Clinical Case 9 of 15 · ~751 words
Clinical Case No. 9. Stimulant Use Disorder, Psychotic Symptoms, and Loss of Housing
From occasional to persistent use
Lucas, 28, worked in Vancouver's restaurant industry and shared an apartment with a friend. In his early twenties, he took MDMA at parties a few times a year. Later, cocaine appeared in his circle: first on weekends, then after exhausting shifts. Over several years, use became a recurring way to stay active and put fatigue out of mind.
Eventually, Lucas switches mainly to methamphetamine: it is available among people he knows and keeps him feeling active longer. Frequency of use, sleep deprivation, and spending increase together.
Missed shifts, borrowed money, and conflicts lead to job loss. Rent arrears accumulate. When his friend moves out, Lucas can no longer keep the apartment. For several months, he alternates between acquaintances' homes and, sometimes, a shelter. His address changes more often than the contact information in his medical record.
At his first presentation, Lucas wants to sleep and stop feeling watched. After several nights with almost no sleep, he hears footsteps, interprets chance conversations as threats, and changes his usual routes. A friend brings him to the emergency department.
Intoxication, psychosis, and the period after stimulant use
On examination, he has tachycardia, tension, suspiciousness, and exhaustion. The emergency physician assesses temperature, cardiovascular symptoms, hydration, and possible injuries, and asks about other substances. The psychiatrist compares the onset of psychotic symptoms with the timing of use; the course after stopping will help clarify the diagnosis.
A calm environment reduces overstimulation. Olanzapine is prescribed briefly for psychotic symptoms, with monitoring of consciousness and physical status. Observation continues after intoxication has resolved. [138]
After sleep, the voices and suspiciousness subside. Prolonged sleeping, fatigue, low mood, and strong cravings emerge. Lucas says he feels worse than on the day he came in. Suicidal thoughts, available support, and where he will stay next are reassessed.
Over the following weeks without methamphetamine, the psychotic symptoms disappear. There is no history of psychosis independent of substance use. The psychiatrist diagnoses stimulant-induced psychotic disorder in the context of severe stimulant use disorder. As remission and abstinence continue, the psychiatrist reviews the need for olanzapine and a plan for gradual discontinuation; follow-up covers both recurrence of psychosis and renewed substance use. [139, 140]
Outpatient treatment and the housing barrier
Lucas starts accessible addiction counselling incorporating CBT. The BCCSU guideline also describes contingency management: systematic reinforcement of agreed changes, such as attendance or verified abstinence. At the beginning of Lucas's local care pathway, individual appointments and work on cravings and high-risk situations are available. [139]
He misses the first appointment after changing where he sleeps. His phone is out of charge, and the reminder went to an old number. With Lucas's consent, the team arranges an additional way to reach him through a support worker.
A housing worker helps with documents and an application for supportive housing. They look for a shelter for the next few nights while maintaining the longer-term plan. An outreach service helps with documents, finding housing, and access to local resources. [130, 131]
Residents of supportive housing in a BC study described affordable rents alongside difficulties with safety, neighbours, and limited choice. For Lucas, the environment matters clinically: he is looking for somewhere he can sleep and reduce daily contact with substance use. [132]
Risks of the unregulated market and returning to work
Lucas denies regular opioid use; there are no signs of OUD. Because of the risk of contaminants in unregulated substances, the team teaches him to recognize opioid poisoning, provides naloxone, and discusses available drug checking and other harm reduction measures. [139, 114]
In the first months, Lucas returns to use after staying with a friend where methamphetamine is always available. At appointments, the team reviews sleep, cravings, symptoms, and the possibility of different accommodation; treatment contacts continue.
After obtaining a more stable temporary place, Lucas finds it easier to sleep and follow a schedule. He eventually starts working a few morning shifts. Morning shifts specifically: returning to his former nighttime environment would create another high-risk situation. Psychotherapy focuses on cravings, responses to setbacks, and rebuilding social connections that do not revolve around the substance.
By the end of the year described, he has not yet regained his previous income. Periods without use have become longer, psychotic symptoms have not returned, and contact with care continues. Clinical improvement is already apparent, although debts, housing uncertainty, and the risk of renewed use remain.