DOCSLIB.ORG

The Cocaine Abusing Parturient: a Review of Anesthetic Considerations [L’Abus De Cocaïne Chez Les Parturientes : Une Revue Des Aspects Anesthésiques]

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Cocaine Abusing Parturient: a Review of Anesthetic Considerations [L’Abus De Cocaïne Chez Les Parturientes : Une Revue Des Aspects Anesthésiques] OBSTETRICAL AND PEDIATRIC ANESTHESIA 145 The cocaine abusing parturient: a review of anesthetic considerations [L’abus de cocaïne chez les parturientes : une revue des aspects anesthésiques] Krzysztof M. Kuczkowski MD Purpose: The prevalence of recreational drug abuse among young conséquences des drogues sur le fœtus et les implications sur l’admi- women, including in pregnancy, has increased markedly over the nistration de l’anesthésie obstétricale. past two decades. Cocaine remains the drug commonly used for Constatations principales : Face à la complexité des actions recreational purposes in pregnancy. However, there appears to be pharmacologiques de la cocaïne, le portrait clinique peut être très an absence of uniform guidelines for obstetric and anesthetic man- imprévisible, le diagnostic souvent difficile et le traitement parfois con- agement of pregnant patients with a history of cocaine abuse. troversé. La symptomatologie clinique changeante de la consomma- Source: A Medline search for articles highlighting drug abuse in tion de cocaïne combinée aux modifications physiologiques de la pregnancy, with particular emphasis on cocaine abuse in pregnancy, grossesse et la physiopathologie des maladies concomitantes spéci- the drug’s impact on the fetus and implications for administration of fiques à la grossesse peuvent entraîner de graves complications et obstetrical anesthesia was performed. influencer significativement la démarche anesthésique obstétricale. Main findings: Because the pharmacological actions of cocaine Conclusion : En l’absence de directives anesthésiques uniformes are complex, the clinical picture can be very unpredictable, the pour les patientes enceintes qui ont abusé de drogues, la décision con- diagnosis often difficult, and management at times controversial. cernant l’analgésie ou l’anesthésie périnatale doit être individualisée et The diverse clinical symptomatology of cocaine intake combined réalisée au cas par cas. Le présent article veut sensibiliser à l’usage et with physiologic changes of pregnancy, and pathophysiology of co- à l’abus de cocaïne pendant la grossesse et revoir la prise en charge existing pregnancy specific disease may lead to life-threatening com- anesthésique périopératoire de ces parturientes à haut risque. plications and significantly impact the management of obstetrical anesthesia. Conclusions: In the absence of uniform anesthetic guidelines for pregnant patients with a history of cocaine abuse the decision Table of Contents regarding the administration of peripartum analgesia or anesthesia Introduction should be individualized and conducted on a case-by-case basis. 1 Pharmacology This article will attempt to heighten the awareness of cocaine use 2 Epidemiology and abuse in pregnancy and review the perioperative anesthetic 3 Pathophysiology management of these high-risk parturients. 4 Clinical symptomatology and diagnosis 5 Impact on pregnancy 6 Obstetric considerations 7 Anesthetic considerations Objectif : La prévalence d’abus occasionnel de drogues par les jeunes 8 Medicolegal considerations femmes, incluant les femmes enceintes, a beaucoup augmenté pen- Summary dant les deux dernières décennies. La cocaïne est la drogue récréative le plus souvent utilisée pendant la grossesse. Il semble pourtant exis- Introduction ter une absence d’uniformité dans les directives sur la prise en charge Behavioural disorders from abuse of psychotropic sub- obstétricale et anesthésique des parturientes qui présentent une his- stances may involve a socially acceptable drug (e.g., toire d’abus de cocaïne. alcohol, tobacco), a medically prescribed drug (e.g., Source : Nous avons cherché, dans Medline, des articles sur l’abus diazepam), or an illegal substance (e.g., cocaine).1 In de drogues pendant la grossesse, surtout sur l’abus de cocaïne, sur les general substance abuse is defined as self-administra- From the Departments of Anesthesiology and Reproductive Medicine, University of California San Diego, San Diego, California, USA. Address corresponcence to: Dr. Krzysztof M. Kuczkowski, Department of Anesthesiology, UCSD Medical Center, 200 W. Arbor Drive, San Diego, CA 92103-8770, USA. Phone: 