Second edition

21.qxd 3/10/08 9:58 AM Page 657
Course
Recreational use of stimulants is not uncommon, and such
occasional use generally causes few, if any, consequences.
Some patients may develop an abusive pattern of use, however,
and continue to seek intoxication despite suffering
social or legal consequences. Addiction is said to occur when
a craving develops for the stimulant, accompanied by the
phenomena of tolerance and withdrawal; such patients may
use stimulants on a daily basis, in relatively modest doses, or
display a ‘binge’ pattern (Kramer et al. 1967), in which they
use ever-escalating doses until, after a matter of days or
more, they either run out of money or become so debilitated
that they have to stop, after which they suffer through a
withdrawal syndrome before going on yet another binge.
Etiology
It appears that the euphoria seen with stimulants occurs
secondary to dopamine release within the ventral striatum
(Drevets et al. 2001), whereas the autonomic symptomatology
is mediated by enhanced noradrenergic tone
(Nurnberger et al. 1984).
Differential diagnosis
Intoxication with cocaine may be clinically indistinguishable
from stimulant intoxication, and the differential may
rest on history or drug screening.
Lacking a history (as is often the case, given the deceit and
denial seen in many cases), the elation and talkativeness of
the intoxication may suggest mania, and the irritability,
fatigue, and sleep disturbance of withdrawal may suggest
depression. Drug screening is helpful here; however, observation
in a controlled environment will also tell the tale, as
the symptoms resolve over the expected time period.
The stimulant-induced psychosis represents one of the
toxic psychoses, discussed in Section 7.1, and is suggested
by its emergence during an intoxication and its resolution
during enforced abstinence.
Treatment
Intoxication, if mild, may be managed with simple observation.
In severe cases one may utilize an antipsychotic
such as haloperidol, in a dose of approximately 5 mg, either
as the concentrate or parenterally, with repeat doses every
hour or so until the patient is calm, limiting side-effects occur
or a maximum dose of approximate 20 mg is reached.
Stimulant psychosis may be treated with an antipsychotic,
such as haloperidol (5–10 mg) or risperidone
(2–4 mg), with the understanding that the medication
may, given the natural course of the disorder, be eventually
discontinued.
21.2 Cocaine 657
Withdrawal symptomatology, if severe and accompanied
by suicidal ideation, may require hospitalization.
Pharmacologic treatment is generally not indicated.
The overall treatment of stimulant addiction has as its
goal abstinence. Hospitalization is often required to break
the pattern of use, and long-term involvement with groups
such as Cocaine Anonymous or Narcotics Anonymous
may be helpful.
21.2 COCAINE
Several different preparations of cocaine are available illegally.
Cocaine hydrochloride is a white powder that may be
insufflated (‘snorted’) into the nasal passages where it is
absorbed through the nasal mucosa; it is also water soluble
and thus may be dissolved and injected intravenously.
Cocaine hydrochloride is destroyed by heat and is thus not
suitable for smoking; it may, however, be treated with
sodium bicarbonate and then either extracted with ether to
yield a ‘free base’ preparation or warmed to create a ‘rock’
of ‘crack’ cocaine. Both the free base and crack preparations
evaporate with heating and thus may be smoked.
Clinical features
The onset of intoxication varies according to the preparation
used; after snorting, peak levels are reached within
30–60 minutes, whereas after intravenous injection or
smoking, peak levels occur within seconds, creating a
much more intense intoxication. During intoxication
(Kleber and Gawin 1984), patients become euphoric,
hyperalert, talkative, and grandiose. Hyperactivity is common,
and with higher doses agitation may occur
(Fischman et al. 1976). Some patients may experience
visual hallucinations, and these are typically of insects,
which are often referred to as ‘cocaine bugs’; these hallucinations
may be accompanied by tactile hallucinations of
bugs crawling beneath the skin, and some patients may
excoriate themselves in an attempt to ‘get’ them. With mild
intoxication libido increases, and in males there may be
delayed ejaculation; with more severe intoxication, however,
there may be erectile dysfunction. In severe intoxication,
especially after intravenous use or smoking, a
delirium may occur, with confusion, incoherence, lability,
and delusions and hallucinations. Other symptoms and
signs include mydriasis, hypertension, headache, nausea
and vomiting, tachycardia, and arrhythmias or cardiac
arrest (Hsue et al. 2007). Uncommonly, there may be
chorea (‘crack dancing’) (Daras et al. 1994), tics (Pascual-
Leone and Dhuna 1990), myocardial infarction (Virmani
et al. 1988), rhabdomyolysis (Roth et al. 1988), stroke (due
to infarction, intracerebral hemorrhage or subarachnoid
hemorrhage [Klonoff et al. 1989; Lichtenfeld et al. 1986;
Nolte et al. 1996]), and, with chronic, repeated use, a cerebral
vasculitis (Fredericks et al. 1991; Krendel et al. 1990).