Responding to global stimulant use: challenges and opportunities.

We did a global review to synthesise data on the prevalence, harms, and interventions for stimulant use, focusing specifically on the use of cocaine and amphetamines. Modelling estimated the effect of cocaine and amphetamine use on mortality, suicidality, and blood borne virus incidence. The estimated global prevalence of cocaine use was 0·4% and amphetamine use was 0·7%, with dependence affecting 16% of people who used cocaine and 11% of those who used amphetamine. Stimulant use was associated with elevated mortality, increased incidence of HIV and hepatitis C infection, poor mental health (suicidality, psychosis, depression, and violence), and increased risk of cardiovascular events. No effective pharmacotherapies are available that reduce stimulant use, and the available psychosocial interventions (except for contingency management) had a weak overall effect. Generic approaches can address mental health and blood borne virus infection risk if better tailored to mitigate the harms associated with stimulant use. Substantial and sustained investment is needed to develop more effective interventions to reduce stimulant use.

Mortality Risk among Cocaine Users before and after the Economic Recession: Results of a Longitudinal Study.

BACKGROUND: Studies have highlighted 2 different groups of cocaine users (CUs): "socially integrated" (stable living conditions, regular employment, use cocaine alone or in combination with other psychoactive substances) and "socially marginalized" (socioeconomic and health problems, former or current heroin users, many injecting cocaine). These differences are also found in the elevated mortality risk for CUs, higher among subjects with cocaine and heroin use. This study targeted residents in Northern Italy who turned to a public treatment center for drug addiction following problems caused by primary cocaine use between 1982 and 2016. OBJECTIVES: To estimate mortality risk for subjects who have never used heroin (CUs) compared to that of subjects who have used heroin (HCUs). METHOD: Retrospective cohort study. We selected 1,993 subjects; 18,015 Person Years (PY). RESULTS: Over time, the quota of subjects injecting cocaine and using heroin decreased, while patients not using heroin increased. Both new patients and crude mortality rates (CMR) decreased during the years 2009-2012 and increased in the following period. CMRs were 5.55 per 1,000 PY, higher for HCUs, men and subjects aged over 44 years. Standardized mortality rates were 3.49, higher for women, injecting cocaine and HCUS. Among CUs, most of the deaths were from injury excluding drug related and tumors; among HCUs, from drug-related causes and diseases of the cardiovascular system. CONCLUSION: The study results show a change in the characteristics of SERD clients being treated for primary cocaine use, which are reflected both in mortality risk and causes of death. After a long period of a decrease, mortality risk increased in the period after the economic recession. Aspects concerning the effects of the economic recession on the problematic consumption of cocaine and on the risk of death are discussed.

Mortality risk in a sample of emergency department patients who use cocaine with alcohol and/or cannabis.

BACKGROUND: Illicit drug use is common among emergency department (ED) patients, yet the association between drug use and subsequent mortality is not well understood. This study examines 36-month mortality rates for a sample of ED patients based on reported use of alcohol, cannabis, and cocaine, both individually and in combination. METHODS: Patients (N = 1669) from 2 urban EDs were surveyed at the time of the visit. The patient survey included the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) and information on physical and mental health, health care utilization, and risk factors associated with substance use. ASSIST scores were used to categorize patients into drug risk groups. Mortality information from the National Death Index was used to calculate mortality rates from 2009 to 2012. A Cox regression model identified associations between drug risk groups and mortality while controlling for patient demographics. RESULTS: The use of cocaine and cannabis both individually and in combination was associated with significantly higher mortality risk compared with other ED patients. CONCLUSIONS: ED patients who use cannabis and cocaine have higher mortality risks than other patients. Further research is necessary to determine whether this result is stable across racial/ethnic groups.

Significance of alanine aminotransferase levels in patients admitted for cocaine intoxication.

