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Acute intoxication with either cocaine or methamphetamine may contribute to formation and rupture of a berry aneurysm by causing transient hypertension and tachycardia. We report the results of a retrospective study to determine the incidence of acute cocaine or methamphetamine intoxication in deaths due to ruptured berry aneurysm in our jurisdictions. We reviewed all deaths from ruptured cerebral aneurysms that fell within our jurisdictions during the seven years from 1 January 1987 to 31 December 1993 and found 83 cases. The mechanism of death invariably involved subarachnoid hemorrhage, although some cases also had intracerebral hemorrhage. A history of drug abuse was found in 13 cases. Toxicological analysis was performed in 39 cases. Of these methamphetamine was detected in six cases and cocaine in three cases--an incidence of 21%. (In one case both methamphetamine and cocaine were detected). The incidence of acute cocaine intoxication in all autopsies in Jefferson County was 13.6%. The incidence of methamphetamine intoxication in all autopsies in San Diego County was 4.9%. Although the exact mechanism by which berry aneurysms form remains undetermined, research indicates that propagation and rupture of the aneurysm are aggravated by hypertension and tachycardia, both of which are pharmacologic side effects of cocaine and methamphetamine. Based on the preponderance of methamphetamine associated with deaths due to ruptured berry aneurysms it appears that methamphetamine is more toxic than cocaine, perhaps owing to the longer half-life of methamphetamine.

All patients who presented to the emergency department as a result of cocaine intoxication during a one-year period were reviewed retrospectively. One hundred thirty-seven cases were reviewed. Patients presented with a wide variety of chief complaints including altered mental status (40%), chest pain (21%), syncope (19%), suicide attempt (13%), palpitations (12%), and seizures (12%), as well as numerous other complaints. There was only one death. Few patients required treatment within the ED; sixteen required hospitalization.

At the Haight-Ashbury Free Medical Clinics in San Francisco, the recreational use of cocaine is on a precipitous incline of popularity. Intensified symptoms of intoxication and the possibility of overdose parallel the current fad of smoking "freebase." We examined the "cocaine reaction," an adrenergic storm affecting CNS, respiratory and cardiovascular systems, which may proceed to generalized collapse and death within minutes. The physiologic and pharmacologic mechanisms of the reaction are elaborated, and a logical algorithm of treatment is outlined. The psychodynamics of the "armed" cocaine personality is discussed, as is the proper psychological approach to these patients. A specific indicated technical and pharmacologic approach, as well as several caveats of therapy that have been clinically developed in the treatment of several hundred cases of cocaine overdose, are presented.

Cocaine- and methamphetamine-related homicides and fatal accidental overdoses in San Diego County were studied retrospectively for the 1987 calendar year. Cocaine was involved in 66 cases (39 homicides, 27 accidental overdoses), methamphetamine in 32 cases (23 homicides, 9 accidental overdoses), and a combination of cocaine and methamphetamine in 10 cases (4 homicides, 6 accidental overdoses). The composite for cocaine-related deaths was a 30-year-old black man in whom was also found at least 1 other drug, usually ethanol or morphine. The composite for methamphetamine-related deaths was a 32-year-old Caucasian man who used methamphetamine with at least 1 other drug (usually ethanol). For cases involving both cocaine and methamphetamine, the composite was a 36-year-old Caucasian man in whom was also found at least 1 other drug, usually ethanol, codeine, or morphine. Mean tissue concentrations of cocaine and benzoylecgonine were significantly higher in accidental overdoses than in homicides except for cocaine concentrations in liver, which did not differ significantly between the two groups. For methamphetamine-related deaths there was no significant difference between mean tissue concentrations in accidental overdoses and in homicides. Cocaine or methamphetamine or both were involved in approximately one third of homicides in San Diego County in 1987, and when fatal accidental overdoses were included, cocaine was involved in twice as many cases as methamphetamine.