619-543-5720; Fax: 619-543-5424; E-mail: [email protected] Accepted for publication June 2, 2003. Revision accepted October 22, 2003. CAN J ANESTH 2004 / 51: 2 / pp 145–154 146 CANADIAN JOURNAL OF ANESTHESIA tion of various drugs that deviates from medically or hydrochloride form back into the alkalinized form. socially accepted use, which if prolonged can lead to This can be accomplished easily by the addition of the development of psychological and physical depen- baking soda and water to the cocaine powder. Today, dence.2 Environmental, social, and perhaps genetic this alkalinized form of cocaine is widely smoked factors have all been implicated in the development of throughout the world.3,4,11,12 By the 1990’s, the use of chemical dependency. Psychological personality char- highly addictive crack cocaine became the most wide- acteristics seem to predispose to, rather than result ly abused illicit substance in the United States.11 from drug addiction.1,2 Cocaine has a biological half-life of 0.5 to 1.5 hr, a Substance addiction is most often first suspected or volume of distribution of 2 L·kg–1, and a systemic diagnosed during medical management of another clearance of 2 L·min–1. It is metabolized by the plas- condition such as hepatitis B, hepatitis C, human ma and liver cholinesterases to water-soluble metabo- immunodeficiency syndrome3 or pregnancy.2,4 lites that are excreted in urine. Only a small Regardless of the drug(s) ingested and clinical mani- percentage (1–5%) of the drug ingested is cleared festations it is always uniformly difficult to predict unmetabolized in urine, where it may be detected for anesthetic implications in substance abusing three to six hours after use.11 However, its two major patients.1,4,5 Knowledge of a parturient’s substance metabolites, ecgonine methyl ester and benzoylecgo- abuse prior to administration of analgesia or anesthe- nine, can be detected in urine for 15 to 60 hr after sia may prevent adverse drug interactions, predict tol- cocaine intake.13 erance to anesthetic agents, and/or facilitate the recognition of drug withdrawal. Concomitant use of 2. Epidemiology several illicit substances is common.1 Among patients The increasing use and abuse of cocaine in Western with addiction to multiple substances, the combina- cultures is an issue of great national and international tion of cocaine and ethanol is the most common.6 concern.14 Five million Americans are regular users of This article will review the epidemiology, pathophysi- cocaine, 6,000 use the drug for the first time each day ology, clinical symptomatology, interactions with and more than 30 million have tried cocaine at least pregnancy, and obstetric, anesthetic, and medicolegal once.15 Cocaine abuse has crossed social, economic, implication of cocaine use, and abuse in pregnancy. geographic and international borders and today it remains a major problem (of global proportions) fac- 1. Pharmacology ing our society.16 The prevalence of cocaine abuse in Cocaine is an alkaloid (benzoylmethylecgonine, young adults, particularly in young women, has C17H21NO4) derived from the leaves of erythroxylon increased markedly over the past three decades.17–19 coca plant, indigenous to Peru, Ecuador and Bolivia.7 Nearly 90% of cocaine-abusing women are of child- Archeological evidence suggests that the Incas of the bearing age.17 Consequently it is no longer uncom- Andes region in South America have used cocaine mon to find pregnant women who abuse this drug, (coca leaves) for perhaps as long as 5,000 years.8 Carl and numerous reports of cocaine abuse in pregnancy Koller, an Austrian ophthalmologist, first introduced have been published.4,15,20–23 cocaine to modern medicine as a local anesthetic for The typical cocaine abusing parturient does not fit ophthalmologic procedures in 1884.9,10 However, as into any specific socioeconomic, ethnic, or cultural cocaine became widely used as a topical local anes- profile.18 Associated risk factors, which may suggest thetic, concerns about addiction began to mount and cocaine use in pregnancy, include lack of prenatal care, over time the drug has been replaced in clinical prac- history of premature labour, and cigarette smok- tice by less toxic, synthetic local anesthetics.11 ing.1,17,24–26 Most patients with a history of cocaine Cocaine hydrochloride, the common pharmaceuti- abuse deny it when interviewed preoperatively by pri- cal form, is prepared by dissolving the alkaloid in mary physicians, obstetricians and anesthesiolo- hydrochloric acid to form