Cocaine

What Kind of Drug Is It?

Cocaine is a natural substance that comes from the leaves of the coca (pronounced KOH-kuh) plant. This plant should not be confused with the cocoa (pronounced KOH-koh) plant, which is the source of chocolate. Cocaine acts as both a stimulant and an anesthetic.

Overview

The coca plant grows in only one part of the world: the northwestern and central regions of South America. A huge portion of the great Andes Mountain system lies along the western coast of the continent. The warm, humid air and rich soil found among these mountain highlands are well suited for the growth of coca. More than a third of the world's supply of coca leaf is grown in Colombia, a South American coastal nation surrounded by the Pacific Ocean to the west and the Caribbean Sea to the north. The rest is grown in the nearby countries of Peru and Bolivia, which share portions of the massive mountain ranges.

Since the mid-1960s, the huge cocaine trade has been the source of violence and political unrest in Colombia. According to Paul M. Gahlinger in Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse, nearly 700 million pounds of coca leaf is produced in South America each year. That is enough leaves to produce well over 500 tons of cocaine. Gahlinger explained that the majority of it "is destined for the United States." The southern part of Colombia is the location of coca leaf processing laboratories. From these labs, converted cocaine powder is shipped to the United States, usually arriving through Mexico; Puerto Rico; Miami, Florida; or New York City.

Official Drug Name: Powder cocaine (cocaine hydrochloride), crack cocaine

Also Known As: Blow, C, coke, nose candy, powder, snow; crack cocaine sometimes referred to as rock

Drug Classifications: Schedule II, stimulant

A Longtime South American Tradition

South Americans in the Andes Mountains have chewed coca leaves for generations. For more than 4,000 years, the mountain people have used coca in much the same way Europeans and North Americans use coffee: for its mild stimulating effects. The leaves are not simply plucked and chewed. Rather, a bit of lime or plant ash is added to the leaves and then the mixture is chewed together. This process helps the naturally

occurring cocaine alkaloid to be released and absorbed into the user's cheek. After about a half an hour, the wad is spit out.

The leaves are also recognized for their medicinal value. When chewed or made into tea, they reportedly ease digestive troubles and reduce the symptoms of certain psychological ills. When used in whole-leaf form, cocaine does not produce a "high" and is not addictive.

Attempts to introduce coca leaves to North American and European nations were largely unsuccessful. The leaves of the coca plant tend to rot quickly. This caused considerable problems with shipping, because the stimulating effects and the medicinal value of the plant were both lost before it could reach its destination. In 1858, however, German chemist Albert Niemann managed to separate cocaine from the coca leaf. In doing so, he unleashed the world's most powerful naturally occurring stimulant. The salt form (cocaine hydrochloride), commonly known as powder cocaine, travels quite well. Soon, large quantities were being consumed far beyond the Andes Mountains.

Cure-All or Curse?

From the 1860s through the early 1900s, cocaine was thought to be a "cure-all." Medical experts mistakenly believed that, like the whole-leaf form, powder cocaine was also non-addictive. For more than four decades, cocaine use was unregulated and widespread in both Europe and the United States. No prescription was necessary to obtain the drug, and it could easily be purchased at grocery stores, at drugstores, and through mail-order catalogs. Containers of 99.9 percent pure powder cocaine were available for sale on the open market.

Cocaine-laced beverages were extremely popular as well. One coca wine known as Vin Mariani was widely recommended by doctors for improving health. The original formula for Coca-Cola, a beverage created by John Pemberton in the 1880s, is said to have contained 60 milligrams of cocaine per serving. However, claims about the exact amount used have not been backed up by solid evidence. (Coca-Cola no longer uses any cocaine in its products.) Cocaine was seen as a remedy for many conditions, including fatigue, toothaches, hay fever, asthma, seasickness, and vomiting during pregnancy.

Although experts maintained that powder cocaine was not an addictive drug, frequent and heavy users began showing unmistakable signs of physical and psychological dependence. By the close of the nineteenth century, reports of nasal damage, addiction, and cocaine-related deaths had surfaced. The toxic and addictive nature of cocaine became public knowledge. By the time the U.S. government stepped in to ban cocaine in 1914, most people were already shunning it.

Usage Decreases until the 1970s

Over the next fifty or so years, cocaine use and abuse was very low. Then, in the 1970s, powder cocaine use began to skyrocket. This trend was followed in the 1980s by a surge in the use of a new form of cocaine called crack. Because crack cocaine is cheaper than powder, it became more readily available to the young and the poor. Crack addiction and crime began to increase rapidly. Television coverage of the epidemic was massive. In response to public concern, the Anti-Drug Abuse Act of 1986 and 1988 was passed. This federal law includes mandatory minimum sentences for first-time offenders. The penalties are much harsher for possession of crack cocaine than powder cocaine.

The Real Thing

It is true that when Coca-Cola was first produced in the mid-1880s, it contained cocaine. In fact, the drink derives its name from its two main ingredients—South American coca leaves and African kola nuts. By 1905 all cocaine had been eliminated from Coca-Cola, but the term "Coca" has remained a part of the popular beverage's name for more than a century.

Andrew Weil and Winifred Rosen noted in their book From Chocolate to Morphine: "Many people can't leave this drug alone if they have it, even though all they get from it after a while is the unpleasant effects characteristic of all stimulants used in excess: anxiety, insomnia, and general feelings of discomfort." Because of

its addictive and destructive nature, a worldwide effort is under way to reduce the production and illicit use of cocaine.

What Is It Made Of?

Cocaine is the most powerful naturally occurring stimulant known. It is found as an alkaloid in the leaves of the Erythroxylon coca trees native to the Andes Mountains. Coca leaves contain 0.5–1.8 percent cocaine, which can be refined to nearly 100 percent purity. The chemical formula for cocaine is C₁₇H₂₁NO₄.

Cocaine in Its Various Forms: Leaves, Paste, Powder, and Freebase

"Drugs and Chemicals of Concern: Cocaine," part of the U.S. Department of Justice, Drug Enforcement Administration (DEA), Diversion Control Program Web site, states that "all mucous membranes readily absorb cocaine." That is why it can be taken in so many different forms. Cocaine is ingested in its mildest form by chewing coca leaves. In addition to cocaine, the leaves contain protein, minerals, vitamins, and more than a dozen alkaloids. Instead of experiencing a rush or a high, chewers first notice numbness of the mouth followed by increased alertness and a general sense of well-being. This form of cocaine use is completely legal and socially acceptable in the mountain regions of South America. Chewing coca leaves is part of the people's religious tradition as well. The leaves can also be made into tea. Coca leaves are not smoked because the temperature needed to burn them destroys the cocaine alkaloid before it can be inhaled.

coca paste is a psychoactive drug that produces a rush followed by a high in those who smoke it. (Psychoactive drugs alter the user's mental state or change behavior.) To make the paste, lime water, kerosene (a type of fuel), and sulfuric acid are added to coca leaves. After the bulky leaf matter is removed, an unpleasant-smelling residue remains. This residue, called coca paste, is usually added to tobacco or marijuana cigarettes and smoked.

