Substance-Related Disorders: Cocaine

Source: Doering PL. Substance-Related Disorders: Overview and Depressants, Stimulants, and Hallucinogens. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://accesspharmacy.com/content.aspx?aid=7987346. Accessed June 9, 2012.

• Cocaine synonyms:
  • Cake
  • Snow
  • Flake
  • Blow

• 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.

• 10% of people who begin using cocaine progress to serious, heavy use.
• After having tried cocaine, progression to frequent, chronic use unpredictable.

• 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 minutes; euphoria from smoking lasts 5–10 minutes.
• 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.

• 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.

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

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.

Laboratory Tests

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

Differential Diagnosis

• Serotonin syndrome
• Lithium toxicity
• Tricyclic antidepressant toxicity
• Neuroleptic malignant syndrome
• Thyroid storm
• Other hyperadrenergic states

• Cessation of use of drug
• Termination of drug-seeking behaviors
• Return to normal functioning

• Establish airway.
• Provide oxygen.
• Monitor cardiac function.
• Ensure IV access.

• Treat cocaine intoxication pharmacologically only if patient agitated or psychotic.
• Lorazepam 2–4 mg IM every 30 minutes to 6 hours as needed for agitation.
• Haloperidol 2–5 mg (or ...