Cocaine Toxicity Follow-up

Updated: Jun 30, 2016
  • Author: Lynn Barkley Burnett, MD, EdD, LLB(c); Chief Editor: Asim Tarabar, MD  more...
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Follow-up

Further Outpatient Care

Refer the patient for drug abuse counseling and treatment.

If domestic violence is identified from the history or physical examination, refer the patient to an appropriate agency that makes referrals for physical and psychological problems and provides safety, treatment, advocacy, and support.

Provide referral for counseling or testing for HIV and other sexually transmitted disease (STD), as appropriate.

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Further Inpatient Care

Patients with chest pain should be admitted if their pain is severe, sustained, recurrent, associated with significant cardiac risk factors, or associated with any acute cardiopulmonary symptoms accompanied by positive cardiac markers or ECG changes suggestive of ischemia.

Other indications for admission to a critical care unit may include unresolved moderate-to-severe signs and symptoms, including seizures and focal neurologic deficits, and suspected ingestion of packages of cocaine.

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Transfer

If critical care is not available, transfer patients requiring such care to an appropriate facility, preferably in an advanced life support unit.

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Deterrence/Prevention

Experimental studies in animals indicate that circulating cocaine can be sequestered by high levels of anticocaine antibodies, thereby facilitating inactivation of the cocaine prior to its entry into the brain, via the action of natural plasma cholinesterase. While the US Food and Drug Administration has not approved any prophylactic pharmacotherapies for cocaine abuse, research using a cocaine-specific vaccine is in the early stages. Using succinylnorcocaine covalently linked with an immunogenic carrier, changes in IgG anticocaine antibody levels have demonstrated response kinetics similar to those of the human conjugate vaccine for nicotine. [56]

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Complications

The principal effect of cocaine, like ethanol, on mortality may be its association with homicide, suicide, and motor vehicle collisions. [57] In a study of 14,843 persons who were fatally injured in New York City over 3 years, fatal injury after cocaine use exceeded all deaths associated with other causes in persons aged 15-24 years. Although approximately one third of deaths associated with cocaine use were the result of its direct pharmacologic effects, two thirds were the result of traumatic injuries.

Cocaine use, determined by detection of its metabolite benzoylecgonine in urine or blood, was found in 26.7% of the above-mentioned patients, with free cocaine, indicating recent use, detected in 18.3%. Ethanol was detected in 28.1% of those who died. For comparison, household surveys of the general population of New York City showed that the estimated frequency of cocaine use in the preceding 30 days was less than 1.3% overall; demographic groups with the highest rates of use were Hispanics and black men, whose rates were 3-4.1%.

In this study, cocaine use was detected in 69.7% of all cases of accidental poisonings, 29.2% of homicides, 15.3% of suicides, and 9.3% of accidents.

Suicide

The use of alcohol and illicit drugs increases the risk of suicide 16-fold, which is substantially higher than the rate observed with either substance alone. A study of suicide cases in New York City demonstrated that 20% of individuals younger than 61 years had used cocaine within days of their death. Nearly one half of Hispanic men who commit suicide have toxicologic screens positive for cocaine. Cocaine users typically choose violent means for self-destruction, especially the use of firearms.

Domestic violence

Illicit use of drugs by members of the household increases a woman's risk of death at the hands of a spouse, lover, or close relative 28-fold.

According to Brookoff, approximately 45% of assailants in domestic violence had used alcohol or other drugs to the point of intoxication on a daily basis for the previous month. [58] Approximately 12% were addicted to drugs, and 14% were addicted to alcohol and drugs. On the day of the assault, the most common intoxicant was cocaine. About 30% of assailants had used cocaine and alcohol, and 13% had used alcohol, marijuana, and cocaine.

In another study of domestic violence, two thirds of assailants had used the combination of alcohol and cocaine on the day of the assault. The active metabolite of this drug combination, cocaethylene, is more intoxicating, longer lived, and possibly more potent in its ability to kindle violent behavior than the parent drugs.

Other concerns

For individuals with one addictive disorder, the risk of having a second addictive disorder is increased 7-fold.

People who use cocaine have an increased incidence of acquiring HIV and other sexually transmitted infections.

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Patient Education

The event that prompted the ED visit may provide an opportunity to strongly caution the patient about future use of cocaine and to encourage the patient to seek treatment for drug abuse.

For patient education resources, see the First Aid and Injuries Center and the Mental Health Center. Also, see the patient education articles Cocaine Abuse, Drug Dependence & Abuse, Substance Abuse, Club Drugs, and Poisoning.

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