Cocaine

Epidemiology

  • Prevalence: cocaine is the most common etiology acute drug-related emergency department visits in the US

Routes of Cocaine Exposure

  • Gastrointestinal
    • Onset: 30-60 min
    • Peak Effect: 60-90 min
    • Duration of Action: unknown
    • Types of Exposure
      • Body Packing: swallowing large quantities of prepackaged drugs with the intent to smuggle them
      • Body Stuffing: swallowing small quantities of drugs to evade prosecution from law enforcement
  • Inhalation/Smoking
    • Onset: <1 min
    • Peak Effect: 3-5 min
    • Duration: 30-60 min
    • Available Preparations
      • Crack Cocaine: smoking or inhalation of solid form of cocaine
      • Free-Basing: smoking or inhalation of cocaine in organic phase of liquid
  • Intravenous Cocaine Injection
    • Onset: <1 min
    • Peak Effect: 3-5 min
    • Duration of Action: 30-60 min
  • Nasal Snorting of Cocaine
    • Onset: 1-5 min
    • Peak Effect: 20-30 min
    • Duration of Action: 60-120 min

Pharmacology

History

  • Cocaine is Isolated from the Coca Plant (Erythroxylum Coca)
    • Erythroxylum Coca is Indigenous to the Andean Highlands in South America
    • Andean Natives Chew or Brew Coca Leaves into a Tea: used for refreshment or to relieve fatigue
  • Purified Cocaine was First Isolated in the 1880’s: first used as a local anesthetic in ocular surgery
    • Utility in Upper Airway and Ocular Surgery is Related to the Anesthetic and Vasoconstrictor Properties of Cocaine

Absorption

  • Cocaine is Rapidly Absorbed from Oral/Nasal/Gastrointestinal/Rectal/Vaginal Mucosa and Pulmonary Alveoli (Via Inhalation)
    • Bioavailability When Smoked: 90%
    • Bioavailability When Used Intranasally: 80%

Mechanisms of Action

  • Cocaine Inhibits the Presynaptic Neuronal Reuptake of Biogenic Amines (Serotonin and Dopamine/Norepinephrine/Epinephrine)
    • Cocaine Functions as an Indirect Sympathomimetic Agent
      • Norepinephrine (and to a Lesser Extent, Epinephrine) Stimulation of α1-Adrenergic Receptors (see α1-Adrenergic Receptor Agonists, [[α1-Adrenergic Receptor Agonists]])
        • Cardiac Vasoconstriction
        • Peripheral Vasoconstriction
      • Norepinephrine (and to a Lesser Extent, Epinephrine) Stimulation of α2-Adrenergic Receptors (see α2-Adrenergic Receptor Agonists, [[α2-Adrenergic Receptor Agonists]])
      • Norepinephrine (and to a Lesser Extent, Epinephrine) Stimulation of β1-Adrenergic Receptors (see β1-Adrenergic Receptor Agonists, [[β1-Adrenergic Receptor Agonists]])
      • Norepinephrine (and to a Lesser Extent, Epinephrine) Stimulation of β2-Adrenergic Receptors (see β2-Adrenergic Receptor Agonists, [[β2-Adrenergic Receptor Agonists]])
    • Cocaine Inhibition of Neuronal Serotonin Reuptake Mediates Euphoric Effects
    • Cocaine Inhibition of Neuronal Dopamine Reuptake Mediates Addictive Effects
  • Cocaine Inhibits the Neuronal Sodium Channel
    • Effect of Neuronal Sodium Channels Mediates Anesthetic Effects
    • Effect on Cardiac Sodium Channels Mediates QRS Prolongation and Negative Inotropy
  • Cocaine Increases the Concentration of Excitatory Amino Acids, Glutamate and Aspartate, in the Brain: especially in the nucleus accumbens

