BY DR FAIZA AKBARSTUDENT OF FINAL YEAR

M.B.B.S

COCAINE RELATED PSYCHIATRIC DISORDERS

AN INTRO TO COCAINE

Cocaine is a naturally occurring alkaloid found within the leaves of coca plant. It has 4 forms;

*coca leaf-<2% cocaine *cocaine HCL-powder *free base-paste *crack-rock cocaine Its first use as a local anesthesia . In the late 19th

century ,cocaine was use for the treatment of depression and cachexia.It is a strong stimulant of CNS,appetite suppressant and topical anesthetic.It can be taken as injected,smoked or sniffed.

HOW IS COCAINE USED?

Cocaine can be snorted, injected, smoked or eaten. The level and length of the effects depend on how the drug was induce

ONSET DURATIONSNORTED 1 MINUTE 20-40 MININJECTED 1-5 SECONDS 15-20 MINSMOKED IMMIDIATE 5-15 MIN

EPIDEMIOLOGY

RESEARCH BY US IN 2005:1)FREQUENCY: According to the National Survey on Drug Use & Health (NSDUH)

for the age group 12 years and older Approximately 33.7 million Americans have tried cocaine at least once in their lifetimes, representing 13.8% of the 12 years and older population

2)Mortality/morbidity: On average, cocaine alone or in combination with other drugs

was reported in 39% of drug misuse deaths

3)RACE: more common in whites then africans.

4)Sex: the 2005 National Youth Risk Behavior Survey, 8.4% of males and 6.8% of females had used cocaine at least once in 2005.

5)AGE:19 to 28 age

Common S/S of Cocaine

• Decreased Appetite• Increased Body Temperature• Increased Heart Rate• Dilated Pupils• Nausea/Vomiting

• Severe Nose Damage (when snorted)• Violent Behavior• Kidney Failure• Seizure and/or Stroke• Heart Attack

• Increased Alertness• Decreased Fatigue• Increased Concentration• Insomnia• Increased Irritability• Increased Psychosis

• Confused Behavior• Increased Fear• Extreme Paranoia• Severe Anxiety Attacks• Hallucinations (in extreme cases)• Aggressive Behavior

ADDICTION AND WITHDRAWAL EFFETCTS

• Those who use cocaine heavily or regularly find it extremely difficult to stop and often suffer through serious withdrawal symptoms such as:

• Severe Irritability • Chronic Depression• Excessive Sleep• Eating Disorders• Nausea / Vomiting • Diarrhea• Heart Attack• Paranoia• Loss of Sex Drive• Insomnia

SIDE EFFECTS OF COCAINE USE

Mechanism Of Action Of Cocaine

CNS:*It blocks reupake of neurotransmissioninto presynaptic vesiclaes(esp DA receptor DAT)

Euphoria

CNS continued..

*Nicotine inc the level of DA in brainin chain smoking*Prolonged exposure

down regulation of DA

depression

CNS…

*prolonged exposure

activation of reward centre

addiction

PNS*Block of NE transporter

sympathomimetic syndrome

Tachycardia,HTN,tachypnea,mydriasis,sss diaphoresis and agitation

PNS CONTINUED…

• Blocking of Na +channels,interfere with AP

Local anesthesia + in heat it will leads to type 1 antidysrythematic activity and more over leads to prolong QRS complex

DSM-IV-TR• DSM-IV-TR describes 10 cocaine induced psychiatric disorders and gives codes to

them are as follows;305.60 Abuse304.20 Dependence292.89 -Induced anxiety disorder292.84 -Induced mood disorder292.11 -Induced psychotic disorder, with delusions292.12 -Induced psychotic disorder, with hallucinations292.89 -Induced sexual dysfunction292.89 -Induced sleep disorder292.89 Intoxication292.81 Intoxication delirium292.9 -Related disorder NOS292.0 Withdrawal

1)COCAINE INTOXICATION:

Diagnosed when the patient must have used cocaine recently and must have developed clinically significant behavioral or psychological changes.

Features:a) Euphoriab) Talkativenessc) Grandiosityd) Anxietye) impaired judgmentf) Angerg) Impaired judgment

Signs and symptoms:1)Tachycardia or bradycardia2)Mydriasis3)Perspiration4)Nausea or vomiting5)Weight loss6)Weakness, respiratory depression, chest pain, or

dysrhythmia7)Disorientation, seizures, dyskinesias, dystonias, or

coma8)Mental state examination shows irritability, impaired

attention and poor judgment

2)COCAINE WITHDRAWAL Diagnostic criteria: include cessation or reduction in previously heavy or prolonged

cocaine use.The patient also must have a dysphoric mood associated with 2 of the following 5 physiological changes which are;

1) Fatigue2) Unpleasant dreams3) isomnia/hypersomnia4) Inc appetite

Mental health exam: may show a sleepy, slowed-down patient who complains of

depressed mood and has a restricted affect. They may express suicidal ideation.

3)COCAINE INTOXICATION DELIRIUM

Diagnostic criteria:include both a disturbance in consciousness resulting in a reduction of the patient's ability to focus, sustain, or shift attention and a change in cognition. These changes must develop over a short period and fluctuate in severity

Mental health exam: shows *patient is distractible and confused with a variable affect

and mood. *Visual illusions may also be present. *Judgment is extremely poor, as is orientation. * suicidal and homicidal ideation may not be present.

