Cocaine

Cocaine is not a medical intervention you are being asked to accept. It is a recreational drug with well-documented acute and chronic harms. The burden of proof is on the person using it, not on a system asking you to take it.

The evidence here shows three distinct injury pathways from cocaine use. The first is coronary vasospasm: a 46-year-old man with chest pain, high blood pressure, and ECG changes that looked like a heart attack had completely normal coronary arteries on angiography [1]. The cause was cocaine-induced spasm of the vessels, which can mimic a heart attack without any blockage. The second is cardiomyopathy: a 43-year-old man with a decade of cocaine use presented with severe heart failure, an ejection fraction below 20%, and ended up being evaluated for a heart transplant [2]. The third is brain damage: a review of 50 postmortem brains from polydrug users found strokes, hemorrhages, and widespread vascular injury, along with molecular changes in dopamine and opioid systems [3].

The evidence is all case reports and a single pathology review. There are no large randomized trials of cocaine's harms because it would be unethical to randomize people to use it. The harms are established through clinical observation and autopsy studies, which is the standard for a substance that is illegal and known to be toxic. The mechanism is clear: cocaine constricts blood vessels, raises blood pressure, and damages the heart muscle directly. The brain injuries come from the same vascular effects plus direct neurotoxicity.

My call: cocaine carries a high risk of heart attack, heart failure, stroke, and brain damage, with no medical benefit for recreational use. Confidence: high.