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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.
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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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- 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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- 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.
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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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- Positive family history of substance abuse related to
speed of developing cocaine dependence and earlier age of onset.
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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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- When toxicology screens necessary, blood or urine should
be collected immediately when patient presents for treatment.
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Differential
Diagnosis
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- Cessation of use of drug
- Termination of drug-seeking behaviors
- Return to normal functioning
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- Establish airway.
- Provide oxygen.
- Monitor cardiac function.
- Ensure IV access.
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- 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 ...