What is Cocaine Toxicity (Cocaine Overdose)?
Cocaine abuse is a serious global health issue. People experiencing severe effects of cocaine use may need immediate medical attention in the emergency department (ED). They may show symptoms like a rapid heart rate, abnormal heart rhythms, high blood pressure, and sudden tightening of the heart arteries. These can lead to severe health conditions such as heart disease, stroke, and even death.
In recent years, there have also been cases of ‘body packers’ – people who ingest sealed packets of drugs – needing emergency care due to packet rupture. Furthermore, the treatment of these cases can be challenging when patients have taken other harmful substances, including alcohol. While cocaine can harm every part of the body, its deadliest effects impact the heart and blood vessels.
What Causes Cocaine Toxicity (Cocaine Overdose)?
The coca plant, known as Erythroxylon coca, has been used as a stimulant in South America for over 4,000 years. In the mid-1800s, a substance called cocaine was first identified in the coca leaves. Back then, it was viewed as safe and found its way into products aiming to cure toothache, nausea, and boost energy, even in the original “Coca-Cola” drink.
However, in 1961, the International Single Convention on Narcotic Drugs classified recreational cocaine use as a global crime. The drug’s popularity resurfaced in the 1970s during the disco era and again in the 1980s with the introduction of crack cocaine.
Today, cocaine is considered a schedule II controlled substance by the DEA. This means that while it can be used for certain medical purposes (as discussed in the StatPearls chapter “Cocaine”), it has a high chance of being misused and can lead to addiction.
Risk Factors and Frequency for Cocaine Toxicity (Cocaine Overdose)
Cocaine abuse is a significant health problem around the world. According to the most recent United Nations World Drug Report, roughly 20 million people worldwide use cocaine. While the number of regular cocaine users had been decreasing since 2006 in North America, it has recently started to increase again. Approximately 1% of the population has reported using the drug. Data from the Drug Enforcement Agency shows that in 2012 in the United States, roughly 639,000 individuals aged 12 and older used cocaine for the first time. This averages to about 1,800 new users each day. In the United States, cocaine is the most commonly abused drug that results in hospital treatment. The Substance Abuse and Mental Health Services Administration reported that in 2011, cocaine was responsible for 505,224 emergency department visits, which represents 40.3% of all drug-related visits. This equates to a rate of 162 emergency visits per 100,000 population.
- According to the United Nations World Drug Report, around 20 million people worldwide are using cocaine.
- In North America, there has been an increase in the number of regular users, with about 1% of the population using the drug.
- In 2012, around 639,000 individuals in the United States used cocaine for the first time. That’s approximately 1,800 new users each day.
- Based on numbers from the Substance Abuse and Mental Health Services Administration, cocaine is the most common drug causing hospital treatment in the United States.
- In 2011, there were 505,224 emergency department visits due to cocaine, which is 40.3% of all drug-related visits.
- The rate of emergency visits due to cocaine is 162 per 100,000 population.
Signs and Symptoms of Cocaine Toxicity (Cocaine Overdose)
When people come to the hospital showing restlessness, chest discomfort, fear, mental confusion, or physical injuries from accidents or violence, it might indicate that they have been using cocaine. They often have high blood pressure and a fast heart rate and might be hesitant to admit their cocaine use. Doctors need to think about many possible diagnoses when first checking these patients. These could include withdrawal symptoms from drug misuse, overactive thyroid, sudden severe mental disorder, infections that have spread throughout the body, a rare tumor that causes high blood pressure, poisoning by a drug that causes dry mouth and blurred vision, a dangerous condition caused by certain psychiatric drugs, or bleeding within the skull.
It’s important to find out if the person has a history of drug misuse, including any previous hospital visits related to drug misuse.
People suspected of having an adverse reaction to cocaine may show the following:
- High blood pressure
- Changes in mental state
- Seizures
- Chest pain, difficulty breathing
- Nosebleeds
- Headaches
- Paranoia
- Neurological issues
- Higher body temperature
- Loss of distal pulses due to vascular spasm
- Excessive sweating
- Extreme restlessness, agitation, confusion
- Itchiness
- Blurred vision
- Damaged cornea, vision loss
- Diarrhea, vomiting, abdominal pain (sign of insufficient blood supply to the intestines)
- Extreme mental and motor excitement
Acute cocaine toxicity, a dangerous condition caused by taking too much cocaine, has three stages:
Stage 1:
- Central Nervous System (CNS): Headache, nausea, large pupils, false sense of movement, mild shaking, hallucinations
- Vascular: High blood pressure, irregular heartbeats
- Respiratory: Rapid breathing
- Skin: Higher body temperature
- Psychiatric: Paranoia, manic behavior, confusion, aggression, sudden changes in mood, restlessness
Stage 2:
- CNS: Brain dysfunction, seizures, hyperactive reflexes, loss of bladder control
- Cardiac: High blood pressure, irregular heartbeats, bluish discoloration of the skin
- Respiratory: Rapid breathing, difficulty in breathing, cessation of breath, pattern of irregular breathing
- Skin: High body temperature
Stage 3:
- CNS: Absence of reflexes, coma, pupils that are wide open and unresponsive, loss of essential body functions
- Cardiac: Low blood pressure, erratic heart rhythms, cardiac arrest
- Respiratory: Cessation of breath, failure of the respiratory system, blue discoloration of the skin, struggling breaths
Testing for Cocaine Toxicity (Cocaine Overdose)
If your doctor thinks you may have taken too much cocaine and it’s affecting your health, they will most likely recommend a few tests. The tests may include a complete blood count, a broad-ranging chemistry test, and checks for heart damage markers like troponin, B-type natriuretic peptide, and creatine kinase. Urine tests can also be done to detect drugs and signs of muscle breakdown.
