Question

A 24-year-old woman has been abusing cocaine for the past year and now wishes to withdraw. She asks about substitute drugs to enable her to do this.

Which is the SINGLE MOST appropriate management option for withdrawal from cocaine?

No drug therapy indicated

Psychosocial interventions are the mainstay of treatment for the misuse of cocaine and other stimulants, and for cannabis and hallucinogens.

Resources

• NICE. Drug misuse in Over 16s: opioid detoxification. CG52. 2007.

• Department of Health. Drug Misuse and Dependence. UK Guidelines on Clinical Management. 2017.

Monitoring

A 35-year-old who engages in the daily misuse of crack cocaine has agreed to attend every three–four months for support and health check monitoring. He has never injected and is human immunodeficiency virus (HIV) negative.

Which of the following should be included in your examination? Select ONE option only.

A. Check his full blood count

B. Check for glycosuria

C. Carry out fundoscopy

D. Check for proteinuria

E. Take his blood pressure

Chronic cocaine use commonly results in cardiovascular disease, raised blood pressure, stroke, seizures and lung disease.

Question

You see a 43-year-old man with a long history of cocaine use. He describes low mood, anxiety, malaise, insomnia and craving since stopping the drug a few days ago.

Withdrawal

Withdrawal is a syndrome resulting from cessation of, or reduction in, heavy and prolonged substance use. It is often divided into psychological phenomena such as craving, anhedonia and agitation; and physical phenomena such as diarrhoea or tachycardia.

Cocaine has a very short half-life resulting in withdrawal symptoms which may occur anywhere from a few hours to a few weeks after the suspension of cocaine use. However, this timeline is dependent on the length of use, size of dose and associated comorbidities or mental health problems.

Driving

Any patient who persistently uses or is dependent on amphetamines, should be advised to notify the Driver and Vehicle Licensing Agency (DVLA). This will lead to licence refusal or revocation. Group 1 (normal car) licences may be reinstated after a minimum of 6 months free of amphetamine use has been attained.

Resources:

Department for Transport. Drug Driving and Medicine: advice for healthcare professionals. 2014.

Scottish Government. Drug Driving and medicine: advice for healthcare professionals. 2019.

Question

You are working a weekend shift for the out-of-hours service and are called urgently to visit a 14-year-old girl. Her parents are concerned that she has become more talkative, aggressive and agitated since arriving home from a friend’s house four hours ago.

She has a history of depression and is currently under the care of the Child and Adolescent Mental Health Service (CAMHS). On examination, her temperature is 41.2°C, her respiratory rate is 24 breaths per minute, her pulse rate is 110 beats per minute and her blood pressure is 160/100 mmHg. You also note that her pupils are dilated and you suspect acute drug intoxication.

Which of the following drugs is the SINGLE MOST likely to have caused this patient’s current symptoms and signs? 

1. Alcohol

2. Diazepam

3. Cannabis

4. Heroin

5. Ecstasy

This case describes the typical features following ingestion of ecstasy ([3,4-methylene-dioxymethamphetamine (MDMA)]). It is associated with increased emotional sensitivity and empathy, loss of inhibitions, reduced anxiety and increased sense of closeness with other people. There is a risk of malignant hyperthermia, which can lead to rhabdomyolysis with subsequent renal and other organ failure.

Cannabis has hallucinogenic properties and induces feelings of well-being, relaxation and tranquillity, although it may also give rise to apprehension, anger and depression. It can cause an acute psychosis but is not associated with a risk of malignant hyperthermia.

Ingestion of alcohol and diazepam would tend to cause sedation rather than agitation, and small (or ‘pin-point’) pupils would be expected with heroin use.

In children and young adults presenting with low mood or symptoms of depression, always consider the possibility of alcohol or illicit drug use.

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Cocaine use can lead to hypertension and arrhythmias, which if untreated can be fatal. The risk of arrhythmias increases greatly during binges, but reduces again during periods of low use/abstinence. Cannabis and cigarette smoking can increase these arrhythmias.

Angina, myocardial infarction and congestive heart failure can result from reduced heart muscle function, increased heart size and arteriosclerosis of the arteries.

Cocaethylene, formed by the combination of cocaine and alcohol greatly increases the risk of cardiovascular problems, including myocardial infarction and sudden death. The combination also increases the risk of suicide and accidents, as well as the incidence of violence.