Chronic Cocaine Abuse

Epidemiology

  • xxx

Clinical Manifestations

Cardiovascular Manifestations

  • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
    • Physiology: dilated cardiomyopathy
  • Coronary Artery Disease (CAD)
    • Epidemiology: associated with chronic cocaine use
    • Physiology: accelerated atherogenesis
  • Left Ventricular Hypertrophy (LVH)
  • Myocarditis (see Myocarditis, [[Myocarditis]])

Infectious Manifestations

  • Increased Risk of Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus, [[Human Immunodeficiency Virus]]): regardless of the route of cocaine use
    • May Be Related to Increased High-Risk Sexual Behaviors
  • Increased Risk of Viral Hepatitis: regardless of the route of cocaine use
    • May Be Related to Increased High-Risk Sexual Behaviors

Neurologic Manifestations

  • Cognitive Impairment
    • Impaired Attention
    • Impaired Risk-Reward Decision Making
    • Impaired Verbal Memory
    • Impaired Visual-Motor Performance
  • Suicidal Ideation/Attempts: risk factors include depression, severe cocaine withdrawal, coexistent ethanol dependence, coexistent opiate dependence, history of childhood trauma, and family history of suicidality

Otolaryngologic Manifestations

  • Chronic Rhinitis: due to intranasal cocaine abuse
  • Nasal Septal Perforation: due to intranasal cocaine abuse
  • Oropharyngeal Ulcers: due to intranasal cocaine abuse
  • Osteolytic Sinusitis: due to intranasal cocaine abuse

Pulmonary Manifestations

  • Moderately Decreased DLCO (see Pulmonary Function Tests, [[Pulmonary Function Tests]]): even when asymptomatic
  • Increased Alveolar Epithelial Permeability
  • Pulmonary Hypertension (see Pulmonary Hypertension, [[Pulmonary Hypertension]])
    • Epidemiology: possibly associated with pulmonary hypertension
  • Talc/Foreign Body Granulomatosis (see Foreign Body Granulomatosis, [[Foreign Body Granulomatosis]])
    • Physiology: xxx

Manifestations Associated with Cocaine Use During Pregnancy (see Pregnancy, [[Pregnancy]])

  • Abnormal Fetal Development

Other Manifestations

  • Risk of General Anesthesia: cocaine abuse does not increase the risk of general anesthesia (assuming that the patient has normal hemodynamic parameters at the time of surgery)

Treatment

  • xxx

Cocaine Intoxication

Diagnosis

Urine Testing for Benzoylecgonine (Main Urinary Metabolite of Cocaine)

  • Benzoylecgonine Can Be Detected in the Urine for Several Days (for Intermittent Use) or Up to 10 days (for Heavy Use): in contrast, cocaine is rapidly metabolized and detectable only hours after use
    • Can Also Test Blood/Saliva/Hair/Meconium Samples
    • Gas Chromatography-Mass Spectrometry: gold standard for testing for cocaine and its metabolites

Clinical Manifestations

Cardiovascular Manifestations

  • Acute Myocardial Infarction/Myocardial Ischemia (see Coronary Artery Disease, [[Coronary Artery Disease]])
    • Epidemiology: associated with crack cocaine use
    • Physiology: coronary vasoconstriction
    • Clinical
      • Diaphoresis (see Diaphoresis, [[Diaphoresis]])
      • Dyspnea (see Dyspnea, [[Dyspnea]])
      • Substernal Chest Pain (see Chest Pain, [[Chest Pain]]): occurs in 76% of cases
  • Aortic Dissection (see Aortic Dissection, [[Aortic Dissection]])
    • Physiology:
    • Clinical: aortic rupture can occur
  • Arrhythmias
    • Epidemiology: associated with crack cocaine use
    • Physiology: due either to myocardial ischemia or catecholaminergic effects
    • Clinical
      • Supraventricular Arrhythmias
      • Ventricular Arrhythmias
  • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
    • Physiology: at high cocaine concentrations, negative inotropy can occur
  • Endocarditis (see Endocarditis, [[Endocarditis]])
    • Epidemiology: associated with crack cocaine use
  • Hypertension (see Hypertension, [[Hypertension]])
    • Epidemiology: typical hemodynamic manifestation
    • Physiology: due to vasoconstriction (with increased systemic vascular resistance)
  • Hypotension (see Hypotension, [[Hypotension]])
    • Epidemiology: may occur in the setting of massive cocaine intoxication
    • Physiology: due to sodium channel blockade, arrhythmias, or myocardial ischemia
  • Myocarditis (see Myocarditis, [[Myocarditis]])
    • Epidemiology: associated with crack cocaine use
  • QT Prolongation without Definite Association with Torsade (see Torsade, [[Torsade]])
  • Sinus Tachycardia (see Sinus Tachycardia, [[Sinus Tachycardia]])

