History

Fact Explanation
Seizures [1] Cocaine intoxication.These changes are caused by the changes in the neurotransmitter levels in brain [1]
Chest pain and palpitations [1] Due to cocaine intoxication [1] Cocaine abuse is associated with left ventricular dysfunction [2]
Somnolence [3] Cocaine withdrawal. Withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. Insomnia also occurs due to cocaine induced sleep disorders [3]
Body pains, joint pains,craving [3] Cocaine withdrawal symptoms.While cocaine use results in a sensation of energy, excitement and confidence, withdrawing from cocaine pretty much results in the opposite effect.The extent of craving variation can depend on certain personality styles [3]
Inability to concentrate or pay attention,change in the ability to think [3] Cocaine induced delirium.These symptoms have rapid onset within hours or days of using cocaine and the symptoms fluctuate throughout the course [3]
Hallucinations [3] Cocaine induced psychotic disorder. Cocaine has numerous effects on many important neurotransmitters in the brain.Excessive dopamine gives rise to hallucinations, specially visual hallucinations. [3]
Delusions [3] Cocaine induced psychotic disorder. Mainly persecutory delusions due to changes in the dopamine levels [3]
Violence [3] Increase in levels of neurotransmitters in the brain's pleasure centers, dramatic change in levels of norepinephrine and serotonin in other parts of the brain might provoke aggression [3]
Anxiety and Panic attacks [4] Cocaine induced anxiety disorder.Cocaine addiction is linked to changes within neural systems and brain regions that are critical mediators of stress system sensitivity [4]
Shoplifting, theft, burglary [3] Cocaine dependency.Spending a great deal of time and energy obtaining and using cocaine [3]
Impaired sexual desire, impaired arousal [5] Cocaine induced sexual disorders [5]
Epistaxis, loss of smell [6] Chronic cocaine snorting leads to destruction of nasal bone. Repeated snorting sets up a cascade of ischemia, inflammation, micronecrosis, infection, and then macronecrosis leading to perforation [6]
Diplopia [6] Adjacent bony structures may become eroded and vital tissues (eg:optic tract) may get damaged [6]
Dental erosions, oral mucosal ulceration [6] Topically applied cocaine (Gingival application) can be locally destructive to the oral mucosa and dentition. Acute ulceration, necrosis, and rapid recession of gingival tissues, as well as erosion of both dentin and enamel, have been reported [6]
Symptoms of drug dependence [3] A compulsion to take the substance Escalation of amount used A withdrawal syndrome following reduction in use Tolerance Neglect of other activities in favour of substance use Persistent use despite evidence of harm [3]
References
  1. BODMER M, ENZLER F, LIAKONI E, BRUGGISSER M, LIECHTI ME. Acute cocaine-related health problems in patients presenting to an urban emergency department in Switzerland: a case series. BMC Res Notes [online] 2014 Mar 25:173 [viewed 10 June 2014] Available from: doi:10.1186/1756-0500-7-173
  2. MACEIRA ALICIA M, RIPOLL CARMEN, COSIN-SALES JUAN, IGUAL BEGOñA, GAVILAN MIRELLA, SALAZAR JOSE, BELLOCH VICENTE, PENNELL DUDLEY J. Long term effects of cocaine on the heart assessed by cardiovascular magnetic resonance at 3T. Array [online] 2014 December [viewed 10 June 2014] Available from: doi:10.1186/1532-429X-16-26
  3. MORTON WA. Cocaine and Psychiatric Symptoms Prim Care Companion J Clin Psychiatry [online] 1999 Aug, 1(4):109-113 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181074/#!po=52.7778
  4. FOX H, SINHA R. The Role of Guanfacine as a Therapeutic Agent to Address Stress-related Pathophysiology in Cocaine Dependent Individuals Adv Pharmacol [online] 2014:217-265 [viewed 10 June 2014] Available from: doi:10.1016/B978-0-12-420118-7.00006-8
  5. KOPETZ CE, REYNOLDS EK, HART CL, KRUGLANSKI AW, LEJUEZ CW. Social context and perceived effects of drugs on sexual behavior among individuals who use both heroin and cocaine Exp Clin Psychopharmacol [online] 2010 Jun, 18(3):214-220 [viewed 10 June 2014] Available from:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3198869/#!po=73.8095
  6. VILLA PD. Midfacial complications of prolonged cocaine snorting. J Can Dent Assoc [online] 1999 Apr, 65(4):218-23 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10224723

