Metabolism, Not Mendacity: Rethinking Prolonged Cocaine Positivity.
Daniel M Bowen, Maryam Soltani
✦ AI-curated · Sources linked
Case in brief
A 42-year-old man with severe stimulant use disorder had urine tests positive for cocaine metabolites for 18 days, including 12 days after abstinence was verified in a residential program. Evaluation found hepatic steatosis and poor-metabolizer phenotypes at CYP2D6 and CYP3A5. Creatinine-corrected benzoylecgonine concentrations declined steadily without fluctuation, and no cross-reactive medications or other confounding substances were identified. The pattern was consistent with delayed metabolite elimination rather than recurrent cocaine use.
What made this case unusual
Persistent positivity after verified abstinence was accompanied by a steady, monotonic decline in creatinine-corrected benzoylecgonine, with hepatic steatosis and poor-metabolizer phenotypes at CYP2D6 and CYP3A5 providing context for delayed clearance.
Diagnostic / clinical pearl
When cocaine metabolites remain detectable, interpret the concentration trend alongside verified abstinence, hepatic findings, pharmacogenomic results, and possible confounders; persistent positivity alone does not establish recurrent use.
Why it matters
Misreading delayed clearance as relapse may undermine treatment engagement and the therapeutic alliance.