BACKGROUND: Experimental studies in animal models and case reports in humans have described the hepatotoxic potential of cocaine. However, there are few data regarding the clinical and laboratory characteristics of patients admitted for cocaine intoxication, particularly regarding the status of the liver enzymes. GOAL: To investigate the significance of alanine aminotransferase (ALT) levels in individuals hospitalized for acute cocaine intoxication. METHODS: Retrospective study with standardized chart review that included patients admitted between January 2003 and December 2010. Bivariate analyses were used to investigate factors associated with ALT above the upper tertile according to gender. Cases of marked ALT elevation were described in detail. RESULTS: Ninety-three patients were included (79% men, mean age of 27.73±9.97 y). ALT above the upper tertile was associated with higher aspartate aminotransferase (AST), creatine phosphokinase, creatinine, and international normalized ratio. Higher levels of ALT were also related to acute renal failure and death. Five subjects had severe ALT elevation during follow-up and all had evidence of hepatocellular dysfunction (jaundice, prolonged prothrombin time with or without hepatic encephalopathy), rhabdomyolysis, and acute renal failure. AST/ALT ratio <2 was present in 2 subjects with severe ALT elevation at admission, but AST/ALT ratio >2 was observed in 3 cases with evidence of progression to acute liver injury. CONCLUSIONS: In acute cocaine intoxication, higher ALT levels were associated with evidence of muscle damage, progression to acute renal failure, and death. Severe liver damage was observed in 5% of the sample and was associated with rhabdomyolysis and renal failure in all cases.

Mortality Risk Among Heroin Abusers: Clients and Non-clients of Public Treatment Centers for Drug Addiction.

UNLABELLED: In Europe, the prevalence of problematic heroin consumption is declining but, in spite of the constant rise in the number of treated patients, many of them do not turn to a public treatment center (PTC) for their drug addiction. The aim of this study is to study the mortality risk separately for heroin abusers PTC clients and non-PTC clients (i.e., those never treated at a PTC). METHODS: Cohort study on 959 subjects resident in the metropolitan area of Bologna who went to a health service (i.e., hospital, emergency unit) or to a PTC following problems due to heroin abuse for the first time between 01/01/2004 and 31/12/2009. Standardized mortality ratios (SMRs) were calculated, and regression analysis using the Poisson method was used. RESULTS: Elevated and statistically significant SMRs were found in both genders, irrespective of the contact facility, being higher for PTC clients. Among non-PTC clients 28% of deaths overall were from AIDS or infectious diseases (6% PTC clients), 17% from opiate overdose (6% PTC clients) and 14% from violent causes (6% PTC clients). Multivariate analysis showed a higher mortality risk for patients who used both heroin and cocaine and for concomitant abuse of benzodiazepines. CONCLUSIONS: The characteristics of patients never before treated for addiction prompts a reflection on the presence of a hidden group of patients who are hard to reach, who have a high mortality risk and who turn to health care treatment facilities only in the event of an emergency.

Impact of acute cocaine use on aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: Acute cocaine use has been temporally associated with aneurysmal subarachnoid hemorrhage (aSAH). This study analyzes the impact of cocaine use on patient presentation, complications, and outcomes. METHODS: Data of patients admitted with aSAH between 1991 and 2009 were reviewed to determine impact of acute cocaine use (C). These patients were compared with aSAH patients without recent cocaine exposure (NC) in relation to their presentation, complications such as aneurysmal rerupture and delayed cerebral ischemia, and outcomes including hospital mortality and functional outcome. RESULTS: Data of 1134 aSAH patients were reviewed; 142 patients (12.5%) had associated cocaine use. Cocaine users were more likely to be younger (mean age: C, 49±11; NC, 53±14; P<0.001). There were no differences in rates of poor-grade Hunt and Hess (4-5); (C, 21%; NC, 26%; P>0.05), associated intraventricular hemorrhage (C, 56%; NC, 51%; P>0.05), or hydrocephalus on admission Head CT (C, 49%; NC, 52%; P>0.05). Aneurysm rerupture incidence was higher among cocaine users (C, 7.7%; NC, 2.7%; P<0.05). The association of cocaine use with higher risk of delayed cerebral ischemia (C, 22%; NC, 16%; P<0.05) was not significant after correcting for other factors. Cocaine users were less likely to survive hospitalization compared with nonusers (mortality: C, 26%; NC, 17%; P<0.05); the adjusted odds of hospital mortality were 2.9 times higher among cocaine users (P<0.001). There were no differences in functional outcomes between the 2 groups. CONCLUSIONS: Acute cocaine use was associated with a higher risk of aneurysm rerupture and hospital mortality after aSAH.

