With the increasingly widespread use of cocaine, a variety of complications continues to emerge (see review by Cregler and Mark). The symptoms of severe intoxication (overdose), noted above, may lead to coma and death and require emergency treatment in an intensive care unit, along the lines indicated for the management of other forms of coma. Seizures often occur in this setting and are treated more effectively with benzodiazepines than with standard anticonvulsant drugs. Spontaneous subarachnoid or intracerebral hemorrhage and cerebral infarction have rarely followed the intranasal use and smoking of cocaine (Levine et al). These complications could be the result of acute hypertension induced by the sympathomimetic actions of cocaine and the incidence of vascular malformations appears to be higher in those patients who have a cerebral hemorrhage (see Chap. 33). Cocaine and amphetamines also, on occasion, produce a state of generalized vasospasm leading to multiple cortical infarctions and posterior white matter changes that are evident on imaging studies, essentially a form of hypertensive, or posterior reversible encephalopathy (PRES) (see Altura and Altura and also Chap. 33). Roth and colleagues have described 39 patients who developed acute rhabdomyolysis after cocaine use; 13 of these had acute renal failure, severe liver dysfunction, and disseminated intravascular coagulation and 6 of them died. Some reports indicate that cocaine use during pregnancy may cause fetal damage, abortion, or persistent signs of toxicity in the newborn infant.
Anxiety, paranoia, and other manifestations of psychosis may develop within several hours of cocaine use. These complications are best treated with antipsychosis drugs, particularly haloperidol.
The psychostimulant khat is used widely in certain countries, almost as a cultural norm in restricted populations, mainly in the Far East. The khat leaf is chewed to release cathionine that produces euphoria by an amphetamine-like effect. A chemically designed congener, the N-methyl analog of cathionine, or methcathinone (“Jeff,” “Cat,” “mulka,” and other street names), is manufactured from over-the-counter cold medications such as ephedrine, pseudoephedrine, and phenylpropanolamine and is frequently abused. Potassium permanganate may be used to reduce the basic substances and is a source of a manganese-induced extrapyramidal syndrome. Furthermore, entirely synthetic cathinones, often called “bath salts,” although they have no relation to that original product, are amphetamine-like substances that are taken orally or nasally and produce rapid activation of behavior and sympathetic hyperactivity.
Included in this category is a heterogeneous group of drugs, the primary effect of which is to alter perception, mood, and thinking out of proportion to other aspects of cognitive function and consciousness. This group of drugs comprises lysergic acid diethylamide (LSD), phenylethylamine derivatives (mescaline or peyote), psilocybin, certain indolic derivatives, cannabis (marijuana), phencyclidine (PCP), and a number of other compounds. They are also referred to as psychoactive or psychotomimetic drugs or as hallucinogens and psychedelics. The problems raised by the nontherapeutic use of these drugs have been reviewed by Nicholi and by Verebey and their associates.