With additional processing, coca paste can be converted into powder cocaine (cocaine hydrochloride), which can be more than a hundred times more powerful than coca leaves. This powder is diluted with fillers before it is sold on the street in the United States. Common fillers include cheaper drugs such as amphetamines or sugars such as lactose. Average street powder cocaine is about 60 percent pure.

The most common way to use powder is to snort it into the nose, but it can also be dissolved in water and injected into the veins. Powder cocaine cannot be smoked, but it can be turned into another substance called freebase, which is smokable. Powder cocaine is addictive regardless of the way it is taken.

There are three freebase forms of cocaine, and all of them are highly addictive. The first, coca paste, has already been mentioned. It is made directly from coca leaves and is usually mixed with tobacco or marijuana before being smoked. The second form, simply called freebase, was developed in the mid-1970s. In this process, powder cocaine is converted into freebase by using water, ammonia, and a liquid anesthetic called ether.

Freebasing is a dangerous process because the chemicals are highly explosive and may ignite. Comedian Richard Pryor was badly burned while freebasing. The third and by far the most common form of freebase is crack. Crack forms when cocaine, water, and sodium bicarbonate are combined.

Crack Cocaine: The Drug of the Eighties

Crack is a form of freebase cocaine made from powder cocaine combined with water and sodium bicarbonate. After the resulting mixture is allowed to dry, it is cut into "rocks" weighing between one-tenth and one-half a gram. These rocks resemble human teeth in size, shape, and color. Ten grams of powder cocaine will convert to 8.9 grams of nearly pure crack.

A rock of crack is smoked in a glass pipe. As the crack heats up, the vapors are released and inhaled through the pipe. Sodium bicarbonate is the ingredient that gave crack its name, since it makes a crackling sound when lit. Because crack is inexpensive and delivers large amounts of cocaine to the lungs, it became the most popular form of cocaine shortly after its creation in the 1980s. Although all forms of cocaine are addictive, crack is known as the most highly addictive.

How Is It Taken?

The speed at which cocaine reaches the brain depends on how it is taken. The faster and more intense the high produced in the user, the greater the risk of addiction. Drug researchers have determined patterns in cocaine use. Cocaine abusers are more likely to take the drug at night rather than earlier in the day. They also tend to use up whatever supply they have in one sitting, snorting or injecting the drug over several hours until all of it is gone.

Cocaine is taken in one of four ways. The leaves of the coca plant, combined with lime or plant ash, are chewed, releasing small amounts of cocaine alkaloid in the process. Some of the cocaine is absorbed by the mucous membranes of the mouth and the intestines absorb some of the juice as it is swallowed. The small amount of cocaine entering the bloodstream numbs the mouth, decreases the feeling of hunger, and has a stimulant effect. Rather than feeling a high, users report feelings of well-being that can last one to two hours.

Snorted, Injected, or Smoked—They Are All Addicting

Powder cocaine is snorted through the nose in 20 to 30 milligram doses called "lines." Lines of powder cocaine, about the width of a straw, are placed on a smooth surface and inhaled through one

nostril at a time. In less than a minute, the cocaine travels through the network of blood vessels in the nasal cavity and reaches the brain. The high obtained from snorting powder cocaine is the least intense of all methods of ingestion. The drug causes the blood vessels in the nose to constrict, or tighten up. Thus, the high that is produced is milder, but longer lasting than the high achieved by the remaining two ingestion methods: injecting and smoking.

Some users take powder cocaine, dissolve it in water, and inject the solution directly into their bloodstream through veins. The intravenous, or iv, method of taking cocaine is considered the most dangerous method because it involves the use of needles. In a matter of seconds, the injected cocaine reaches the brain, resulting in an almost immediate rush. IV cocaine use is highly addictive because the rush generally lasts only a few minutes, and the remaining high drops off quickly. To maintain the high, users inject another dose after about fifteen minutes.

Cocaine is also smoked. Users change the cocaine powder into paste or rock form in order to smoke it. If inhaled deeply into the lungs, cocaine vapors will enter the bloodstream in just three seconds. The immediate brain rush occurs slightly faster than the injection method and is achieved without the use of needles. Smoking cocaine is highly addictive because it creates the fastest and most intense rush and subsequent high.

Are There Any Medical Reasons for Taking This Substance?

The age-old tradition of chewing coca leaves continues to be part of the daily culture of South American Indians. This practice has often been compared to the American coffee break. Coca leaves are chewed to increase energy and reduce feelings of nausea in users.

After 1860, cocaine was being processed into powder and shipped to the United States and Europe. When mixed with water and taken by mouth in its liquid form, it was considered a common nonprescription remedy for hay fever, children's toothaches, asthma, and nausea. Snorting and injecting cocaine were somewhat less popular methods of ingestion through the early 1900s.

Only Acceptable Use Is as an Anesthetic

As more and more people used cocaine, it became increasingly obvious that the drug was harmful. Users were getting addicted. In 1914, the Harrison Narcotic Act banned the use of cocaine in the United States, except when used by a physician as a local anesthetic.

Cocaine was the first local, or topically applied, anesthetic ever used. In 1884, physician Carl Koller (1857–1944) started using the drug as a topical anesthetic for eye surgery. Soon it was being used by dentists and veterinarians to deaden pain at the site of surgical incisions. But it was William S. Halsted, the father of modern surgery, who found that cocaine injected under the skin (rather than just rubbed on top of the skin) made an even more effective local anesthetic for surgery. When used in this way, cocaine numbs the site of application almost immediately and lessens bleeding.

Did You Know?

How much do you know about cocaine? Did you know that:

• In 2003, an estimated 2.3 million Americans were current cocaine users. That is nearly 1 percent of the U.S. population. One out of every four of those 2.3 million users was considered "hooked" or dependent on cocaine.
• Research reveals that the coca plant produces cocaine to kill insects that prey on it.
• Cocaine is the second most commonly used illicit drug in the United States, according to Heather Lehr Wagner's 2003 book Cocaine. About 10 percent of Americans over the age of 12 have tried cocaine at least once in their lifetimes. About 2 percent have tried crack. And nearly 1 percent of all Americans are currently using cocaine.

