hyperactive reflexes, talkativeness, irritability, weakness, insomnia, and fever In addition, confusion, anxiety, delirium, paranoid hallucinations, panic states, and suicidal or homicidal tendencies can occur, especially in patients who have underlying mental illnesses However, these psychotic effects may occur in anyone who chronically abuses amphetamines Cardiotoxic effects include palpitations, anginal pain, and rarely, hypertensive crisis or circulatory collapse GI effects include anorexia, nausea, vomiting, diarrhea, and abdominal cramps Severe overdoses may cause convulsions, coma, and cerebrovascular accidents Both psychological and physical dependence occurs with chronic use Chronic amphetamine abuse causes symptoms similar to many of those seen after acute overdose The most common serious effect is a psychotic reaction with vivid hallucinations and paranoid delusions, often mistaken for schizophrenia Recovery may not occur after withdrawal of the drug In patients with persistent psychotic symptoms, it has been theorized that the amphetamine has hastened the onset of incipient schizophrenia Chronic amphetamine abuse is also associated with the development of cerebral vasculitis In addition to the sympathomimetic features noted above, unique features of MDMA toxicity may include hyponatremia, serotonin syndrome, and hepatotoxicity Consider GI decontamination for treatment of intoxication after ingestion For severe agitation, use a benzodiazepine or haloperidol (0.01 to 0.05 mg/kg IM) Severe hypertension unresponsive to benzodiazepines may require such agents as phentolamine, hydralazine, or IV sodium nitroprusside Provide ample IV fluids to promote urinary excretion Cocaine CLINICAL PEARLS In addition to stimulant effects, cocaine is a Type Ib antidysrhythmic with cardiac sodium channel blocking activity Toxicity may include EKG abnormalities, seizures, and dysrhythmias Cocaine toxicity can lead to myocardial ischemia Current Evidence Cocaine occurs in the leaves of Erythroxylum coca and other species of Erythroxylum trees indigenous to Peru and Bolivia, where the leaves have been used for centuries by the natives to increase endurance and to promote a sense of