- Email: [email protected]
Medical complications of cocaine
I CORRESPONDENCE
CAREERS IN ACADEMIC MEDICINE To the Editor: The essay by Drs. Applegate and Williams ( A m J M e d 1990; 88: 263-7) enlightened this young faculty m e m b e r on strategies for promotion, but I wish to challenge the assumption that young faculty should adopt only the current goals of medical academia. Scholarship must ultimately improve the clinical practice of medicine. Academic divisions must produce not only scholarship but doctors who will use the new information to care for patients [1]. As medical students increasingly shun careers in internal medicine [2], academic physicians must ask what went wrong. No one who views clinical time as a burden can inspire young physicians. Some who teach medicine must love to practice it. Some faculty must retain their joy in caring for patients despite the emotional demands, the bureaucratic headaches, and the malpractice worries. Medical students and residents need mentors, also. We must expand our goals. Enthusiastic, energetic clinicians may entice students to careers in internal medicine. Competent, humane, personal doctors may reverse medicine's worsening public reputation. These goals cannot proceed from physicians pursuing a traditional and laudable research career. But that is not the only worthy task for our medical school faculty, nor is it the only activity that should be rewarded with promotion. RACHEL SOROKIN, M.D. Jefferson Medical College Philadelphia, Pennsylvania I. Petersdorf RG. General internal medicine: fad or future? J Gen Intern Med 1989; 4: 527-32. 2. McCarty DJ. Why are today's medical students
choosing technology specialties over internal medicine? N Engl J Med 1987; 317: 567-9. Submitted April 26, 1990, and accepted July 23, 1990
The Reply: We are in agreement with Dr. Sorokin t h a t scholarship conducted in medical centers must ultimately improve the clinical practice of medicine. We also agree t h a t academic divisions must focus both on scholarship and on training doctors who will use the new information to care for patients. However, Dr. Sorokin misunderstands the intent of a number of statements made in our article. First, it is our contention that many young physicians in academic medicine who wish to pursue traditional academic careers are currently overburdened with clinical care. As we indicated in the article, we refer here to an imbalance of time allocation such that a disproportionate amount of time is allocated to clinical care versus research interest. In no way does our article state or imply that clinical care itself should be perceived as a burden or that physicians who pursue a research career should not also pursue their clinical and teaching responsibilities with absolute dedication. We strongly disagree with Dr. Sorokin's contention that the goal of training competent, humane, personal physicians cannot be promoted by faculty who pursue a traditional research career. Active investigators should be m e a n i n g f u l l y i n v o l v e d in teaching since this helps promote a stimulating training environment in which value is placed on finding new answers to clinical problems as well as promoting an emphasis on lifelong pursuit of knowledge. Close reading of our
original article will reveal that one of the criteria we advised young faculty to evaluate in the search for a job is the depth and breadth of clinical activities in their area of interest.W e do state frankly in our articlethat it is our opinion that success in obtaining research grants and publishing research papers remains the surest way of achieving a successful and lasting career in academic medicine. This is not to demean the importance of other paths but rather to describe the world as we see it and believe it is likely to remain. Dr. Sorokin is mistaken in stating that an underlying assumption of our article was that all young faculty should adopt only the goals of a traditional research career. In fact, our article clearly states that a young physician should firstevaluate whether he or she is suited for a research career. M a n y young faculty m e m b e r s would be better suited for careers more oriented toward a combination of clinical work and teaching. W e do agree with Dr. Sorokin that a more classic research career is not the only path that should be rewarded with promotion and tenure in an academic medical center. WILLIAMB. APPLEGATE,M.D. University of Tennessee, Memphis Memphis, Tennessee MARK WILLIAMS,M.D. University of North Carolina at Chapel Hill Chapel Hill, North Carolina
MEDICAL COMPLICATIONS OF COCAINE To the Editor: We read with intense interest the article by Brody and colleagues (Am J Med 1990; 88: 325-31). This is an important article as little data are available on the inci-
December 1990 The American Journal of Medicine
Volume 89
833
CORRESPONDENCE
dence of medical complications of cocaine. However, a number of statements by the authors are of some concern and may be somewhat misleading. Forty-nine percent of patients in this retrospective study used cocaine intravenously. This has not been the experience of other groups. Intranasal use is the most common pattern of use in this country [1] and is being rapidly replaced by crack smoking. Many individuals have changed their pattern of use to crack smoking due to fear of contracting the acquired immunodeficiency syndrome (AIDS) from intravenous cocaine use. The authors state that most medical complications of cocaine are short-lived and appear to be related to cocaine's hyperadrenergic effects. The effects of cocaine on catecholamines is important but there may be other mechanisms in addition. The mechanisms responsible for the cardiotoxic effects of cocaine remain largely unknown [2]. The mechanisms may include hypersensitivity, and toxic effects of the drug itself; and cocaine may be a thrombogenic agent. Many complications including myocarditis, myocardial infarction, vascular thrombosis, and cardiomyopathy are not short-lived. The statement that complications of cocaine rarely result in serious illness and death is misleading and is probably incorrect. This statement would tend to glamorize the use of cocaine, which I am sure was not the intent of the authors. Addiction is a major complication of cocaine abuse and a chronic disorder with exacerbations and remissions. Cocaine abuse resulting in medical complications is the rule rather than the exception [3]. LOUIS L. CREGLER, M.D., F.A.C.P.
