Pediatric Cocaine Abuse Treatment & Management

Unless a patient presents in an acutely intoxicated state or with cocaine-related complaints, the most important intervention is education and prevention. Most mild intoxications require only supportive care. Prevention of absorption is difficult because most cocaine exposures travel through IN, IV, or intrapulmonary routes.

Cocaine abuse and addiction is a complex mixture of neurobiologic, social, environmental, and familial problems. No pharmacologic agents have proven effective to treat or counteract cocaine addiction, although the NIDA is actively involved in research on this problem. Antidopaminergic agents, disulfiram, and antidepressants for the mood swings of early abstinence have been investigated. In 1999, selegiline entered phase III of a multicenter clinical trial and has shown some promise.

• The most effective therapies available focus on behavioral interventions. Intervention should involve several approaches and should address associated psychiatric disorders.

  • Discuss the medical, behavioral, psychological, and social effects of cocaine use with patients, patients' families, and others who provide support. Family therapy and self-help groups such as Cocaine Anonymous, which use 12-step programs, can have important support roles.
  • Behavioral interventions are effective for cocaine addiction. Contingency management is a popular and effective form of behavioral therapy. Patients are awarded points for drug-free urine samples. These points then can be traded for positive prosocial items (eg, passes to a gymnasium, tickets to a movie). Cognitive-behavioral therapy's aim is to maintain recovery states by helping patients "...recognize, avoid, and cope." Substance refusal, anger control, problem solving, and leisure-time management are crucial skills needed for successful recovery.
  • Relapse prevention is challenging. Therapy provided in an outpatient setting requires frequent follow-up appointments. Missed appointments commonly signal a relapse. Examples of relapse prevention include monitoring the temptations and urges to use cocaine or other drugs, rehearsing ways to avoid friends who encourage drug use, and living with relatives who are drug-free. Relapses can range in severity from slips involving several days of drug use to resumption of regular drug use and addiction.
  • Inpatient treatments (eg, residential communities) offer 6- to 12-month stays designed to provide comprehensive treatment. Programs may include treatment for coexisting mental problems, vocational rehabilitation, and other services to help the cocaine or polydrug-addicted patient return to constructive activity in society and avoid relapse.
  • Coexisting psychiatric disorders may require treatment. Early symptoms of abstinence may resemble symptoms of a psychiatric disorder. Depression during early abstinence may be sufficiently severe to cause suicidal ideation or attempts; therefore, carefully assess cocaine users in early abstinence for mood disorder and maintain concern for their safety. Medication for psychiatric syndromes may be indicated when symptoms persist beyond a few weeks into the abstinence period. Medication may be initiated more rapidly in cases involving a documented comorbid psychiatric disorder.
  • Encourage the patient toward a community environment or activities that limit temptations for relapse and that promote prosocial alternatives to deviant behavior and relationships. Some patients' interests may be served by relocating to another neighborhood.
• Agitation and hyperthermia are the major causes of death due to cocaine toxicity. Medical treatment for these conditions includes the following:

  • Establish airway control, if necessary, and IV access.
  • Obtain a core temperature.
  • Sedation is the mainstay of treatment. Benzodiazepines are very useful in the management of toxicity. Administer benzodiazepines titrated to sedation. (Avoid neuroleptic agents, if possible, because they may impair heat dissipation, lower the seizure threshold, and cause a dystonic reaction.)
  • Avoid restraints because they may exacerbate hyperthermia and acidosis and may cause death if used alone. If necessary, use restraints only until the person is calm.
  • Aggressive cooling with ice water baths, mist and fans, and ice packs is important until a core temperature of 101-102°F is reached within 30-45 minutes.
• To treat seizures, initial airway control and IV access are critical. Subsequent management steps include the following:

  • Evaluate for hypoxia, hypoglycemia, and electrolyte disturbances.
  • Treat seizures with benzodiazepines; however, refractory cases may require phenobarbital or neuromuscular blockade. Avoid succinylcholine because of the risk of exacerbating hyperkalemia in a patient with cocaine-induced rhabdomyolysis.
  • Brain CT scanning is highly recommended in patients with cocaine-induced seizures because of the risk of intracranial hemorrhages.
• Treat hypertension as follows:

  • Treatment for agitation and anxiety often reduces the elevated blood pressure (BP); therefore, sedation with benzodiazepines is a prudent initial therapy.
  • Some patients continue to have high BP despite sedation; these individuals require other pharmacologic agents as well as sedation and decreased environmental stimuli.
  • Nitroprusside, nitroglycerin, or phentolamine can be used to lower BP more aggressively.
  • Avoid beta-blocker use because of the unopposed alpha stimulation that results. Labetalol has both alpha and beta antagonism but in a 1:7 ratio. Theoretically, labetalol has insufficient alpha blockage. Esmolol has a safer profile because of its beta-1 selective antagonism, rapid onset, and short duration of activity.
• Cardiovascular treatment includes the following:

  • Use aspirin, nitrates, and benzodiazepines to treat patients with cocaine-related myocardial ischemia.
  • Although thrombolysis may be considered, the authors strongly recommend consultation with a cardiologist.
  • The efficacy of calcium channel blockers is controversial.
  • Treatment with nonselective beta-blockers is contraindicated because they may potentiate cocaine-induced coronary vasoconstriction.
  • Depleted norepinephrine stores may result in hypotension, which necessitates treatment with dopamine or norepinephrine.
  • Ventricular dysrhythmias can be treated with bretylium.
  • Lidocaine is usually the advanced cardiac life support (ACLS) drug of choice in ventricular tachydysrhythmia. However, lidocaine may lower the seizure threshold in a patient with cocaine intoxication patient.
• Treatment for patients with rhabdomyolysis requires aggressive hydration. Diuretics, such as mannitol or furosemide, can be used to ensure that urine output is at least 3 mL/kg/h. Dialysis may be needed to treat renal failure.

Neurosurgical care may be necessary for intracranial bleeding (eg, to monitor for intracranial pressure or to surgically decompress subdural or epidural hematomas).

Other cocaine-related complications and pertinent surgical care include the following:

• Pneumothorax - Chest tube placement
• Abscess - Incision and drainage
• Fractures or dislocations - Orthopedic reduction/immobilization or intraoperative repair

Referral to a primary care physician to exclude medical causes is recommended. A more encompassing evaluation by a child and adolescent psychiatrist is then indicated. Input from behavioral and developmental pediatric specialists should be sought for truly specialized and long-term care especially with the large volume of patients that are in need.

Specialized psychiatric/mental health care, also called substance use disorder (SUD) treatment, must be emphasized. SUD treatment helps identify risks factors for cocaine relapse and provides effective strategies to reduce the risk of cocaine relapse. According to the 2008 National Survey on Drug Use and Health, only 7% of adolescents who were candidates for SUD treatment actually received the treatment. An 8-year (2001-2008) cross-sectional survey of data from the National Survey of Drug Use and Health revealed that while substance use disorder referral and treatment is quite low amongst all adolescents, it is especially low in African American and Latino adolescents (8.4%) and up to 23.5% in Native Hawaiian/Pacific Islander adolescents.^[16]

The following additional consultants may be needed:

• Cardiologist
• Toxicologist
• Drug counselor
• Neurologist
• Neurosurgeon
• Infectious diseases specialist