Most of the cocaine usually leaves the body within a day. However, a byproduct of this drug, called benzoylecgonine, may linger for weeks causing harm to your nervous system. If there are concerns about a heart attack, the troponin test can help rule it out. If meningitis or brain infection is suspected, a lumbar puncture, a procedure to collect spinal fluid, may be required.
Imaging tests could include chest x-rays, which may reveal signs of fluid in the lungs, collapsed lungs, or pneumonia caused by inhaling food or vomit into the lungs. Abdominal x-rays might be done if it’s suspected that packets of cocaine have been swallowed. Because simple x-rays can miss some cases, a more detailed imaging method like a CT scan could be recommended. It’s crucial to diagnose and treat any cases of swallowed cocaine packets promptly, as there’s a risk they could burst.
The doctor might also recommend a CT scan for the head, especially if seizures are present, to identify any other potential causes for the symptoms. An ECG, a test that records the electrical activity of your heart, may be needed if you have chest pain, difficulty breathing, an irregular pulse, or a shortage of oxygen in your blood.
Treatment Options for Cocaine Toxicity (Cocaine Overdose)
Patients experiencing cocaine poisoning need immediate medical help and the first priority is to ensure their basic vital functions are stable. This includes checking their airway, breathing, and circulation. If the patient has a fever, it needs to be controlled. It’s also important to check if low blood sugar might be causing any mental or emotional symptoms. Women who could be pregnant should take a pregnancy test.
The best treatment for agitation and heart problems due to cocaine toxicity usually starts with medications called benzodiazepines. These drugs can lessen the harmful effects of cocaine on the nervous system. However, there is a risk that taking too many doses of these drugs can cause over-sedation and problems with breathing.
Other types of medications, such as diltiazem and verapamil, can help reduce high blood pressure, but won’t slow down a rapid heart rate. It’s generally not recommended to use drugs like nifedipine, as they can cause an unwanted increase in heart rate. Drugs called alpha-blockers, like phentolamine, can help with high blood pressure, but they are rarely used and don’t help with a rapid heart rate. Drugs like nitroglycerin and nitroprusside can also lower blood pressure, but may lead to an increase in heart rate as well.
A medication called labetalol can be effective for treating both high blood pressure and a fast heart rate caused by cocaine, and is generally considered safe.
For patients who are especially agitated, antipsychotic medications like haloperidol and olanzapine can be useful. Combining these drugs with benzodiazepines has shown to be more effective than using either type of drug alone. Sometimes, a medication called diphenhydramine is added to help with sedation and to prevent involuntary muscle contractions and restlessness.
If someone’s heart rhythm becomes seriously abnormal due to cocaine, more specialized treatments can be used, such as lidocaine, or a treatment known as intravenous lipid emulsion.
If a patient has a high body temperature from cocaine use, it’s important to cool them down with external methods. The easiest and safest way to do this in the emergency department is by misting them with lukewarm water and using a fan to help the water evaporate.
What else can Cocaine Toxicity (Cocaine Overdose) be?
- Low blood sugar (Hypoglycemia)
- Poisoning from certain medications or substances that block nerve impulses (Anticholinergic toxicity)
- Bleeding in the brain (CNS hemorrhage)
- Severe alcohol withdrawal syndrome (Delirium tremens)
- Sudden onset of symptoms in schizophrenia (Acute schizophrenia)
- Reactions caused by a drug called angel dust or PCP (Phencyclidine toxicity)
- A severe reaction to antipsychotic drugs (Neuroleptic malignant syndrome)
What to expect with Cocaine Toxicity (Cocaine Overdose)
Cocaine toxicity is linked with high death rates. Additionally, injecting cocaine can lead to severe health problems such as collapsed lungs (pneumothorax), blood clots (thrombosis), an infection of the inner lining of the heart (endocarditis), bulging of major blood vessels (pseudoaneurysm), and abnormal connections between arteries and veins (arteriovenous fistulas). Other resulting health issues can be skin infection (cellulitis), HIV infection, inflammation of a vein caused by a blood clot (thrombophlebitis), abscesses, tetanus, and tissue death (necrosis).
For people who develop symptoms that affect their mental health, the recovery process can often be long, and may not result in full recovery.
Possible Complications When Diagnosed with Cocaine Toxicity (Cocaine Overdose)
- Blood clot in a vein (Thrombophlebitis)
- HIV
- Skin infection (Cellulitis)
- Liver infection (Hepatitis)
- Heart Valve infection (Endocarditis)
- Blood clot in lung (Pulmonary emboli)
- Blood vessel bulge (Aneurysms)
