Validity testing of commercial urine cocaine metabolite assays: III. Evaluation of an enzyme-linked immunosorbent assay (ELISA) for detection of cocaine and cocaine metabolite

A validity assessment study was performed on the Genetic Diagnostic Enzyme Immunoassay test kit, a new enzyme-linked immunosorbent assay (GDC ELISA) for detection of cocaine and cocaine metabolite in urine. A set of 290 urine specimens, comprised of clinical cocaine urines collected from 5 male subjects who had received single doses of intravenous cocaine, drug-free urines spiked with cocaine, cocaine metabolites, cocaine isomers, and other drugs of abuse, were assayed by GDC ELISA. The results were compared with results by gas chromatography/mass spectrometry (GC/MS) assay for benzoylecgonine. Concordance was high between the GDC ELISA assay and GC/MS and with results reported earlier for other commercial assays. Detection times and specificity of the GDC ELISA antibody were most similar to those of the Abuscreen radioimmunoassay for cocaine metabolite. Overall, the assay produced no false negative or false positive results and appeared to be a reliable screening test for detection of cocaine and benzoylecgonine in human urine.     

Drug contamination of US paper currency

It is known that US paper currency in the general circulation is contaminated with cocaine. Several mechanisms have been offered to explain this finding, including contamination due to handling during drug deals and the use of rolled up bills for snorting. Drug is then transferred from one contaminated bill to others during counting in financial institutions. The possibility of contamination of currency with other drugs has not been reported. In this study, the author reports the analysis of 10 randomly collected US$ 1 bills from five cities, for cocaine, heroin, 6-acetylmorphine (6-AM), morphine, codeine, methamphetamine, amphetamine and phencyclidine (PCP). Bills were immersed in acetonitrile for 2h prior to extraction and GC-MS analysis. Results showed that 92% of the bills were positive for cocaine with a mean amount of 28.75+/-139.07 microg per bill, a median of 1.37 microg per bill, and a range of 0.01-922.72 microg per bill. Heroin was detected in seven bills in amounts ranging from 0.03 to 168.50 microg per bill: 6-AM and morphine were detected in three bills; methamphetamine and amphetamine in three and one bills, respectively, and PCP was detected in two bills in amounts of 0.78 and 1.87 microg per bill. Codeine was not detected in any of the US$ 1 bills analyzed. This study demonstrated that although paper currency was most often contaminated with cocaine, other drugs of abuse may be detected in bills.     

Further studies on spot tests and microcrystal tests for identification of cocaine

The presence of cocaine in illicit drug samples is still being determined in some laboratories using spot tests and microcrystal tests. Seventeen chemical species were tested using three different spot tests (Wagner, Marquis, and cobalt thiocyanate followed by stannous chloride reactions) and two microcrystal tests (gold chloride and platinic chloride) to determine whether the results could be differentiated from the results of these tests on cocaine. The data obtained indicated that nine of the 17 compounds gave results similar to those from cocaine using the three spot tests, but that the results from microcrystal testing allowed for differentiation of all nine compounds from cocaine.     

Cocaine and homicide in Memphis and Shelby county: an epidemic of violence

In Memphis and the surrounding county, there were a record number of homicides (179) in 1986. During the same year, there was a marked increase in medical examiner cases where tests were positive for cocaine or its metabolites. Review of medical examiner and toxicology records from 1980 to 1986 found 87 cocaine related deaths; 46 of these were homicides. In 1986 alone, there were 53 cocaine related deaths, all manners, and 31 cocaine related homicides. In this year, 17.3% of the homicides were positive for cocaine or metabolite. The cocaine related homicides were similar to other homicides in terms of age, race, sex, blood ethanol concentration, and cause of death being due most often to firearms. In homicide cases in which an abuse drug was detected, cocaine accounted for the entire increase in 1986. Police records indicated that cocaine directly contributed to the homicide in 39% of the cases in which the drug was found. In other cases, we speculate that cocaine altered behavior may have contributed to the victim's being murdered either during the drug "high" or during the posteuphoric depression or withdrawal phase.     