Mount Sinai School o/ Medicine New York, New York
834
1. Washton AM, Gold MS, Pottash AC. Intranasal cocaine addiction. Lancet 1983; 2: 1374. 2. Billman GE. Mechanisms responsible for the cardiotoxic effects of cocaine. FASEBJ 1990; 4: 246975. 3. Cregler LL, Mark H. Medical complications of cocaine abuse. N Engl J Med 1986; 315: 1495-1500. Submitted June 19, 1990, and accepted August 3, 1990
To the Editor:
I read with interest the retrospective analysis by Brody et al (Am J Med 1990; 88: 325-31) of cocainerelated medical problems in an emergency room setting. They noted that among those presenting to their emergency room and admitting to the recent use of cocaine, cardiopulmonary and neuropsychiatric complaints were "very common." Chest pain was the most frequent complaint (prevalence 39.5%), although "rarely was it believed to represent ischemia." Other frequently occurring symptoms (prevalence 3% to 22%) included tachycardia, anxiety, shortness of breath, dizziness, palpitations, tremulousness, diaphoresis, throat tightness, nausea, and vomiting. According to the authors, many of these patients experienced multiple symptoms. The authors concluded t h a t these complications of cocaine were "short-lived" and appeared "to be related to cocaine's hyperadrenergic effects," but added "the mechanism of cocaine-associated chest pain has not been definitively elucidated." However, the authors should have considered another etiology to explain the clinical presentation of many of these patients: the phenomenon of cocaine-associated panic attacks. Panic attacks are manifested by the sudden onset of intense apprehension, fear, or terror, and often associated with the feeling of impending doom. Indeed, it is often this fear that drives its victims to seek emergency medical attention bearing the hypochron-
December1990 The American Journal of Medicine Volume 89
driacal conviction of having a heart attack or some other cardiopulmonary crisis. Panic attacks are routinely associated with somatic symptoms, and at least four of the following symptoms are required to meet formal DSM-III-R [1] criteria for a p a n i c episode: d y s p n e a or smothering sensations, dizziness or faintness, chest pain or discomfort, palpitations or tachycardia, trembling or shaking, choking, sweating, gastrointestinal distress, hot and cold flashes, paresthesias, depersonalization or derealization, and a fear of dying or of going crazy. The similarity of these symptoms as compared to those reported by Brody et al may be more than coincidental. It has been well documented that cocaine can incite panic attacks [2-5]. These attacks appear to be clinically identical to those that occur spontaneously, and a pattern of chronic, substantial cocaine abuse has often predated the initial panic attack [6]. Panic attacks precipitated by cocaine arise soon after ingestion of the drug and can occur whether cocaine is smoked (free-basing), intravenously injected, or intranasally snorted. Cocaine's local anesthetic properties are believed responsible for its procliviW to induce panic, as a pharmacologic kindling process may occur with repeated use of the drug [7]. The frequency of occurrence of cocaine-induced panic attacks is difficult to estimate, but Washton and Gold [8] found that, of the first 500 callers to a cocaine hotline to report adverse psychologic effects, some 50% reported experiencing such panic attacks. Is it t h e n conceivable t h a t many of the patients retrospectively reviewed by Brody et al had had cocaine-induced panic attacks? If so, this clarification in diag-
CAREERS IN ACADEMIC MEDICINE To the Editor: The essay by Drs. Applegate and Williams ( A m J M e d 1990; 88: 263-7) enlightened this young faculty m e m b e r on strategies for promotion, but I wish to challenge the assumption that young faculty should adopt only the current goals of medical academia. Scholarship must ultimately improve the clinical practice of medicine. Academic divisions must produce not only scholarship but doctors who will use the new information to care for patients [1]. As medical students increasingly shun careers in internal medicine [2], academic physicians must ask what went wrong. No one who views clinical time as a burden can inspire young physicians. Some who teach medicine must love to practice it. Some faculty must retain their joy in caring for patients despite the emotional demands, the bureaucratic headaches, and the malpractice worries. Medical students and residents need mentors, also. We must expand our goals. Enthusiastic, energetic clinicians may entice students to careers in internal medicine. Competent, humane, personal doctors may reverse medicine's worsening public reputation. These goals cannot proceed from physicians pursuing a traditional and laudable research career. But that is not the only worthy task for our medical school faculty, nor is it the only activity that should be rewarded with promotion. RACHEL SOROKIN, M.D. Jefferson Medical College Philadelphia, Pennsylvania I. Petersdorf RG. General internal medicine: fad or future? J Gen Intern Med 1989; 4: 527-32. 2. McCarty DJ. Why are today's medical students