Typically, a 1–4 percent cocaine solution is used for surgical purposes. This highly diluted solution does not have a psychoactive or changing effect on the brain. While cocaine is still used for ear, nose, and throat surgery, another drug called lidocaine has replaced it as the most widely used local anesthetic of modern times.

Usage Trends

When cocaine became popular in the late 1870s, it was thought to be a non-addictive "cure-all." The drug was routinely found in family medicine cabinets, and its use was completely legal. Cocaine use was accepted among factory workers to boost energy and ensure peak efficiency. But by the 1890s, cocaine had become an increasingly abused recreational drug, taken purely for the high it produced in users. During this time of widespread use, medical journals began to report on the toxic and addictive properties of cocaine.

The Era of Prohibition

Public support turned against cocaine around the same time that efforts were being made to ban alcohol in the United States. From 1920 to 1933, a nationwide ban existed on the manufacture and sale of all alcoholic beverages. This was known as the era of prohibition. At that time, alcohol was viewed as a destructive force in society. Crime, poverty, gambling, prostitution, and declining family values were blamed on excessive alcohol use. Even before this great push for Prohibition, however, the Harrison Act of 1914 was passed. This act classified cocaine as a narcotic and prohibited its use in the United States except as a local anesthetic. Tough drug laws were passed between the 1930s and the 1960s, and cocaine use dropped dramatically.

It was not until the 1970s that cocaine use began to rise once more. The drug became part of the disco scene, an era well known for its glittery nightlife, brightly lit dance clubs, outrageous outfits, and distinctive music. Cocaine gave clubbers the energy to dance the night away. Powder cocaine was quite expensive, though, and by the 1980s a new and cheaper form of the drug was being manufactured. It was called crack cocaine, and it was inexpensive enough to appeal to middle- and lower-income buyers. Crack can be smoked, it delivers a more intense high than powder cocaine, and it costs about one-tenth the price. Drug dealers had opened up a whole new market, and hundreds of thousands of new users became hooked on crack.

Cocaine use peaked in 1985 when the number of Americans who had ever used cocaine soared to 25 million. In response to the increase in cocaine-related hospital emergency visits, crack gained

a reputation as the most destructive and addictive drug of the 1980s. The Anti-Drug Abuse Act of 1986 and 1988 was passed, making possession of crack a far more serious offense than possession of powder cocaine.

By the time the law was passed, cocaine use was already on its way down. It declined steeply until 1992, when the trend once again reversed. According to the U.S. Department of Health and Human Services, the cocaine-using population had crept back up to about 3 million people by 1993. The gradual increase continued. By 1999, reported cocaine use hit 3.7 million or 1.7 percent of Americans.

Four years later, the 2003 National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), showed a downward trend in cocaine use among Americans. About 2.3 million persons were classified as "current cocaine users" that year, and 604,000 of those users smoked crack. Rates of use were highest among people age eighteen to twenty-five, with 2.2 percent of that age group using powder cocaine.

User Characteristics

The typical cocaine user comes from a large metropolitan area rather than a small town, but these metropolitan areas span the entire country. In other words, cocaine is abused widely throughout the big cities of the United States, with no concentration of use showing up in any specific state or section of the country.

According to "Pulse Check," a report available on the Office of National Drug Control Policy Web site, as of January 2004, the characteristics of powder cocaine users had not changed. The crack-using population, however, was aging considerably. Only in Cleveland, Ohio, and St. Louis, Missouri, were there reports of new use among young people. The results of the Monitoring the Future (MTF) survey, a joint effort of the University of Michigan and the National Institute on Drug Abuse (NIDA), seemed to back up these results. Annual use of powder cocaine among tenth and twelfth graders rose about one-half of 1 percent between 2003 and 2004. However, increases in crack cocaine use were reported to be much lower.

No single risk factor predicts cocaine use, but a person's willingness to take risks is often a factor in his or her decision to try it for the first time. Young people who smoke cigarettes are ten times as likely to use an illegal drug than their nonsmoking peers. In the past, students who used cocaine had to be willing to be very different from the norm. The trend of acceptance began changing in the 1990s, however. According to the 2004 MTF study, the perceived risk and disapproval of powder cocaine and crack use decreased among eighth, tenth, and twelfth graders.

Effects on the Body

When smoked or injected, cocaine quickly brings on an intense rush in the user, followed by a high. Snorting the drug does not produce the rush, and the high is slightly delayed because constricted blood vessels release the cocaine into the system at a slower rate.

Small doses of cocaine can cause users to feel self-confident, uninhibited, talkative, clever, and in control. Users have reported that they feel as if they can take on and accomplish just about any task. Their energy levels increase, and their appetites decrease. Larger doses and heavy use can cause the opposite effects. Heavy users often have difficulty expressing themselves verbally. They just cannot seem to find the right words to say what they want to say. They may also suffer memory problems, become extremely confused, and show signs of aggression, antisocial behavior, and paranoia.

The pleasurable feelings from cocaine use last only twenty to thirty minutes if it is snorted and only five to ten minutes if it is smoked or injected into the veins. When the high is over, the user feels tired, sluggish, and low. This cycle can trigger a dangerous pattern of repeated cocaine use as the user tries to recapture the first high. As the user "takes more of the drug," explained Elaine Landau in Cocaine, "he or she develops a tolerance for it. The same amount of cocaine will no longer make that person feel as good as it once did. Higher cocaine doses and increasingly frequent use of the drug become necessary. Many cocaine users say that in time they [need] significant amounts of the drug just to feel normal."

Harm to the Brain

In 1999, two NIDA-funded studies confirmed that heavy cocaine use could cause long-lasting brain impairment. Because cocaine reduces blood flow to the brain, some abusers develop problems with their attention span, memory, and problem-solving skills. Even a month after their last use, heavy users still found it difficult to perform tasks involving planning and reasoning. Users can become psychologically dependent on cocaine, using the drug to take the place of real-life experiences and problem-solving strategies. People who become dependent and then quit using cocaine often experience an intense craving for the drug long after the last use.

It has been known for years that cocaine use narrows blood vessels, raises blood pressure and body temperature, and increases the user's heart rate. These changes put a user at a high risk for life-threatening events. Sudden death can result from heart failure, respiratory failure, seizures, and strokes. In 2003, even more evidence came to light about cocaine's negative effects on the heart and circulatory system. Patrick Zickler reported in NIDA Notes that heavy users of cocaine also seem to "have elevated levels of … a blood protein that increases in concentration" among people at risk for a heart attack.

