Cocaine Use Disorders: Clinical Course

Cocaine Use Disorders: Clinical Course

Cocaine use is characterized by binge use that can occur over ex-tended periods of time and is limited only by the supply of drug or money to purchase the drug. Cocaine toxicity may occur with repeated use of the drug over the course of a binge. Symptoms can include hypervigilance, psychomotor agitation, hyperawareness and psychosis. While these symptoms generally resolve within 24 hours of cessation of cocaine use, prolonged symptoms may be indicative of an underlying bipolar disorder that will need further assessment. Another facet of cocaine toxicity that may be mani-fested as psychiatric symptoms is that of a syndrome of hyperther-mia and agitation resembling neuroleptic malignant syndrome. An additional serious complication of cocaine intoxication is that of stimulant delirium characterized by confusion, disorientation and agitation. This should be treated as a medical emergency since such symptoms may be indicative of cocaine overdose. Cocaine abstinence symptoms occur with the cessation of binge use (Margolin et al., 1996; Foltin and Fischman, 1998; Milby et al., 2000). The abstinence syndrome is characterized by extreme ex-haustion after a binge. Initial depression, agitation and anxiety are a common experience, followed by craving for sleep. Prolonged hypersomnolence and hyperphagia are usually followed by a re-turn to normal mood, although some dysphoria may remain.

Cocaine abusers may present to urgent care settings in the context of cocaine toxicity or severe psychiatric symptoms associ-ated with acute abstinence including anxiety, depression, or psy-chosis. Symptoms may be of a severity that require emergent use of benzodiazepines or antipsychotics. Lorazepam is a good choice for treatment of anxiety, agitation, or psychosis because it can be ad-ministered orally; it is also well-absorbed by the intramuscular route. The use of benzodiazepines in the severely agitated patient may decrease the need to employ the use of restraints. Antipsychotics should be used sparingly because, like cocaine, these drugs may lower the seizure threshold. In considering the choice of an an-tipsychotic, low-potency antipsychotics may be more likely than high-potency neuroleptics to lower seizure threshold and there-fore should be avoided. Psychiatric management must also include clinical observation because suicidal ideation is not uncommon. Symptoms resembling those of a major depressive episode occur frequently in newly abstinent cocaine abusers. The occurrence of major depressive disorder must be excluded by observation over several days following the initiation of abstinence.

Individuals with cocaine use disorders will experience a withdrawal syndrome upon cessation of binge cocaine abuse that can last for as long as 10 weeks. Cocaine withdrawal is marked by decreased energy, lack of interest and anhedonia. These symp-toms fluctuate and are usually not severe enough to meet diag-nostic criteria for a major depressive episode. However, this sub-jective state experienced by the cocaine abuser is contrasted with vivid memories of cocaine-induced euphoria and constitutes a strong inducement to resume cocaine use. It is during this time that relapse is most likely. Withdrawal symptoms generally di-minish over several weeks if abstinence is maintained.

The withdrawal phase is followed by what has been termed “extinction”, an indefinite period during which evoked craving can occur, placing the individual at increased risk for relapse. Craving is evoked by moods, people, locations, or objects asso-ciated with cocaine use (money, white powder, pipes, mirrors, syringes) that act as cues to conditioned associations with drug use and drug-induced euphoria.