Mortality risk for cocaine abusers in relation to heroin use: a follow-up study.

Cohort study on 471 subjects resident in the metropolitan area of Bologna who had visited a public treatment center for problems due to the abuse of cocaine from January 1, 1988 to December 31, 2009. Two user typologies were created: cocaine users (no heroin) and heroin and cocaine users. Crude mortality rates and standardized mortality ratios were calculated. We performed a regression analysis using the Poisson method. The study results show a higher mortality risk for those injecting substances and for subjects who took both heroin and cocaine. They appear to have different characteristics from their counterparts who do not use heroin. Future studies should be oriented to this aspect.

Trajectories of drug use and mortality outcomes among adults followed over 18 years.

BACKGROUND: For adults in general population community settings, data regarding long-term course and outcomes of illicit drug use are sparse, limiting the formulation of evidence-based recommendations for drug use screening of adults in primary care. OBJECTIVE: To describe trajectories of three illicit drugs (cocaine, opioids, amphetamines) among adults in community settings, and to assess their relation to all-cause mortality. DESIGN: Longitudinal cohort, 1987/88-2005/06. SETTING: Community-based recruitment from four cities (Birmingham, Chicago, Oakland, Minneapolis). PARTICIPANTS: Healthy adults, balanced for race (black and white) and gender were assessed for drug use from 1987/88-2005/06, and for mortality through 12/31/2008 (n = 4301) MEASUREMENTS: Use of cocaine, amphetamines, and opioids (last 30 days) was queried in the following years: 1987/88, 1990/91, 1992/93, 1995/96, 2000/01, 2005/06. Survey-based assessment of demographics and psychosocial characteristics. Mortality over 18 years. RESULTS: Trajectory analysis identified four groups: Nonusers (n = 3691, 85.8%), Early Occasional Users (n = 340, 7.9%), Persistent Occasional Users (n = 160, 3.7%), and Early Frequent/Later Occasional Users (n = 110, 2.6%). Trajectories conformed to expected patterns regarding demographics, other substance use, family background and education. Adjusting for demographics, baseline health status, health behaviors (alcohol, tobacco), and psychosocial characteristics, Early Frequent/Later Occasional Users had greater all-cause mortality (Hazard Ratio, HR = 4.94, 95% CI = 1.58-15.51, p = 0.006). LIMITATIONS: Study is restricted to three common drugs, and trajectory analyses represent statistical approximations rather than identifiable "types". Causal inferences are tentative. CONCLUSIONS: Four trajectories describe illicit drug use from young adulthood to middle age. Two trajectories, representing over one third of adult users, continued use into middle age. These persons were more likely to continue harmful risk behaviors such as smoking, and more likely to die.

Understanding Stimulant Use and Use Disorders in a New Era.

Extending from the triple wave epidemic of opioid-related overdose deaths, a fourth wave of high mortality involving methamphetamine and cocaine use has been gathering force. This article provides a review of the published literature on stimulants including epidemiology, pharmacology, neurobiology, medical and psychiatric consequences, withdrawal management, and medical and behavioral treatments.

Cocaine-related sudden death: a prospective investigation in south-west Spain.

