Cocaine abuse

Last reviewed: February 2019

Last updated: April 2018

Summary

Episodic cocaine use leads to short-lived states of autonomic arousal. Chronic use can lead to scarring of heart tissue and myocardial hypertrophy and other changes collectively known as myocardial remodeling. These changes constitute the substrate for the occurrence of lethal arrhythmias.

Cocaine binds to the hERG (rapid repolarizing potassium) channel, disrupting the normal process of depolarization in heart muscle. Cocaine should not, therefore, be used concomitantly with drugs known to cause QT interval prolongation

While chest pain related to cocaine use is a common reason for seeking medical care, occasional use is rarely associated with acute myocardial infarction (AMI) unless there is pre-existing coronary artery disease.

Psychosis can be seen in chronic users as an isolated condition or as a feature of "excited delirium". It is an agitated confusional state associated with potentially lethal hyperthermia.

There is no evidence to support the use of antipsychotic agents for cocaine dependence. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death.

Definition

Cocaine is a drug of abuse that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine is a type IA antidysrhythmic, local anesthetic, and sympathomimetic. It can also bind the hERG (slowly depolarizing inward potassium channel), which is prodysrhythmic.

History and exam

Key diagnostic factors

presence of cocaine or other substance use disorders in family members
hypertension
tachycardia
chest pain
mydriasis
diaphoresis
tremulousness
agitation (mild to severe)
mood changes (e.g., irritability, euphoria, dysphoria)

Full details

Other diagnostic factors

anxiety (panic state: mild to severe)
drug-induced formication
previous hospitalization for detoxification
suspicion of body packing (swallowing drug packets for transport)
suspicious burns (e.g., crack lip, crack thumb)
nasal septum ulceration, perforation
focal neurologic abnormalities
seizure activity
loss of consciousness/altered consciousness
skin lesions (e.g., subcutaneous salmon-colored patches, infections, erosions, necrosis)
dyspnea

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Risk factors

history of alcohol/other drug abuse
history of mental illness

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Diagnostic investigations

1st investigations to order

urine toxicology ± gas chromatography/mass spectrometry testing for levamisole
ECG
CT head
EEG

Full details

Investigations to consider

x-ray abdomen
CT abdomen with oral contrast
CBC

Full details

Treatment algorithm

ACUTE

Contributors

Authors VIEW ALL 

Steven B. Karch, MD, FFFLM, FCSFS

Consultant Cardiac Pathologist/Toxicologist (ret.)

Office of the Chief Medical Examiner

San Francisco

Disclosures

SBK is an author of a number of references cited in this monograph. SBK declares that he has no other competing interests.

Peer reviewers VIEW ALL 

Timothy Albertson, MD, PhD, MPH

Chief

Division of Pulmonary and Critical Care Medicine

University of California, Davis

Sacramento

Disclosures

TA declares that he has no competing interests.

Andrew Stolbach, MD

Assistant Professor

Department of Emergency Medicine

Johns Hopkins University Hospital

Baltimore

Disclosures

AS declares that he has no competing interests.

Russel Falck, MA

Assistant Professor of Community Health and Associate Director

Center for Interventions

Treatment and Addictions Research

Wright State University Boonshoft School of Medicine

Dayton

Disclosures

RF declares that he has no competing interests.

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Consultant Psychiatrist and Honorary Senior Lecturer

Addictions, Alcohol Research

Institute of Psychiatry

King's College London

London

Disclosures

CK declares that he has no competing interests.

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Cocaine abuse

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

non-body packer with acute hyperadrenergic state

confirmed body-packer syndrome

chronic cocaine addiction

Contributors

Authors VIEW ALL 

Steven B. Karch, MD, FFFLM, FCSFS

Disclosures

Peer reviewers VIEW ALL 

Timothy Albertson, MD, PhD, MPH

Disclosures

Andrew Stolbach, MD

Disclosures

Russel Falck, MA

Disclosures

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Disclosures

Differentials

Guidelines

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