Pediatric Cocaine Abuse Clinical Presentation

Any patient who presents with symptoms of a cardiac, vascular, pulmonary, neurologic, or psychological problem should provide a drug history. Coordination, response, and judgment may have been influenced by psychoactive drugs in patients involved in vehicular accidents, falls, near-drowning experiences, domestic violence, rapes, and other violent acts or misfortunes. The history should attempt to elicit answers to the following questions:

• Identifying the drug or drugs

  • Which drug was used?
  • Was the drug used with any other drugs?
  • How much of the drug was used?
  • The use occurred over what period of time?
  • Was the drug obtained from a usual source?
• Prior cocaine use

  • Has the patient used cocaine before?
  • How often?
  • How much?
  • By what route?
  • How long?
  • Has tolerance developed?
  • What withdrawal signs have developed in the past?
• Alcohol and nicotine use

  • Does the patient use nicotine or alcohol?
  • What is the extent of either use or dependence?
  • Does the patient smoke or drink before or during cocaine use?
• Existing symptoms

  • What symptoms present?
  • Are pain (eg, headache, chest, extremity, abdominal), respiratory problems, anxiety, confusion, seizures, hallucinations, altered mental status, syncope, or dizziness present?
  • Did these symptoms occur with prior use of cocaine?
  • How long after cocaine use did symptoms begin?
  • Are these symptoms due to withdrawal from cocaine?
• Comorbid medical conditions

  • Does the patient have other medical conditions (eg, liver disease, pregnancy [lowered serum cholinesterases]) that may lead to greater toxicity from cocaine?
  • Comorbid disorders may include the following:
    • Suicidal ideation or behavior
    • Mood disorders
    • Attention deficit hyperactivity disorder
    • Anxiety disorder
    • Sleep disturbances
    • Oppositional defiant disorder/behavior
    • Schizophrenia or psychotic symptoms
    • Conduct disorder or antisocial behavior
    • Eating disorder
    • Aggressive behavior
    • Developmental problems
• Behaviors prompting this evaluation: What behaviors prompted this evaluation? Many psychiatrically disturbed adolescents and young adults brought into emergency departments (EDs) because of emotional outbursts or demonstrative, even dangerous, extremes of behavior may be intoxicated with psychoactive drugs, such as phencyclidine (PCP), cocaine, amphetamines, and lysergic acid diethylamide (LSD). Knowing the duration of action of the various illicit drugs (eg, cocaine's stimulatory effects typically last for 1 h, whereas amphetamines usually cause stimulation for several hours) can help the clinician to determine if behavior displayed is due to a drug or due to an underlying psychiatric illness.
• History of present illness from caregiving sources: Elicit reasons for the concern if it is a referral or complaint. What led to the referral and what outcome is expected by the referring person? Determine parents' knowledge of the child's cocaine use patterns and any response and attitude to prior substance abuse treatment.
• Interactions with peers and environment

  • Does the patient show any signs of disruptive behaviors or practices present?
  • Does the patient have prosocial hobbies, interests, or recreational activities?
• Family history

  • Do any family members have histories of substance use or abuse?
  • Are any family members currently involved in substance use or abuse?
  • What are family members' attitudes about substance abuse?
  • Do any family members have a history of psychiatric disorders?
  • What is the family's socioeconomic status?
  • What is the nature of family functioning (ie, support styles, interaction of family members, demonstrated behaviors and emotions, supervision, disciplinary methods, family stressors)?
  • What family stressors (eg, physical or sexual abuse, neglect, violence, other trauma) are present?
• Developmental history

  • Does the patient have developmental delays that may affect current functioning?
  • Does the patient have social skills or communication deficits?
  • What was the patient's highest level of functioning prior to substance use?
• Full medical history
• School performance and attitudes toward school
• Job history
• RAFFT questionnaire: The RAFFT questionnaire is a sensitive screening instrument for identifying substance abuse.

  • R (relax): Does the individual drink or take drugs to relax, improve self-image, or fit in?
  • A (alone): Does the individual ever drink or take drugs while alone?
  • F (friends): Do any close friends drink or use drugs?
  • F (family): Does a close family member have a problem with alcohol or drugs?
  • T (trouble): Has the individual ever gotten into trouble from drinking or taking drugs?

Because of the myriad of acute and chronic effects of cocaine use and abuse, the physical examination can be revealing, even in patients who are not acutely intoxicated.

• Vital signs: The patient may be hyperthermic, tachycardic, and hypertensive; however, a patient who abuses cocaine and is not currently intoxicated may have normal vital signs.
• Head, ears, eyes, nose, and throat (HEENT): Nasal septal ulcerations or perforations with atrophy of the mucosa suggest IN cocaine abuse. Patients intoxicated with cocaine may have a sympathomimetic syndrome with mydriasis. The patient may have "crack eye," with corneal abrasions and ulcerations from the heat and particulate smoke of crack. Singed nasal hairs and carbonaceous sputum may suggest thermal burns of the respiratory tract.
• Lungs: Pneumothorax and pneumomediastinum may result from crack use. Careful listening to the lungs and assessing for any subcutaneous air is important. Cocaine use may also lead to noncardiogenic pulmonary edema or to diffuse alveolar hemorrhage. Wheezing may occur from exacerbated asthma or hypersensitivity pneumonitis.
• Cardiac: Cocaine use is associated with MI, aortic dissection, endocarditis, cardiomyopathy, and bradycardia, as well as virtually all types of tachydysrhythmia. Careful auscultation of the heart, close monitoring, assessment of the pulses, and an ECG are important.
• GI: Inspect the abdomen for distension, ecchymosis, and bowel sounds. Pain out of proportion to tenderness may suggest bowel ischemia. A rectal examination to detect GI bleeding is indicated.

  • Body packers: Cocaine is carefully wrapped in small well-sealed packets. If body packing is suspected, carefully search the patient's body cavities.
  • Body stuffers: Cocaine is hastily ingested. Carefully search the patient's body cavities if stuffing is suspected.
• Skin: Inspect skin for needle punctures (ie, "track marks") or evidence of "skin-popping." Cellulitis, abscesses, and retained needles are complications. Acutely intoxicated patients may be warm and diaphoretic, in contrast to patients who have anticholinergic toxicity, who present with hot and dry skin.
• Neurologic: Conduct a thorough neurologic examination of any patient with possible cocaine abuse. Mental status, strength, reflexes, sensation, and gait help determine the possibility of cerebral ischemia, infarction, subarachnoid hemorrhage, movement disorders, or seizures.
• Obstetrical: Assess both fetal and maternal health. Fetal heart and motion monitoring is important. Withhold bimanual examination for third-trimester bleeding until ultrasonography can exclude a placenta previa or abruptio diagnosis.

The NIDA has identified the following risk factors for the development of drug use and abuse^[5] :

• Unstable home environment due to parental substance abuse or mental illness
• Fractured relationship of parents and adolescent or child
• Poor level of supervision of the adolescent's activities
• Peer use of drugs
• Liberal parental attitude of their own drug use or adolescent's use of drugs
• Children with conduct disorder or difficult temperaments coupled with ineffective parenting
• Poor performance in school
• Apparent ambivalence or approval of drug-using behavior in the school, peer group, or the community
• Availability of drugs in the community, peer group, or home environment

The consequences of cocaine use, abuse, and dependence include lowered educational achievements, increased trouble with law enforcement (including increased arrests, incarcerations, longer sentences), limited and more limited employment options with worse outcomes, and increased suicidal attempts and completed suicides.