The Way to the Heart Is Up the Nose – Cardiovascular Effects of Cocaine
The recreational use of cocaine was once thought to be the preserve of rock stars but tumbling prices and opportunities to buy it online have broadened its use. An estimated 1.5 million Europeans aged 15 to 34 will have taken cocaine in the past month.1 Almost 2 million Americans have a cocaine habit, and the drug is responsible for more than 500,000 emergency hospital admissions in the U.S. each year.2 Many of these visits are due to cardiac problems - 25% of heart attacks in people under age 45 are associated with cocaine in the US.3
Cocaine increases sensitivity to adrenaline, thereby prolonging its effect. This leads to increased heart rate and blood pressure, resulting in higher oxygen demands from the heart muscle. The drug restricts blood flow in the coronary arteries, reducing oxygen availability, and is associated with the formation of blood clots and heart arrhythmias. With prolonged use it damages the cells lining the coronary arteries further, raising the risk of a fatal heart attack.4
The majority of the world’s cocaine is consumed in the Americas, Europe and Australasia, with relatively limited use in Asia. Cocaine is the most commonly used illicit drug in Europe, which represents the second largest market.5 Users are concentrated in Germany, France, Italy and the UK.
The stereotypical view is that regular users of cocaine are socially marginalized individuals, often with addictions to other opioid drugs including heroin, who have little demand for insurance product. However, socially integrated users are likely to be people who take cocaine intermittently in a recreational context, putting them at risk of acute cardiovascular problems.
The apparent persistence of excess mortality may be related to “lifestyle” issues but also the long-term damage to the heart of repeated cocaine use. Drug-related mortality is a complex phenomenon that accounts for about 4% of all deaths among European adults below age 35.6 Many of the deaths are associated with opioid abuse but significant numbers are due only to cocaine use.
In a U.S. population applying for life cover, the mortality risk is lower in cocaine-positive smokers than nonsmokers - male cocaine-positive nonsmokers, age 20-29 had a relative mortality of 500%. There was little change in the pattern of survival between early and later years up to 16 years after the applicant was tested positive. The prevalence of cocaine use judged by urine testing (0.3%) was half that of the population as a whole.7
Asking insurance applicants to disclose illicit drug taking history in a structured manner is vital. Asking questions will help identify 50% of people with a history of illicit drug use than does urine toxicology.8 Deciding on any terms of acceptance for insurance can pose a challenge, not least because cardiac imaging studies of users reveal a variety of harmful effects that progress in otherwise healthy young people. This means their risk of a cardiac event increases over time but a single dose can cause significant problems.
The disclosure of cardiac problems at a young age should prompt the underwriter to consider requesting a drug screen, regardless of the requested amount of coverage.
- European Monitoring Centre of Drugs and Drug Addiction (2015) Mortality among drug users in Europe: new and old challenges for public health. Luxemburg.
- Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
- Devlin RJ, & Henry JA. (2008) Clinical review: Major consequences of illicit drug consumption. Critical Care. 12:202-9.
- Stankowski, RV et al. (2015) Cardiovascular consequences of cocaine use. Trends in Cardiovascular Medicine. 25. 517-526.
- World Drug Report 2014, UNODC http://www.unodc.org/wdr2014/en/cocaine.html.
- Ibid at Note 1.
- Dolan, VF et al. (2010) Mortality associated with positive cocaine test results. On The Risk. 26. 46-49.
- Lee, MO et al. (2009) Is the self-report of recent cocaine or methamphetamine use reliable in illicit stimulant drug users who present to the emergency department with chest pain? Journal of Emergency Medicine. 37. 237–41.