choosing technology specialties over internal medicine? N Engl J Med 1987; 317: 567-9. Submitted April 26, 1990, and accepted July 23, 1990
The Reply: We are in agreement with Dr. Sorokin t h a t scholarship conducted in medical centers must ultimately improve the clinical practice of medicine. We also agree t h a t academic divisions must focus both on scholarship and on training doctors who will use the new information to care for patients. However, Dr. Sorokin misunderstands the intent of a number of statements made in our article. First, it is our contention that many young physicians in academic medicine who wish to pursue traditional academic careers are currently overburdened with clinical care. As we indicated in the article, we refer here to an imbalance of time allocation such that a disproportionate amount of time is allocated to clinical care versus research interest. In no way does our article state or imply that clinical care itself should be perceived as a burden or that physicians who pursue a research career should not also pursue their clinical and teaching responsibilities with absolute dedication. We strongly disagree with Dr. Sorokin's contention that the goal of training competent, humane, personal physicians cannot be promoted by faculty who pursue a traditional research career. Active investigators should be m e a n i n g f u l l y i n v o l v e d in teaching since this helps promote a stimulating training environment in which value is placed on finding new answers to clinical problems as well as promoting an emphasis on lifelong pursuit of knowledge. Close reading of our
original article will reveal that one of the criteria we advised young faculty to evaluate in the search for a job is the depth and breadth of clinical activities in their area of interest.W e do state frankly in our articlethat it is our opinion that success in obtaining research grants and publishing research papers remains the surest way of achieving a successful and lasting career in academic medicine. This is not to demean the importance of other paths but rather to describe the world as we see it and believe it is likely to remain. Dr. Sorokin is mistaken in stating that an underlying assumption of our article was that all young faculty should adopt only the goals of a traditional research career. In fact, our article clearly states that a young physician should firstevaluate whether he or she is suited for a research career. M a n y young faculty m e m b e r s would be better suited for careers more oriented toward a combination of clinical work and teaching. W e do agree with Dr. Sorokin that a more classic research career is not the only path that should be rewarded with promotion and tenure in an academic medical center. WILLIAMB. APPLEGATE,M.D. University of Tennessee, Memphis Memphis, Tennessee MARK WILLIAMS,M.D. University of North Carolina at Chapel Hill Chapel Hill, North Carolina
MEDICAL COMPLICATIONS OF COCAINE To the Editor: We read with intense interest the article by Brody and colleagues (Am J Med 1990; 88: 325-31). This is an important article as little data are available on the inci-
December 1990 The American Journal of Medicine
Volume 89
833
CORRESPONDENCE
dence of medical complications of cocaine. However, a number of statements by the authors are of some concern and may be somewhat misleading. Forty-nine percent of patients in this retrospective study used cocaine intravenously. This has not been the experience of other groups. Intranasal use is the most common pattern of use in this country [1] and is being rapidly replaced by crack smoking. Many individuals have changed their pattern of use to crack smoking due to fear of contracting the acquired immunodeficiency syndrome (AIDS) from intravenous cocaine use. The authors state that most medical complications of cocaine are short-lived and appear to be related to cocaine's hyperadrenergic effects. The effects of cocaine on catecholamines is important but there may be other mechanisms in addition. The mechanisms responsible for the cardiotoxic effects of cocaine remain largely unknown [2]. The mechanisms may include hypersensitivity, and toxic effects of the drug itself; and cocaine may be a thrombogenic agent. Many complications including myocarditis, myocardial infarction, vascular thrombosis, and cardiomyopathy are not short-lived. The statement that complications of cocaine rarely result in serious illness and death is misleading and is probably incorrect. This statement would tend to glamorize the use of cocaine, which I am sure was not the intent of the authors. Addiction is a major complication of cocaine abuse and a chronic disorder with exacerbations and remissions. Cocaine abuse resulting in medical complications is the rule rather than the exception [3]. LOUIS L. CREGLER, M.D., F.A.C.P.
