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cocaine abuse

- 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 [5] Clinical manifestations: - mydriasis, diaphoresis, tachycardia, hypertension, hyperthermia [5] - non-exertional chest pain due to coronary vasospasm - malnutrition & cachexia with recurrent use [5] Laboratory: - urine drug screen (also see cocaine) Special laboratory: - electrocardiogram (image) [3] - coronary angiography (image) [3] Complications: 1) acute myocardial infarction (most frequent) a) may occur in habitual or 1st time users b) 90% are men c) uncommonly occurs > 12 hours after use d) dosage, frequency of use, route of administration do NOT affect likelihood of MI e) 1/3 of victims have normal coronary arteries f) coronary artery vasospasm [3] (image) 2) cardiomyopathy (5-10% of chronic cocaine users) 3) myocarditis (up to 20% of chronic cocaine users) 4) contraction band necrosis due to repeated episodes of endocardial ischemia 5) arrhythmias a) supraventricular tachycardia (SVT) b) ventricular tachycardia - ventricular fibrillation [3] 6) pericardial effusion (case report) [3] Management: 1) acute myocardial infarction: - nitroglycerin - calcium channel blockers - thrombolytic therapy - avoid beta-blockers (unapposed alpha-activity) 2) detoxification a) benzodiazepines - anxiety - CNS irritability b) avoid beta-blockers (unopposed alpha-activity) 3) relapse prevention a) bromocryptine b) buprenorphine c) carbamazepine d) tricyclic antidepressants (TCA) e) sertraline 200 mg QD in patients with depression & at least 2 weeks of abstinence may prevented relapse [4] - sertraline might work best to sustain rather than to initiate abstinence [4] 5) acupuncture NOT useful [2]

Related

cocaine (Depsocaine, Eritroxilina)

General

substance abuse

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18. American College of Physicians, Philadelphia 1998, 2015, 2018
  2. Journal Watch 22(4):33, 2002 Margolin et al, JAMA 287:55, 2001
  3. Almaddah N, Ajayi TO (image) IMAGES IN CLINICAL MEDICINE. Cocaine-Induced Coronary-Artery Vasospasm. N Engl J Med 2016; 374:e5. February 4, 2016 http://www.nejm.org/doi/full/10.1056/NEJMicm1503339
  4. Bashiri M, Mancino MJ, Stanick VAet al. Moderators of response to sertraline versus placebo among recently abstinent, cocaine dependent patients: A retrospective analysis of two clinical trials. Am J Addict 2017 Dec; 26:807. PMID: 29115703
  5. NEJM Knowledge+ Psychiatry