Complications
Medical emergency. Encompasses a variety of medical and psychiatric sequelae as a result of excessive adrenergic activity.
Hyperthermia, seizures, and cardiovascular collapse may all occur, necessitating aggressive sedation and medical treatment (cardiovascular agents, anticonvulsants) in a highly monitored setting.
Medical emergency.
Typically seen in people with long-term cocaine use disorder as long-term use causes changes in brain temperature regulation that can lead to fatal hyperthermia. It is considered by some to be a variant of neuroleptic-malignant syndrome.
Temperatures may rise above 41ºC (106ºF), requiring aggressive cooling measures. The biomarkers for this condition include an increase in heat shock protein (HSP) 70 (but not any of the other HSPs) and a decrease in dopamine transporters.[43]
Antipsychotic agents are widely used as an adjunct in patients with hyperactive delirium with extreme agitation, although there are no studies to document effectiveness. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death.
In the presence of neurological signs, testing to rule out heat-related cerebral infarction may also be indicated.[88]
There is a high prevalence of cocaine-induced psychosis among people with cocaine use disorder.[95] Not to be confused with hyperactive delirium with extreme agitation, which is associated with extreme fever and rhabdomyolysis. Patients may experience paraesthesia and believe that insects are trapped beneath their skin (formication). This can lead to serious excoriations during the process of trying to remove the imaginary insects.
Cocaine anaesthetises the cornea, and accidental corneal abrasions may occur.
Local ophthalmic antibiotics are indicated.
This is an uncommon complication. Its occurrence indicates either an underlying, pre-existing seizure disorder, underlying central nervous system pathology, or overdose.
Recurrent seizures following cocaine use require treatment as they may contribute to complicating conditions (hyperthermia, rhabdomyolysis, acidosis).
Phenytoin may not be an effective agent for the treatment of recurrent seizures in the setting of recent cocaine use.
Brain imaging studies, electroencephalogram, and cerebrospinal fluid analysis may be indicated following seizure control.
Chronic crack cocaine smokers may present with transient choreoathetoid movements.[94]
Can occur in the smokers of any illicit drug but, whatever the aetiology, the treatment is pain relief and observation.
Occasionally seen in people who smoke crack cocaine.
Typical clinical presentations include chest pain, cough with haemoptysis, dyspnoea, or bronchospasm. Histology shows alveolar haemorrhage and interstitial and intra-alveolar eosinophilic infiltrate.[97] It can, on occasion, progress to the point of requiring assisted ventilation and intensive medical treatment. Smoking crack cocaine can cause cumulative lung effects, including emphysematous changes.[98]
Cocaine is often mixed with levamisole, which is converted to aminorex in vivo.[99] Long-term ingestion of aminorex has been associated with cases of idiopathic pulmonary fibrosis.[100] Pulmonary fibrosis is characterised by progressive dyspnoea, cough, and a restrictive pattern on pulmonary function tests. Diagnosis is confirmed by high-resolution computed tomography (CT) chest scans.
Cocaine use may trigger a state resembling mania that may persist in patients with an underlying vulnerability to this condition.
Abstinence from cocaine can be associated with depression that reaches a severe state (including suicidal ideation) and persists in some patients.
Those with persisting mood symptoms after the cessation of cocaine use may need psychiatric care and psychotropic medication treatment (antidepressants and/or mood-stabilising agents, as indicated).
Cocaine-induced kidney injury can be caused by a number of pathologies, including rhabdomyolysis, vasculitis, infarction, and malignant hypertension.[96]
People who use cocaine intravenously risk exposure to blood-borne infections.
People who use cocaine intravenously risk exposure to blood-borne infections.
People who use cocaine intravenously risk exposure to blood-borne infections.
Pregnant women with cocaine use disorder experience increased obstetric complications, such as spontaneous abortion, perinatal mortality, premature labour, low birth weight, pre-eclampsia, and placental abruption.[106][107]
Patients will need to be closely monitored and require perinatal counselling and follow-up.
Cocaine-related AMI is uncommon and is more likely to occur in older patients and those with pre-existing coronary disease. However, in adults aged 45 years and younger, around 1 in 4 non-fatal AMIs occur in people who have used cocaine 10 or more times.[89]
Management is the same as for AMI of any other aetiology. The position paper on cocaine-associated AMI released by the American Heart Association recommends the avoidance of all beta-blockers acutely, but indicates that recommendations for antithrombotic and antiplatelet therapy should be followed.[90]
Standard Advanced Cardiac Life Support protocols should be followed, but they may not be effective in people with long-term cocaine use disorder as there is likely to be underlying cardiomegaly and concomitant sodium and potassium channel blockade. Defibrillation may be difficult to achieve.
People with cocaine use disorder only develop this change after prolonged stimulant use.[91] The aetiology of cocaine cardiomyopathy is not clear. It may be directly from cocaine, a result of multiple small infarcts, or both.
If this occurs, the patient should receive routine care (avoiding beta-blockers), as well as referral for cocaine medically supervised withdrawal.
Chronic cocaine use may lead to loss of appetite, malnourishment, and weight loss. All routes of cocaine use can cause xerostomia and bruxism.[103][104] Cocaine prevents the reuptake of noradrenaline, reducing gastric motility and inhibiting gastric emptying. Cocaine-induced ischaemia may result in gastropyloric ulcers, gangrene, and perforation.[105]
Use of this content is subject to our disclaimer