cocaine abuse

Introduction

• Crack cocaine is the alkaloid in its base form.
• Its name stems from the popping sound it makes when heated.
• At higher temperatures, it vaporizes & is absorbed through all mucous membranes including those of the nasal passages, pharynx, mouth & lungs.
• Onset of action is 3-5 minutes.
• Peak effect is 1-20 minutes.
• Duration of direct action is variable, from 5-90 minutes.

Epidemiology

• cocaine abuse accounts for < 1% of new illicit drug use by young adults

Clinical manifestations

• mydriasis, diaphoresis, tachycardia, hypertension, hyperthermia
• non-exertional chest pain due to coronary vasospasm
• malnutrition & cachexia with recurrent use

Laboratory

• urine drug screen (also see cocaine)

Diagnostic procedures

• electrocardiogram (image)
• coronary angiography (image)

Complications

• acute myocardial infarction (most frequent)
  • may occur in habitual or 1st time users
  • 90% are men
  • uncommonly occurs > 12 hours after use
  • dosage, frequency of use, route of administration do NOT affect likelihood of MI
  • 1/3 of victims have normal coronary arteries
  • coronary artery vasospasm (image)
• cardiomyopathy (5-10% of chronic cocaine users)
• myocarditis (up to 20% of chronic cocaine users)
• contraction band necrosis due to repeated episodes of endocardial ischemia
• arrhythmias
  • supraventricular tachycardia (SVT)
  • ventricular tachycardia
    • ventricular fibrillation
• pericardial effusion (case report)

Management

• acute myocardial infarction:
  • nitroglycerin
  • calcium channel blockers
  • thrombolytic therapy
  • avoid beta-blockers (unapposed alpha-activity)
• detoxification
  • benzodiazepines
    • anxiety
    • CNS irritability
  • avoid beta-blockers (unopposed alpha-activity)
• relapse prevention
  • bromocryptine
  • buprenorphine
  • carbamazepine
  • tricyclic antidepressants (TCA)
  • sertraline 200 mg QD in patients with depression & at least 2 weeks of abstinence may prevented relapse
    • sertraline might work best to sustain rather than to initiate abstinence
• acupuncture NOT useful

More general terms

• substance abuse

Additional terms

• cocaine (Depsocaine, Eritroxilina)