Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm in order to prevent pathological sequelae such as acute coronary syndrome, stroke, and death. This activity reviews the evaluation and management of cocaine toxicity and highlights the role of the interprofessional team in caring for affected patients.
Objectives:Describe the toxicokinetics of cocaine toxicity.Describe the typical history and physical exam findings for a patient with cocaine toxicity.Summarize the management options for cocaine toxicity.Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with cocaine toxicity.Access free multiple choice questions on this topic.
Sys Manage Copyright2 Crack Coca
Over the past few decades, body packers have also presented to the emergency department following bag ruptures. The other problem is that many patients have also ingested other illicit agents, including alcohol, which makes management difficult. While cocaine can adversely affect every organ in the body, its most lethal effects are on the cardiovascular system.
Patients with cocaine toxicity need to be stabilized, and attention should be paid to the ABCDEs. The patient's fever should be managed, and one should rule out hypoglycemia as a cause of the neuropsychiatric symptoms. A pregnancy test should be ruled in women of childbearing age. The treatment should be based on clinical symptoms, and one should avoid physical restraints.
Mortality is a significant outcome among Brazilian crack/cocaine-dependent patients yet not well understood and is under investigated. This study examined a range of mortality indicators within a cohort of 131 crack/cocaine-dependent patients admitted into treatment and meeting criteria for dependence of crack (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). After 12 years of treatment discharge, 107 individuals were reassessed and 27 death cases were confirmed by official records, wherein in its majority were caused by homicide (n = 16). In this group, survival rate was 0.77 (95% confidence interval [CI] = 0.74-0.81) and previous history of IV cocaine use was identified as a predictor of mortality (2.5, 95% CI = 1.08-5.79). High mortality rates among Brazilian crack/cocaine-dependent patients, exposure to violence, and HIV/AIDS were topics discussed in this study. This research highlights the importance of ongoing programs to manage crack/cocaine use along with other treatment features within this population.
The "War on Drugs" reached new heights in the 1980s. Nancy Reagan's "Just Say No" campaign flooded the schools and media outlets. In this environment, a new drug emerged that horrified and mobilized people: crack cocaine. The media screeched that crack was more addictive, concentrated and destructive than any other drug, fueling the drug-war blaze.
Already, the existence of crack cocaine shows the naivete inherent in the deterrence rationale of prohibition. Instead of deterring cocaine use, prohibition spurred the black market to adapt to prohibition by producing stronger, cheaper and more highly addictive versions of existing drugs. Prohibition and the resulting black markets have been co-evolving.
In response, Congress united in support of new federal mandatory minimum sentences meant to crack down on high-level traffickers under the 1986 Anti-Drug Abuse Act (ADAA). The law imposed a five year mandatory minimum sentence for distribution of five grams of crack cocaine, enough to fill a sugar packet, while imposing the same sentence for 500 grams of powder cocaine.
Rather than deterring drug trafficking, this "get tough" posture led to utter disaster in the African American community. By the early 1990s, nearly 90 percent of crack cocaine defendants in federal court were black, even though nearly two-thirds of crack cocaine users were white or Hispanic. Imprisonment rates and sentence lengths skyrocketed. Many black communities were ravaged as enforcement disproportionately affected the young and their families. Yet harsh sentences have only partly been mitigated by the Fair Sentencing Act of 2010.
Class-based policing was aggravated by several features unique to crack cocaine. The triggering thresholds for the mandatory minimums were so low that it facilitated police focus on small-time crack users, who were easier to catch and subdue than dangerous high-level dealers. The nature of crack cocaine, which is usually cooked from powder cocaine by users, further ensured that street-level dealers and users would be targeted. In other words, there were rarely high-level dealers with crack cocaine.
At the prosecutorial level, the targeting of poor minorities was also exacerbated. Crack cocaine penalties were representative of the increasing array of tools available for prosecutors, increasing their power relative to defendants and judges. First, the surge of crack-cocaine-dealing arrests gave prosecutors fodder for easy convictions. Second, mandatory minimums provided leverage in plea bargaining: when faced with a possible five- or 10-year sentence, many defendants would accept a plea agreement rather than risk conviction at trial. Third, federal conspiracy laws allowed prosecutors to pin the drug amount in the entire conspiracy on any given defendant, even if her involvement was minimal. This led to the infamous "girlfriend problem," where girlfriends of crack dealers became eligible for lengthy federal sentences after serving as couriers or using drug money to feed their children. Prosecutorial harshness was backed up by the Department of Justice's general stance in favor of severity in these cases.