AIMS: With an estimated 12 million consumers in Europe, cocaine (COC) is the illicit drug leading to the most emergency department visits. The aim of this study was to examine a consecutive series of sudden deaths (SDs) to focus on the prevalence, the toxicological characteristics, and the causes of death in COC-related fatalities. METHODS AND RESULTS: Prospective case-control study of forensic autopsies was carried out in the time interval November 2003 to June 2006 at the Institute of Legal Medicine, Seville, south-west Spain, with a reference population of 1 875 462 inhabitants. Toxicology included blood ethanol analysis and blood and urine investigation for drugs of abuse and medical drugs. Autopsy was performed according to the European standardized protocol. Ten age- and sex-matched patients who died of violent causes with no antecedents of COC consumption and negative toxicology served as controls. During the study period, 2477 forensic autopsies were performed, including 1114 natural deaths. Among the latter, 668 fulfilled the criteria of SD and 21 (all males, mean age 34.6 +/- 7.3 years) resulted to be COC-related (3.1%). Cocaine was detected in 67.1% of the blood (median 0.17 mg/L, interquartile range 0.08-0.42) and in 83.0% of the urine samples (median 1.15 mg/L, interquartile range 0.37-17.34). A concomitant use of ethanol was found in 76.0% and cigarette smoking in 81.0%. Causes of SD were cardiovascular in 62.0%, cerebrovascular in 14.0%, excited delirium in 14.0%, respiratory and metabolic in 5.0% each. Left ventricular hypertrophy was observed in 57.0%, small vessels disease in 42.9%, severe atherosclerotic coronary artery disease in 28.6%, and coronary thrombosis in 14.3%. CONCLUSION: Systematic toxicology investigation indicates that 3.1% of SDs are COC-related and are mainly due to cardio-cerebrovascular causes. Left ventricular hypertrophy, small vessel disease, and premature coronary artery atherosclerosis, with or without lumen thrombosis, are frequent findings that may account for myocardial ischaemia at risk of cardiac arrest in COC addicts.

Clinical profiles, complications, and disability in cocaine-related ischemic stroke.

Cocaine use is associated with ischemic stroke through unique mechanisms, including reversible vasospasm, drug-induced arteritis, enhanced platelet aggregation, cardioembolism, and hypertensive surges. To date, no study has described disability in patients with cocaine-related ischemic stroke. The present study compared risk factors, comorbidities, complications, laboratory findings, medications, and outcomes in patients with cocaine-related (n = 41) and non-cocaine-related (n = 221) ischemic stroke (n = 147) and transient ischemic attack (n = 115) in 3 academic hospitals. The patients with cocaine-related stroke were younger (mean age, 51.9 years vs 59.1 years; P = .0008) and more likely to be smokers (95% vs 62.9%; P < .004). The prevalence of arrhythmias was significantly higher in the patients with cocaine-related stroke, and that of diabetes was significantly higher in those with non-cocaine-related strokes. The prevalence of hypertension and lipid profiles were similar in the 2 groups; however, those with cocaine-related stroke were less likely to receive statins. Antiplatelet use was similar in the 2 groups. Survivors of both groups had similar modified Rankin scores and lengths of hospital stay. In the older urban population, smoking and cocaine use may coexist with other cerebrovascular risk factors, and cocaine-related strokes have similar morbidities and mortality as non-cocaine-related strokes. Moreover, because the patients with cocaine-related stroke is younger, they have an earlier morbidity. New strategies for effective stroke prevention interventions are needed in this subgroup.

Health consequences of cocaine use in France: data from the French Addictovigilance Network.