a water-soluble salt, which gists.1,17,27 A high index of suspicion for cocaine use in has the topical anesthetic properties.7 Cocaine is com- pregnancy, combined with non-judgemental ques- mercially available in a hydrochloride form as white tioning of every parturient is therefore essential to powder, granules or crystals. The hydrochloride form determine the differential diagnosis of cocaine toxici- of cocaine undergoes heat degradation and therefore, ty, avoid drug interactions and subsequent peripartum cannot be smoked for recreational purposes.7 In the complications.1,17 mid-1980’s, however, the use of “crack,” a new form In addition to cocaine, other substances abused in of cocaine, surged.11 Crack is almost pure, highly con- pregnancy include caffeine, tobacco, ethanol, marijua- centrated cocaine obtained by converting
Load more

Recommended publications
  • Cocaine Use Disorder
    COCAINE USE DISORDER ABSTRACT Cocaine addiction is a serious public health problem. Millions of Americans regularly use cocaine, and some develop a substance use disorder. Cocaine is generally not ingested, but toxicity and death from gastrointestinal absorption has been known to occur. Medications that have been used as substitution therapy for the treatment of a cocaine use disorder include amphetamine, bupropion, methylphenidate, and modafinil. While pharmacological interventions can be effective, a recent review of pharmacological therapy for cocaine use indicates that psycho-social efforts are more consistent over medication as a treatment option. Introduction Cocaine is an illicit, addictive drug that is widely used. Cocaine addiction is a serious public health problem that burdens the healthcare system and that can be destructive to individual lives. It is impossible to know with certainty the extent of use but data from public health surveys, morbidity and mortality reports, and healthcare facilities show that there are millions of Americans who regularly take cocaine. Cocaine intoxication is a common cause for emergency room visits, and it is one drug that is most often involved in fatal overdoses. Some cocaine users take the drug occasionally and sporadically but as with every illicit drug there is a percentage of people who develop a substance use disorder. Treatment of a cocaine use disorder involves psycho-social interventions, pharmacotherapy, or a combination of the two. 1 ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com Pharmacology of Cocaine Cocaine is an alkaloid derived from the Erthroxylum coca plant, a plant that is indigenous to South America and several other parts of the world, and is cultivated elsewhere.
    [Show full text]
  • Cocaine Intoxication and Hypertension
    THE EMCREG-INTERNATIONAL CONSENSUS PANEL RECOMMENDATIONS Cocaine Intoxication and Hypertension Judd E. Hollander, MD From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA. 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.11.008 [Ann Emerg Med. 2008;51:S18-S20.] with cocaine intoxication is analogous to that of the patient with hypertension: the treatment should be geared toward the Cocaine toxicity has been reported in virtually all organ patient’s presenting complaint. systems. Many of the adverse effects of cocaine are similar to When the medical history is clear and symptoms are mild, adverse events that can result from either acute hypertensive laboratory evaluation is usually unnecessary. In contrast, if the crisis or chronic effects of hypertension. Recognizing when the patient has severe toxicity, evaluation should be geared toward specific disease requires treatment separate from cocaine toxicity the presenting complaint. Laboratory evaluation may include a is paramount to the treatment of patients with cocaine CBC count; determination of electrolyte, glucose, blood urea intoxication. nitrogen, creatine kinase, and creatinine levels; arterial blood The initial physiologic effect of cocaine on the cardiovascular gas analysis; urinalysis; and cardiac marker determinations. system is a transient bradycardia as a result of stimulation of the Increased creatine kinase level occurs with rhabdomyolysis. vagal nuclei. Tachycardia typically ensues, predominantly from Cardiac markers are increased in myocardial infarction. Cardiac increased central sympathetic stimulation. Cocaine has a troponin I is preferred to identify acute myocardial13 infarction. cardiostimulatory effect through sensitization to epinephrine A chest radiograph should be obtained in patients with and norepinephrine.