Brain concentrations of cocaine and benzoylecgonine in fatal cases

Since cocaine in blood rapidly hydrolyzes to benzoylecgonine, cocaine concentrations determined in postmortem blood may not reflect the presence or concentration of cocaine in the body at the time of death. The interpretative value of the determination of cocaine and benzoylecgonine in brain tissue was investigated. Cocaine and benzoylecgonine were quantitated by coextraction and formation of the propyl derivative of benzoylecgonine followed by selected ion monitoring gas chromatography/mass spectrometry (GC/MS) using electron ion impact ionization. Cocaine and benzoylecgonine were found to be evenly distributed throughout the brain. Cocaine and benzoylecgonine concentrations were stable in frozen brain tissue (-4 degrees C) on reanalysis after 1 to 3 months of storage, and in refrigerated tissue (10 degrees C) after 30 days of storage. Blood, brain, and liver concentrations of cocaine and benzoylecgonine in 37 cocaine overdose cases and 46 cases in which cocaine was incidental to the cause of death were reviewed. The ratios of cocaine/benzoylecgonine in the toxic cases (brain mean 14.7 and blood mean 0.64) were clearly different from those found in the incidental cases (brain mean 0.87 and blood mean 0.27). The brain/blood ratios of cocaine and benzoylecgonine concentrations generally were characteristic of the time elapsed since cocaine dosing. In cocaine overdose cases, the mean ratio was 9.6 for cocaine and 0.36 for benzoylecgonine. These are within the range found in animal studies for brain/blood ratios of cocaine and benzoylecgonine 0.5 to 2 h after cocaine administration. In incidental cases, the brain/blood ratios were mean 2.5 for cocaine and 1.4 for benzoylecgonine.(ABSTRACT TRUNCATED AT 250 WORDS)     

Classical stimulants in Dallas County: A retrospective review of toxicological,seized drug,and demographical data from 2017 to 2022

Cocaine and methamphetamine remain highly abused drugs in the United States due to their euphoric effects. This study examines classical stimulant casework, defined as cases positive for methamphetamine and/or cocaine, received by the Toxicology Laboratory and the Drug Analysis Laboratory at the Dallas County Southwestern Institute of Forensic Sciences from local law enforcement agencies and/or the Office of the Medical Examiner (OME) between January 1, 2017, and December 31, 2022. Methamphetamine positivity increased from 10.4% to 20.3% in the Toxicology Laboratory over the 6 years, whereas cocaine positivity remained relatively stable at approximately 17%. Similarly, in the Drug Analysis Laboratory, the methamphetamine positivity rate changed from 24.8% to 33.2%, whereas cocaine identification remained stable at approximately 20%. Blood concentrations of methamphetamine in OME cases ranged from 10.1–42,740.0 ng/mL while they were lower in DWI casework ranging from 10.2–2385.0 ng/mL. The blood concentration trends of cocaine were similar to methamphetamine, with OME casework ranging higher (10.0–24,501.0 ng/mL) than DWI casework (10.2–371.6 ng/mL). Polydrug use was evident for both methamphetamine and cocaine in postmortem cases, and the top three most frequently co-occurring drug/drug class were opioids/opiates, cannabinoids, and ethanol. The results from this study aid in the understanding of historical usage trends of cocaine and methamphetamine in Dallas County and how those trends have changed over time as newer stimulant drugs have emerged.     

Cocaine-associated rhabdomyolysis and excited delirium: different stages of the same syndrome.

Previous case reports indicate that cocaine-associated rhabdomyolysis and excited delirium share many similar features, suggesting that they may be different stages of the same syndrome. We tested this hypothesis by comparing data from 150 cases of cocaine-associated rhabdomyolysis reported in the medical literature with data from an autopsy registry for 58 victims of fatal excited delirium and 125 victims of fatal acute cocaine toxicity. Patients with rhabdomyolysis are similar to victims of fatal excited delirium with regard to age; gender; race; route of cocaine administration; the experiencing of excitement, delirium, and hyperthermia; and the absence of seizures. Compared with victims of fatal acute cocaine toxicity, patients with rhabdomyolysis are different with regard to each of these variables. Compared with victims of fatal acute cocaine toxicity, both victims of rhabdomyolysis and fatal excited delirium are more likely to be black, male, and younger; to have administered cocaine by smoking or injection; and to have experienced excitement, delirium, and hyperthermia; they are also less likely to have had seizures. Because cocaine-associated rhabdomyolysis and excited delirium have similar clinical features and risk factors, occur in similar populations of drug users, and can be explained by the same pathophysiologic processes, we conclude that they are different stages of the same syndrome. It appears that this syndrome is caused by changes in dopamine processing induced by chronic and intense use of cocaine rather than by the acute toxic effects of the drug.     