Dermatologic Manifestations

Gastrointestinal Manifestations

  • Acute Mesenteric Ischemia (see Acute Mesenteric Ischemia, [[Acute Mesenteric Ischemia]])
  • Anorexia (see Anorexia, [[Anorexia]])
  • Colonic Ischemia (Ischemic Colitis) (see Colonic Ischemia, [[Colonic Ischemia]])
  • Elevated Liver Function Tests (LFT’s) (see xxxx, [[xxxx]])
    • Epidemiology: common
  • Perforated Peptic Ulcer Disease (PUD) (see Peptic Ulcer Disease, [[Peptic Ulcer Disease]])
    • Physiology: due to increased sympathetic tone with increased gastric acid production and/or local gastro-intestinal ischemia
  • Subfulminant Hepatic Failure (see Fulminant Hepatic Failure, [[Fulminant Hepatic Failure]])
    • Epidemiology:
  • Weight Loss (see Weight Loss, [[Weight Loss]])

Hematologic Manifestations

  • Splenic Infarction (see Splenic Infarction, [[Splenic Infarction]])
    • Epidemiology: uncommon

Neurologic/Psychiatric Manifestations

  • Akathisia (see Akathisia, [[Akathisia]])
  • Buccolingual Dyskinesia (“Twisted Mouth”)
  • Choreoathetosis (“Crack Dancers”) (see Chorea, [[Chorea]])
  • Dystonia (see Dystonia, [[Dystonia]])
    • Epidemiology: neuroleptic medications may compound the risk of dystonia
  • Euphoria
  • Exacerbation of Tardive Dyskinesia (see Tardive Dyskinesia, [[Tardive Dyskinesia]])
  • Exacerbation of Tourette’s Syndrome
  • Headache (see Headache, [[Headache]])
    • Epidemiology: common
    • Physiology: due to neurotransmitter dysregulation and hemodynamic effects
  • Improved Performance on Tasks of Vigilance
  • Increased Alertness
  • Intracerebral Hemorrhage (Hemorrhagic Cerebrovascular Accident) (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]])
  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
    • Physiology: due to cerebral vasoconstriction, hypertension, vasospasm, and Intravascular thrombosis (due to platelet aggregation)
  • Obtundation-Coma (see Obtundation-Coma, [[Obtundation-Coma]])
  • Psychomotor Agitation (see Agitation, [[Agitation]])
    • Physiology: due to central nervous system excitatory amino acids (glutamate, aspartate) and release of excitatory neurotransmitters (norepinephrine, serotonin, dopamine)
  • Psychotic Symptoms (see Psychosis, [[Psychosis]])
    • Delusions
    • Hallucination (see Hallucination, [[Hallucination]]): visual and/or tactile hallucinations are typical of stimulant-associated psychosis
      • Formication (“Cocaine Bugs”): sensation of insects crawling under the skin
    • Paranoia
  • Repetitive Behaviors
    • Foraging for Drugs
    • Picking at the Skin
  • Seizures (see Seizures, [[Seizures]])
    • Epidemiology: occur in 3-4% of cocaine-related emergency department visits associated with acute/chronic abuse
      • May occur even with first-time cocaine use
    • Clinical: usually tonic-clonic and occurring within 90 min of cocaine use
  • Sense of Self-Confidence
  • Sleep Disturbance
    • Decreased Need for Sleep
    • Insomnia (see Insomnia, [[Insomnia]])
  • Subarachnoid Hemorrhage (SAH) (see Subarachnoid Hemorrhage, [[Subarachnoid Hemorrhage]])
    • Epidemiology: cocaine is associated with both aneurysmal and non-aneurysmal subarachnoid hemorrhage
  • Transient Ischemic Attack (TIA) (see Transient Ischemic Attack, [[Transient Ischemic Attack]])
  • Tremor (see Tremor, [[Tremor]])
  • Vasospasm-Induced Anterior Spinal Cord Syndrome (see Spinal Cord Infarction, [[Spinal Cord Infarction]])
    • Epidemiology: rare

