Journal Reading

Cocaine-Related Psychiatric
Disorders
Christopher P Holstege, MD; Chief Editor: David Bienenfeld, MD

Adviser:
dr. Iwan Sis, Sp.KJ
Wa Ode Nurlaily Hanifaty
201710401011024

Science of Psychiatric
Medical Faculty
University of Muhammadiyah Malang
8/11/2019 2019 1
Background
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• Cocaine is a naturally occurring alkaloid found within
the leaves of a shrub, Erythroxylon coca
• The earliest reported use of cocaine dates back to
times when the ancient inhabitants of Peru used the
leaves for religious ceremonies
• Cocaine was first isolated from the coca leaf in 1859.
Its first use as a local anesthetic was reported in
1884

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• In the late 19th century, Sigmund Freud proposed
cocaine for the treatment of depression, cachexia,
and asthma. It later became prescribed for almost
any illness

• In 1885, John Styth Pemberton registered a cocaine-

containing drink in the United States. This drink was
later named Coca-Cola.

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• In 1914, the Harrison Narcotics Act banned all
nonprescription use of cocaine.

• Finally, in 1970, the Controlled Substances Act

prohibited the possession of cocaine in the United
States, except for limited medical uses

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 There are 5 categories of stimulant-related
disorders according to DSM-5. They are as follows:
a. Stimulant use disorder
b. Stimulant intoxication
c. Stimulant withdrawal
d. Other stimulant-induced disorders
e. Unspecified stimulant-related disorder

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 Pathophysiology

The time to peak effects of cocaine depends on the dose

and route of administration.

When cocaine is injected intravenously or crack is smoked,

the onset of action is within seconds and peak effects occur
within 5 minutes.

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 When snorted, the onset of action of cocaine is
within the first 5 minutes and its effects typically peak
within 30 minutes

Cocaine can be absorbed across any mucosal

surface, including the respiratory, gastrointestinal, and
genitourinary tracts

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 Two major routes account for cocaine's metabolism:

(1) enzymatic metabolism by both liver esterases and plasma

cholinesterase to ecgonine methyl ester
(2) nonenzymatic degradation to benzoylecgonine.

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 Epidemiology

The following statistics are from the 2014 National Survey

on Drug Use & Health (NSDUH) for the age group 12 years
and older
The National Epidemiologic Survey on Alcohol and Related
Conditions (NESARC) study suggests the transition from use to
dependence was highest for nicotine users, followed by
cocaine, alcohol, and cannabis users

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 Mortality/Morbidity
Regarding emergency department (ED) visits in 2011,
reports that cocaine and marijuana were the most
commonly involved drugs, with 505,224 ED visits (40.3%)
and 455,668 ED visits (36.4%), respectively

Race
Hispanic (9.5%) than white (4.8%) and black (2.1%)

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Sex
Male (6.6%) than female (4.5%) students

Age
According to the 2013 National Youth Risk Behavior
Survey, the prevalence of having ever used cocaine
was higher among 11th-grade (6.8%) and 12th-grade
(7.1%) than 9th-grade (4.4%) and 10th-grade (4.0%)
students

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Presentation

History
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 Diagnostic Criteria (DSM 5)
• The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) classifies cocaine use under the
categoryof stimulant-related disorders. The five disorders
now recognized are as follows:[1]
a. Stimulant use disorder
b. Stimulant intoxication
c. Stimulant withdrawal
d. Other stimulant-induced disorders
e. Unspecified stimulant-related disorder

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• Manual Diagnostik dan Statistik Gangguan Mental,
Edisi Kelima (DSM-5) mengklasifikasikan penggunaan
kokain di bawah kategori gangguan terkait stimulan.
Kelima kelainan yang sekarang dikenali adalah sebagai
berikut: [1] Gangguan penggunaan stimulan
Keracunan stimulan Penarikan stimulan Gangguan
stimulan lainnya Gangguan terkait stimulan yang tidak
spesifik

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 Stimulant use disorder

Symptoms of stimulant use disorders include craving for

stimulants, failure to control use when attempted, continued
use despite interference with major obligations or social
functioning, use of larger amounts over time, development of
tolerance, spending a great deal of time to obtain and use
stimulants, and withdrawal symptoms that occur after
stopping or reducing use

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• Gejala gangguan penggunaan stimulan termasuk
keinginan untuk stimulan, kegagalan untuk
mengontrol penggunaan ketika dicoba, penggunaan
berkelanjutan meskipun ada gangguan dengan
kewajiban utama atau fungsi sosial, penggunaan
jumlah yang lebih besar dari waktu ke waktu,
pengembangan toleransi, menghabiskan banyak
waktu untuk mendapatkan dan menggunakan
stimulan , dan gejala penarikan yang terjadi setelah
berhenti atau mengurangi penggunaan

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Stimulant intoxication

Clinically significant problematic behavioral or

psychological changes that developed during, or
shortly after, use of stimulant

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• Perubahan perilaku atau psikologis yang bermakna
secara klinis yang berkembang selama, atau segera
setelah, penggunaan stimulan

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• Two or more of the following signs or symptoms:
a. Tachycardia or bradycardia
b. Pupillary dilation
c. Elevated or lowered blood pressure
d. Perspiration or chills
e. Nausea or vomiting
f. Evidence of weight loss
g. Psychomotor agitation or retardation
h. Muscular weakness, respiratory depression, chest pain,
or cardiac arrhythmias
i. Confusion, seizure, dyskinesias, dystonias, or coma
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• Dua atau lebih dari tanda atau gejala berikut:
Takikardia atau bradikardia Pelebaran pupil Tekanan
darah tinggi atau rendah Keringat atau kedinginan
Mual atau muntah Bukti penurunan berat badan
Agitasi atau keterlambatan psikomotor Kelemahan
otot, depresi pernapasan, nyeri dada, atau aritmia
jantung Kebingungan, kejang, diskinesia, distonia,
atau koma