    [Show full text]
  • Why Does Smoking So Often Produce Dependence? a Somewhat Diverent View
    62 Tobacco Control 2001;10:62–64 Tob Control: first published as 10.1136/tc.10.1.62 on 1 March 2001. Downloaded from COMMENTARY Why does smoking so often produce dependence? A somewhat diVerent view John R Hughes Abstract These explanations often give little emphasis The usual explanation for why smoking to the possibility that nicotine induces depend- produces dependence focuses on the ence because it produces beneficial eVects that eVects of nicotine on dopamine and other can help smokers cope with their environ- neurobiological explanations. This review ment.89 By beneficial eVects, I mean positive oVers four somewhat diVerent explana- eVects that are not due to relief of withdrawal tions: (1) nicotine can oVer several but rather are eVects above and beyond a “nor- psychopharmacological benefits at the age mal” baseline functioning.10 when such benefits are especially needed; Whether nicotine via smoking causes true (2) cigarettes provide for a rapid, beneficial eVects is, to many, debatable.891112 frequent, reliable and easy-to-obtain My belief (and that of others before me89) that reward; (3) nicotine is not intoxicating, nicotine can cause true beneficial eVects is allowing chronic intake; and (4) the long based on three sets of data. First, nicotine often duration of the nicotine withdrawal causes improvements in animals with no syndrome eVectively undermines cessa- history of nicotine exposure, in never smokers, tion. This article reviews the evidence for and in non-deprived smokers.8911 Second, the above views and the tobacco control most other drugs of dependence produce ben- activities these views suggest. eficial eVects—for example, cocaine produces (Tobacco Control 2001;10:62–64) stimulation and alcohol produces relaxation http://tobaccocontrol.bmj.com/ Keywords: nicotine; substance use disorder; substance and increased confidence.
    [Show full text]
  • Treatment of Patients with Substance Use Disorders Second Edition
    PRACTICE GUIDELINE FOR THE Treatment of Patients With Substance Use Disorders Second Edition WORK GROUP ON SUBSTANCE USE DISORDERS Herbert D. Kleber, M.D., Chair Roger D. Weiss, M.D., Vice-Chair Raymond F. Anton Jr., M.D. To n y P. G e o r ge , M .D . Shelly F. Greenfield, M.D., M.P.H. Thomas R. Kosten, M.D. Charles P. O’Brien, M.D., Ph.D. Bruce J. Rounsaville, M.D. Eric C. Strain, M.D. Douglas M. Ziedonis, M.D. Grace Hennessy, M.D. (Consultant) Hilary Smith Connery, M.D., Ph.D. (Consultant) This practice guideline was approved in December 2005 and published in August 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org. 1 Copyright 2010, American Psychiatric Association. APA makes this practice guideline freely available to promote its dissemination and use; however, copyright protections are enforced in full. No part of this guideline may be reproduced except as permitted under Sections 107 and 108 of U.S. Copyright Act. For permission for reuse, visit APPI Permissions & Licensing Center at http://www.appi.org/CustomerService/Pages/Permissions.aspx. AMERICAN PSYCHIATRIC ASSOCIATION STEERING COMMITTEE ON PRACTICE GUIDELINES John S. McIntyre, M.D., Chair Sara C. Charles, M.D., Vice-Chair Daniel J. Anzia, M.D. Ian A. Cook, M.D. Molly T. Finnerty, M.D. Bradley R. Johnson, M.D. James E. Nininger, M.D. Paul Summergrad, M.D. Sherwyn M.