Trace evidence dynamics of cocaine on banknotes: A comparison study of paper and polymer banknotes

It is well established that a large proportion of paper banknotes in circulation contain traces of cocaine. Being able to discriminate between the innocent transfer of illicit drug particles acquired through everyday interactions with surfaces such as banknotes, as opposed to transfer resulting from criminal activities can provide valuable intelligence that can inform an investigation. With many countries adopting polymer banknotes as legal tender, it is important to consider the transfer of cocaine from these surfaces as well as the retention of these particulates on polymer banknotes for evaluative interpretation in crime reconstruction. This comparison study assessed three contact variables (force, time, and rotation) on the transfer of cocaine particulates from paper and polymer banknotes onto a human skin proxy. The persistence of cocaine particulates was assessed through a realistic scenario which mimicked a cash transaction. Quantifiable amounts of cocaine were transferred onto the human skin proxy across all of the contacts assessed, with a greater transfer observed with contacts involving polymer banknotes and those contacts which involved rotation. Following extensive handling, cocaine persisted on both banknote types, with paper banknotes retaining larger amounts of cocaine than polymer banknotes. These findings show that cocaine can persist on both paper and polymer banknotes for extended periods of time following handling and is therefore available for transfer. This transfer then readily occurs, even when contact is brief and involves relatively small forces. A key distinction between the banknote types was that cocaine particulates are more likely to transfer from polymer banknotes due to the lower retention rate of particulates on this surface. Such insights can aid in evaluating the relevance of illicit drug particles identified on items or persons of interest in crime reconstruction approaches.     

Testing human hair for drugs of abuse. IV. Environmental cocaine contamination and washing effects

Active cocaine use results in sequestration of parent drug in hair. In addition, hair has unique physicochemical properties that permit absorption of cocaine from the environment. When hair is tested for evidence of cocaine, it is important to consider whether the positive test resulted from active drug use or environmental contamination. In a series of laboratory experiments, it was found that exposure of ‘cut’ hair to cocaine vapor (‘crack’ smoke) and to aqueous solutions of cocaine hydrochloride resulted in significant contamination of hair samples. Similar results were obtained with two subjects who were exposed to cocaine vapor in an unventilated room. The amount of contamination adsorbed by hair depended upon both time and extent of exposure. Washing the hair samples with methanol removed >70% of the cocaine contaminant after cocaine vapor exposure, but was less effective (<50%) following contamination with aqueous cocaine. Shampoo treatment cycles (overnight soaking) progressively removed increasing amounts of cocaine from the contaminated hair, but residual cocaine remained after 10 cycles. Studies were also performed to determine the usefulness of benzoylecgonine as a marker of active cocaine administration. Small amounts of benzoylecgonine (ca. 1 ng/mg) were formed in hair as a result of environmental contamination with cocaine. Also, it was found that benzoylecgonine could be adsorbed from illicit cocaine contaminated with benzoylecgonine. It was concluded that positive hair test results should be interpreted cautiously due to the possibility of environmental contamination from cocaine and related constituents.     

Evidence on unusual way of cocaine smuggling: cocaine-polymethyl methacrylate (PMMA) solid solution--study of clandestine laboratory samples

An abandoned clandestine laboratory was seized in Slovenia. All confiscated exhibits were analysed in a forensic laboratory, where the following analytical methods were applied: capillary gas chromatography coupled with mass spectrometry (GC-MS) combined also by solid-phase micro extraction (SPME) and pyrolysis (Py) technique, Fourier transform infrared spectrometry (FTIR) and scanning electron microscopy with energy dispersive X-ray detector (SEM-EDX). The most interesting analytical findings can be summarised as follows: at the crime scene some plastic pieces, which contained cocaine dissolved (as solid solution) in polymethyl methacrylate-plexiglass (PMMA), were found. The highest cocaine concentration measured in the plastic sample was about 15% by weight. Two larger lumps of material (12 and 3 kg) were composed mainly of PMMA and CaCO3 and contained only 0.4 and 0.5% of cocaine, respectively. As for the low cocaine concentration, we assume that those two lumps of material represent discarded waste product--residue after the isolation of cocaine from plastic. Higher quantities of pure solvents (41 l) and solvent mixtures (87 l) were seized. We identified three types of pure solvents (acetone, gasoline and benzine) and two different types of solvent mixtures (benzine/acetone and gasoline/acetone). The total seized volume (87 l) of solvent mixtures holds approximately 395 g of solid residue formed mainly of PMMA and cocaine. Obviously solvent mixtures were used for isolation of cocaine from the plastic. Small quantities of relatively pure cocaine base were identified on different objects. There were two cotton sheets, most probably used for filtration. One sheet had traces of cocaine base (76% purity) on the surface, while cocaine in hydrochloride form (96%) was identified on the other sheet. GC-MS analyses of micro traces isolated from analytical balances showed the presence of cocaine and some common adulterants: phenacetine, lidocaine and procaine. A cocaine sample compressed in the shape of block was also seized. The above analytical findings inferred us to the conclusion that the illicit laboratory was used for the isolation of cocaine from PMMA resin. Further more, analyses confirm that not only isolation but also further manipulation of cocaine, i.e. adulteration/dilution, as well as the formation of cocaine blocks took place in the house. The information obtained through analyses also allowed us to make some hypotheses about possible multistage isolation procedure.     

Cocaine babies: the scourge of the '90s

Six cases of cocaine-related deaths of infants have covered the spectrum of potentially devastating effects. They include an intrauterine death of a 35-week-old fetus following acute maternal cocaine abuse; anoxic encephalopathy at birth with 3 months' vegetative survival from a similar episode; traumatic compression asphyxia in a 4-month-old; infectious cardiomyopathy with heart failure in a twin at age 21 months following maternal cocaine abuse at birth; malnutrition and dehydration in a 7-week-old during continuing cocaine abuse by the parents; and a teenage sibling's cocaine lacing of a baby milk bottle ingested by his 6-week-old brother. All the cases had positive toxicological screening for cocaine or metabolites or both in the mother at delivery or in the infant at birth, or both. There were no instances of sudden infant death syndrome (SIDS, or "crib death"). Pathologic and toxicologic, as well as birth, developmental, and social data are presented. An integrated medical, public health, law enforcement, and educational policy to prevent or at least ameliorate these tragic cases, now approaching epidemic proportions, has yet to be developed. A careful obstetrical history and examination of the mother, indication on the birth certificate of maternal drug abuse, and notification of health authorities (by birth certificate checking, among other ways) may send an early warning message to providers for intercession. Active ingestion/injection and passive inhalation by older children and teenagers require more intensive monitoring and aggressive interaction by pediatricians, social workers, school authorities, and employers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Application of discriminant analysis to differentiate between incorporation of cocaine and its congeners into hair and contamination

The requirement to differentiate between incorporation and external contamination of drugs into hair is undisputed, in particular when dealing with compounds which are administered by sniffing or inhalation (e.g. cocaine). With the aim of making this discrimination, hair samples from cocaine (COC) users (group IN) and seized cocaine samples (group OUT) were compared regarding the parameters benzoylecgonine (BZE), ecgonine methyl ester (EME), ecgonine (ECG), anhydroecgonine methyl ester (AEME), cocaethylene (CE) and norcocaine (NCOC). Since most of these compounds may be minor by-products of COC or be formed by biotransformation or chemical degradation, the stability of each substance was carefully examined. COC was found to be converted into significant amounts of BZE, EME and ECG even under mild extraction conditions, while traces of NCOC proved to be a ubiquitous by-product of COC. Cocaine positive hairs and seized cocaine samples (diluted to relevant concentrations) were equally preprocessed and analyzed by LC-MS-MS. Out of the metabolites listed above, NCOC, CE and AEME (each normalised to COC) were significantly increased in the incorporation group (i.e. hair samples from cocaine users). Based on this approach, a statistical discriminant analysis enabled us to make a prediction (and estimation of uncertainty) for each cocaine positive hair sample as to its likelihood of belonging to the group of cocaine users or of being contaminated.     

Concentrations of cocaine and its major metabolite benzoylecgonine in blood samples from apprehended drivers in Sweden

Cocaine and its major metabolite benzoylecgonine (BZE) were determined in blood samples from people arrested in Sweden for driving under the influence of drugs (DUID) over a 5-year period (2000-2004). Venous blood or urine if available, was subjected to a broad toxicological screening analysis for cannabis, cocaine metabolite, amphetamines, opiates and the major benzodiazepines. Verification and quantitative analysis of cocaine and BZE in blood was done by gas chromatography-mass spectrometry (GC-MS) at limits of quantitation (LOQ) of 0.02mg/L for both substances. Over the study period 26,567 blood samples were analyzed and cocaine and/or BZE were verified in 795 cases (3%). The motorists using cocaine were predominantly men (>96%) with an average age of 28.3+/-7.1 years (+/-standard deviation, S.D.). The concentration of cocaine was below LOQ in 574 cases although BZE was determined at mean, median and highest concentrations of 0.19mg/L, 0.12mg/L and 1.3mg/L, respectively. In 221 cases, cocaine and BZE were together in the blood samples at mean and (median) concentrations of 0.076mg/L (0.05mg/L) and 0.859mg/L (0.70mg/L), respectively. The concentrations of BZE were always higher than the parent drug; mean BZE/cocaine ratio 14.2 (median 10.9) range 1-55. Cocaine and BZE were the only psychoactive substances reported in N=61 cases at mean (median) and highest concentrations of 0.095 (0.07) and 0.5mg/L for cocaine and 1.01 (0.70) and 3.1mg/L for BZE. Typical signs of drug influence noted by the arresting police officers included bloodshot and glossy eyes, agitation, difficulty in sitting still and incoherent speech.     

Four deaths due to intravenous injection of cocaine

Cocaine is a potent psychotropic drug that alters mood and behavior by stimulating the central nervous system. Deaths from abuse of cocaine are relatively rare. Most such deaths appear to be related to the intravenous injection of the drug. Acute fatal cocaine intoxication is characterized by headache, cold sweats, rapid pulse, tremors and nausea, followed by convulsions, unconsciousness and death. The prime mode of death appears to be respiratory paralysis, secondary to the effects of cocaine on the medullary portion of the brain. This paper presents four deaths due to acute cocaine intoxication following intravenous injection. Blood concentrations of cocaine were 0.11, 0.37, 0.36 and 0.75 mg/dl.     

Radioimmunological determination of cocaine in human hair

A simple procedure for the determination of cocaine in human hair was described. After washing hair samples were crushed in 0.1 m HCl and incubated overnight at 45 degrees C. The acid extracts were neutralized with 1 m NaOH. Phosphate buffer (pH 7.4) was added to the extracts. The cocaine concentrations were measured by radioimmunoassay. Detection in hair was achieved in all hair samples obtained from cocaine users. This method appears to be suitable for the routine determination of cocaine.     

Detection of cocaine and its polar transformation products and metabolites in human urine

This paper describes a method for the analysis of thermal degradation compounds generated from cocaine during the smoking process, together with chemical and enzymatic biotransformation products which, by virtue of their polarity, are not recovered by existing analytical procedures. The method employs cation exchange solid phase extraction coupled with gas chromatography/mass spectrometry. Compounds identified in urine from subjects of cocaine-related death included cocaine, benzoylecgonine, ecgonine methyl ester and ecgonine, which were measured quantitatively, and ecgonidine, ecgonidine methyl ester, ecgonine ethyl ester, ethyl benzoylecgonine, norcocaine, benzoylnorecgonine, cinnamoylcocaine, and cinnamoylecgonine. The concentrations of ecgonine (0–104 μg/ml) and ecgonine methyl ester (0–177 μg/ml) were substantial and averaged about one tenth the concentrations of benzoylecgonine (0–1074 μg/ml) and cocaine (0–1221 μg/ml). These and several of the other compounds identified will be valuable markers for cocaine use, in degraded samples and for indicating the route of administration.     

The effect of sodium fluoride preservative and storage temperature on the stability of cocaine in horse blood, sheep vitreous and deer muscle

