Mental health assessment

As described above, mental health symptoms usually resolve over hours or days after stopping use of cocaine, but they may be more persistent.

Chronic use or heavy binges can lead to the development of paranoid ideation associated with anxiety, panic attacks and feeling agitated. Cocaine use can also lead to depression and suicidal thoughts. Initial anxiety and paranoia may sometimes progress to a psychotic disorder with paranoid delusions and hallucinations (which may be auditory or tactile "cocaine bugs").

In some cases, individuals can present only with delusional parasitosis, Ekbom Syndrome, which is the unshakable belief that the skin is infested by parasites in the absence of other mental health symptoms. Characteristic is the self-damage of skin by individuals affected in an attempt to remove parasites. Presentation to primary care and A&E for treatment rather than to mental health or addiction services is common. To prove infestation, containers with specimens or photos (‘matchbox sign’) may be brought to consultations. Psychological distress secondary to delusions can lead to depressed mood and may require further assessment and/or treatment.

When working with people using stimulants, it can be helpful to screen for mental health problems. It is important to enquire about sleep patterns, anxiety, fears, delusional beliefs or hallucinations. People should be asked about thoughts of self-harm and suicide. Any concerns should be appropriately escalated. A particular focus on sleep hygiene, anxiety management techniques and building a safe environment to recover from acute effects of cocaine can be helpful.

Persistent mental health symptoms beyond the acute effects of cocaine should be treated as they arise. Awareness of interaction risks when prescribing medication to people who use cocaine should be considered. A specific consideration is that cocaine can mask the depressant effect of sedative medication. People should be aware of risks of respiratory depression and need for additional caution when using sedatives alongside cocaine. Selective serotonin re-uptake inhibitors (SSRIs) and stimulants have been known to produce toxic reactions, although not commonly. The Medicines and Healthcare Products Regulatory Agency (MHRA) has reminded prescribers to note the potential increased risk of bleeding when citalopram is prescribed to patients who are taking cocaine.

Cocaine use can lead to acute psychiatric presentations which require emergency assessment and possible admission. This would be applicable if a person presents with symptoms of paranoia, hallucinations and in a state of agitation after the acute effects of cocaine have worn off, or if a person presents with acute distress leading to suicidal ideation.

Some helpful contacts when further emergency assessment or admission may be required or to form part of a safety plan for a patient:

Breathing Space: 0800 83 85 87 (a free confidential service which offers telephone support to people experiencing low mood, depression and anxiety).

NHS 24 Mental Health Hub can be accessed by calling 111. They are available 24 hours a day for patients in mental health crisis and hub staff will then support access to the OOHs CPN Service if specialist mental health assessment is required. This provides people with one point of access and no call charges. They can also be supported to access the most appropriate response to meet their needs at the time they need it.

In addition, there is direct access to the Out of Hours CPN service via the Mental Health Assessment Units based at Leverndale and Stobhill Hospitals, which can be accessed through the NHS GG&C switchboard or by calling 0141 211 3600. This number is for profession-to-profession referrals only and not for general public use.

Where there is uncertainty around roles of addiction workers and Adult Mental Health colleagues it may be helpful to refer to the following document which can be found on the MyPsych website & app: Adult Mental Health & Addictions Service Shared Guidance and Specification for Interface Working March 2021.