Examination

Fact Explanation
Hypertention [1] Cocaine intoxication.Cocaine leads to impaired neurotransmitter release [1]
Tachycardia [1] Cocaine intoxication.Due to impaired neurotransmitter release [1]
Tremors [2] Cocaine intoxication.Due to impaired neurotransmitter release [2]
Blood pressure fluctuations [2] Cocaine induced delirium.Changes in dopamine, norepinephrine, and serotonin levels have been associated with these effects [2]
Shortness of breath [3] Due to panic attacks caused by anxiety disorders [3]
Depressed mood [2] Cocaine induced psychotic disorder.Due to imbalance of neurotransmitters [2]
Nasal septal defects,saddle nose deformity [4] Chronic cocaine snorting leads to destruction of nasal bone. Repeated snorting sets up a cascade of ischemia, inflammation, micronecrosis, infection, and then macronecrosis leading to perforation [4]
Palatal perforation,nasopalatal fistula [4] Chronic cocaine snorting leads to destruction of palatal bones [4]
Dental erosions, oral mucosal ulceration [4] Topically applied cocaine (Gingival application) can be locally destructive to the oral mucosa and dentition. Acute ulceration, necrosis, and rapid recession of gingival tissues, as well as erosion of both dentin and enamel, have been reported [4]
Loss of visual acuity [4] Adjacent bony structures may become eroded and vital tissues (eg:optic tract) may get damaged [4]
References
  1. BODMER M, ENZLER F, LIAKONI E, BRUGGISSER M, LIECHTI ME. Acute cocaine-related health problems in patients presenting to an urban emergency department in Switzerland: a case series. BMC Res Notes [online] 2014 Mar 25:173 [viewed 10 June 2014] Available from: doi:10.1186/1756-0500-7-173
  2. MORTON WA. Cocaine and Psychiatric Symptoms Prim Care Companion J Clin Psychiatry [online] 1999 Aug, 1(4):109-113 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181074/#!po=52.7778
  3. FOX H, SINHA R. The Role of Guanfacine as a Therapeutic Agent to Address Stress-related Pathophysiology in Cocaine Dependent Individuals Adv Pharmacol [online] 2014:217-265 [viewed 10 June 2014] Available from: doi:10.1016/B978-0-12-420118-7.00006-8
  4. VILLA PD. Midfacial complications of prolonged cocaine snorting. J Can Dent Assoc [online] 1999 Apr, 65(4):218-23 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10224723

Differential Diagnoses

Fact Explanation
Bipolar disorder [1] The symptoms of cocaine intoxication, such as increased talkativeness, poor sleep, and the intense feelings of happiness are similar to the symptoms for bipolar disorder [1]
Schizophrenia [1] Patients with cocaine intoxication with hallucinations and delusions can be mistaken for schizophrenic patients [1]
Depression [1] Cocaine withdrawal may lead to depression.If cocaine use is causing depression, the depression should resolve within a couple of weeks of stopping drug use. [1]
Cushing syndrome [1] Give rise to similar symptoms of cocaine intoxication (eg: restless,tremor) [1]
References
  1. ROSENTHAL R. N., MINER C. R.. Differential Diagnosis of Substance-induced Psychosis and Schizophrenia in Patients With Substance Use Disorders. Schizophrenia Bulletin [online] 1997 January, 23(2):187-193 [viewed 10 June 2014] Available from: doi:10.1093/schbul/23.2.187

Investigations - for Diagnosis

Fact Explanation
Urine tests to detect cocaine metabolites [1] The breakdown products of cocaine remain in the urine.Maximum concentration tends to be high after intravenous route [1]
Neuropsychological assessments [2] Diagnosis can be done according to ICD 10 or DSM-IV criteria. Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, and language [2]
Drug dependence [3] Diagnostic features for substance dependence Three or more of the following should have been present in the previous year: 1.A compulsion to take the substance 2.Escalation of amount used 3.A withdrawal syndrome following reduction in use 4.Tolerance 5.Neglect of other activities in favour of substance use (salience) 6.Persistent use despite evidence of harm [3]
References
  1. CONE E. J., SAMPSON-CONE A. H., DARWIN W. D., HUESTIS M. A., OYLER J. M.. Urine Testing for Cocaine Abuse: Metabolic and Excretion Patterns following Different Routes of Administration and Methods for Detection of False-Negative Results. Journal of Analytical Toxicology [online] 2003 October, 27(7):386-401 [viewed 10 June 2014] Available from: doi:10.1093/jat/27.7.386
  2. MORTON WA. Cocaine and Psychiatric Symptoms Prim Care Companion J Clin Psychiatry [online] 1999 Aug, 1(4):109-113 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181074/#!po=52.7778
  3. Clinical topics in addiction: RCPsych publications.[viewed 10 June 2014] Available from: https://www.rcpsych.ac.uk/files/samplechapter/ClinTopicsAddictionsChapter.pdf