Ophthalmologic Manifestations

  • Acute Angle-Closure Glaucoma (see Glaucoma, [[Glaucoma]])
  • Corneal Epithelial Injury
    • Physiology: due to crack cocaine use -> thermal injury to cornea
  • Mydriasis (see Mydriasis, [[Mydriasis]]): pupil remains reactive to light
  • Vision Loss (Unilateral or Bilateral)
    • Physiology: due to retinal vasoconstriction

Pulmonary Manifestations

Acute Respiratory Distress Syndrome (ARDS) (see Acute Respiratory Distress Syndrome, [[Acute Respiratory Distress Syndrome]])
  • Epidemiology: associated with inhalational crack cocaine use
  • Diagnosis
    • Open Lung Biopsy: diffuse alveolar damage, organizing pneumonia
  • Clinical: dyspnea
  • Treatment: supportive
Angioedema (see Angioedema, [[Angioedema]])
  • Epidemiology: associated with crack cocaine use
  • Physiology: due to crack cocaine being heated to the high temperatures required for vaporization
Aspiration Pneumonia (see Aspiration Pneumonia, [[Aspiration Pneumonia]])
  • Epidemiology
Asthma Exacerbation (see Asthma, [[Asthma]])
  • Epidemiology: associated with crack cocaine use
Barotrauma
  • Epidemiology: associated with crack cocaine use
  • Physiology: associated with intranasal and inhalational cocaine abuse -> forceful inhalation with Valsalva maneuver
  • Clinical
Cough (see Cough, [[Cough]])
  • Clinical: sometimes with black sputum production
“Crack Lung” (Hemorrhagic Alveolitis)
  • Epidemiology: associated with inhalational crack cocaine use
    • Usually Occurs Minutes-Hours After Crack Use
  • Diagnosis
  • Clinical
  • Treatment: corticosteroids have been used (although there are no trials to support this) (see Corticosteroids, [[Corticosteroids]])
Cryptogenic Organizing Pneumonia (COP) (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])
  • Epidemiology: associated with crack cocaine use
Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage, [[Diffuse Alveolar Hemorrhage]])
  • Epidemiology: associated with inhalational crack cocaine use
    • Usually Occurs Minutes-Hours After Crack Use
  • Physiology: may involve damage due to pulmonary vasoconstriction or due to direct alveolar injury
  • Clinical
    • Autopsy studies demonstrate pulmonary hemorrhage in >50% of cases
    • May coexist with peripheral eosinophilia
Dyspnea (see Dyspnea, [[Dyspnea]])
  • Epidemiology: associated with crack cocaine use
Lung Mass with/without Cavitation (see Lung Nodule or Mass, [[Lung Nodule or Mass]])
  • Epidemiology
Pharyngeal Burns
  • Epidemiology: associated with inhalational crack cocaine use
  • Physiology: due to crack cocaine being heated to the high temperatures required for vaporization
Pulmonary Infarction (Am J Med, 1991) [MEDLINE]
  • Epidemiology
    • In Contrast, There is No Known Association Between Cocaine Abuse and the Risk of Acute Pulmonary Embolism (PE)
  • Physiology: due to vasoconstriction, vasospasm, and increased thrombus formation
  • Clinical
    • Dyspnea
    • Pleuritic Chest Pain
Thermal Airway Injury
  • Epidemiology: associated with crack cocaine abuse
  • Physiology: due to crack cocaine being heated to the high temperatures required for vaporization