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Stimulant withdrawal
• Withdrawal manifests after cessation or reduction of
prolonged use of cocaine and results in a dysphoric
mood and two (or more) of the following changes:
a. Fatigue
b. Vivid, unpleasant dreams
c. Insomnia or hypersomnia
d. Increased appetite
e. Psychomotor retardation or agitation

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• Penarikan bermanifestasi setelah penghentian atau
pengurangan penggunaan kokain yang
berkepanjangan dan menghasilkan suasana hati
dysphoric dan dua (atau lebih) dari perubahan
berikut: Kelelahan Jelas, mimpi yang tidak
menyenangkan Insomnia atau hipersomnia Nafsu
makan meningkat Keterbelakangan atau agitasi
psikomotor

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 Physical
Vital sign : tachycardia and hypertension
Skin and extremities : may be cool as a result of the
vasoconstrictive effects of cocaine
Head, ears, eyes, nose : edema, ecchymosis (exclued of
headtrauma), mydriasis, nasal septa
perforations
Cardiovascular : murmurs, rubs (pericarditis), or
dysrhythmias
Pulmonary : rales (edema paru, pneumonia,
atelectasis), decreased breath
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sounds (pneumothorax) 24
Gastrointestinal : vomiting, diarrhea, and
hyperactive bowel sounds
Neurologic : seizures, agitation, tremor, and
hyperreflexia
Psychiatric : delirium, psychosis, delusions,
hallucinations, depression, mania,
and anxiety

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Causes

• The US National Institute on Drug Abuse estimates

that approximately 10% of people who begin to use
cocaine progress to heavy, chronic abuse
• A family history of substance abuse directly correlates
both with the development of cocaine abuse and with
earlier age of onset of cocaine abuse
• Approximately 50% of those who abuse illicit drugs
also have a co-occurring mental disorder.

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 Differential Diagnoses
• Amphetamine-Related • Panic Disorder
Psychiatric Disorders • Phencyclidine (PCP)-Related
• Anxiety Disorders Psychiatric Disorders
• Attention Deficit • Schizoaffective Disorder
Hyperactivity Disorder • Schizophrenia
(ADHD)
• Schizophreniform Disorder
• Bipolar Disorder
• Sleep Disorders
• Delirium
• Delusional Disorder
• Depression
• Hallucinogen Use
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Workup

Laboratory Studies
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Electrolytes
• Hypokalemia occurs in acute cocaine intoxication
• Hyperkalemia In severe cocaine toxicity

Toxicology
• Urine drug screens
• Plasma cocaine levels
• Cardiac enzymes

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Other lab test include the following:

• Glucose
• Renal function tests
• Creatine kinase
• Urinalysis
• Pregnancy test
• Liver function tests
• Complete blood cell

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Imaging Studies
• Chest radiographs
• Head CT scan
• Positron emission tomography (PET) imaging

Other Tests
• Arterial blood gas determinatio
• ECG

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Treatment

Medical Care
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1. Cocaine intoxication : Benzodiazepines
2. Cocaine-induced chest pain : Chest pain associated with
cocaine use may be from musculoskeletal, cardiovascular,
or pulmonary etiologies.
3. Hypertension : Benzodiazepines, phentolamine,
Nitroprusside and nitroglycerin also may be considered.
4. Seizures : benzodiazepines, followed by barbiturates.
5. Rhabdomyolysis
6. Dyspnea
7. Sleep disturbance

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Consultations
Include medical toxicologists, regional
poison control center personnel, cardiologists,
neurologists, psychiatrists, substance, abuse
clinicians, and social services personnel,
depending on the presenting signs and
symptoms.
Prevention
Vaccination

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Medication
 Benzodiazepines
 Antipsychotic agents
 Antidepressants

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Follow Up

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 Further Outpatient Care

• Outpatient treatment is effective for many patients with

cocaine addiction.

• The goals of treatment for cocaine addiction are 3-fold:

(1) achievement of abstinence
(2) prevention of relapse, and
(3) rehabilitation

• Cognitive and behavioral therapies have been designed to

prevent relapse in patients addicted to cocaine
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 Further Inpatient Care

• Patients with marked cognitive impairment, acute psychosis,

severe depression, delirium, mania, and medical
complications should be considered for admission to an
inpatient facility

• All patients should also be assessed for risk of harm to self

or to others

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Inpatient & Outpatient Medications

• Cocaine-induced mood disorder: Pharmacotherapy with

antidepressant medications, such as SSRIs, may
benecessary.
• Cocaine-induced psychotic disorder: Pharmacotherapy with
antipsychotic medications may be necessary.
• Cocaine-induced anxiety disorder: Pharmacotherapy with
anxiolytics, such as benzodiazepines, may be necessary.

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Complications
oRhabdomyolysis
oAcute coronary syndrome
oCerebral vascular accidents
oAcute renal failure
oSeizures
oHyperthermia
oPneumothorax
oPneumomediastinum
oPulmonary infarct
oPulmonary edema

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 Prognosis
• Among subjects who present for cocaine dependence
treatment, concurrent alcoholism predicts higher relapse
risk and poorer outpatient therapy attendance
• Studies suggest that patients who have used cocaine as a
primary drug of abuse for extended periods constitute a
group with particularly high underlying psychopathology

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 Patient Education

Intensive education is an important part of

the success of any drug treatment
program

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