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  1. 1. Ihab Abdallah Under Supervision: Dr. Mayada Wazaify
  2. 2. References 1- 2- Uptodate 3- National Institute of Drug Abuse (NIDA).
  3. 3. • Cocaine (Benzoylmethylecgonine) Is a crystalline alkaloid prepared from the leaves of the Erythroxylon coca plant . Cocaine Crystalline Odorless White Bitter
  4. 4. NIDA According to the National Institute of Drug Abuse (NIDA) Cocaine A powerfully addictive drug that can be Snorted Injected Chewed Smoked
  5. 5. Cocaine ( Schedule II ) The 2nd Harmful Drug
  7. 7. Form’s of Cocaine Cocaine HCL (powder) Prepared by dissolving the alkaloid in hydrochloric acid, forming a water soluble salt. Crack Cocaine Produced when cocaine hydrochloride is mixed with sodium bicarbonate and water, and then heated.
  8. 8. Must Watch • Video
  9. 9. Route of Administration Cocaine can be administered as a drug of abuse in the following ways : 1. Cocaine hydrochloride:  Snorting (intranasal)  Intravenous injection
  10. 10. Route of Administration 2. Crack Cocaine: Inhalation of vapor from heated foil or pipe. (Smoked) 3. Coca leaves: Chewed or ingested.
  11. 11. Comparison Route Onset of Action Duration of Action Smoking 7 seconds 20 minutes Intravenous injection 15 seconds 22-30 minutes Snorting 3 minutes 45-90 minutes Oral 10 minutes 60 minutes
  12. 12. Brain Storming The most common cause of Recurrent Epistaxis in young adult is ??? 3 2 Cocaine use Ref: USMLE 1
  13. 13. Mechanism of Action
  14. 14. Mouse Party
  15. 15. Clinical Usage  Cocaine is used by health care professionals to temporarily numb the lining of the mouth, nose, and throat (mucous membranes) before certain medical procedures (biopsy, stitches, wound cleaning).  It is an anesthetic that works quickly to numb the area about 1-2 minutes after application.
  16. 16. Cycle of Addiction Reward System Cocaine Dependence Cocaine Addiction (Craving) (Anhedonia) Inability to feel pleasure Cocaine Release of the impulses from NA to activate the reward system Craving This pathway activated also in the absence of cocaine
  17. 17. Metabolism • Serum half life of 45-90 minutes. • Only 1% of the drug is recovered in urine after ingestion. • Cocaine can be detected in blood or urine only for several hours after its use. • Cocaine metabolites are detectable for 2-5 days. • Hair analysis provides a very sensitive marker for cocaine use within the preceding weeks to months.
  18. 18. Short Term Effect Initial Dose Physical Effect Psychological Effect Tachycardia Euphoria Dilated pupils Sense of well being Sweating Impaired reaction time Reduced appetite Impaired attention span Reduced need for sleep Impaired learning of new skills Reduced lung function
  19. 19. Short Term Effect Increased Doses Physical Effect Psychological Effect Seizures Anxiety, Irritability, Insomnia Cardiac arrhythmias Depression, Paranoia Myocardial infarction Aggressiveness, Impulsivity Stroke Delusions Respiratory arrest Agitated, Excited delirium Reduced psychomotor function
  20. 20. Long Term Effect Physical Effect Psychological Effect Erosions, necrosis Dependence Rhinorrhea and nasal eczema Disturbed eating Chest pain, muscle spasms Disturbed sleeping patterns Sexual impotence Weight loss Malnutrition Vascular disease
  21. 21. Specific Organ Systems
  22. 22. Central Nervous System o Cocaine euphoria is associated with transient increases in EEG activity. o Seizures may occur in persons without a seizure history, even with first time use of cocaine. o These are usually single, generalized tonic-clonic seizures occurring within 90 minutes of cocaine use.
  23. 23. Central Nervous System o Cerebral vasoconstriction, cerebrovascular disease, and hemorrhagic and ischemic stroke are increased in cocaine users. o MRI, PET imaging in chronic cocaine users demonstrate structural and functional brain abnormalities.
  24. 24. Central Nervous System o A pathologic study using melanin immunoreactivity found cocaine users to have 16 percent fewer midbrain dopamine neurons than non-using subjects. This and related findings o suggest that cocaine may have a neurotoxic effect on dopamine neurons, contributing to development of cocaine dependence in some users.
  25. 25. Central Nervous System o Cocaine use is associated with a variety of movement disorders: Stereotyped Behaviors Choreoathetosis Buccolingual Dyskinesia Tourette’s Syndrome Acute Dystonic Reactions Akathisia (Crack Dancers) • Cocaine users are at increased risk of acute dystonic reactions from neuroleptic (antipsychotic) medications.
  26. 26. PET Brain images showing decreased dopamine2 receptors in the brain of a person addicted to cocaine versus a nondrug user. The dopamine system is important for conditioning and motivation, and alterations such as this are likely responsible, in part, for the diminished sensitivity to natural rewards that develops with addiction.
  27. 27. Respiratory System o The effects of cocaine on the respiratory system depend on the route of administration. o Intranasal cocaine use (snorting) may cause chronic rhinitis, perforation of the nasal septum, oropharyngeal ulcers. Why ?? Due to vasoconstriction and resulting ischemic necrosis.
