Blog Feature.
Crack cocaine abuse is highly prevalent in the United States. Though physical withdrawal occurs rarely, the compulsion to smoke crack is powerful. In this case, a patient attempted to smoke crack through her tracheostomy and aspirated her glass crack pipe.Case Report: A 50 year-old woman presented to the Emergency Department (ED) complaining of dyspnea for two hours. She had a history of laryngeal cancer and tracheostomy several years prior but because of longstanding discomfort at the tracheostomy site, she did not have a tracheostomy tube in place. She had a history of polysubstance abuse and was enrolled in a drug treatment program where she received methadone and psychosocial support. Urine toxicology reports at the program were intermittently positive for cocaine. In the ED she reported that an object had fallen into her tracheostomy. On physical examination the patient was tachypneic and agitated. Her lungs were clear to auscultation. Her oxygen saturation was 78% on room air. Chest radiography revealed a tubular radiodensity overlying the region of the carina and right mainstem bronchus. Bronchoscopy was performed urgently and a glass tube 3.2 cm in length was removed from the right mainstem bronchus. The tube was the size and shape of a pipe used to smoke crack cocaine [circled in the above image]. Copious secretions had accumulated behind the obstruction, but no injury to the airways was observed. The patient recovered uneventfully and continued intermittent crack abuse until just prior to her death three years later. She died due to a recurrence of her laryngeal cancer.
Discussion
Cocaine, including crack, is the second most commonly abused non-prescription illicit drug with 1.9 million Americans reporting use in the past month (1). Cocaine is associated with more emergency department visits than any other illicit drug (2). Cocaine abuse can lead dysfunction of multiple organ systems. For example, injecting cocaine can lead to skin and soft tissue infections as well as transmission of viral hepatitis and HIV. Smoking crack increases risk of pulmonary infections and chronic pulmonary disease. By any route, cocaine can cause myocardial infarction, cardiac arrhythmia and seizure.
Cocaine is highly addictive. Few psychosocial interventions have proved effective in treating cocaine abuse. Though multiple medications have been tried, none have proved effective in treating cocaine abuse in randomized controlled trials Cocaine vaccine is currently being investigated as a tool to prevent relapse among prior cocaine users.
Amongst poor urban populations, cocaine is most frequently smoked in the form of crack, the least expensive form of cocaine. Crack is commonly smoked from a glass pipe (“stem”) with a steel wool filter. Oral injuries such as burns and lacerations are common among crack abusers and can be routes of viral infection when smoking paraphernalia is shared. Tracheal and esophageal aspiration of smoking paraphernalia are rare sequelae of crack abuse. Published reports include cases of aspiration of bagged cocaine by a “body packer” (3), aspiration and ingestion of a steel wool filter (4) and ingestion of a crack pipe (5).
This unusual case graphically illustrates the tremendous compulsion to smoke crack, even in the face of extreme risk. Given the morbidity associated with cocaine abuse, efforts to prevent cocaine abuse as well as identify and treat patients who abuse cocaine are warranted.
— Melissa Stein, MD
Albert Einstein College of Medicine/Montefiore Medical Center
References
1. Substance Abuse and Mental Health Services Administration. (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network,2007: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD, 2010.
3. Cobaugh DJ, Schneider SM, Benitez JG, Donahoe MP. Cocaine balloon aspiration: successful removal with bronchoscopy. Am J Emerg Med. 1997; 15(5):544-6.
4. Moettus A, Tandberg. Brillo crack pad aspiration and ingestion. J Emerg Med. 1998; 16(6):861-3.
5. Young J, Beech D, Offodile R. Foreign body ingestion and management: “I swallowed a crack pipe”. Am Surg. 2007; 73(11):1144-6.