Cocaine Bugs

Heavy users of cocaine can experience paranoia, mood disturbances, and hallucinations (visions or perceptions of things that are not really there) of all sorts. A tactile hallucination (one involving the sense of touch) called "cocaine bugs" causes users to feel imaginary bugs or even snakes crawling under their skin. Users frequently scratch themselves until they bleed—using tweezers or a knife—to try to remove the imagined "bugs" from their bodies.

The Dopamine Connection

Drug researchers found out long ago that cocaine interferes with the regulation of the brain's dopamine levels. Dopamine is a neuro-transmitter and acts on the part of the brain responsible for filtering incoming information, making choices, judging behavior, and deciding when and how to act. Dopamine levels are associated with movement, emotional response, and the ability to experience pleasure.

Cocaine blocks the normal flow of dopamine, allowing greater-than-normal amounts of the chemical to build up in the spaces between the neurons. Too much dopamine in the brain produces negative effects: dopamine receptors become over-stimulated, and this can cause the brain to lose the ability to produce feelings of pleasure on its own. Although a cocaine-induced high typically lasts from fifteen to thirty minutes, the low can last from one to two days. Scientists suspect that continued use of cocaine actually reduces both the amount of dopamine and the number of dopamine receptors in the brain. So, once the cocaine-induced high is over, the user can fall into a period of deep and lasting depression. "In the same way that [the] brain will interpret the presence of cocaine as one of the most pleasurable experiences," wrote Heather Lehr Wagner in Cocaine, "it will interpret the absence of cocaine as one of the most painful."

The Myth of Nonaddiction

As late as the 1980s, there was a myth that cocaine was not addictive. Addiction occurs when drug use is no longer a voluntary choice but an uncontrollable compulsion. Some crack users report addiction after just one use.

When a person addicted to a substance stops taking that substance, he or she experiences unpleasant withdrawal symptoms. Cocaine withdrawal symptoms include an intense and irresistible craving for the drug, along with depression, irritability, exhaustion, extreme hunger, and sometimes paranoia. It is now known that cocaine is extremely addictive. In fact, it is one of the easiest drugs to get animals to take willingly. Animal research indicates that after repeated ingestion of cocaine, nearly 100 percent of monkeys and rats tested will continue to self-administer the drug whenever they are given the chance.

The most serious effect of using cocaine is the possibility of sudden death. It can happen after the first use or anytime thereafter. Sudden death can occur with cocaine use alone, but is more common when combined with alcohol or other drugs. Other side effects include irreversible damage to the heart and liver, along with damage inflicted by strokes and seizures.

And There Is More.…

The point of ingestion determines the specific side effects cocaine will cause in a user. For instance, snorting powder cocaine over time will damage the septum and ulcerate the mucous membrane of the nose. Users who snort cocaine are prone to nosebleeds.

The bleeding may occur without warning and could cause considerable disruption if it happens in public. For instance, schools are required to evacuate and thoroughly clean areas where human blood has spilled. This precaution must be taken to decrease the risk of transmitting blood-borne viruses such as HIV (the human immunodeficiency virus), which causes AIDS (acquired immunodeficiency syndrome).

Smoking crack cocaine can cause lung trauma and bleeding. Injecting cocaine into the veins often causes inflammation and infections. It also carries a greater risk for contracting HIV/AIDS and hepatitis because users sometimes share needles. Cocaine also has a reputation for lowering users' inhibitions. Users may take unusual risks that can lead to long-term consequences. These risks can range from unsafe sexual encounters to automobile crashes caused by poor judgment or aggression.

New information released by NIDA in 2004 revealed that cocaine might negatively affect a user's immune system. "Cocaine itself has a direct biological effect that may decrease an abuser's ability to fight off infections," wrote Patrick Zickler in NIDA Notes. This information, reported by a team of doctors at Harvard Medical School and the McLean Hospital Alcohol and Drug Abuse Research Center, could help explain why drug abusers have such a high incidence of infections.

Other research findings published in NIDA Notes show that cocaine has a definite negative effect on unborn babies. Children born to mothers who took cocaine when they were pregnant usually have lower-than-average birth weights, small heads, and the potential for more behavioral problems than other children. "At age two," wrote Robert Mathias, "cocaine-exposed children did significantly poorer in mental development than children" who were not exposed to cocaine.

These findings suggest that cocaine-exposed children may require extra assistance to overcome learning difficulties. Experts such as Dr. Lynn Singer of Case Western Reserve University believe that early educational programs can help these youths develop the skills they will need to succeed in school.

Reactions with Other Drugs or Substances

Cocaine is almost always used with other drugs, including alcohol, heroin, amphetamines, and marijuana. Combining drugs increases the chances of overdosing or experiencing serious side effects. The most common drug to be combined with cocaine is alcohol. Alcoholic beverages prolong the cocaine high and tend to reduce drug-induced paranoia. This combination creates a new substance, cocaethylene. Cocaethylene is as powerful as cocaine, and its effects last longer. However, it can be more toxic to the heart. NIDA statistics indicate that the combination of cocaine and alcohol results in more deaths than any other illegal drug combination.

The combination of cocaine and heroin is called a "speedball." It is especially dangerous because cocaine speeds up the respiratory system, while heroin depresses it, or slows it down. At very high doses, however, cocaine can begin to depress the respiratory system as well. In speedballing, cocaine and heroin are typically ingested at the same time, but some users ingest the drugs alternately to feel either more energetic or more relaxed. This combination can be more toxic than using either drug alone. Comedian John Belushi died from speedballing in 1982.

Amphetamines are often combined with cocaine to extend the high. Cocaine creates a rush but it is short-lived. Adding amphetamines extends the high for up to ten hours. Using these drugs together increases the chances of an overdose and increases toxic effects.

Treatment for Habitual Users

In an article for the New York Times, Linda Carroll reported that certain people are more likely to become addicted to cocaine than others. The reason for this seems to be some sort of inborn flaw in the brain's wiring. "The leading suspect," noted Carroll, "is a defect in the dopamine system." Studies conducted on monkeys seem to back up this theory. Five monkeys involved in a Wake Forest University medical school experiment were allowed to take cocaine whenever they wanted for a whole year. At the end of the year, the "addicted monkeys ended up with a 15 percent to 20 percent decrease in dopamine receptors," wrote Carroll. The five monkeys were reexamined nine months after the conclusion of the experiment. The brains of three of them had returned to normal, but the brains of the other two still had lower-than-normal amounts of dopamine receptors in them.