As the number and severity of complications related to cocaine use reported to the French Addictovigilance Network have increased, the French health authorities requested a national epidemiologic study of the data collected by this network from 2010 to 2016. For this purpose, the spontaneous reports (SRs) linked to cocaine notified by health professionals were analyzed as well as the data from the pharmacoepidemiological surveys OPPIDUM (observation of illegal drugs and misuse of psychotropic medications) and DRAMES (deaths related to the abuse of licit and illicit psychoactive substances). In total, 1 265 SRs were analyzed (510% increase from 2010 to 2016). Users were mainly men (952/1 261; 75%), with a median age of 35.0 years [IQ25-75 : 28-42]. Cocaine was consumed through the intranasal route by 52% of users (416/797), followed by intravenous administration (32%, 253/797) and inhalation (24%, 190/797). The use of cocaine powder and crack cocaine was reported in 70% (475/674) and 23% (154/674) of SRs, respectively. Cocaine was consumed with other psychoactive substances and alcohol in 47% (603/1265) and 60% (387/649) of cases, respectively. The main cocaine-related complications were psychiatric complications (29%), neurologic complications (24%) and cardiovascular complications (23%). Analysis of the OPPIDUM survey data showed that in 2016, 15.9 and 2.4% of the included subjects consumed cocaine or crack cocaine the week preceding the survey, the highest rate for the 2006-2016 period. The DRAMES survey indicated that cocaine-related deaths increased by threefold from 2014 to 2016. These data confirm that cocaine use in France is worrying with an increase in the number of severe complications and deaths.

Suicide mortality risk in a cohort of individuals treated for alcohol, heroin or cocaine abuse: Results of a follow-up study.

Cohort study. This follow-up study (from 1975 to 2016) was aimed to estimate the mortality risk for suicide in a cohort of patients presenting to a public treatment centre for addiction (SERD) with Alcohol Use Disorder (AUD), Heroin Use Disorder - HUD or Cocaine Use Disorder (CUD), also relating to their access to a Mental Heath Service. Crude Mortality Rates for suicide were higher for patients with AUDs, for men and subjects 45-64 years old. Hanging was the main cause of suicide death. We highlight an increase in mortality in the period 2009-2012, which coincides with the economic recession, and in the year of first contact with a SERD. The Standardized Mortality Ratios (SMRs) were 4.9, higher among females than males. From the multivariate analysis, a higher risk for patients that were separated or divorced was observed. The results of our study provide some guidance on the features of subjects at greatest risk of death from suicide, which may be useful in reducing and preventing suicide and gaining a better clinical management of patients with SUDs.

Cocaine-related admissions to an intensive care unit: a five-year study of incidence and outcomes.

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Cocaine in Hospital Admissions for Diseases of the Circulatory System and as the Underlying Cause of Death: Analysis and Discussion.

Cocaine is a cardiotoxic drug which has been associated with morbi-mortality due to cardiovascular diseases (CVD). This study aims to: (1) analyze the hospitalizations due to cardiovascular processes and the presence of cocaine among the toxic habits of patients; and (2) discuss the forensic difficulties in sudden cardiac death (SCD) in the presence of cocaine. Hospital discharges due to CVD reporting cocaine consumption as a secondary diagnosis between 2003 and 2013 in Spain were analyzed. Subsequently, a review of judicial autopsies (SCD in cocaine users) was carried out to illustrate the forensic difficulties in the determination of the manner and underlying cause of death when cocaine use is involved. The average CVD morbidity rate was 1104.4 per 100,000 population. The most common main diagnoses of which cocaine use was recorded as a secondary diagnosis were rheumatic fever, ischemic heart disease and cerebrovascular disease in male patients between 15 and 44 years. The cardiovascular findings in the autopsies of cocaine users vary, and determining the mechanism that triggered the death in forensic practice is a challenge. The presence of cocaine among the toxic habits of young patients admitted for CVD in Spain is increasing. In our opinion, criteria must be unified to establish the manner and underlying cause of death in SCD and toxicological analysis can be a key part in the process.

Cocaine use and overdose mortality in the United States: Evidence from two national data sources, 2002-2018.