Investigations - Fitness for Management

Fact Explanation
ECG [1] / blood pressure [2] To detect effects of cocaine on cardiovascular system [1] Cocaine blocks the reuptake of norepinephrine and dopamine, causing an accumulation of catecholamines causing high blood pressure and increased heart rate [2]
Echocardiogram, cardiovascular magnetic resonance [1] Included measurement of left and right ventricular (LV, RV) dimensions and ejection fraction (EF),to detect effects of cocaine on heart [1]
Platelet count [2] Cocaine increases the risk of thrombus formation due to associated increase in platelet count, increased platelet activation [2]
References
  1. MACEIRA ALICIA M, RIPOLL CARMEN, COSIN-SALES JUAN, IGUAL BEGOñA, GAVILAN MIRELLA, SALAZAR JOSE, BELLOCH VICENTE, PENNELL DUDLEY J. Long term effects of cocaine on the heart assessed by cardiovascular magnetic resonance at 3T. Array [online] 2014 December [viewed 10 June 2014] Available from: doi:10.1186/1532-429X-16-26
  2. MCCORD J., JNEID H., HOLLANDER J. E., DE LEMOS J. A., CERCEK B., HSUE P., GIBLER W. B., OHMAN E. M., DREW B., PHILIPPIDES G., NEWBY L. K.. Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation [online] 2008 April, 117(14):1897-1907 [viewed 09 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.107.188950

Investigations - Followup

Fact Explanation
Neuropsychological assessments [1] Studies have shown dose-related effects on complex tasks of higher cortical functions (attention, planning, mental flexibility, executive functioning, psychomotor functioning) which improve with treatment [1]
Echocardiography [2] To identify left ventricular hypertrophy which is positive in long term cocaine users [2]
Coronary Angiography [2] Coronary artery occlusion due to increased thrombotic risk (increased platelets) due to chronic cocaine use [2]
References
  1. MORTON WA. Cocaine and Psychiatric Symptoms Prim Care Companion J Clin Psychiatry [online] 1999 Aug, 1(4):109-113 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181074/#!po=52.7778
  2. MCCORD J., JNEID H., HOLLANDER J. E., DE LEMOS J. A., CERCEK B., HSUE P., GIBLER W. B., OHMAN E. M., DREW B., PHILIPPIDES G., NEWBY L. K.. Management of Cocaine-Associated Chest Pain and Myocardial Infarction: A Scientific Statement From the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation [online] 2008 April, 117(14):1897-1907 [viewed 09 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.107.188950

Investigations - Screening/Staging

Fact Explanation
Neuropsychological assessments [1] Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, and language [1]
Information from the patient's relatives/caregivers [1] To inquire about the symptoms of cocaine induced disorders [1]
References
  1. MORTON WA. Cocaine and Psychiatric Symptoms Prim Care Companion J Clin Psychiatry [online] 1999 Aug, 1(4):109-113 [viewed 10 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181074/#!po=52.7778

Management - General Measures

Fact Explanation
Cognitive behavioral therapy [1] Typical cognitive strategies employed are recognizing and challenging dysfunctional thoughts about substances and recognizing seemingly irrelevant decisions that lead to a relapse [1]
Motivational interviews [1] Helps people to explore and resolve their ambivalence about their substance use and begin to make positive behavioral and psychological changes [1]
Relapse prevention [1] Has been theorized to be a set of strategies to help the client maintain treatment gains rather than a specific intervention [1]
Self help groups [1] Support groups and group therapy led by a therapist can be helpful because other addicts can share coping and relapse-prevention strategies [1]
Social support [2] Studies have shown that normalization of social bonding and rewarding can strengthen cognition against drug intake [2] Social function (marital disharmony, work relationships etc.) is a strong predictor of the subjective effects of cocaine addiction, thus good social support is needed in the management [3]
References
  1. JHANJEE S. Evidence Based Psychosocial Interventions in Substance Use Indian J Psychol Med [online] 2014, 36(2):112-118 [viewed 10 June 2014] Available from: doi:10.4103/0253-7176.130960
  2. VERDEJO-GARCIA A. Social cognition in cocaine addiction. Proc Natl Acad Sci U S A [online] 2014 Feb 18, 111(7):2406-7 [viewed 09 September 2014] Available from: doi:10.1073/pnas.1324287111
  3. GRASING K, MATHUR D, NEWTON TF, DESOUZA C. Individual predictors of the subjective effects of intravenous cocaine. Psychiatry Res [online] 2013 Aug 15, 208(3):245-51 [viewed 09 September 2014] Available from: doi:10.1016/j.psychres.2013.05.028

