Fl Cocaine Rpt

Cocaine Intoxication: Focus on Psychological Effects

R. Vandervoort, Pharm.D.

Overview

• Introduction to cocaine: prevalence, methods, effects

• Features and Prevalence of Cocaine-induced psychiatric effects

• Conclusions

Cocaine Abuse- Prevalence

• As of 1996, 7.1% of high school seniors had tried cocaine

• Accounts for 150,000 ER visits annually in the US

• In 1996, 4.6 million Americans had used Crack cocaine at least once

Cocaine- Methods of Abuse

• Intranasal- least efficient way of absorbing the drug; poor and inconsistent absorption through nasal mucosa

• IV injection- Risks of infection (including HIV); invasive’

• Inhalation into the lungs- Crack is the easiest way to produce smokeable cocaine.

Cocaine- Methods of Abuse

Route Onset Peak Duration

Inhalation 3-5 sec 1-3 min 5-15 min

Intravenous 10-60 sec 3-5 min 20-60 min

Intranasal orother mucosal

1-5 min 15-20 min 60-90 min

Cocaine- Physiologic Effects• Blocks Reuptake of Norepinephrine,

dopamine (main effect), and serotonin in the CNS

• Physical Effects: hyperthermia, HR, BP, dilated pupils

• Subjective Effects: hyperstimulation, reduced fatigue, feelings of increased mental clarity and alertness

• Psychiatric Effects: Paranoia, suicidal and homicidal thoughts, agitation

Cocaine Intoxication

• May be characterized by enhanced vigor, hyperactivity, grandiosity, anxiety, anger and impaired judgement– DSM IV, p.224

Cocaine Intoxication Delirium

• Delirium is defined as a disturbance of consciousness accompanied by a change in cognition (that can’t be explained by a pre-existing or evolving dementia), characterized by a reduced clarity of awareness of the environment– DSM IV, p.124

Cocaine Intoxication Delirium• DSM IV has the following to say concerning

fear as an associated feature of delirium, including cocaine intoxication delirium:“The individual may exhibit emotional disturbances

such as anxiety, fear, euphoria, and apathy. There may be rapid and unpredictable shifts from one emotional state to another…Fear often accompanies threatening hallucinations or transient delusions. If fear is marked, the person may attack those who are falsely perceived as threatening.”

-DSM IV, p.125

Cocaine-Induced Psychotic Disorder (a.k.a. Cocaine Psychosis)

“Smoking a high dose of cocaine may produce psychosis within minutes”

-DSM IV, p.312• Similar in presentation to acute paranoid

schizophrenia. Biol Psychiatry 1988;24:865-885


“Delusions and Hallucinations of Cocaine Abusers and Paranoid Schizophrenics: A Comparative Study”– Mitchell and Vierkant Journal of

Psychology 1991;125(3) :301-310

• Compared 100 cocaine abusers and 100 paranoid schizophrenics regarding specific hallucinations and delusions


PS cocaine

• Tactile hallucinations: 3 5

• Auditory hallucinations: 36 50

• Persecution Delusions: 49 74• Identity/grandiosity/possession delusions:

30 0– “Those in the cocaine group were more often fearful

of being “caught” by police or family members”


• A psychotic disorder manifests with prominent hallucinations or delusions

• Patients with stimulant-induced psychosis specifically often report persecutory delusions

• The enhanced vigor and hyperactivity associated with cocaine intoxication can make for violent actions in a patient suffering from a psychotic disorder


“ED staff may be severely injured by a wild, combative patient intoxicated with cocaine. Talk down therapy, which may be effective with hallucinogens, is not useful for cocaine-induced psychosis. Such patients must be restrained and given IV benzodiazepines.”

- Rosen: Emergency Medicine: Concepts and Clinical Practice, 4th ed. Copyright 1998 Mosby-Year Book, inc.


“High doses of cocaine and/or prolonged use can trigger paranoia. Smoking crack cocaine can produce a particularly aggressive paranoid behavior in users.”

- National Institute on Drug Abuse, National

Institutes of Health, infofax #13546

Cocaine Psychosis-How Common?

• “Stimulant effects [at high doses] …may result in accidents, illegal acts, or atypical sexual behavior. Such adverse effects occur in more than 80% of regular cocaine users. As a binge lengthens…states of severe transient panic accompanied by a terror of impending death can occur in persons with no preexisting psychopathologic conditions, as can paranoid psychoses. Surveys of abusers indicate that such states are common.”– Garwin FH, Ellinwood EH. Cocaine and other stimulants: actions, abuse, and

treatment. N Engl J Med 1988;318:1173


“(quote continues) When the paranoia is severe, reality testing becomes markedly impaired and in extreme cases, homicide can result.”– Garwin FH, Ellinwood EH. Cocaine and other stimulants: actions,

abuse, and treatment. N Engl J Med 1988;318:1173

Cocaine Psychosis-How Common?• In a study of 55 patients admitted to the hospital

for cocaine dependence, 53% of them reported experiencing cocaine-induced psychosis

• In this study, of those who experienced cocaine-induced psychosis, 90% developed delusions, and 96% hallucinated. 48% reported that they were currently experiencing psychosis with each use of the drug.– Brady KT, Lydiard RB, Malcolm R, Ballenger JC. Cocaine-

induced Psychosis. J Clin Psychiatry 1991;52:12


• In a chart-review analysis in the Bahamas, one third of free-base cocaine smokers reported regularly experiencing symptoms consistent with paranoid psychosis while intoxicated .– Manschreck TC et al. Characteristics of freebase

cocaine psychosis. Yale J Biol Med 1988;61:115-122


• 68% of 50 male cocaine users were found to have transient paranoid psychosis. The subjects reported that the paranoia was typically related to the illicit activities associated with the drug use.– Satel SL, et al. Clinical Features of Cocaine-induced

Paranoia. American Journal of Psychiatry. 1991;148:495-8.

“Because many, perhaps most, chronic cocaine abusers are intermittently psychotic while intoxicated, and because it is often impossible to identify the cocaine intoxicated patient, it seems especially wise in the 1990’s to cautiously approach any patient who appears afraid, anxious, or suspicious. Similarly, because the delusions and hallucinations of the cocaine user often causes him to perceive those around him as enemies, it is recommended to physically restrain angry or agitated psychotic patients before their condition escalates into violence.

-High Incidence of Psychosis in Cocaine Intoxication and Preventing Violence in the ED. American Journal of Emergency Medicine 1993;11(6):676

Conclusions• A high percentage of individuals who are

intoxicated with cocaine manifest psychotic symptoms

• Specifically, delusions often relate to a fear of being caught doing illegal activities related to using cocaine

• It is very unlikely that a person in this condition may be dealt with through talk-down tactics, hence recommendations for physical restraint and sedation to avoid injury to the patient and ED staff

Fl Cocaine Rpt

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