    [Show full text]
  • Drugs of Abuse 2 Ceus By: Louis Durkin, MD
    Drugs of Abuse 2 CEUs By: Louis Durkin, MD INTRODUCTION An overview of the epidemiology, demographics, and pharmacology of the most common drugs of abuse. It covers the likely complications and side effects of the drugs, as well as potential interaction with other drugs. You will also learn about the most recent trends in abuse, such as "rave" and date rape drugs. Objectives By the end of this lecture, the participant should be able to... 1. Describe the new drugs of abuse 2. Explain "rave" drugs 3. Explain date rape drugs 4. List the pharmacology of the common drugs of abuse 5. List the clinical signs and symptoms of drugs of abuse 6. Explain the most likely life-threatening presentations of drugs of abuse 7. Explain treatment, including specific antidotes for patients taking these drugs 8. Describe intoxication and withdrawal symptoms and their treatment Introduction • Drug abuse is a common problem in the US. • There are many common drugs of abuse, each with it's own mechanism of action and potential unwanted side effects. • Most of the traditional drugs of abuse are still widespread among the youth of this country, with many newer versions on the rise. • Many of the familiar drugs such as marijuana, amphetamines, heroin and alcohol have leveled off in usage over the past few years with a recent surge of the newer "rave" and date rape drugs. Some, such as ecstasy, are just new versions of an old drug, where others, such as GHB are in a class unto themselves. • This lecture will cover the pharmacology of the most common agents, and focus on recognition and treatment of the various agents.
    [Show full text]
  • A Guide to Substance Abuse Services for Primary Care Clinicians
    Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment A Guide to Substance Abuse Services for Primary Care Clinicians Treatment Improvement Protocol (TIP) Series 24 A Guide to Substance Abuse Services for Primary Care Clinicians Treatment Improvement Protocol (TIP) Series 24 Eleanor Sullivan, Ph.D., R.N., F.A.A.N. Michael Fleming, M.D., M.P.H. Consensus Panel Co-Chairs U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 This publication is part of the Substance Abuse I.C.A.D.C., served as the CSAT government Prevention and Treatment Block Grant technical project officer. Paddy Cook, Constance Grant assistance program. All material appearing in Gartner, M.S.W., Lise Markl, Randi Henderson, this volume except that taken directly from Margaret K. Brooks, Esq., Donald Wesson, M.D., copyrighted sources is in the public domain and Mary Lou Dogoloff, Virginia Vitzthum, and may be reproduced or copied without Elizabeth Hayes served as writers. Special permission from the Substance Abuse and thanks to Daniel Vinson, M.D., M.S.H.P., Mim J. Mental Health Services Administration’s Landry, Mary Smolenski, C.R.N.P., Ed.D., (SAMHSA) Center for Substance Abuse MaryLou Leonard, Pamela Nicholson, Annie Treatment (CSAT) or the authors. Citation of Thornton, Jack Rhode, Cecil Gross, Niyati the source is appreciated. Do not reproduce or Pandya, and Wendy Carter for their distribute this publication for a fee without considerable contributions to this document.
    [Show full text]
  • CLINICAL PRESENTATIONS: NEUROLOGY Withdrawal with Delirium, Convulsions and Hallucinations and 16% of Patients and the Onset of the Syndrome May Be Acute, Delusions
    CATEGORY I – CLINICAL PRESENTATIONS: NEUROLOGY 1.0 Introduction The overlap between neurological and substance use disorders is significant. About one in five of neurology patients have a lifetime history of a substance use disorder with 13% reporting a current episode. In addition to overdose, withdrawal, and addictive behaviour, licit and illicit drugs produce a wide range of neurologic complications, therefore detection and treatment are essential. Substance misuse use can also lead to problems with memory, attention and decision-making as well as resulting in medical emergencies, seizures, acute confusional states and cognitive deterioration. S LEARNING OUTCOMES l Concomitant intoxication with different substances may confuse the clinical picture. T Medical students will gain knowledge in: 2.2 Barriers to access E 1. Describing the range of neurological symptoms associated with substance use disorders. l Neurological symptoms either not recognised or E ignored by patient. 2. Identifying signs and symptoms of neurological disorders affected by substance use. l Lack of skills in taking a history and ascertaining H substance use. 3. Describing an appropriate care plan. l S Patient may not disclose substance use because the relevance to the neurological problem may not be Vignette obvious. T Lianne is 26 and started using methamphetamine eight 2.3 Effects of substances on the nervous system C months ago, to which she was introduced by her (Intoxication and withdrawal) boyfriend. She suffered a cerebrovascular accident (CVA) Excessive or protracted substance misuse can lead to a A and following tests and investigations, it was diagnosed number of problems due to neurotoxicity. Some of the that her use of methamphetamine was one of the F social problems associated, such as violence and loss of primary causes of the high blood pressure that caused a control over the drug, may be directly related to the blood vessel in her brain to rupture.
