Summary
Definition
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)
Other diagnostic factors
- anxiety (panic state: mild to severe)
- drug-induced formication
- previous hospitalization for detoxification
- 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
Risk factors
- history of alcohol/other drug abuse
- history of mental illness
- male sex
Diagnostic investigations
1st investigations to order
- urine toxicology ± gas chromatography/mass spectrometry testing for levamisole
- ECG
- chest x-ray
- CT head
- electroencephalogram
Investigations to consider
- CBC
- CT chest
- bronchoalveolar lavage
- transthoracic echocardiogram
Treatment algorithm
acute intoxication
nonpregnant adults and adolescents: mild cocaine use disorder
nonpregnant adults and adolescents: moderate to severe cocaine use disorder
pregnant
sustained remission
continued use or relapse
treatment resistant
Contributors
Authors
Steven B. Karch, MD, FFFLM, FCSFS
Consultant Cardiac Pathologist/Toxicologist (ret.)
Office of the Chief Medical Examiner
San Francisco
CA
Disclosures
SBK is an author of a number of references cited in this topic. SBK gives expert testimony and receives royalties from a textbook that he authored.
Kim Wolff, MBE, PhD
Professor of Analytical, Forensic, and Addiction Science, Director, King’s Forensics
Faculty Life Science and Medicine
King’s College London
London
UK
Disclosures
KW declares that she provides expert opinion and reports as a panel member of the Secretary of State Medical Panel for Drink and Drug Driving and as a member of the World Health Organization Expert Panel on Drug Dependence.
Peer reviewers
Timothy Albertson, MD, PhD, MPH
Chief
Division of Pulmonary and Critical Care Medicine
University of California, Davis
Sacramento
CA
Disclosures
TA declares that he has no competing interests.
Andrew Stolbach, MD
Assistant Professor
Department of Emergency Medicine
Johns Hopkins University Hospital
Baltimore
MD
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
OH
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
UK
Disclosures
CK declares that he has no competing interests.
Differentials
- Thyrotoxicosis
- Methamphetamine abuse
- Amphetamine abuse
More DifferentialsGuidelines
- Screening and intervention for mental health disorders and substance use and misuse in the acute trauma patient
- Clinical practice guideline for the management of substance use disorders
More GuidelinesPatient leaflets
Cocaine use disorder
More Patient leafletsLog in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer