Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Stimulant-Related Disorders (Cocaine)


Related Terms

  • Cocaine Abuse
  • Cocaine Addiction
  • Crack Abuse

Differential Diagnosis

Specialists

  • Cardiovascular Internist
  • Clinical Psychologist
  • Occupational Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

It has been demonstrated that the most reliable predictor of treatment outcome, regardless of treatment strategy, is the individual's readiness to change. The severity of the abuse or dependence/stimulant use disorder, the success of the treatment program, appropriate individual-treatment matching, and any physical complications may influence the length of disability as well. A stable history of employment is also a major predictor of permanent abstinence.

Medical Codes

ICD-9-CM:
304.20 - Cocaine Dependence; Unspecified
305.60 - Cocaine Abuse; Unspecified
305.61 - Cocaine Abuse; Continuous
305.62 - Cocaine Abuse; Episodic
305.63 - Cocaine Abuse; in Remission

Overview

Cocaine is a naturally occurring substance produced from the leaves of the coca plant. It belongs to a class of drugs known as stimulants, acting as a dopamine reuptake inhibitor, which directly affects the balance of neurotransmitters in the central nervous system (brain). Repeated cocaine consumption can cause addiction and other adverse health consequences.

While cocaine has proven to be associated with a high potential for abuse, it is sometimes prescribed for legitimate medical uses, such as a local anesthetic for some eye, ear, and throat surgery.

Cocaine may be inhaled through the nose, smoked, chewed, or injected into the veins, producing almost immediate central nervous system effects. These effects include feelings of well-being, confidence, and euphoria. Cocaine can come in many forms. Cocaine hydrochloride salt is a white powder that dissolves in water. Users can inject the resulting solution into a vein (intravenously) or inhale it into the nose (snorting). The freebase form of cocaine that has not been neutralized by an acid to make the hydrochloride salt can be smoked. The white powder sold on the street is usually diluted with inert substances such as cornstarch or talcum powder, or with active drugs such as the local anesthetic procaine or with stimulants such as amphetamines.

Cocaine dependence usually begins with episodic use (abuse), which may involve using the drug 2 or 3 days a week, or binging. During binges, the user may consume a significant amount of cocaine in a short period, stopping only when exhausted or when the cocaine supply ends. Because cocaine's effects dissipate within about 30 to 50 minutes, there is a need for frequent dosing to maintain the desired psychological effects. The more frequent use can lead to dependence after only a few weeks or months of recreational use.

Note: For the substance/medication-induced disorders approach established by the DSM-IV-TR, and the DSM-5, please see the following topics: Substance/Medication-Induced Anxiety Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Substance/Medication-Induced Depressive Disorder, Substance/Medication-Induced Major or Mild Neurocognitive Disorder, Substance/Medication-Induced Obsessive-Compulsive and Related Disorder, Substance/Medication-Induced Psychotic Disorder, Substance/Medication-Induced Sexual Dysfunction, and Substance/Medication-Induced Sleep Disorder.

Incidence and Prevalence: The National Survey on Drug Use and Health (NSDUH) estimated that in 2008 there were 1.9 million current (past-month) cocaine users, of which about 359,000 were current crack users. According to the NSDUH, in 2008, nearly 1.4 million Americans met the Diagnostic and Statistical Manual of Mental Disorders criteria for dependence or abuse of cocaine (in any form) in the past 12 months (Substance Abuse and Mental Health Services Administration). Data from a Drug Abuse Warning Network (DAWN) report showed that cocaine was involved in 422,896 of the almost 4.6 million visits to emergency departments for drug misuse or abuse in 2009 (Highlights).

Adults aged 18 to 25 years have a higher rate of current cocaine use than other age groups; 1.5% of young adults report past month cocaine use. Cocaine use is more prevalent in men than in women. The 2009 Monitoring the Future survey (an annual survey of teen attitudes and drug use) reported a significant decline in the 30-day prevalence of powder cocaine use among 8th-, 10th-, and 12th-graders from its peak use in the late 1990s, as well as significant declines in past-month use among 10th- and 12th-graders from 2008-2009 (Johnston). In recent years (2007-2012), cocaine use has decreased; the number of current users aged 12 or older dropped from 2.1 million to 1.7 million (DrugFacts).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Risk factors for drug abuse and dependence include a family history of addiction; being male (although progression of addictive disorders is faster in females); presence of another mental disorder; peer pressure; lack of family support; depression, anxiety, and loneliness; and consumption of a highly addictive drug (such as cocaine).

Source: Medical Disability Advisor



Diagnosis

History: The euphoric effects of cocaine are extremely potent, and individuals exposed to it can develop dependence/stimulant use disorder after using the drug for very short periods of time. When cocaine is taken in small amounts (up to 100 mg), these effects may include intense elation (euphoria), feeling energetic, becoming more talkative, and being more mentally alert, with temporarily decreased need for food and sleep. Some users report that they can perform simple physical and mental tasks more quickly, while others report the opposite effect.

Individuals who have been using cocaine for a significant period of time may suffer from restlessness, extreme excitability, and insomnia. Repeated use of high doses of cocaine in some individuals may lead to a toxic psychosis characterized by mounting anxiety, paranoia, and auditory, visual, and tactile hallucinations.
For those who only occasionally use cocaine, physical symptoms associated with withdrawal will be minimal, if they occur at all, and may include abdominal cramps, nausea, diarrhea, fever, chills, and exhaustion. However, with chronic use, abrupt cessation of cocaine use will result in depression, sleep disturbances, sluggishness (lethargy), muscle aches, and often a powerful craving for the drug.

An early sign of cocaine dependence is when the individual finds it increasingly difficult to resist using cocaine when it is available. Because of its short half-life (approximately 30-50 minutes), there is a need for frequent dosing to maintain a "high."

Both DSM-5 and DSM-IV-TR agree that individuals with cocaine dependence/stimulant use disorder will manifest at least 2 (as specified in DSM-5) or 3 (as specified in DSM-IV-TR) of the following, occurring at any time in the same one-year period: (1) Tolerance, as defined by a need for greatly increased amounts of the substance to achieve intoxication or desired effect (regardless of the route of administration); (2) withdrawal, characterized by hypersomnia, increased appetite, and dysphoric mood, or other feature that leads to pursuit of the drug to alleviate withdrawal symptoms (see withdrawal syndrome below); (3) the substance is taken in larger amounts or over a longer period of time than was intended; (4) there is a persistent desire or unsuccessful efforts to cut down or control substance use; (5) a great deal of time is spent in activities necessary to obtain the substance; (6) important social, occupational, or recreational activities are given up or reduced because of substance abuse; (7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by the substance.

Withdrawal syndrome for cocaine appears after cessation and consists of a dysphoric mood and at least two of the following: fatigue; vivid, unpleasant dreams; insomnia or hypersomnia; increased appetite; and psychomotor retardation or agitation. The signs or symptoms develop within a few hours to several days after the cessation of cocaine; cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; are not attributable to another medical condition, and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance (DSM-5).

Once a diagnosis is made, it is also necessary to specify the current severity: mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms) (DSM-5). It is important to specify if there is physiological dependence (evidence of tolerance or withdrawal, that is associated with an earlier onset of dependence and more cocaine-related problems), or if there is no physiological dependence (no evidence of tolerance or withdrawal). The course specifiers are: early full remission, early partial remission, sustained full remission, sustained partial remission, on agonist therapy, and in a controlled environment (DSM-IV-TR).

Physical exam: After a single dose of 100 mg or less, there may be enlarged (dilated) pupils (mydriasis), constricted blood vessels (causing pale, cool skin), increased blood pressure (hypertension), and increased core body temperature and heart rate (tachycardia). In long-term users, exam may reveal enlarged (dilated) reactive pupils, tachycardia and hypertension, rapid breathing (tachypnea), increased perspiration (diaphoresis), and anxiety. The individual should be examined for a perforated nasal septum or decreased sense of smell (from inhaling cocaine), or needle marks and abscesses indicating injection. With time, marked weight loss may be evident. A mental status examination may reveal signs of confusion, paranoia, hallucinations, impulsivity, agitation, and hyperactivity. Symptoms of a cocaine overdose include an elevated temperature, shallow respirations, and tachycardia and hypertension.

Tests: A poly-drug blood or urine screen test can confirm cocaine use and the approximate amount used, if done within a few hours of use. Electrocardiogram (ECG) may reveal disturbances of heart rhythm.

Note: It must be kept in mind that just because a physical diagnosis cannot be established as the cause of the presenting symptomatology, it does not necessarily mean that the cause is a mental one. That is to say that the presence of medically unexplained symptomatology does not necessarily establish the presence of a psychiatric condition. The first step in identifying the presence of a mental disorder is excluding the presence of malingering and/or of factitious disorder. Although factitious disorder is conscious and purposeful, it is classified as a psychiatric disorder. The strong need for this step is especially true whenever there is a medicolegal context associated with the presenting problem(s). Additionally, using DSM-5 and/or ICD-9-CM or ICD-10-CM, the clinician will find that many presentations fail to fit completely within the boundaries of a single mental disorder. There are systematic ways to go about making psychiatric diagnoses, however.

Source: Medical Disability Advisor



Treatment

In the acute or chronic phases of cocaine intoxication, any medical complications must be treated promptly, including disturbances in the heart rhythm (arrhythmias) or dangerous elevations of blood pressure. Loss of blood flow (ischemia) that causes death (necrosis) of a part of the heart muscle (heart attack, or myocardial infarction) or intestine (ischemic colitis) must be treated appropriately. There is some debate over whether therapy to dissolve blood clots (thrombolytic therapy) should be used in heart attack related to cocaine abuse. A perforated nasal septum sometimes needs surgical repair, and abscesses for infected injection sites may need antibiotic treatment or surgical drainage.

Abstinence from cocaine use is the treatment goal. After the individual ceases using cocaine, it takes about a week to rid the body of the acute effects of cocaine withdrawal, including fatigue, unpleasant dreams, insomnia or hypersomnia, increased appetite, slowed thinking and physical reactions (psychomotor retardation), or agitation. Medication therapy may include dopamine antagonists, mixed dopamine receptor agonists such as pergolide, and/or antidepressants. Because most individuals do not benefit from any currently available pharmacotherapy for withdrawal symptoms, drug therapy is not ordinarily indicated as an initial treatment. However, individuals with a more severe dependence or who fail to respond to psychosocial treatment should be considered for treatment with dopaminergic medications. Other common psychological disorders common to cocaine addicts—depression and bipolar affective disorder—may require treatment with antidepressants or lithium.

Acupuncture has also been shown to reduce withdrawal symptoms as well as counteract the craving for cocaine.

Treatment services, which include individual psychotherapy, family therapy, drug education, acupuncture, and relaxation training, are usually conducted in an outpatient setting. Twice-weekly sessions have been found to be effective, whereas once-per-week sessions have not. The only clearly accepted factors indicating a need for inpatient cocaine abuse treatment are severe depression or psychotic symptoms lasting beyond 1 to 3 days after abstinence or repeated outpatient failures. Therefore, hospitalization may be necessary if the individual is violent towards others, suicidal, or is having severe withdrawal symptoms during detoxification. Ongoing structured self-help programs, such as Cocaine Anonymous and Rational Recovery, are recommended as an adjunct to treatment services. Regular but random drug screens should be part of the treatment process. It should also be understood that relapse is often part of the recovery process. The most effective treatment for cocaine use disorders is one of intensive (more than twice a week) outpatient treatment (during the initial stage of treatment), in which a variety of treatment modalities are used simultaneously and in which the focus is abstinence. Cocaine intoxication can produce hypertension, tachycardia, seizures, and paranoid delusions. Usually self-limited and requiring only supportive care, acute agitations may benefit from sedation with benzodiazepines. The psychosocial treatments found to be most effective for individuals with cocaine use disorders are cognitive behavioral therapies, behavioral therapies, and psychodynamic-psychotherapy. Cognitive behavioral therapy is a short-term, problem-focused approach. Assuming that learning processes play an important role in the development and continuation of cocaine abuse or dependence/stimulant use disorder, the same learning processes are used to help individuals reduce drug use. The individual is taught to recognize the situations in which they are most likely to use cocaine, avoid these situations when appropriate, and cope more effectively with a range of problems and behaviors associated with drug abuse.

A behavioral therapy component showing positive results is "contingency management" (also called behavioral contracting). When compared to a 12-step self-help group, behavioral contracting demonstrated better retention rates and abstinence rates. This approach uses a voucher-based system to give positive rewards (contingent) for staying in treatment and remaining cocaine free. Based on drug-free urine tests, the individual earns points that can be exchanged for items that encourage healthy living, such as joining a gym or going to a movie and dinner. The treatment plan should consider all underlying psychiatric or general medical conditions, sex-related factors (including the possibility of pregnancy), social and living environment, cultural factors, and family characteristics. Withdrawing from long-term cocaine abuse requires close supervision because the individual may become depressed and suicidal.

Individuals with more severe problems, such as coexisting psychiatric disorders or criminal involvement, often benefit from therapeutic communities or residential programs with planned lengths of stay of 6 to 12 months. These help integrate the individual back into society and include on-site vocational rehabilitation and other supportive services. When combined with cognitive behavioral therapy, recovery support groups (such as Narcotics Anonymous) also appear to be effective in long-term drug-free recovery. Duration of treatment should be tailored to the individual's needs and may vary from a few months to extended therapy lasting more than 1 year. Monitoring for substance use should be intensified during periods of high relapse risk, including the early stages of treatment, periods of transition to less intensive levels of care, and the first year after completion of active treatment.

Source: Medical Disability Advisor



Prognosis

The mortality risks related to cocaine abuse are significant. An estimated one-third of deaths after cocaine use are due to intoxication directly associated with use of the drug itself, while the other two-thirds are the result of traumatic injuries (e.g., homicides, suicides, falls, motor vehicle collisions) secondary to use of the drug.

There are a significant number of individuals who respond to treatment and stay in remission from cocaine dependence/stimulant use disorder for many years. Only a minority of individuals (15% to 29%) exhibit a pattern of chronic relapse requiring repeated intervention. There are individuals who experience periods of relapse, in which they begin cocaine use after a period of remission, and again meet the criteria for substance dependence/stimulant use disorder.

Of those who remain abstinent for 2 years, almost 90% are substance-free at 10 years, and those who remain substance-free for 10 years have a very high likelihood (over 90%) of being substance-free at 20 years.

There are other individuals who are never able to abstain from cocaine use and who do not experience any periods of remission.

Source: Medical Disability Advisor



Complications

Complications of cocaine use may include sinusitis, runny nose (rhinitis), perforated nasal septum, nosebleeds, lung damage, and respiratory paralysis. Users who inject the drug risk not only overdose but also infections from non-sterile needles, such as skin abscesses, inflammation of the membranes of the spinal cord or brain (meningitis), bacterial endocarditis, as well as hepatitis or acquired immune deficiency syndrome (AIDS) from sharing needles with others.

The most common cardiac complications of cocaine use are heart attack (myocardial infarction), irregular or abnormal heart rhythm (cardiac arrhythmias), stroke, and rupture of the ascending aorta and sudden cardiac death. Other complications include poly-drug abuse. Narrowing of blood vessels supplying the intestine may cause ischemic colitis, a potentially life-threatening complication in which bowel tissue dies, giving way to massive infection. Because cocaine use decreases appetite and food intake, significant weight loss and malnutrition may result. Psychiatric complications include severe anxiety and depression.

Individuals who have chronically used stimulants can occasionally become sensitized (kindling) to any future use of stimulants. When this happens, small amounts of even mild stimulants, such as caffeine, can cause symptoms of paranoia and auditory hallucinations.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many employers have systems in place for individuals recovering from substance dependence disorder/stimulant use disorder to return to work under special contracts or conditions. These conditions may provide guidelines for testing blood and urine levels of identified substances and provide work performance and substance abuse treatment guidelines for the recovering individual. Cocaine should not be tolerated at the workplace, because employees who use cocaine on the job endanger their safety and that of their coworkers, and often create a negative work environment.

Temporary work accommodations may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity.

Risk: An individual with cocaine abuse or dependence may display extreme anxiety, psychosis, and insomnia that presents a safety risk for both the individual and his or her coworkers; therefore, such individuals must be closely monitored and should be prevented from performing safety-sensitive work tasks. Risk of recurrence may be reduced by scheduling regular yet random blood and urine tests to ensure compliance with the work contract, and by encouraging attendance in substance abuse treatment and support groups during the individual's personal time.

Capacity: Capacity may be temporarily reduced if the individual has sustained traumatic injuries from an accident that occurred while using the drug; capacity may be chronically reduced if malnutrition and heart damage occurs from prolonged drug use. Individuals who come to work while intoxicated should be prevented from working.

Tolerance: Tolerance is typically not a concern with this diagnosis.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is expected at 6 months of treatment or less.

Note: MMI is estimated under the assumption that the vagaries involved in psychiatric diagnoses have been taken into consideration.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was a comprehensive assessment completed on this individual?
  • Does individual exhibit at least 3 psychological symptoms of cocaine dependence or abuse, or at least 2 of stimulant use disorder?
  • Were all underlying medical and psychiatric disorders identified?
  • Were other conditions with similar long-term effects such as amphetamine psychosis and paranoid schizophrenia ruled out?

Regarding treatment:

  • Does individual receive intensive (at least twice a week) outpatient treatment where a variety of treatment modalities are used simultaneously and that focuses on abstinence?
  • Has individual experienced any withdrawal symptoms such as cravings and lack of pleasure in what is normally pleasurable?
  • Has individual responded to psychosocial treatment? If not, would individual respond to dopaminergic medications?
  • Would individual benefit from addition of drug therapy to the overall treatment plan?
  • Is cognitive-behavioral therapy part of individual's current treatment plan?
  • Would individual benefit from the contingency management approach?
  • Does individual's current treatment plan take underlying psychiatric or general medical conditions into consideration? What changes could be made to better meet this individual's needs?
  • Would individual benefit from involvement in a therapeutic community or residential program?
  • Does individual participate in a recovery support group?
  • Is individual currently in any of the higher risk periods such as periods of high relapse risk or periods of transition to less intensive levels of care? What monitoring system is in place?

Regarding prognosis:

  • Where is individual in the treatment regimen?
  • Has individual experienced relapses? Are they decreasing in frequency?
  • Would individual benefit from more frequent, more intense, or longer treatment duration?
  • Is individual currently involved in a support group? Which one? Does individual participate in a formal support group? What other support systems does individual have in place?
  • Is individual receiving necessary tools, skills, and encouragement to move ahead with his or her life?
  • Does individual have an underlying condition that may impact recovery?
  • Have any complications developed from cocaine intoxication such as hypertension, tachycardia, seizures, or paranoid delusions?

Source: Medical Disability Advisor



References

Cited

"DrugFacts: Nationwide Trends." National Institute on Drug Abuse. Jan. 2014. National Institutes of Health (NIH). 4 May 2015 <http://www.drugabuse.gov/publications/drugfacts/nationwide-trends>.

"Highlights from the 2009 Drug Abuse Warning Network." National Institute on Drug Abuse. May. 2011. National Institutes of Health (NIH). 4 May 2015 <http://www.drugabuse.gov/publications/drugfacts/drug-related-hospital-emergency-room-visits>.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association, 2013.

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Johnston, L. D. , et al. Monitoring the Future. National Results on Adolescent Drug Use: Overview of Key Findings, 2009 (DHHS Pub. No. 10-7583). US Department of Health and Human Services, 2010.

Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings (DHHS Pub. No. SMA 09-4443). US Department of Health and Human Services, 2009.

Source: Medical Disability Advisor






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