BACKGROUND: Cocaine-involved overdose mortality has recently risen in the United States (US), yet it is unclear to what extent patterns in cocaine-involved overdose mortality parallel patterns in cocaine use. This study: examined time trends (2002-2018) in past-year cocaine use and cocaine-involved overdose mortality in the US; and compared demographics and drug involvement of adults who reported past-year cocaine use versus adults who died of a cocaine-involved overdose. METHODS: Data from two sources were utilized: (1) the National Survey on Drug Use and Health (n = 1,334 adults self-reporting cocaine use in 2018); and (2) the Multiple Cause of Death dataset of the National Center for Health Statistics (N = 14,630 adults who died of a cocaine-involved overdose in 2018). The study examined prevalence of past-year cocaine use, mortality rates for cocaine-involved overdose, 2002-2018 trends, demographic characteristics, and involvement of other drugs. RESULTS: Results of Joinpoint Regression indicated that the prevalence of past-year cocaine use increased after 2011, with an annual percent change of 5.13, while age-adjusted cocaine-involved overdose mortality rates escalated after 2012, with an annual percent change of 26.54. In 2018, prevalence of past-year cocaine use did not significantly differ (p = 0.09) by racial/ethnic group, yet Non-Hispanic Blacks had an age-adjusted cocaine-involved overdose mortality rate more than double the rate in Non-Hispanic Whites and significantly higher (p < 0.001) than in any other group. CONCLUSIONS: While the prevalence of cocaine use has increased modestly, cocaine-involved overdose mortality has risen dramatically. Cocaine-involved overdose mortality is disproportionately affecting individuals who are Black, older, or with lower educational attainment.

Circumstances and witness characteristics associated with overdose fatality.

STUDY OBJECTIVE: Emergency physicians have an opportunity to provide overdose fatality prevention interventions to individuals at risk for experiencing or witnessing an overdose to reduce fatality. The present study uses data about the most recent overdose observed by a sample of inner-city drug users to determine the circumstances of overdose that are associated with overdose fatality. METHODS: Participants (n=690) aged 18 years or older were recruited with targeted street outreach. All participants had used heroin or cocaine in the previous 2 months and had witnessed at least 1 overdose. Survey data included the circumstances of the last overdose witnessed, including actions taken, drug use behavior, the location of the event, and whether or not the overdose was fatal (the outcome measure). RESULTS: One hundred fifty-two (21.7%) of the witnessed overdoses were fatal. Witness powdered cocaine use (adjusted odds ratio=1.6; 95% confidence interval [CI] 1.0 to 2.6) and injection drug history (adjusted odds ratio=0.5; 95% CI 0.3 to 0.9) were associated with the last witnessed overdose being fatal. Witnessed overdoses that occurred in public or abandoned buildings compared with homes were more likely to be fatal (adjusted odds ratio=1.9; 95% CI 1.0 to 3.5), as were overdoses in which witnesses sought outside medical help (adjusted odds ratio=1.5; 95% CI 1.0 to 2.1). CONCLUSION: Future prevention interventions may fruitfully target users of powdered cocaine, drug users without a history of injecting, and individuals who use drugs in public or abandoned buildings for brief interventions on responding when witnessing an overdose to reduce mortality.

A bacterial cocaine esterase protects against cocaine-induced epileptogenic activity and lethality.

STUDY OBJECTIVE: Cocaine toxicity results in cardiovascular complications, seizures, and death and accounts for approximately 20% of drug-related emergency department visits every year. Presently, there are no treatments to eliminate the toxic effects of cocaine. The present study hypothesizes that a bacterial cocaine esterase with high catalytic efficiency would provide rapid and robust protection from cocaine-induced convulsions, epileptogenic activity, and lethality. METHODS: Cocaine-induced paroxysmal activity and convulsions were evaluated in rats surgically implanted with radiotelemetry devices (N=6 per treatment group). Cocaine esterase was administered 1 minute after a lethal dose of cocaine or after cocaine-induced convulsions to determine the ability of the enzyme to prevent or reverse, respectively, the effects of cocaine. RESULTS: The cocaine esterase prevented all cocaine-induced electroencephalographic changes and lethality. This effect was specific for cocaine because the esterase did not prevent convulsions and death induced by a cocaine analog, (-)-2beta-carbomethoxy-3beta-phenyltropane. The esterase prevented lethality even after cocaine-induced convulsions occurred. In contrast, the short-acting benzodiazepine, midazolam, prevented cocaine-induced convulsions but not the lethal effects of cocaine. CONCLUSION: The data showed that cocaine esterase successfully degraded circulating cocaine to prevent lethality and that cocaine-induced convulsions alone are not responsible for the lethal effects of cocaine in this model. Therefore, further investigation into the use of cocaine esterase for treating cocaine overdose and its toxic effects is warranted.