Addicts and Addiction

Some people believe that drug addiction is a voluntary behavior—that addicts simply choose to use drugs again and again. However, with continued use over a period of weeks or months, a person can go from being a voluntary drug user to being a compulsive, out-of-control drug user. Addictive drugs can actually change the brain in ways that result in more and more drug use.

Drug use is a very hard habit to break, even for the most determined individuals. It really does not matter which drug a person is abusing. In general, many drugs of abuse have similar effects on the brain. Such effects are discussed in Alan I. Leshner's article "Exploring Myths about Drug Abuse" on the NIDA Web site. Among the effects are:

• changes in the chemical makeup of brain cells
• a shift in mood
• transformation in memory processes
• alteration of motor skills needed to walk and talk.

These changes greatly impact the addict's behavior. The user's biggest motivation in life becomes obtaining and using the drug. Such behavior is not the result of a weak will or a character flaw. Rather, the drug use has caused major changes in the structure and the functioning of the user's brain—changes that are beyond the user's control.

The biggest challenge to cocaine treatment and rehabilitation is preventing relapse (the return to using drugs) caused by a persistent and intense craving for cocaine. Although cocaine addiction can be treated successfully, there is no single program that is effective for

everyone. NIDA recommends a dual approach to treatment, healing both the body and the mind. It suggests behavioral therapies, medications, rehabilitation, and social services. The idea is to treat the whole person.

Regarding medication, NIDA research reports that medications that act on dopamine receptors might reduce the intense craving and depression in former cocaine users. Behavioral therapies can include group and/or individual counseling, popular twelve-step programs, and chemical dependency inpatient and outpatient programs.

A Simple but Promising New Treatment Approach

On January 5, 2005, the National Institutes of Health (NIH) announced that peer counseling actually helped reduce cocaine and heroin abuse. The study was conducted by doctors at Boston University Schools of Medicine and Public Health and involved 1,175 male and female drug abusers. The process took only twenty minutes and consisted of "a motivational interview with a substance abuse outreach worker who also was a recovering addict," according to the NIH press release.

Members of the study were also given referrals to drug abuse treatment programs and a list of different types of treatment methods. In addition, they received a phone call ten days later to check on their progress. These simple interventions motivated a significantly higher percentage of abusers to stay away from drugs over a six-month period.

Consequences

When cocaine use progresses to a point of dependence, it can be devastating. At this stage, drug seeking often becomes the user's first priority. Suddenly, values such as love of family and friends and commitment to work can take second place to finding, buying, and using cocaine. "Cocaine addiction almost always interferes with social and economic functioning," stated Weil and Rosen. Addicts may end up spending "phenomenal amounts of money on their habits ($15,000 a year and more)," the authors explained. "They become paranoid, isolated, and depressed, unable to stop thinking about their next dose."

Habitual users often find themselves trapped in a web of deception and criminal behavior. Users desperate for more drugs may turn to robbery or prostitution in order to finance their habit. NIDA Notes stated that "cocaine use in 'crack' exchanges also contribute[s] to transmission of HIV/AIDS." Conviction of an illegal drug offense can trigger minimum mandatory prison sentences. Also, students convicted of cocaine possession can be disqualified from obtaining federal college grants and loans. In addition, NIDA-funded research shows that drug abusers cost employers about twice as much in medical and workers' compensation claims than drug-free workers. As a result, more and more businesses are requiring drug screening for employees.

The Law

Under the U.S. Controlled Substance Act of 1970, cocaine is a Schedule II drug. This means that cocaine has a high potential for abuse and that abuse may lead to severe physical and psychological dependence. It also means that cocaine has accepted medical uses with severe restrictions. The only legal use of cocaine in the United States is as a local anesthetic.

The Anti-Drug Abuse Act of 1986 and 1988 established mandatory minimum drug sentencing guidelines for cocaine use and possession. Federal law carries a much harsher penalty for crack cocaine than for powder cocaine. Because more African Americans tend to use crack than powder, this law continues to result in harsher prison terms for blacks. Possession of 5 grams of crack or 500 grams of powder carries a first-offense penalty of not less than five years in prison. Despite the severity of this penalty, according to Landau, about "85 percent of those imprisoned for drug abuse" will continue to "use cocaine or other drugs after leaving prison."

In the United Kingdom, cocaine and crack are considered Class A drugs under the 1971 Misuse of Drugs Act. Possession of the drugs can result in a fine and a prison term of up to seven years. Supplying, or selling, either form of cocaine can lead to a lifetime prison sentence.

For More Information

Books

Brecher, Edward M., and others. The Consumers Union Report on Licit and Illicit Drugs. Boston: Little Brown & Co., 1972.

Gahlinger, Paul M. Illegal Drugs: A Complete Guide to Their History, Chemistry, Use, and Abuse. Las Vegas, NV: Sagebrush Press, 2001.

Landau, Elaine. Cocaine. New York: Franklin Watts, 2003.

Robbins, Paul R. Crack and Cocaine Drug Dangers. Berkeley Heights, NJ: Enslow Publishers, Inc., 1999.

Wagner, Heather Lehr. Cocaine. Philadelphia: Chelsea House, 2003.

Weil, Andrew, and Winifred Rosen. From Chocolate to Morphine. New York: Houghton Mifflin, 1993, rev. 2004.

Periodicals

Carroll, Linda. "Genetic Studies Promise a Path to Better Treatment of Addictions." New York Times (November 14, 2000).

Web Sites

"2003 National Survey on Drug Use and Health (NSDUH)." U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.http://www.oas.samhsa.gov/nhsda.htm (accessed June 30, 2005).

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Leshner, Alan I. "Exploring Myths about Drug Abuse." National Institute on Drug Abuse: The Science of Drug Abuse and Addiction.http://www.drugabuse.gov/published_articles/myths.html (accessed June 30, 2005).

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"Pulse Check: Drug Markets and Chronic Users in 25 of America's Largest Cities." Executive Office of the President, Office of National Drug Control Policy.http://www.whitehousedrugpolicy.gov/publications/drugfact/pulsechk/january04/january2004.pdf (accessed June 30, 2005).

"Stimulants." NIDA for Teens: The Science behind Drug Abuse, Mind over Matter.http://www.teens.drugabuse.gov/mom/mom_stim1.asp (accessed June 30, 2005).

