Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

9. Cocaine and Stimulants 201guide addiction treatment needs to address a variety of issues, including the dosage,patterns, chronicity, and method of cocaine use; other drug use; antedatingand drug-related medical, social, and psychological problems; the patient’s cognitiveability and social skills; and the patient’s knowledge, motivation, attitude,and expectations of treatment (Washton, Stone, & Hendrickson, 1988).Additional factors indicating increased severity of addiction that may necessitateinpatient treatment include chronic smoking of freebase or intravenouscocaine use, the demonstrated inability to abstain from use while in outpatienttreatment, and the lack of family and social supports.Once the patient is stabilized and assigned to an appropriate level of care, amore detailed medical, psychiatric, and psychosocial history and physical examinationshould be performed. Patient motivation and readiness for change mayenhance retention and positive treatment outcomes. The search for evidence ofmedical, neuropsychological, and psychiatric sequelae should be stressed, aswell as consequences of self-neglect. The following laboratory tests shouldbe considered supplements to those obtained previously on an acute carebasis: pulmonary function testing with diffusing capacity of carbon monoxide(DLCO, DCO) in smokers of freebase and crack cocaine, and purified proteinderivative (PPD) tubercular skin testing with controls; rapid plasma reaginagglutination test (RPR; syphilis serology); hepatitis B surface antigen and hepatitisC antigen; and HIV serology in intravenous users. Because these patientsgenerally have poor follow-up rates, immunizations should be given, and generalpreventive health maintenance should be performed at this time as well.OverdoseTREATMENTIn the case of a massive cocaine overdose, patients are likely to present withadvanced cardiorespiratory distress and seizures. Treatment is performed in anemergency setting, with attention to cardiac function, and with an eye to thepresence of other substances. The principles of resuscitation, along with theadministration of thiamine, glucose, and naloxone (Narcan), are necessary(Goldfrank & Hoffman, 1993).IntoxicationIntoxicated persons who seek assistance with less severe cocaine complicationsare more likely to present with panic, irritability, hyperreflexia, paranoia, hallucinations,and stereotyped repetitive movements. Assurance in a calm,nonthreatening environment is a prerequisite for successful patient management.Psychosis can be treated with haloperidol, although caution is necessary,