Renal Manifestations

  • Lactic Acidosis (see Lactic Acidosis, [[Lactic Acidosis]])
    • Physiology: decreased oxygen delivery to tissues + epinephrine-induced β2-adrenergic receptor stimulation
      • In Addition, Clenbuterol (Found as an Adulterant in Cocaine) Can Cause Lactic Acidosis (see Clenbuterol, [[Clenbuterol]]))
    • Clinical: marked hyperlactatemia may be seen in in patients having seizures or who are restrained
  • Renal Infarction (see Renal Infarction, [[Renal Infarction]])
    • Epidemiology: uncommon

Rheumatologic Manifestations

Toxicologic Manifestations

  • Hyperthermia (see Fever, [[Fever]])
    • Physiology: peripheral vasoconstriction prevents heat dissipation
    • Prognosis: mortality can be as high as 33% in the presence of cocaine-induced hyperthermia
  • Methemoglobinemia (see Methemoglobinemia, [[Methemoglobinemia]])
    • Epidemiology: case reports (Acute Med, 2013) [MEDLINE]
  • Serotonin Syndrome (see Serotonin Syndrome, [[Serotonin Syndrome]])
    • Epidemiology: case reports (Case Rep Med, 2015) [MEDLINE]

Manifestations Associated with Cocaine Use During Pregnancy

Manifestations Related to Cocaine Adulterants

Levamisole (see Levamisole, [[Levamisole]])
  • Epidemiology: common adulterant
    • In 2010 in Colorado, 78% of Patients with Positive Urine Drug Screens for Cocaine were Also Positive Also for Levamisole (JAMA, 2011) [MEDLINE]
  • Pharmacology: immunomodulator
  • Clinical (Acad Emerg Med, 2011) [MEDLINE]
    • Agranulocytosis
      • Neutropenia (see Neutropenia, [[Neutropenia]])
        • Oropharyngeal Complaints: common in this setting
        • Soft Tissue Infection: common in this setting
    • Cutaneous Vasculitis
      • Purpura (see Purpura, [[Purpura]])
      • May lead to cutaneous necrosis
    • Leukoencephalopathy
Clenbuterol (see Clenbuterol, [[Clenbuterol]])

Treatment

Supportive Care

  • Mechanical Ventilation (see General Ventilator Management, [[General Ventilator Management]]): as required
  • Sedation: including induction agents for intubation
    • Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]])
    • Etomidate (Amidate) (see Etomidate, [[Etomidate]])
    • Propofol (Diprivan) (see Propofol, [[Propofol]])
  • Paralysis
    • Avoid Succinylcholine (see Succinylcholine, [[Succinylcholine]])
      • Plasma cholinesterases metabolize succinylcholine and cocaine -> succinylcholine use can prolong the effects of both agents
      • Succinylcholine may worsen hyperkalemia

Treatment of Cocaine Intoxication Associated with Body Packing/Body Stuffing

  • General Comments: most patients who will have adverse clinical outcomes have symptoms at presentation or within the first few hours
  • Gastrointestinal Decontamination: for cocaine intoxication associated with body packing/body stuffing
  • Activated Charcoal (see Activated Charcoal, [[Activated Charcoal]]): useful for orally ingested cocaine
    • Administration: 1 g/kg (up to max: 50 g) q4hrs PO x several doses
  • Surgery: may be required for intestinal obstruction or symptoms due to large quantities of packets in GI tract

Treatment of Chest Pain/Acute Myocardial Ischemia or Infarction (see Coronary Artery Disease, [[Coronary Artery Disease]])