    [Show full text]
  • Passive Inhalation of Cocaine by Infants
    Henry Ford Hospital Medical Journal Volume 38 Number 4 Article 14 12-1990 Passive Inhalation of Cocaine by Infants Sabrina M. Heidemann Mark G. Goetting Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Heidemann, Sabrina M. and Goetting, Mark G. (1990) "Passive Inhalation of Cocaine by Infants," Henry Ford Hospital Medical Journal : Vol. 38 : No. 4 , 252-254. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol38/iss4/14 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Original Contributions and Case Studies Passive Inhalation of Cocaine by Infants Sabrina M. Heidemann, MD,* and Mark G. Goetting, MD^ Cocaine abuse has increased gready in recent years, creating important medical, legal, and social problems. Urine drug testing is used to diagnose cocaine ingestion. The presence of the cocaine metabolite benzoylecgonlne (BZ) is commonly believed to be proof of recent cocaine intoxication. However, oral ingestion of even a minute quantity of cocaine can resull in a positive test resuh. BZ was delected in the urine of four nonbreast-fed infants aged 6 weeks to 14 months who were admitted with diagnoses unrelated to cocaine poisoning. These infants were exposed to cocaine hy passive inhalation of vapors generated by adult caretakers smoking "crack" cocaine. Two ofthe infants were retested 12 hours later and had no detectable BZ, strongly suggesting ingestion of a subpharmacologic amounl of cocaine.
    [Show full text]
  • DRUG INTOXICATION and WITHDRAWAL SYMPTOMS From: American Psychiatric Association
    DRUG INTOXICATION AND WITHDRAWAL SYMPTOMS From: American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. George S. Braucht, LPC & CPCS; brauchtworks.com INTOXICATION WITHDRAWAL Depressants: Alcohol, Sedative, Hypnotic or Anxiolytics Behavioral-Psychological changes: Within several hours (4-12) or several days of reducing/stopping: 1) inappropriate sexual or aggressive behavior 1) autonomic hyperactivity (sweating or pulse rate >100) 2) mood liability or impaired judgment 2) increased hand tremor Physiological changes: 3) insomnia 1) slurred speech 4) nausea or vomiting 2) incoordination 5) transient visual, tactile or auditory hallucinations or 3) unsteady gait illusions 4) nystagmus (involuntary side-to-side 6) psychomotor agitation eye movement) 7) anxiety 5) attention or memory impairment 8) grand mal seizures Stimulants: Amphetamine, methamphetamine, cocaine, etc. Behavioral-Psychological changes: Within a few hours to several days dysphoric mood plus two 1) euphoria with enhanced vigor, gregariousness of the following: 2) hyperactivity, restlessness, or hypervigilance 1) fatigue 3) interpersonal sensitivity and talkativeness 2) vivid, unpleasant dreams 4) anxiety, tension, alertness, or grandiosity 3) insomnia or hypersomnia 5) repetitive behavior, anger, or fighting 4) increased appetite 6) affective blunting with fatigue, or sadness 5) psychomotor retardation or agitation and social withdrawal A “crash” typically follows and episode of intense, high-dose Physiological changes: using:
    [Show full text]
  • Cocaine and the Heart M Egred, G K Davis
    568 Postgrad Med J: first published as 10.1136/pgmj.2004.028571 on 2 September 2005. Downloaded from REVIEW Cocaine and the heart M Egred, G K Davis ............................................................................................................................... Postgrad Med J 2005;81:568–571. doi: 10.1136/pgmj.2004.028571 Cocaine is the second commonest illicit drug used and the N Genitourinary and obstetric: renal and testi- cular infarction, abruptio placentae, sponta- most frequent cause of drug related deaths. Its use is neous abortion, prematurity, and growth associated with both acute and chronic complications that retardation.9 may involve any system, the most common being the N Neurological: seizures, migraine, cerebral 10 cardiovascular system. Cocaine misuse has a major effect infarction, and intracranial haemorrhage. N Musculoskeletal and dermatological: rhabdo- in young adult drug users with resulting loss of productivity myolysis, skin ischaemia, superficial and deep and undue morbidity