Substance-Related Disorders: Cocaine

SOURCE

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.

CONDITION/DISORDER SYNONYMS

• Cocaine synonyms:

  • Cake.

  • Snow.

  • Flake.

  • Blow.

DEFINITION

• 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.

ETIOLOGY

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

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

PATHOPHYSIOLOGY

• 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.

EPIDEMIOLOGY

• 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.

RISK FACTORS

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

CLINICAL PRESENTATION

SIGNS AND SYMPTOMS

• 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.

DIAGNOSIS

LABORATORY TESTS

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