  28. 28. Respiratory System o Smoked cocaine use produces acute respiratory symptoms in up to half of users. Including Productive Cough Shortness of Breath Chest Pain Hemoptysis Wheezing Exacerbation of Asthma These effects are probably due to direct damage to the alveolar-capillary membrane by cocaine or inhaled micro particles.
  29. 29. Cardiovascular System  Cardiopulmonary symptoms are the most frequent complaints in cocaine users who seek medical help, with chest pain being the most frequent symptom. Cocaine By increasing adrenergic activity in the heart, and • Increase HR • Increase BP • Increase SVR indirectly via the CNS.
  30. 30. Cardiovascular System  The increased myocardial oxygen demand, coupled with decreased coronary blood flow from vasospasm and vasoconstriction, can cause acute myocardial infarction.  Cocaine appears to enhance the progression of renal disease in patients with hypertension.  Cocaine use increases risk for cardiac arrhythmias and sudden death.
  31. 31. Cardiovascular System  Chronic use is associated with left ventricular hypertrophy, cardiomyopathy, myocardial fibrosis, and myocarditis.
  32. 32. DSM V 1- Cocaine is often taken in larger amounts or over a longer period than was intended. 2- There is a persistent desire or unsuccessful efforts to cut down or control cocaine use 3- A great deal of time is spent in activities necessary to obtain cocaine, use cocaine, or recover from its effects 4- Craving, or a strong desire or urge to use cocaine 5- Recurrent cocaine use resulting in a failure to fulfill major role obligations at work, school, or home.
  33. 33. 6- Continued cocaine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cocaine. 7- Important social, occupational, or recreational activities are given up or reduced because of cocaine use. 8- Recurrent cocaine use in situations in which it is physically hazardous. 9- Tolerance. 10- Withdrawal. ≥2 10
  34. 34. Cocaine Tolerance Initially o Cocaine produces an intense high and may not cause an emotional depression when the drug wears off. As a result The user may conclude that cocaine is harmless. With Repeated use o A craving as well as a tolerance for the drug develops.
  35. 35. Cocaine Tolerance • Over time, the high produced by a given amount of cocaine decreases while the depression when the drug wears off deepens. • The addict ends up "chasing a high" by taking ever- increasing amounts of cocaine more and more frequently. When the supply of cocaine is gone, the addict is left with an intense craving along with severe depression that may reach a suicidal level.
  36. 36. Cocaine Frenzy o As tolerance to cocaine develops, an increased susceptibility to seizures and psychosis also develops. • An extreme form of this reverse tolerance can be called • The person in a cocaine frenzy displays psychotic and violent behavior, panic, and superhuman strength.
  37. 37. HIV & Hepatitis B and C o Cocaine abusers are at increased risk for contracting such infectious diseases as and . o This risk stems not only from sharing contaminated needles and drug paraphernalia but also from engaging in risky behaviors as a result of intoxication. o Potentially lead to risky: 1-sexual encounters 2- Needle sharing 3-Trading sex for drugs—by both men and womens.
  38. 38. HIV & Hepatitis B and C o Hepatitis C has spread rapidly among injecting drug users. o Risk begins with the first injection, and within 2 years, nearly 40% of injection drug users (IDUs) are exposed to HCV. o By the time IDUs have been injecting for 5 years, their chances of being infected with HCV are between 50-80%.
  39. 39. Pregnancy Common Adverse Effect of Cocaine use in Pregnancy!! 1- Restricts blood flow to the uterus, cause fetal hypoxia. 2- Uterine contractions, CNS infarction, Heart defects. 3- Persistent neonatal arterial hypertension. 4- Decreased neonatal weight and size ( head circumference). 5-sudden infant death syndrome, Mental retardation. 6- Babies may be irritable at birth and exhibit symptoms such as: tremor, hypertension, abnormal reflexes, tachypnea, autonomic instability, vomiting, diarrhea, seizures and poor feeding.
  40. 40. Brain Storming Why baby look like this ??? 3 2 1 Crack Baby !!!! A baby who is not strong and healthy at birth and whose mother used crack cocaine while she was pregnant.
  41. 41. Treatment
  42. 42. Psychosocial Treatment lead to small reductions in cocaine use BY: Motivational interviewing Psychodynamic Cognitive therapy Behavioral therapy Supportive therapy
  43. 43. o More intensive treatment. o More frequent visits. o Longer duration of treatment. o Cocaine Anonymous. Associated with better outcomes
  44. 44. Behavioral Treatment o One of behavioral therapy that is showing positive results in cocaine addicted population is contingency management or motivational incentives (MI). o MI: is particularly useful for helping patients achieve initial abstinence from cocaine and for helping patients stay in treatment. o Cognitive behavioral therapy: is an effective approach for preventing relapse.
  45. 45. Medications 1- Cocaine Vaccine: Is composed of a cocaine hapten conjugated to inactivated cholera toxin B, resulting in the creation of a molecule capable of stimulating an antibody response. Cocaine vaccine that prevents entry of cocaine into the brain holds great promise for reducing the risk of relapse.
  46. 46. Medications 2- Others: Disulfiram Vigabtrin Modafinil Tiagabine Topiramate Show promise and have been reported to reduce cocaine use in controlled clinical trials.