The in vitro stability of cocaine in horse blood, sheep vitreous humour (VH) and homogenised deer muscle is described. The stability of cocaine in horse blood was of interest because many toxicology laboratories utilise horse blood for the preparation of calibration and check standards and the latter are typically stored during routine use. The storage stability of cocaine in human VH and muscle has not been previously reported. In the absence of blank human VH and muscle, cocaine stability under varying conditions was demonstrated in animal tissues. Blood and VH were stored with and without addition of NaF at room temperature (RT), 4°C and -18°C for 84 days. Muscle homogenates were prepared in water, water/2% NaF, and phosphate buffer (pH 6.0)/2% NaF, and stored for 31 days at RT, 4°C and -18°C. Cocaine stability in human muscle obtained from cocaine positive forensic cases was assessed following storage at -18°C for 13 months. Cocaine and benzoylecgonine (BZE) were extracted using SPE and quantified by GC-MS/MS. Cocaine was stable for 7 days in refrigerated (4°C) horse blood fortified with 1 and 2% NaF. In the absence of NaF, cocaine was not detectable by day 7 in blood stored at RT and 4°C and had declined by 81% following storage at -18°C. At 4°C the rate of cocaine degradation in blood preserved with 2% NaF was significantly slower than with 1% NaF. The stability of cocaine in horse blood appeared to be less than that reported for human blood, probably attributable to the presence of carboxylesterase in horse plasma. Cocaine stored in VH at -18°C was essentially stable for the study period whereas at 4°C concentrations decreased by >50% in preserved and unpreserved VH stored for longer than 14 days. Fluoride did not significantly affect cocaine stability in VH. The stability of cocaine in muscle tissue homogenates significantly exceeded that in blood and VH at every temperature. In preserved and unpreserved samples stored at 4°C and below, cocaine loss did not exceed 2%. The increased stability of cocaine in muscle was attributed to the low initial pH of post-mortem muscle. In tissue from one human case stored for 13 months at -18°C the muscle cocaine concentration declined by only 15% (range: 5-22%). These findings promote the use of human muscle as a toxicological specimen in which cocaine may be detected for longer compared with blood or VH.     

14C analyses quantify time lag between coca leaf harvest and street-level seizure of cocaine

Measurements were made on the natural abundance (14)C content (Δ(14)C) of cocaine specimens seized between 2003 and 2009. The objective of this study was to determine the extent to which Δ(14)C analyses could quantify the "age" of recent cocaine seizures. Here "age" of a seized cocaine specimen is defined as the time period between when a coca leaf was harvested in South America and its seizure as cocaine at either the international or domestic street levels. Based on Δ(14)C analyses of seizure specimens, there were no statistically significant differences in the ages of domestic cocaine HCl and cocaine base specimens seized on the streets in different locations across the United States. Between 2007 and 2009, the average age of a street-level cocaine seizure in the United States was 24.6±1.1 months. Cocaine shipment seizures that were in excess of 150 kg during this time period had an average age of 18.2±1.4 months, whereas smaller shipment seizures were significantly older with an average age of 22.3±0.6 months. Analyses of the largest cocaine shipment seizures suggested that these seizures were composed of specimens with different ages, possibly representing accumulations over as much as a 31-month period.     

Hair and urine analysis: relative distribution of drugs and their metabolites

This work studies the distribution of cocaine and heroin metabolites in hair and urine of living polidrug abusers. Cocaine, benzoylecgonine (BEG), ecgonine methyl ester (EME), morphine, codeine and 6-monoacetylmorphine (6-MAM) were simultaneously extracted and analyzed by GC/MS in SIM mode. The results obtained show a different distribution of heroin and cocaine metabolites in urine and hair. In urine, we generally find BEG and EME for cocaine abuse, and morphine for heroin abuse. In hair, we detect cocaine and MAM as major metabolites for cocaine and heroin abuse, respectively.     

Cocaine‐Induced Intracerebral Hemorrhage in a Patient with Cerebral Amyloid Angiopathy*

Abstract: Intracerebral hemorrhage (ICH) is a well‐recognized complication of recreational cocaine use. The precise mechanism of the cocaine‐induced hemorrhagic event is unclear, although multiple factors have been implicated. We report a case of a 62‐year‐old woman who suffered left parieto‐occipital ICH with herniation and death, following a cocaine binge. Microscopic examination also revealed extensive cerebral amyloid angiopathy (CAA) in the vicinity of the hemorrhage. We additionally studied brain tissue in eight subjects between ages of 60 and 80 who were positive for cocaine metabolites at autopsy; of these, none had vascular amyloid‐β deposits by immunohistochemistry. Whereas we found no evidence that chronic cocaine use is a risk factor for CAA, given the age‐associated nature of CAA and the aging population using cocaine, CAA‐induced hemorrhage in the setting of cocaine use may be more common than recognized. This is the first reported case of CAA‐associated ICH precipitated by cocaine.