4)COCAINE INDUCED PSYCHOTIC DISORDERS+DELUSIONS

Diagnostic Criteria: include prominent delusions developing during or within a month of cocaine intoxication or withdrawal.

• Presenting features:psychosis,communication and interaction gap with others, inability to recognize and accept reality.

• Mental state exam:shows *tense patientwho appear fearful or anxious. *They may

be suspicious of questions asked. *Impaired judgement *may think for homicidal or suicidal acts

5)Cocaine Induced Psychotic Disorders + Halucinations

The diagnostic criteria :prominent hallucinations developing during or within a month of cocaine intoxication or withdrawal.

Mental status examination: shows * a patient who is distracted by internal stimuli,

may show thought blocking (verbal outflow is stopped mid thought by internal stimuli)

*Attention is variable *homicidal and suicidal ideation may be present.

6)Cocaine Induced Mood Disorders diagnostic criteria: a prominent and persistent disturbance in mood

that arises only in association with the abuse of cocaine must occur. The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms.

presenting features:depressed mood,dec interest in daily activities,apathy,wt changes,fatigue,excessive guilt,feeling of worthlessness

Mental state exam: shows *depressed mood with restricted or flat affect, *depressed mood with slowed movements and responses *reduced concentration and suicidal ideation *Orientation is intact. If manic, their affect is reactive *mood is elevated and/or irritable *speech is pressured *Judgment is often impaired

7)Cocaine Induced Anxiety Disorder

Diagnostic criteria: a patient must have prominent anxiety, panic attacks, obsessions, or compulsions. The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms.

PF:diffuse, highly unpleasant, often vague feeling of apprehension accompanied by one or more bodily sensations, such as tightness in the chest or pounding heart.

Mental health exam:shows *a pat with reactive affect *anxious mood *restlessness *difficulty in concentrating *Judgment and orientation are usually intact. *Due to distress, suicidal ideation may be present.

8)Cocaine Induced Sexual Dysfunction

• Diagnostic criteria: a patient must have prominent sexual dysfunction that results in distress or interpersonal difficulty.

• PF: impaired sexual desire, impaired arousal,

impaired orgasm, or sexual pain.

9)Cocaine Induced Sleep Disorder

• Diagnostic criteria: To be diagnosed with cocaine-induced sleep disorder, a patient must have a The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely

• corresponds to these symptoms. The symptoms must not be better accounted for by another sleep disorder that is not induced by cocaine, must not occur exclusively during delirium, and must cause significant impairment in areas of functioning, such as social or occupational.

D/D

• Amphetamine-Related Psychiatric Disorders• Anxiety Disorders• Attention Deficit Hyperactivity Disorder• Bipolar Affective Disorder• Delirium• Delusional Disorder• Depression• Hallucinogens• Panic Disorder• Phencyclidine (PCP)-Related Psychiatric Disorders• Schizoaffective Disorder• Schizophrenia• Schizophreniform Disorder

LAB INVESTIGATION

1) CBC:for anemia,leukocytosis,leukopenia2) Electrolytes:hypokalemia because acute

intoicaion shift intracellular k+ ions.in severe condition hyperkalemia may occur->cardiac arrythmia.

3) Renal function test:check for rhabdomyolysis and renal artery thrombosis has been reported for te use of cocaine

LAB INVESTIGATION

4)Serum bicarbonate levels: dec5)Urine analysis: to check myoglobin dur to

rhabdomyolysis6)Glucose: should be checked in every patirent

having altered consciousness due o hypoglycemia

7)Creatine kinase: for rhabdomyolysis

LAB INVESTIGATION

8)Plasma cocaine levels9)Cardiac enzymes10)LFTs:heaptic damage occus after acute

intoxication of cocaine + patients who take cocaine are at the high risk of developing infectious hepatitis.

11)Urine drug screen:to detect benzoylegonine which is a metabolite of cocaine excreat in urine for 60 hours after first dose of cocaine.

LAB INVESTIGATION

12) Imaging studies:*CXR: for pulmonary signs of cocaine like

Pneumomediastinum, pneumothorax, pneumonia, pulmonary embolism, atelectasis

*head CT scan:Patients exhibiting acute mental status changes or focal neurological signs and symptoms may require a head CT scan. Cocaine use has been associated with intracranial bleeding and embolic and thrombotic strokes.

13)EKG :for dysrhythmia

TREATMENT:

• Establish the patient's airway, breathing, and circulation (ABCs)

• Ensure adequate ventilation if patient is unconscious.• provide oxygen• frequently check vital signs • monitor glucose levels for patients with altered mental

status; carefully use naloxone for patients with altered mental status.

• Benzodiazepines are the drugs of choice for the management of patients with agitation, seizures, tachycardia, and hypertension.

TREATMENT

• If the condition persist specific antihypertensive therapy (e.g., intravenous nitrates or calcium-channel blockers) can be given.

• If the patient is volume depleted this is corrected with intravenous isotonic saline.

• Patients should be continued to be observed until they have normal vital signs and mental status.

• Manage the temperature

TREATMENT

• Manage Cardiac arrhythmias;

*ventricular tachycardiaequires immediate defibrillation.

*wide –complex tachycardias can be treated withsodium bicarbonate