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SOURCE

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Source: Doering PL, Li RM. Substance-related disorders I: overview and depressants, stimulants, and hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146064131. Accessed April 12, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Cocaine synonyms:

    • Cake.

    • Snow.

    • Flake.

    • Blow.

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DEFINITION

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  • Substance-related disorders include disorders of:

    • Intoxication.

    • Dependence.

    • Withdrawal.

  • Intoxication: maladaptive behavior during waking state after recent ingestion and presence in body of substance causing central nervous system (CNS) effects.

  • Substance dependence: continued pattern of substance use in spite of repeated adverse consequences related to repeated use.

  • Physical dependence: state of adaptation manifested by withdrawal syndrome following:

    • Cessation.

    • Rapid dose reduction.

    • Decreasing blood levels.

    • Administration of antagonist.

  • Withdrawal: development of substance-specific syndrome after cessation or reduced intake of substance that had been used regularly.

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ETIOLOGY

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  • 10% of people who begin using cocaine progress to serious, heavy use.

  • After having tried cocaine, progression to frequent, chronic use unpredictable.

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PATHOPHYSIOLOGY

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  • Cocaine hydrochloride is inhaled or injected.

  • Can be converted to cocaine base (crack or rock) and smoked to achieve almost instant absorption and intense euphoria.

  • Euphoria from snorting lasts 15–30 min; euphoria from smoking lasts 5–10 min.

  • Tolerance to euphoria develops quickly.

  • In presence of alcohol, cocaine is metabolized to cocaethylene, longer-acting compound than cocaine with greater risk for causing death.

  • Cocaine elimination half-life: 1 hour.

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EPIDEMIOLOGY

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  • In 2009, 4.8 million Americans age 12 and older had abused cocaine in any form and 1 million had abused crack at least once in year prior to being surveyed.

  • 2010 study showed that:

    • 1.6% of 8th graders, 2.2% of 10th graders, and 2.9% of 12th graders had abused cocaine in any form.

    • 1.0% of 8th graders, 1.0% of 10th graders, and 1.4% of 12th graders had abused crack at least once in year prior to being surveyed.

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RISK FACTORS

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  • Positive family history of substance abuse related to speed of developing cocaine dependence and earlier age of onset.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Cocaine intoxication:

    • Agitation.

    • Elation.

    • Euphoria.

    • Grandiosity.

    • Loquacity.

    • Hypervigilance.

    • Sweating or chills.

    • Nausea.

    • Vomiting.

    • Tachycardia.

    • Arrhythmias.

    • Respiratory depression.

    • Mydriasis.

    • Altered blood pressure.

    • Seizures.

  • Complications of cocaine use include:

    • Ulceration of nasal mucosa.

    • Nasal septal collapse.

    • Tachycardia.

    • Heart failure.

    • Hyperthermia.

    • Shock.

    • Seizures.

    • Psychosis (similar to paranoid schizophrenia)

    • Sudden death.

  • Withdrawal signs and symptoms:

    • Fatigue.

    • Sleep disturbances.

    • Nightmares.

    • Depression.

    • Changes in appetite.

    • Bradyarrhythmias.

    • Myocardial infarction.

    • Tremors.

  • Withdrawal symptoms begin within hours of discontinuation and last up to several days.

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DIAGNOSIS

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LABORATORY TESTS
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  • When toxicology screens necessary, blood or urine should be collected immediately when patient presents for treatment.

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