  • Aspirin (see Acetylsalicylic Acid, [[Acetylsalicylic Acid]]): as used standard lay (when aortic dissection is not present)
  • Avoid Beta Blockers in Cocaine Intoxication see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]]): due to fact that they may allow unopposed α1-adrenergic receptor stimulation, resulting in coronary vasoconstriction and end-organ ischemia
    • Paradoxical Hypertension and Clinical Deterioration Have Been Demonstrated to Occur in Cocaine Intoxication with the Administration of Esmolol and Metoprolol: these agents are selective β1-adrenergic receptor antagonists
    • In Rare Cases Where Beta Blockers May Be Necessary, Phentolamine Should Be Given First
  • Avoid Labetalol (Trandate) in Cocaine Intoxication (see Labetalol, [[Labetalol]]): due to its alpha/beta antagonism ratio or 1:7, labetalol use has not been demonstrated to reverse cocaine-induced coronary artery vasospasm (and may result in unopposed α1-adrenergic receptor stimulation)
  • Lorazepam (Ativan) (see Lorazepam, [[Lorazepam]]): has been demonstrated to add benefit over nitroglycerin alone (Am J Emerg Med, 2003) [MEDLINE]
  • Nitroglycerin (see Nitroglycerin, [[Nitroglycerin]]): useful
  • Oxygen (see Oxygen, [[Oxygen]]): useful
  • Phentolamine (Regitine, OraVerse) (see Phentolamine, [[Phentolamine]])
    • Pharmacology: inhibits the norepinephrine-related, α1-adrenergic-mediated effects of cocaine -> decreases cocaine-induced coronary artery vasoconstriction and hypertension
    • Administration: 5 mg IV bolus q5-15 min PRN

Treatment of Ventricular Arrhythmias

Treatment of Agitation (see Agitation, [[Agitation]])

  • Avoid Restraints: as these may contribute to the development of hyperthermia
  • Benzodiazepines (see Benzodiazepines, [[Benzodiazepines]])
    • Diazepam (Valium) (see Diazepam, [[Diazepam]]): IV
    • Lorazepam (Ativan) (see Lorazepam, [[Lorazepam]]): IM or IV

Treatment of Hyperthermia (see Fever, [[Fever]])

  • Surface Cooling: ice packs or ice water are rapidly effective

Treatment of Hypertension (see Hypertension, [[Hypertension]])

  • Avoid Beta Blockers in Cocaine Intoxication (see β-Adrenergic Receptor Antagonists, [[β-Adrenergic Receptor Antagonists]]): due to fact that they may allow unopposed α1-adrenergic receptor stimulation, resulting in coronary vasoconstriction and end-organ ischemia
    • Paradoxical Hypertension and Clinical Deterioration Have Been Demonstrated to Occur in Cocaine Intoxication with the Administration of Esmolol and Metoprolol: these agents are selective β1-adrenergic receptor antagonists
    • In Rare Cases Where Beta Blockers May Be Necessary, Phentolamine Should Be Given First
  • Avoid Labetalol (Trandate) in Cocaine Intoxication (see Labetalol, [[Labetalol]]): due to its alpha/beta antagonism ratio or 1:7, labetalol use has not been demonstrated to reverse cocaine-induced coronary artery vasospasm (and may result in unopposed α1-adrenergic receptor stimulation)
  • Nitroprusside (Nipride) (see Nitroprusside, [[Nitroprusside]]): may be used in cases with severe hypertension
  • Phentolamine (Regitine, OraVerse) (see Phentolamine, [[Phentolamine]])
    • Pharmacology: inhibits the norepinephrine-related, α1-adrenergic-mediated effects of cocaine -> decreases cocaine-induced coronary artery vasoconstriction and hypertension
    • Administration: 5 mg IV bolus q5-15 min PRN
    • Blood Pressure Target: aim to decrease diastolic blood pressure to 100-105 mm Hg within 2-6 hrs (with decrease not to exceed 25% below the presenting diastolic blood pressure value)