with cocaine related cardiac and venous thrombosis, and thrombophlebitis.11 cerebrovascular effects. Many cocaine users have little or In this review we will focus on the cardiovas- no idea of the risks associated with its use. Patients, health cular effects of cocaine. care professionals, and the public should be educated about the dangers and the considerable risks of cocaine PHARMACOLOGY OF COCAINE use. This review concentrates on the cardiovascular effects Cocaine (benzoylmethylecgonine, C17,H21,NO4) is an alkaloid extract from the leaf of the of cocaine and their management. Erythroxylon coca plant, which usually grows in ........................................................................... South America. It is available in two forms: N Hydrochloride salt: prepared by dissolving the alkaloid in hydrochloric acid forming a water ocaine is the second commonest illicit drug soluble powder or granule that decomposes used and the most frequent cause of drug when heated.
    [Show full text]
  • Cocaine Abuse and Addiction
    CLINICAL REVIEW Cocaine Abuse and Addiction Frank H. Gawin, MD New Haven, Connecticut The National Institute on Drug Abuse now considers cocaine the “ drug of greatest national public health concern." Lower prices and a new administration route, co­ caine smoking, have increased the potential for addiction. An estimated 2 million individuals in the United States may be addicted to cocaine, or four times the number addicted to heroin. Contrary to population representations of the intracta­ ble power of cocaine addiction, cocaine dependence is a treatable disorder. The primary care physician must become familiar with signs of dependence and with therapeutic approaches to cocaine abuse, with particular attention to emerging advances in both psychotherapy and pharmacotherapy. he National Institute on Drug Abuse has called co­ centers in the United States, leading to unprecedented T caine “the drug of greatest national public health con­ cocaine abuse and treatment-seeking in these urban areas. cern,” estimating there are 2 million addicts1—four times An estimated 95% of the 20 to 30 million individuals the number of heroin addicts. A new mode of using the who have used cocaine have thus far avoided dependence,1 drug, specifically smoking “cocaine base,” has proven to promoting the illusion that cocaine can be used safely. Two be as addictive as intravenous injection,2,3 generating un­ to 4 years usually pass from an initial intranasal exposure precedented popular concern about cocaine. to cocaine, followed by decreasing control of use, to ulti­ Cocaine has previously been sold as a water-soluble hy­ mate cocaine dependence.4 Other than in acute toxic over­ drochloride salt for intranasal (snorting) or intravenous dose, early adverse effects are seldom presented to physi­ (shooting) use.
    [Show full text]
  • Interpretation and Death Certificate
    Interpretation and Death Certificate Peter J. Koin PhD., D-ABFT CDC Foundation July 17, 2019 Learning Objectives • Become familiar with the OSAC/NAME recommendations and guidelines • Know how to report the toxicology results and autopsy findings • Know the case definitions for drug-caused death, drug poisoning death, drug-detected death, and drug Medicolegal Death Investigation Subcommittee Recommendations • Complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings • A complete scene investigation extends to reconciliation of prescription information and pill counts • Blood, urine, and vitreous humor when available, should be retained in all cases • A toxicological panel should be comprehensive and include opioid and benzodiazepines, as well as other potent depressant, stimulant, and anti-depressant medications • Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings • If death is attributed to any drug or combination of drugs, the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate Toxicology Interpretation • Data interpretation of toxicology report must be taken with careful and critical consideration of other information 4 False Assumptions for Toxicology Interpretation • Postmortem blood drug concentrations reflect those at the moment of death •
    [Show full text]