Swan, Neil. "Brain Scans Open Window to View Cocaine's Effects on the Brain." National Institute on Drug Abuse, NIDA Notes.http://www.nida.nih.gov/NIDA_notes/NNVol13N2/Brain.html (accessed June 30, 2005).

Zickler, Patrick. "Cocaine May Compromise Immune System, Increase Risk of Infection." National Institute on Drug Abuse, NIDA Notes.http://www.nida.nih.gov/NIDA_notes/NNVOL18N6/Cocaine.html (accessed June 30, 2005).

Zickler, Patrick. "Methamphetamine, Cocaine Abusers Have Different Patterns of Drug Use, Suffer Different Cognitive Impairments." National Institute on Drug Abuse, NIDA Notes.http://www.nida.nih.gov/NIDA_notes/NNVOL16N5/Meth_Coc.html (accessed June 30, 2005).

See also: Alcohol; Amphetamines; Heroin; Marijuana

COCAINE

OFFICIAL NAMES: Powder cocaine, crack cocaine

STREET NAMES: Base, Bernice, blow, "C", coke, dream, dust, flakes, nose candy, Peruvian marching powder, powder, rock, stardust, snow, sugar, the devil's dandruff, white lady

DRUG CLASSIFICATIONS: Schedule II, stimulant

OVERVIEW

South Americans in the Andes Mountains legally and liberally chew coca leaves. By adding a little lime or plant ash, the naturally occurring cocaine alkaloid is released and absorbed into the cheek. This has a mild stimulating effect similar to drinking several cups of strong coffee. In this way, the mountain people have combated heat, cold, hunger, and fatigue for over 4,000 years. The leaves are used medicinally to alleviate problems of the digestive system, altitude sickness, and psychological ills. Used in the whole-leaf form, cocaine does not produce a "high" and is not addictive.

Coca leaves were not used in Europe or the United States because coca leaves do not travel well. But in 1860, a German chemist, Albert Niemann, separated cocaine from the leaf. In doing so, he unleashed the most powerful naturally occurring stimulant. In the salt form (cocaine hydrochloride), which is commonly known as powder cocaine, it travels very well. Soon, large quantities were being consumed abroad.

Initially, cocaine was thought to be a "cure-all," and, like the whole-leaf form, powder cocaine was believed to be non-addictive. Due to this misinformation, from the 1860s until the early 1900s, the use of cocaine was unregulated. It was used widely in Europe and in the United States. People could buy anything from cocaine-laced beverages, such as Vin Mariani coca wine and Coca-Cola, to 99.9% pure powder cocaine. Vin Mariani was a wine and cocaine concoction endorsed by Pope Leo XVIII and by over 7,000 physicians. In the 1880s, John Pemberton created Coca-Cola—the non-alcoholic "health drink" containing 60 mg of cocaine. (It should be noted that Coca-Cola no longer uses cocaine in its products.) Cocaine was believed to remedy many conditions, including fatigue, toothache, hay fever, asthma, seasickness, and vomiting during pregnancy. No prescription was necessary, and cocaine could easily be purchased at grocery stores, drug stores, and through mail-order catalogues.

Bona fide scientific and medical research lagged behind the commercial marketing of cocaine. It was not until the 1880s that cocaine was seriously studied. A German physician did a study on the effects of cocaine on the Bavarian army. He wrote a paper on the endurance enhancing qualities of cocaine. This paper was read by Dr. Sigmund Freud, who then experimented on himself. Freud discovered that cocaine affects the heart and produces a powerful "high." He later prescribed cocaine for heart disease, psychiatry, and morphine addiction. He wrote his own paper, "On Coca," extolling the virtues of the drug, which he claimed was non-addictive. In 1884, Karl Koller started using cocaine as a topical anesthetic for eye surgery and it was soon used in dentistry. In 1885, cocaine was used as a spinal anesthetic for dogs. William S. Halsted, considered to be the father of modern surgery, discovered that cocaine injected under the skin makes an effective local anesthetic for surgery.

It was not until the 1890s that public opinion began to shift against cocaine use. By then, reports of nasal damage, addiction, and cocaine-related deaths had begun to circulate. The toxic and addictive nature of cocaine became public knowledge. By the time the government stepped in to ban cocaine in 1914, most people were already shunning it.

In the 1970s there was a resurgence of powder cocaine use. This preceded the epidemic of crack cocaine in the 1980s. Because crack cocaine is cheaper than powder, it became more readily available to the young and the poor. Crack addiction and crime began to increase rapidly and this increase was publicized in the media. In response to public concern, the Anti-Drug Abuse Act of 1986 and 1988 was passed. Known sometimes as the 100:1 law, this federal law includes mandatory minimum sentences for first-time offenders. The penalties are much harsher for possession of crack cocaine than powder cocaine.

In a 2001 study entitled Global Illicit Drug Trends conducted by the United Nations Office for Drug Control and Crime Prevention (ODCCP), it was estimated that 14 million people used cocaine worldwide. Though cocaine use has leveled off in the United States, it still leads the world in cocaine abuse. In 1999, cocaine use was stable in the United States, but increased in Western Europe and in several South American countries. Because of the addictive and destructive nature of cocaine, there is a concerted worldwide effort to reduce the production and illicit use of cocaine.

CHEMICAL/ORGANIC COMPOSITION

Cocaine is the most potent naturally occurring stimulant. It is found as an alkaloid (nitrogen-containing organic base) in the leaves of the Erythroxylon coca trees in the Andes Mountains. Coca leaves contain0.5–1.8% cocaine (benzoylmethylecgonine or BZ) that can be refined to nearly 100% purity. Research indicates that the plant produces cocaine to kill insects that prey on it. In humans, it is a central nervous system (CNS) stimulant.

TYPES OF COCAINE

Anesthetic

Cocaine was the first local anesthetic to be discovered and this is its only legal use in the United States. Cocaine is particularly effective as a local anesthetic because it numbs the site of application almost immediately and it minimizes bleeding. Typically a 1–4% solution is used clinically. This highly diluted solution does not have a psychoactive or changing effect on the brain.

While cocaine is still used for ear, nose, and throat surgery, Lidocaine, a synthetic derivative of cocaine, is the most widely used local anesthetic.

