What medications should be avoided in a patient with cocaine intoxication?

Medications to Avoid in Cocaine Intoxication

Beta-blockers should NOT be administered to patients with acute cocaine intoxication due to the risk of unopposed alpha-adrenergic stimulation causing potentially fatal coronary vasospasm. 1, 2, 3

Primary Contraindications

Beta-Blockers (Class III: Harm)

• Absolute contraindication in patients showing signs of acute cocaine intoxication (euphoria, tachycardia, hypertension) 1, 3
• Cocaine stimulates both alpha- and beta-adrenergic receptors; blocking beta receptors leaves unopposed alpha stimulation, worsening coronary spasm 1, 2
• This prohibition applies specifically during acute intoxication, not necessarily to patients with remote cocaine use who are clinically non-toxic 3
• If beta-blockade is absolutely necessary for life-threatening hypertension or tachycardia, use combined alpha/beta-blockers (labetalol or carvedilol) ONLY after administering a vasodilator (nitroglycerin or calcium channel blocker) within the previous hour 2, 4

Short-Acting Nifedipine

• Should never be used in cocaine-associated acute coronary syndrome 1
• Associated with worse outcomes in ACS patients generally 1

Fibrinolytic Therapy (Use with Extreme Caution)

• Should be reserved only for clear ST-elevation MI when percutaneous coronary intervention is unavailable 1
• Case reports document higher rates of intracranial hemorrhage after fibrinolytic administration in cocaine users 1
• Many young cocaine users have benign early repolarization mimicking STEMI, making fibrinolytics particularly risky 1
• Percutaneous coronary intervention by experienced operators is strongly preferred over fibrinolytics 1

Medications to Use with Caution

Calcium Channel Blockers (Verapamil/Diltiazem)

• Should be avoided in patients with heart failure or left ventricular dysfunction 1
• Not recommended as first-line treatment; reserve for patients unresponsive to benzodiazepines and nitroglycerin 1
• While verapamil reverses cocaine-associated coronary vasoconstriction in catheterization studies, clinical outcome data are limited 1
• Calcium channel blockers showed variable results in animal models regarding survival, seizures, and dysrhythmias 1

Antipsychotics

• May worsen cocaine toxicity consequences by interfering with heat dissipation, causing arrhythmias, and lowering seizure threshold 5
• Can improve agitation but with inconsistent cardiovascular effects and risk of extrapyramidal symptoms 4

Dexamphetamine

• Should NOT be offered for treatment of stimulant use disorders 2

Critical Timing Considerations

• Most cocaine-associated myocardial infarctions occur within 3 hours of use, with 24-fold increased MI risk in the first hour 3
• Cocaine metabolites persist up to 24 hours and can cause delayed coronary vasoconstriction, with symptoms potentially occurring 18 hours after use 3
• The beta-blocker prohibition applies specifically to acute intoxication; evidence suggests it may be safe to administer beta-blockers in patients with recent cocaine ingestion who are clinically non-toxic, though data during acute intoxication stages are lacking 1

Common Pitfalls to Avoid

• Do not assume self-reporting is accurate—urine testing for benzoylecgonine is the most reliable method to detect recent use, as self-reporting significantly underestimates exposure 3
• Do not use nonselective beta-blockers like propranolol even in combination therapy, as their beta-blocking effects far outweigh any alpha-blocking properties 6
• Do not use phentolamine as first-line therapy—while it reverses coronary vasoconstriction, its equal affinity for alpha-1 and alpha-2 receptors may result in significant reflex tachycardia 6
• Avoid lidocaine for ventricular dysrhythmias as it may have additive effects with cocaine, potentially lowering the seizure threshold 6