Cocaine use in trauma: effect on injuries and outcomes.

BACKGROUND: It has been reported that cocaine is associated with trauma patients at epidemic proportions. However, the injury patterns, complications, and mortality in cocaine test-positive trauma patients are not well known. METHODS: Retrospective review of all trauma patients with toxicology screen at a Level I trauma center between January 2002 and December 2005. A total of 1,096 patients were positive for cocaine but no other substances of abuse or alcohol. Nine hundred eighty-five patients of these cocaine test-positive patients were matched to a pool of 4,846 toxicology test-negative patients admitted during the same period with respect to age (< or = 18, 19-55, > 55 years), gender, mechanism (blunt, penetrating), Injury Severity Score (ISS < 16, 16-25, > 25), head Abbreviated Injury Score (AIS < 3, > or = 3), chest AIS (< 3, > or = 3), abdominal AIS (< 3, > or = 3), and extremity AIS (< 3, > or = 3). Matched pairs of binary outcomes were analyzed using McNemars, and continuous data were tested using the Wilcoxon signed-ranks test. RESULTS: The two groups had similar injury patterns and there was no difference in surgical procedures between cocaine test-positive and toxicology test-negative patients. Overall, there was no difference in mortality between the cocaine and test-negative patients (6.5% vs. 6.2%; p = 0.81), or between cocaine and test-negative patients with an ISS < 16 (1.4% vs. 1.5%; p = 1.00), ISS 16 to 25 (13% vs. 12%; p = 1.00), and ISS > 25 (59% vs. 54%; p = 0.70). The overall incidence of complications was 4% in cocaine patients and 3.6% in test-negative patients (p = 0.72), although the incidence of pneumonia was significantly higher in the cocaine test-positive patients (p = 0.04). CONCLUSION: Cocaine abuse in trauma patients is concerning. This study did not show a difference in mortality or length of intensive care unit stay between cocaine positive and negative patients. However, there was a significantly higher incidence of pneumonia in cocaine positive patients. Implementation of effective prevention strategies may help reduce cocaine related victims of trauma.

Suicides, homicides, and unintentional injury deaths after trauma center discharge: cocaine use as a risk factor.

BACKGROUND: : To study whether trauma center patients with positive toxicology findings for cocaine-positive (COC+) are at a higher risk for suicide, homicide, and unintentional injury death after discharge than cocaine-negative (COC+) trauma patients. METHODS: : Patients admitted between July 1983 and June 1995 and discharged alive from a level I trauma center were prospectively followed up for 1.5 years to 14.5 years. The occurrence of suicide, homicide, and unintentional injury death was explored in relation to COC+ status at admission using Cox proportional hazards methodology. Models included possible confounders. Interactions with each of the main effects were explored. RESULTS: : Of the 27,399 admissions, 21,500 had urine COC toxicology testing performed and were included in the study. COC was positive in 11.4% of the studied population. COC+ patients were significantly younger, with 72% of COC+ versus 43% of COC- in the 25 to 44 years age group. COC+ patients were more likely to be men, positive for alcohol, and intentional injury victims. COC+ status was not associated with subsequent suicide. Furthermore, the COC+ status association with subsequent homicide became nonsignificant after adjusting for confounders. Unadjusted COC+ status was associated with unintentional injury death (odds ratio = 1.65 [1.14-2.40]). Interactions were found in the association with unintentional injury death such that COC+ status tripled the odds of injury death (odds ratio = 2.75 [1.58-4.78]) among the alcohol-negative patients within the 25 to 45 years age group. CONCLUSION: : COC+ trauma patients are at an increased risk of subsequent unintentional injury death after discharge from a trauma center. Suicide and homicide occurrence seems to be unaffected.