Coca leaves

Cocaine is ingested in its mildest form by chewing coca leaves. Alkalines such as lime or ash are added to the leaves to release the cocaine alkaloid. In addition to cocaine, the leaves contain protein, minerals, vitamins, and over 14 alkaloids. Instead of experiencing a "rush"

or a "high," chewers first notice numbness of the mouth followed by alertness and a sense of well-being. The stimulant effect is about as potent as the caffeine in several cups of strong coffee. Regular coffee breaks in the United States is the social equivalent of regular coca leaf breaks in the mountains of South America. Chewing coca leaves is also part of the religious tradition. In addition to chewing coca leaves, the people also make the leaves into tea. Coca leaves are not smoked because the temperature needed to burn the leaves destroys the cocaine alkaloid before it can be inhaled.

Coca paste

Sometimes called "bazooka," coca paste is an impure free-base form of cocaine that is smoked. It contains 20–90% cocaine and it is psychoactive. Smokers experience a "rush" or a "spike" similar to the effects of smoking crack or injecting powder cocaine. This is followed by a "high." Coca paste is highly addictive. To make the paste, lime water, kerosene, and sulfuric acid are added to coca leaves. By removing the bulky leaf matter, 250 lbs (114 kg) of coca leaves are converted into 22 lbs (10 kg) of coca paste. Solvent residues give the paste an unpleasant taste and odor. It is usually added to tobacco or marijuana cigarettes. Use of coca paste is restricted mainly to South America as it is bulky and difficult to ship. With additional processing, coca paste can be converted into powder cocaine, which is easier to smuggle and is much more profitable for South American cartels.

Powder cocaine

Powder cocaine (cocaine hydrochloride) can be over 100 times more potent than coca leaves. By adding acids and purifying agents, 22 lbs (10 kg) of coca paste can be refined to 2.2 lbs (1 kg) of powder. This powder approaches 100% purity, but it is diluted with fillers before it is sold on the streets in the United States. Common fillers are cheaper drugs such as amphetamines or sugars such as lactose or inositol. Average street powder purity is 60%. The most common way to use powder is to snort it into the nose, but it can also be dissolved in water and injected into the veins. Powder cocaine cannot be smoked. Powder cocaine is addictive when snorted and highly addictive when injected.

Free base

Free base is a form of cocaine that can be smoked. There are three free-base forms of cocaine: coca paste, free base, and crack. Coca paste is made directly from coca leaves with solvents and acids. It is not available in the United States. Another form called "free base" was developed in the mid-1970s. In this process, powder cocaine is changed into free base by using water, ammonia, and highly flammable ether. It is a dangerous process because the volatile chemicals sometimes explode or ignite. Comedian Richard Pryor was badly burned while "freebasing." By far, the most common free base is crack. In a very stable process, cocaine and sodium bicarbonate are combined. The precipitate, crack, is nearly 100% pure cocaine. All three forms of free base are highly addictive.

Crack cocaine

Crack is free-base cocaine extracted from powder cocaine using water and sodium bicarbonate. The resulting precipitate is dried and cut into "rocks" weighing between one-tenth to one-half a gram. Ten grams of powder cocaine will convert to 8.9 grams of nearly pure crack. A rock is placed into a glass pipe, heated, and the vapors are inhaled. It is called "crack" because when it is heated, the sodium bicarbonate makes a crackling sound. Because crack is inexpensive and delivers large amounts of cocaine to the lungs, it has become the most popular form of cocaine. Crack is highly addictive.

INGESTION METHODS

The way cocaine is ingested greatly determines the intensity of the effect it will have on the brain and the body. As ingestion methods increase the speed at which cocaine reaches the brain, it also increases the "high" and the risk of addiction.

Mouth and stomach

South American natives chew coca leaves mixed with lime or plant ash to gradually release small amounts of cocaine alkaloid. Some of the cocaine is absorbed by the mucous membranes of the mouth and the intestines absorb some of the juice as it is swallowed. The small amount of cocaine entering the bloodstream numbs the mouth, decreases the feeling of hunger, and has a stimulant effect similar to drinking several cups of strong coffee. It does not cause a "high," but the feeling of wellbeing can last one to two hours.

Snorting

Typically, a line of 20–30 mg of powder cocaine is placed on a mirror or glass and is snuffed into the nose. In less than one minute, this blood-vessel-rich nasal area transports the cocaine to the brain, resulting in a "high" or "euphoria." Because of the constricting effect cocaine has on the blood vessels, absorption is slower than when cocaine is smoked or used intravenously. The "high" from snorting is less intense, but it lasts longer. Snorting cocaine is addictive.

Injecting

Powder cocaine can be dissolved in water and injected into the veins. In less than 16 seconds, the cocaine is mixed with the blood, sent to the lungs, returned to the heart and received by the brain. The intense euphoria is greater than a "high" and is referred to as a "rush." The "rush" generally lasts only a few minutes and the remaining "high" drops off quickly. This is the least socially acceptable way to ingest cocaine. Injecting cocaine is highly addictive.

Smoking

Powder cocaine and coca leaves cannot be smoked. The heat required to smoke these forms of cocaine destroys its psychoactive properties. In order to smoke cocaine, it must be changed to a free-base form. In South America, the most common free base is coca paste. In the West, people smoke crack, and to a much lesser extent, free base made with ether. The free base or crack is put into a glass pipe, heated, and the vapors are inhaled.

If it is inhaled deeply into the lungs, the vapors will come in contact with over 300 million alveolar sacs representing 171 yd² (143 m²) of surface area. Within three seconds, cocaine is absorbed into the blood and pumped directly to the brain. This immediate brain "rush" or "spike" is slightly faster than the injection method and is achieved without the use of needles. Smoking cocaine by inhaling free-base vapors creates the fastest and most intense "rush" and subsequent "high." This is highly addictive.

THERAPEUTIC USE

The medicinal and ceremonial uses of cocaine via coca leaves can be traced back over 4,000 years to pre- Columbian times. It continues to be used legally and is part of the daily culture of South American Indians. Coca leaves are chewed to combat fatigue and to ward off hunger. They are also used to alleviate problems of the larynx, digestive system, metabolism of carbohydrates, vertigo, altitude sickness, and for psychological ills.

After 1860, cocaine was being processed into powder and shipped to the United States and Europe. As described, in the 1880s, people could buy 99.9% pure powder cocaine at the grocery store and in mail-order catalogs, and could drink cocaine-laced "health" drinks. It was a common nonprescription remedy for hay fever, children's toothaches, asthma, mountain sickness, seasickness, vomiting during pregnancy, and cramps. Snorting also became popular and some people began injecting cocaine. One company, Parke-Davis, not only sold cocaine—it offered needle and syringe kits.

As use proliferated, the toxic effects of cocaine became apparent. People were getting addicted. In 1914, the Harrison Narcotic Act banned cocaine in the United States. Only use as a local anesthetic was legally retained. It is still used today in nasal, mouth, and throat surgery. Anesthetic solutions contain 1–4% cocaine.