Mount Sinai School o/ Medicine New York, New York
834
1. Washton AM, Gold MS, Pottash AC. Intranasal cocaine addiction. Lancet 1983; 2: 1374. 2. Billman GE. Mechanisms responsible for the cardiotoxic effects of cocaine. FASEBJ 1990; 4: 246975. 3. Cregler LL, Mark H. Medical complications of cocaine abuse. N Engl J Med 1986; 315: 1495-1500. Submitted June 19, 1990, and accepted August 3, 1990
To the Editor:
I read with interest the retrospective analysis by Brody et al (Am J Med 1990; 88: 325-31) of cocainerelated medical problems in an emergency room setting. They noted that among those presenting to their emergency room and admitting to the recent use of cocaine, cardiopulmonary and neuropsychiatric complaints were "very common." Chest pain was the most frequent complaint (prevalence 39.5%), although "rarely was it believed to represent ischemia." Other frequently occurring symptoms (prevalence 3% to 22%) included tachycardia, anxiety, shortness of breath, dizziness, palpitations, tremulousness, diaphoresis, throat tightness, nausea, and vomiting. According to the authors, many of these patients experienced multiple symptoms. The authors concluded t h a t these complications of cocaine were "short-lived" and appeared "to be related to cocaine's hyperadrenergic effects," but added "the mechanism of cocaine-associated chest pain has not been definitively elucidated." However, the authors should have considered another etiology to explain the clinical presentation of many of these patients: the phenomenon of cocaine-associated panic attacks. Panic attacks are manifested by the sudden onset of intense apprehension, fear, or terror, and often associated with the feeling of impending doom. Indeed, it is often this fear that drives its victims to seek emergency medical attention bearing the hypochron-
December1990 The American Journal of Medicine Volume 89
driacal conviction of having a heart attack or some other cardiopulmonary crisis. Panic attacks are routinely associated with somatic symptoms, and at least four of the following symptoms are required to meet formal DSM-III-R [1] criteria for a p a n i c episode: d y s p n e a or smothering sensations, dizziness or faintness, chest pain or discomfort, palpitations or tachycardia, trembling or shaking, choking, sweating, gastrointestinal distress, hot and cold flashes, paresthesias, depersonalization or derealization, and a fear of dying or of going crazy. The similarity of these symptoms as compared to those reported by Brody et al may be more than coincidental. It has been well documented that cocaine can incite panic attacks [2-5]. These attacks appear to be clinically identical to those that occur spontaneously, and a pattern of chronic, substantial cocaine abuse has often predated the initial panic attack [6]. Panic attacks precipitated by cocaine arise soon after ingestion of the drug and can occur whether cocaine is smoked (free-basing), intravenously injected, or intranasally snorted. Cocaine's local anesthetic properties are believed responsible for its procliviW to induce panic, as a pharmacologic kindling process may occur with repeated use of the drug [7]. The frequency of occurrence of cocaine-induced panic attacks is difficult to estimate, but Washton and Gold [8] found that, of the first 500 callers to a cocaine hotline to report adverse psychologic effects, some 50% reported experiencing such panic attacks. Is it t h e n conceivable t h a t many of the patients retrospectively reviewed by Brody et al had had cocaine-induced panic attacks? If so, this clarification in diag-