Special Pathologies in Chronic Cocaine Use

Abstract

Cocaine produces an array of neuropsychiatric states, and the violently agitated patient is perhaps the most dramatic ED presentation caused by this drug. This person typically arrives with a multitude of personnel who are attempting physical control. There is an appearance of incredible strength, but this may reflect an indifference to pain; the risk of physical harm to both caregivers and the patient is significant. The patient is delusional, paranoid, and often overtly psychotic. This state does not clearly relate to cocaine dosage, blood level [21], route of administration, or frequency of use. It does not seem to be precipitated by adulterants or concomitant use of other drugs, with the possible exception of alcohol; the role of cocaethylene.

While there is an increasing rate of use among young adults in all western countries over the past years (Fig. 42), more often, the combination of cocaine with alcohol is being advertised as this allegedly results in a prolongation of effects. Some 99% of contemporary Western users mix cocaine and ethyl alcohol. Cocaine and alcohol combine to be metabolized to another hugely reinforcing compound, cocaethylene. Coca-use only really took off in the West when it was blended with an alcoholic beverage. However, such combination is substantially more toxic than either substance on their own. For instance, about twelve million Americans combine ethanol with cocaine to produce a pronounced and prolonged euphoria. However it is known that the combination of these two drugs is substantially toxic. This may be a result of cocaethylene, detected in the serum of emergency patients. Cocaethylene is a cocaine metabolite, formed in the liver only in the presence of ethanol [9]. Being pharmacologically active it depresses the myocardium causing cardiotoxicity [22].