallucinogens and dissociatives; also, this review presents common pitfalls with drugs commonly encountered. Management emphasises oxygen administration, benzodiazepine sedation for agitation, and specific interventions like naloxone for opioids. Given rising trends in cocaine and novel psychoactive substance use, enhanced understanding of pharmacological profiles and standardised emergency protocols are critical for improving patient outcomes. Although specific treatment may be lacking for most drugs, novel psychoactive drugs pose new challenges due to lack of robust data preventing us from presenting a typical clinical picture and providing standardised care. This synthesis aims to support emergency physicians in the structured and evidence-based management of acute recreational drug intoxications.