Treatment of Hypotension (see Hypotension, [[Hypotension]])

  • Intravenous Fluid Resuscitation
  • Vasopressors
    • Norepinephrine (Levophed) (see Norepinephrine, [[Norepinephrine]])
    • Phenylephrine (Neosynephrine) (see Phenylephrine, [[Phenylephrine]])

Treatment of QRS Prolongation


Cocaine Withdrawal

Clinical Manifestations

General Comments

  • Duration of Symptoms: generally mild symptoms lasting 1-2 wks

Cardiovascular Manifestations

  • Myocardial Ischemia (see Coronary Artery Disease, [[Coronary Artery Disease]]): observed during the first week of withdrawal (possibly due to coronary vasospasm)

Neurologic/Psychiatric Manifestations

  • Anhedonia (see Anhedonia, [[Anhedonia]])
  • Anxiety (see Anxiety, [[Anxiety]])
  • Chills (see Chills, [[Chills]])
  • Cocaine Craving
  • Depression (see Depression, [[Depression]])
  • Difficulty Concentrating
  • Fatigue (see Fatigue, [[Fatigue]])
  • Involuntary Motor Movements
  • Psychomotor Retardation with Depression and Suicidal Ideation (“Crash”)
  • Sleep Disturbance
    • Increased REM Sleep: with increased dreaming
    • Increased Sleep
  • Tremor (see Tremor, [[Tremor]])

Gastrointestinal Manifestations

  • Increased Appetite

Treatment

  • Supportive Care

References

  • Crack lung: an acute pulmonary syndrome with a spectrum of clinical and histopathologic findings. Am Rev Respir Dis. 1990;142(2):462 [MEDLINE]
  • Pulmonary infarction associated with crack cocaine use in a previously healthy 23-year-old woman. Am J Med. 1991;91(1):92 [MEDLINE]
  • Cocaine-induced eosinophilic lung disease. Thorax 1992; 47:478-479 [MEDLINE]
  • The pulmonary complications of crack cocaine, a comprehensive review. Chest 1995; 107:233-240 [MEDLINE]
  • NIDA conference report on cardiopulmonary complications of crack cocaine use: clinical manifestations and pathophysiology. Chest 1996; 110:1072-1076 [MEDLINE]
  • Cocaine-induced pneumopericardium. Circulation. 2000 Nov 28;102(22):2792-4 [MEDLINE]
  • Cardiovascular complications of cocaine use. N Engl J Med. 2001;345(5):351 [MEDLINE]
  • A prospective, randomized, controlled trial of benzodiazepines and nitroglycerine or nitroglycerine alone in the treatment of cocaine-associated acute coronary syndromes. Am J Emerg Med. 2003;21(1):39 [MEDLINE]
  • Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117(14):1897 [MEDLINE]
  • Cocaine-induced spinal cord infarction. Postgrad Med J. 2008 Jul;84(993):391. doi: 10.1136/pgmj.2007.062224 [MEDLINE]
  • Levamisole exposure and hematologic indices in cocaine users. Acad Emerg Med. 2011 Nov;18(11):1141-7 [MEDLINE]
  • Prevalence of levamisole in urine toxicology screens positive for cocaine in an inner-city hospital. JAMA. 2011;305(16):1657 [MEDLINE]
  • An unusual complication of cocaine toxicity. Acute Med. 2013;12(2):96-7 [MEDLINE]
  • Stimulants and the lung : review of literature. Clin Rev Allergy Immunol. 2014 Feb;46(1):82-100 [MEDLINE]
  • High-resolution computed tomographic findings of cocaine-induced pulmonary disease: a state of the art review. Lung. 2014 Apr;192(2):225-33. Epub 2014 Jan 16 [MEDLINE]
  • Serotonin Syndrome in the Setting of Lamotrigine, Aripiprazole, and Cocaine Use. Case Rep Med. 2015;2015:769531. doi: 10.1155/2015/769531. Epub 2015 Aug 2 [MEDLINE]