HIV Insight: Cocaine Abuse in Later Life: A Case Series and Review of the Literature

To raise awareness about the growing trend of cocaine abuse in later years as an underdiagnosed, undertreated, and comorbid condition in older individuals. Three cases of cocaine use in patients over the age of 50 years in the Malcolm Randall Veterans Medical Center, Gainesville, Florida, within a 10-day span in 2013 are presented.

PubMed was searched using combinations of keywords, including cocaine, addiction, elderly, and aging, to find articles published between 1986 and 2013.

In total, 37 articles were selected for inclusion on the basis of their relevance to the objective and importance to the representation of cocaine abuse, including international guidelines for addiction.

Each article was reviewed for eligibility. Final decisions were made following full-text review.

Cocaine addiction remains a high-morbidity chronic-relapsing illness with few treatment options. A review of the literature shows that late-life cocaine use is sparsely recognized. Of particular interest are the clinical presentations in which a higher index for detection is warranted. The high rate of medical comorbidity associated with cocaine use, especially cerebrovascular deficits, presents special treatment and social challenges.

As the number of older individuals admitted for substance use continues to climb, clinicians must adapt to the changing demographics by increasing screening, early detection, and treatment options for older persons...

Case 1

Mr A, a 60-year-old man with history of posttraumatic stress disorder and chronic back, neck, and knee pain, presented to urgent care requesting admission for detoxification from cocaine and alcohol. He had been admitted for 1 week of acute detoxification 1 month earlier for a similar presentation; however, he relapsed 1 week postdischarge. He attributed his relapse as an attempt to dull his chronic pain. He presented to urgent care after he had spent $3,000 on cocaine in 3 weeks. Mr A reported that he started drinking alcohol at age 11, escalating to daily use at age 18 during his tenure in the army; he also started cocaine during this same period. He reported discontinuing cocaine use in his early 20s, but stated that he restarted at the age of 57 in an attempt to manage knee pain. He reported continuous lifelong issues with alcohol, including 2 previous hospitalizations, 4 charges of driving under the influence, and “countless arrests” for bar fights, domestic abuse, and self-reported stalking. At this presentation, Mr A reported that his last use of both alcohol and cocaine was 1 day prior. His urine drug screen was positive for cocaine, and his blood alcohol level was < 10 mg/dL. Mr A was admitted for acute detoxification and arrangement of long-term care.

Case 2

Mr B, a 56-year-old man with a history of schizoaffective disorder, alcohol dependence, previous acute myocardial infarction, and chronic deep venous thrombosis, presented to the emergency department for bright red blood per rectum. He reported that he had smoked large, undefined amounts of crack cocaine in a suicide attempt due to his inability to tolerate “the voices” anymore. Mr B reported that he started drinking alcohol in his early 20s, requiring 1 hospitalization, but that his drinking never resulted in legal or employment issues. His alcohol use continued for decades to the present, with his last drink 2 weeks prior to admission, consisting of eighteen 12-ounce beers in 1 sitting. He reported that he started using cocaine at 50 years of age at the suggestion of a girlfriend due to feelings of depression, anxiety, and distress over the voices. Mr B used cocaine daily for 5 years followed by a period of sobriety of 11 months before his most recent cocaine binge. He also endorsed occasional marijuana use throughout his life (last use > 1 month prior to admission). His urine drug screen was positive only for cocaine, and his blood alcohol level was < 10 mg/dL. After medical stabilization, Mr B was transferred to the inpatient psychiatry unit for transition to substance abuse care.

Case 3

Mr C, a 61-year-old man with a history of diabetes, hypertension, anxiety, and atrial fibrillation, presented to the emergency department seeking voluntary admission for alcohol detoxification. He reported first drinking alcohol socially at age 16, with escalation to daily intake by age 26. At the time of presentation, Mr C was drinking 2 pints of liquor daily, with his last drink on the morning of admission. He denied any previous hospitalizations, legal issues, or employment issues. He endorsed daily marijuana use in his 20s, with continued occasional use throughout his life (last use 2 months previous). He also reported occasional use of cocaine: first use in his 30s associated with social pressure of the period (mid 1980s), with continued occasional use limited only by finances throughout his life. His most recent reported use was 1 week prior to admission. However, in the emergency department, his urine drug screen was positive for cocaine with a blood alcohol level of 173 mg/dL. He denied any correlation between atrial fibrillation and cocaine use. Admission laboratory values revealed electrolyte imbalances, but following medical stabilization, Mr A was transferred to the inpatient psychiatry unit for transition to substance abuse care.

Full article at: http://goo.gl/5pKeF4

By: Stephanie C. Yarnell, MD, PhD corresponding author