History
Diagnostic Criteria (DSM-5)
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies cocaine use under the category of stimulant-related disorders. The five disorders now recognized are as follows: [1]
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Stimulant use disorder
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Stimulant intoxication
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Stimulant withdrawal
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Other stimulant-induced disorders
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Unspecified stimulant-related disorder
Stimulant use disorder
Symptoms of stimulant use disorders include craving for stimulants, failure to control use when attempted, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use stimulants, and withdrawal symptoms that occur after stopping or reducing use, including fatigue, vivid and unpleasant dreams, sleep problems, increased appetite, or irregular problems in controlling movement. [1]
Stimulant intoxication
Criteria for stimulant intoxication are as follows: [1]
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Recent use of an amphetamine-type substance, cocaine, or other stimulant.
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Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, use of stimulant.
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Two or more of the following signs or symptoms:
- Tachycardia or bradycardia
- Pupillary dilation
- Elevated or lowered blood pressure
- Perspiration or chills
- Nausea or vomiting
- Evidence of weight loss
- Psychomotor agitation or retardation
- Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
- Confusion, seizure, dyskinesias, dystonias, or coma
Stimulant withdrawal
Withdrawal manifests after cessation or reduction of prolonged use of cocaine and results in a dysphoric mood and two (or more) of the following changes: [1]
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Fatigue
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Vivid, unpleasant dreams
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Insomnia or hypersomnia
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Increased appetite
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Psychomotor retardation or agitation
These signs usually cause clinically significant distress or impairment and are not attributable to another medical condition or disorder.
Physical
Cocaine affects multiple organ systems. A thorough physical examination must be performed on patients suspected of cocaine abuse.
Vital signs
Acute cocaine intoxication is most commonly associated with tachycardia and hypertension due to an induced sympathomimetic syndrome.
Any patient presenting with a history of cocaine abuse and altered mental status must have an adequate temperature taken, preferably a core temperature, such as rectal. Hyperthermia associated with acute cocaine toxicity must be closely monitored.
Tachypnea may be simply a result of cocaine's stimulant effects. However, other etiologies of tachypnea include pulmonary edema, pneumothorax, pulmonary embolism, acute coronary syndrome, panic attacks, and withdrawal syndromes.
Skin and extremities
Acute cocaine toxicity is typically associated with diaphoresis.
The skin may be cool as a result of the vasoconstrictive effects of cocaine, despite an elevated core temperature.
Examine the skin for evidence of intravenous (track marks) or subcutaneous (skin popping) drug abuse.
Head, ears, eyes, nose, and throat
Close inspection of the head for signs such as edema, ecchymosis, or bony deformity is necessary to help exclude the possibility of head trauma.
Examine the eyes for pupil size (mydriasis with acute cocaine abuse), presence of nystagmus, and extraocular muscle function.
Individuals who chronically abuse cocaine who insufflate cocaine may have nasal septa perforations as a result of necrosis from repetitive cocaine-induced vasoconstriction and subsequent ischemia.
Cardiovascular
Heart sounds may reveal murmurs (endocarditis and/or valvular damage), rubs (pericarditis), or dysrhythmias.
Pulmonary
Rales due to pulmonary edema (cardiac and noncardiac etiologies associated with cocaine), pneumonia (infectious or aspiration), or atelectasis (pulmonary embolism) may be present.
Decreased breath sounds may be noted as a result of a pneumothorax.
Acute bronchospasm (wheezing) may be noted secondary to smoking crack cocaine or cocaine insufflation abuse.
Gastrointestinal: Vomiting, diarrhea, and hyperactive bowel sounds may be noted with acute cocaine abuse.
Neurologic
People who abuse cocaine may present with seizures, agitation, tremor, and hyperreflexia.
Focal muscular weakness or sensory changes may occur secondary to cerebral vascular accident.
Psychiatric
The American Psychiatric Association recognizes a number of cocaine-induced psychiatric conditions.
Patients may present with delirium, psychosis, delusions, hallucinations, depression, mania, and anxiety (see History).
Causes
Numerous potential causes and risks factors have been cited as associated with cocaine abuse.
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The US National Institute on Drug Abuse estimates that approximately 10% of people who begin to use cocaine progress to heavy, chronic abuse.
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A family history of substance abuse directly correlates both with the development of cocaine abuse and with earlier age of onset of cocaine abuse.
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Approximately 50% of those who abuse illicit drugs also have a co-occurring mental disorder.
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For example, individuals who abuse cocaine have higher rates of antisocial personality disorder, depression, anxiety, and attention-deficit/hyperactivity disorder.
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Low levels of family bonding and high levels of peer antisocial activity were consistently associated with higher prevalence of illicit drug initiation among youths aged 12-21.