Management - Specific Treatments

Fact Explanation
Anti psychotics [1] Typical antipsychotics, which promote a potent blockage of D2 receptors, show little effectiveness in the treatment of dependence. In contrast, atypical antipsychotics, which act on serotoninergic receptors, dissociate from the D2 receptor faster than the typical [1]
Fluoxetine [2] Chronic fluoxetine treatment attenuated cocaine-primed reinstatement.However, SSRIs have had limited success in clinical trials for cocaine abuse, possibly due to neurobiological changes that occur during chronic administration [2]
Dopaminergic medication [3] Normalizes dopamine signaling.To date, the most promising results are with a combination of a dopaminergic medication with a contingency management behavioral intervention [3]
Propranolol [4] The beta-blocker, propranolol, appears to be promising for the treatment of patients who present for treatment with severe cocaine withdrawal symptoms [4] It also increases the duration of abstinence [5]
Baclofen [4] Baclofen is GABA B agonist used as a muscle relaxant. As a GABA agonist, baclofen may reduce the amount of dopamine released into the nucleus accumbens as a result of cocaine stimulation or cocaine craving [4]
Tiagabine [4] Tiagabine is another GABAergic medication that may be promising for the treatment of cocaine dependence.Currently approved for the treatment of seizures [4]
Topiramate [4] An excellent medication for relapse prevention based on its effects on both GABA neurotransmission and glutamate neurotransmission [4] It also increases the rate of abstinence [5]
Disulfiram [4] Cocaine relapse prevention medication.It blocks the enzymatic degradation of cocaine and dopamine and leads to extremely high cocaine and dopamine levels when cocaine is ingested.This does not increase the cocaine-induced high, as one might expect, but rather it makes the high less pleasant by increasing the associated anxiety. [4] It also increases the duration of abstinence [5]
Modafinil [4] May be efficacious for cocaine dependence by ameliorating glutamate depletion seen in chronic cocaine users [4]
The vaccine (TA-CD) [4] For relapse prevention.Works by stimulating the production of cocaine-specific antibodies that bind to cocaine molecules and prevent them from crossing the blood brain barrier [4]
References
  1. SABIONI P, RAMOS AC, GALDURóZ JC. The Effectiveness of Treatments for Cocaine Dependence in Schizophrenic Patients: A Systematic Review Curr Neuropharmacol [online] 2013 Sep, 11(5):484-490 [viewed 10 June 2014] Available from: doi:10.2174/1570159X11311050003
  2. SAWYER EILEEN K, MUN JIYOUNG, NYE JONATHON A, KIMMEL HEATHER L, VOLL RONALD J, STEHOUWER JEFFREY S, RICE KENNER C, GOODMAN MARK M, HOWELL LEONARD L. Neurobiological Changes Mediating the Effects of Chronic Fluoxetine on Cocaine Use. Neuropsychopharmacology [online] December, 37(8):1816-1824 [viewed 11 June 2014] Available from: doi:10.1038/npp.2012.29
  3. MARIANI JJ, LEVIN FR. Psychostimulant Treatment of Cocaine Dependence Psychiatr Clin North Am [online] 2012 Jun, 35(2):425-439 [viewed 11 June 2014] Available from: doi:10.1016/j.psc.2012.03.012
  4. KAMPMAN KM. New Medications for the Treatment of Cocaine Dependence Psychiatry (Edgmont) [online] , 2(12):44-48 [viewed 12 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994240
  5. YAHYAVI-FIROUZ-ABADI N, SEE RE. Anti-relapse medications: preclinical models for drug addiction treatment. Pharmacol Ther [online] 2009 Nov, 124(2):235-47 [viewed 09 September 2014] Available from: doi:10.1016/j.pharmthera.2009.06.014