Finally, at a macro political level, crack-cocaine-sentencing policy was at the center of political infighting between Congress and the judiciary. In the 1980s, members of Congress opposed leniency in sentencing by mandating that a commission create sentencing guidelines that would bind judges. In order to write rational and proportionate guidelines, the commission was forced to incorporate the 1986 mandatory minimums as a sentencing floor, thus skewing sentences for all crimes upwards. The "ratchet up" effect was amplified as Congress passed a flurry of directives in order to micro-manage the guidelines amendment process, and increase its own power relative to the judiciary. When the commission voted to reduce the sentencing guideline for crack cocaine in the mid-1990s, Congress rejected the amendment. Tough-on-crime rhetoric and power politics proved more important to Congress than reality.
In years past, someone convicted in federal court of possessing crack cocaine would receive the same sentence as someone who possessed 100 times more powder cocaine (also known as coke). You might wonder what the difference is between crack and coke to justify this 100-to-1 ratio, but as it turns out, there's no significant chemical difference between them: They're both forms of cocaine. The huge difference in federal sentencing laws for possession of each form of the same drug had more to do with wrong information and political pressure than with public safety and health. A 2010 federal law fixed some, though not all, of the sentencing differences for crack and cocaine, and a 2018 law took those changes further.
Crack is made by dissolving powder cocaine (which comes from coca leaves) and baking soda in boiling water and then cutting the resulting paste into small "rocks" after it dries. The rocks are usually sold in single doses to users who smoke them. Because of the inexpensive additive (baking soda), a rock of crack cocaine is cheaper than a similar "dose" of powder cocaine. But the two forms of the drug are chemically the same and affect the user in the same physical and psychological ways. A person smoking crack cocaine (as compared to snorting or injecting powder cocaine) experiences a faster, more intense high simply because smoke in the lungs affects the brain more quickly than other methods of ingestion.
The harsh sentences for crack came after reports in the mid-80s that the United States was experiencing a "crack epidemic." News outlets reported that crack was more potent, more addictive, and more likely to lead to violence than powder cocaine or other drugs. For example, a 1986 Newsweek article quoted a drug expert who said crack was "the most addictive drug known to man." But within four years, that magazine, and most other media outlets, academics, and law enforcement agencies abandoned that view because no real evidence supported it.
While crack was a hot topic in the news in 1986, Congress held hearings to address the so-called crack epidemic. At the hearings, several senators recited the unscientific (and later discredited) claims about the heightened dangers of crack and its impact on urban communities. The result was the Anti-Drug Abuse Act of 1986, which severely penalized crack cocaine offenses, and was arguably one of the most unjustified sentencing schemes ever created in the United States.
The Anti-Drug Abuse Act of 1986 created a five-year mandatory minimum sentence for possession of five grams (or just a few rocks) of crack cocaine. (21 U.S.C. 841 (2006).) "Mandatory minimum" means just what it says: A conviction for possessing five grams of crack required at least five years in federal prison, even if it was the person's first offense. By contrast, under the Anti-Drug Abuse Act, people arrested for powder cocaine had to possess 100 times more than that (500 grams, or over a pound) to face a five-year mandatory minimum. This 100-to-1 ratio was not based on evidence: During the debate on the Act, Congress simply considered various arbitrary ratios (including 20-to-1) and settled on the 100-to-1 ratio, with no evidence to support that figure.
Crack cocaine's lower price, ease of production, and manner of distribution (small quantities sold to individuals for personal use) made it widely accessible in poor, urban communities, which included many Black communities. Although white people also used crack, police efforts to control crack focused mainly on urban Black communities, in part because it was easier; drug deals in those communities usually happened in public on the street, not in private residences as in white communities. They also happened more often, because, unlike people who have the money to stock up on their drug supply, lower-income people can afford only one dose at a time, and each drug deal carries a risk of arrest. The increase in arrests of Black people and the increase in sentences for crack meant that Black people went to prison for cocaine offenses far more often and much longer than white people, even though white people used cocaine (both powder and crack) more than Black people did. 2ff7e9595c
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