Approach
In common with all substance use disorders, diagnosis of cocaine use disorder is based on clinical assessment via a combination of patient interview, collateral history, and review of available medical records. A number of signs and symptoms in addition to laboratory tests may provide further evidence of recent or long-term substance use, or of withdrawal from use.
For patients who have used cocaine recently, it it important to assess for cocaine intoxication symptoms such as chest pain, loss of consciousness (as a result of a cocaine-induced seizure), or focal neurological complaints (e.g., weakness, sensory loss, aphasia, visual field deficit, ataxia). Any of these require emergency investigation and treatment. See Cocaine toxicity.
History
Cocaine use disorder is defined as two or more of the following over a 12-month period:[1]
Using larger amounts of cocaine or over a longer period than was intended
Persistent desire to cut down or unsuccessful efforts to control use
Great deal of time spent obtaining, using, or recovering from use
Craving, or a strong desire or urge to use substance
Failure to fulfill major role obligations at work, school, or home due to recurrent cocaine use
Continued use despite recurrent or persistent social or interpersonal problems caused or exacerbated by the effects of cocaine use
Giving up or reducing social, occupational, or recreational activities due to cocaine use
Recurrent cocaine use in physically hazardous situations
Continued cocaine use despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by its use
Tolerance (a need for markedly increased amounts; markedly diminished effect with continued use of the same amount)
Withdrawal as manifested by cessation of cocaine or use of cocaine (or a closely related substance) to relieve or avoid withdrawal symptoms.
Severity of cocaine use disorder is categorised as mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms). It should be specified if the individual is in an environment where access to cocaine is restricted.
Asking about the following guides the risk assessment, and informs harm reduction measures:[27]
Amount and frequency of use, including binge use
Route of administration
Use of stimulants with nobody else present
Co-use with alcohol or other drugs
History of overdose
History of stimulant-related visits to the accident and emergency department, and hospitalisation
History of previous treatment (including medically supervised withdrawal)
Risky sexual behaviours
History of mental health disorder, including depression
Suicidal ideation
Biopsychosocial assessment is recommended, including age of onset of substance use, family history of substance-use related issues, ongoing risks related to substance use and associated behaviours, treatment history and outcomes, psychosocial functioning, and factors which may guide treatment and recovery support needs. This includes social determinants of health, such as access to safe housing, economic well-being, and transportation challenges.[27]
Examination
Cocaine use causes a hyperadrenergic state associated with abnormal mentation. The symptoms of hyperadrenergic state are the same regardless of the causative drug or disease; they include nausea, jitteriness, trouble concentrating, anxiety, paranoia, and euphoria. While some hyperadrenergic symptoms (tachycardia, hypertension, hyperthermia, and agitation) suggest a need for inpatient medical admission (often in critical care), mild hyperadrenergic symptoms can be managed in the clinical setting.[27]
A number of physical effects may be seen among patients who have smoked, injected, or snorted cocaine over a longer period of time.[1][28][29][30][31][32]
Physical effects of smoking cocaine include:
Oral heat-related injuries such as blisters, sores, and cuts
Burns on the thumbs
Respiratory problems (e.g., dyspnoea, cough, bronchitis)
Oral disorders (e.g., xerostomia, mouth sores)
Physical effects of injecting cocaine include:
Puncture marks on the skin (usually forearms)
Skin and soft tissue infections
Physical effects of intranasal use of cocaine include:
Sinusitis, nasal septum perforation, and bleeding of the nasal mucosa
Other possible findings associated with long-term use include gastrointestinal problems, neurocognitive impairment, diaphoresis, mydriasis, bruxism, and focal neurological complaints (e.g., weakness, tremulousness, altered sensation, difficulty speaking, visual field loss, co-ordination problems).
Cocaine contaminated with levamisole may cause agranulocytosis and other haematological disorders, skin necrosis, and symptoms consistent with pulmonary hypertension.[3][4][33]
Withdrawal syndrome is characterised by the development of dysphoric mood accompanied by two or more physiological changes: fatigue, vivid or unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation. Bradycardia is often present and is a reliable measure of stimulant withdrawal.[1]
Initial investigations
Following the history taking and physical examination, further tests may be required.[34]
Urine toxicology testing: the results provided by most screening tests are based on the detection of benzoylecgonine, an inactive metabolite with a much longer half-life than cocaine. Benzoylecgonine is used both clinically and forensically to indicate cocaine use given the short half-life of cocaine. Cocaethylene may be detected in the presence of alcohol. If substantial weight is to be placed on the test result (e.g., forensic reasons, child protection), then a confirmatory test using either gas or liquid chromatography/mass spectrometry should be performed.[34]
Cardiovascular examination: indicated in patients with chest pain and/or dangerous blood pressure elevation.[35] Cocaine use may precipitate acute myocardial infarction in people with cocaine use disorder who have underlying myocardial pathology and/or coronary artery disease.
Neurological examination: brain imaging and/or electroencephalogram may be warranted if the patient presents with seizures (particularly if recurrent) or focal neurological symptoms.
After stabilisation, patients should be evaluated for infectious diseases if not carried out already, including testing for HIV, hepatitis B and C, and other STIs, as well as tuberculosis.[34] The location of testing for chlamydia and gonorrhoea is guided by all sites of exposure. Although evidence is lacking, this advice is based on expert opinion given the higher prevalence of these conditions in patients with stimulant use disorders, regardless of route of administration.[27]
Other investigations
Based on history, symptomatology, and presence of risk factors, further tests may be required to evaluate for medical complications of substance use.[27] These include full blood count, electrolytes, liver and kidney function tests, and muscle enzymes. The cocaine contaminant levamisole has been associated with agranulocytosis.[3][27][33]
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