What are the best antihypertensive medications for individuals with a history of cocaine abuse?

Best Blood Pressure Medications for Cocaine Abuse

For cocaine-induced hypertension, benzodiazepines are the first-line treatment, followed by alpha-blockers (phentolamine), calcium channel blockers (verapamil), or nitroglycerin—while pure beta-blockers must be strictly avoided due to risk of unopposed alpha-stimulation causing paradoxical hypertension and worsening coronary vasospasm. 1, 2

First-Line Treatment: Benzodiazepines

• Benzodiazepines (diazepam, lorazepam) are the cornerstone of managing cocaine-induced hypertension and tachycardia by reducing sympathetic outflow and treating the underlying agitation 1, 3, 2
• They effectively control blood pressure, heart rate, and reduce coronary vasospasm through anxiolysis and sedation 1, 4
• Diazepam specifically demonstrated improved autonomic findings and resolution of chest pain in cocaine-associated presentations 1
• Should be used for short periods (7-14 days) to prevent dependence 3

Second-Line Antihypertensive Options

Alpha-Blockers (Preferred)

• Phentolamine is the preferred traditional antihypertensive as it directly reverses cocaine-induced coronary artery vasospasm and hypertension without risk of unopposed alpha-stimulation 1
• Works by blocking alpha-adrenergic receptors that cocaine stimulates through catecholamine excess 1

Calcium Channel Blockers

• Verapamil effectively resolves cocaine-induced coronary vasospasm and hypertension 1
• May not consistently control tachycardia but addresses the critical vasospasm component 4
• Safer alternative when alpha-blockers unavailable 1

Nitroglycerin

• Reverses cocaine-induced coronary vasospasm and reduces blood pressure 1
• In one study, 45% of patients with cocaine-associated acute coronary syndrome had reduced chest pain severity with nitroglycerin 1
• Caution: Risk of severe hypotension and reflex tachycardia 4

Mixed Beta/Alpha-Blockers: Controversial but Potentially Safe

• Carvedilol and labetalol (mixed β/α-blockers) attenuated cocaine-induced increases in heart rate and blood pressure without apparent adverse effects in controlled studies 1
• These agents may be safer than pure beta-blockers because they provide concurrent alpha-blockade 4, 5
• However, labetalol did not change cocaine-induced coronary vasoconstriction in one study 1
• Use with extreme caution and only after benzodiazepines have been administered 4

Absolutely Contraindicated: Pure Beta-Blockers

• Pure beta-blockers (propranolol, esmolol) are contraindicated in acute cocaine intoxication (within 72 hours of use) 3, 2, 6
• Propranolol worsened cocaine-induced coronary artery vasoconstriction in clinical trials 1
• Esmolol showed no consistent improvement and caused adverse effects (hypertension, hypotension, CNS depression) in 3 of 7 patients 1
• Mechanism: Beta-blockade leaves alpha-adrenergic stimulation unopposed, causing paradoxical hypertension and severe coronary vasospasm 2, 7, 5
• One case report documented propranolol-induced paroxysmal hypertension requiring nitroprusside rescue 7

Treatment Algorithm

1. Immediate management: Administer benzodiazepines (diazepam 5-10mg IV or lorazepam 2-4mg IV) for hypertension, tachycardia, and agitation 1, 3, 2

2. If hypertension persists despite benzodiazepines:

   • First choice: Phentolamine (alpha-blocker) 1
   • Alternative: Verapamil (calcium channel blocker) 1
   • Alternative: Nitroglycerin (monitor for hypotension) 1, 4

3. For coronary vasospasm/chest pain:

   • Nitroglycerin plus benzodiazepines 1
   • Consider phentolamine or verapamil if nitroglycerin ineffective 1

4. Avoid pure beta-blockers entirely in acute setting (first 72 hours) 3, 2

Critical Pitfalls to Avoid

• Never use pure beta-blockers (propranolol, metoprolol, esmolol) in acute cocaine toxicity—this can cause life-threatening unopposed alpha-stimulation 2, 7, 5
• Do not assume all beta-blockers are contraindicated—mixed β/α-blockers may be safer but should still be used cautiously 4, 5
• Nitroglycerin can cause severe hypotension; monitor blood pressure closely 4
• The 2010 International Consensus states no single drug is superior to another among the safe options (benzodiazepines, alpha-blockers, calcium channel blockers, nitroglycerin), so choice depends on availability and clinical context 1

Long-Term Management Considerations

• For chronic hypertension in patients with cocaine use history (not acute intoxication), standard antihypertensives can be used once acute effects have resolved (>72 hours) 3
• Address underlying substance use disorder with naltrexone (50mg/day) to reduce cocaine craving and prevent relapse 3
• Treat psychiatric comorbidities (depression, anxiety) that commonly coexist with cocaine abuse 3