A need was seen for a synthetic and less toxic anesthetic. In 1905, Procaine was synthesized and became the prototype for synthesized anesthetics for the next 50 years. In 1948, Lidocaine was developed and is now the most commonly used local anesthetic. Other synthesized local anesthetics include bupivacaine and tetracaine.

USAGE TRENDS

Americans' attitude toward cocaine has run the gamut from acceptance to ambivalence to outrage. In the late 1870s, soon after cocaine was first introduced as a non-addictive "cure-all," the drug was found in family medicine cabinets for dozens of applications. Also, in keeping with the spirit of the American Industrial Revolution, cocaine was touted as a tonic to energize workers and ensure peak efficiency. By the 1890s, cocaine had gone beyond medical application and began to contribute to the pleasure-centered Gay Nineties. During this time of widespread use, medical journals began to report on the toxic and addictive properties of cocaine.

Public support turned against cocaine and it became a focal point of the temperance crusade in 1903. The Harrison Act of 1914 classified cocaine as a narcotic and prohibited its use in the United States except as a local anesthetic. During that same year, all 48 states passed similar laws. The 1930s through the 1960s became a time of intolerance as exemplified by the tough drug laws that were passed. Then ambivalence set in. People forgot the reason for the outrage. In the 1960s, few people personally knew a cocaine user or addict.

By the 1970s, another epidemic of cocaine use was underway. Cocaine became part of the disco scene with bright lights, glittery clothes, and the energy to dance the night away. Cocaine, generally snorted, gained a reputation as being a drug for the affluent. In the 1980s, a new form of cocaine known as crack became available. Crack could be smoked, delivered a more intense high, and cost about one-tenth as much as powdered cocaine. Cocaine use peaked in 1985 when the number of Americans who had ever used cocaine soared to 25 million.

As cocaine-related hospital emergency visits increased and negative media stories began to proliferate, public opinion once again moved against recreational cocaine use. Crack especially was singled out as being extremely addictive and destructive. Amid this outcry, the Anti-Drug Abuse Act of 1986 was passed and crack possession now carried much heavier penalties than its counterpart, powder cocaine.

By the time the law was passed, cocaine use was already on its way down. It declined steeply until 1992 when the trend once again reversed. According to the National Household Survey on Drug Abuse (NHSDA), the cocaine-using population had crept back up to about three million people by 1993. The gradual increase continued. By 1999, the NHSDA reported cocaine use by3.7 million or 1.7% of Americans. The Community Epidemiology Work Group (CEWG), which follows drug abuse trends in 21 major U.S. metropolitan areas showed a slight downward trend in crack/cocaine use in their 2000 report.

Scope and severity

The fact that less than 2% of the American population uses cocaine is not cause to minimize its scope and severity. These three million or so Americans consume about 50% of the world's cocaine production. According to the Drug Abuse Warning Network (DAWN) for 2000, cocaine was the second most frequently mentioned drug that caused people to be admitted to hospital emergency rooms. Also, of the 32,288 suspects referred to federal prosecutors for drug charges during 1999, 43% were charged with offenses relating to powder cocaine or crack. The Office of National Drug Control Policy (ONDCP) reports in the November 2001 Pulse Check,

that over half the Pulse Check communities listed crack as the drug with the most severe or second-most severe consequences, whether medically, legally, or otherwise. The same report listed powder cocaine as widely available in 85% of the 21 Pulse Check cities. Crack was listed as widely available by 75% of the Pulse Check sources.

As of 2002, about 14 million people worldwide use cocaine. According to the ONDCP, the United States leads the world in cocaine abuse. While U.S. cocaine use has remained relatively stable over the last decade, the United Nations Commission on Narcotic Drugs reported in March 2000 that 34 countries out of 112 reported an increase in cocaine use from 1997 to 1998. In the European Union, the increase in cocaine use was mainly in the group of people aged 16 to 29 years.

Age, ethnic, and gender trends

In 2000, according to the NHSDA, cocaine use dropped over the course of the year from 0.2% to 0.1% in youths aged 12 and 13. Youths aged 14 and 15 had no change for the same time period with 0.5% using cocaine. Cocaine use increased in youths aged 16 and 17, from 0.9% to 1.1%. Crack use declined in young adults aged 18 to 25 and went from 0.3% to 0.1%. Adults aged 26 and older had no change in cocaine use, but there was a decline in crack use for adults 26 to 34 years. This study also indicated that 43% of cocaine users were under the age of 26. The ONDCP reports in November 2001 that nine Pulse Check cities considered young adults (18–30 years) to be the primary crack user group, while eight cities cited adults older than 30 years.

Though crack and powder cocaine are different forms of the same drug, clearly divided ethnic preferences exist. The NHSDA reported in 2000, African Americans are the predominant users of crack, whereas whites are the predominant users of powder cocaine. Socioeconomic status may contribute to this trend. The Hispanic population uses more powder cocaine than crack, but figures overall remain low.

Regarding gender differences, again the NHSDA separates the statistics for powder cocaine and crack. Males are more likely than females to use powder cocaine. However, males and females are equally likely to use crack in many surveyed cities. Studies indicate that female crack use has been increasing over the past five years.

No single risk factor predicts cocaine use. However, because cocaine use is approved of and practiced by such a small percentage of the population, a person's willingness to take risks is often a factor. Other factors include a person's level of impulsiveness, other available sources of attaining pleasure, the availability of cocaine, and the relationship of adolescents with their parents. Because recreational cocaine use is against the law, how people view breaking the law is also a factor. It is noteworthy that young people who illegally smoke are ten times as likely to use an illegal drug than their non-smoking peers.

Students who use cocaine must be willing to deviate greatly from the norm. However, the trend of acceptance is changing. According to the "Monitoring the Future" study, in the decade of the 1990s, perceived risk and dis-approval of powder cocaine and crack decreased in eighth, tenth, and twelfth grades.

MENTAL EFFECTS

Small doses of cocaine can cause users to feel both mentally and sexually excited, self-confident, uninhibited, talkative, clever, and in control. Larger doses and heavy use can cause the opposite effects. Heavy users can become confused mentally, uninterested in sex, paranoid (feeling everyone is against them), antisocial, aggressive, and are subject to cocaine psychosis (a mental illness whose symptoms include paranoia, disorientation, and severe depression).

The pleasurable feelings from cocaine use last only 15–30 minutes if it is snorted and only five to 10 minutes if cocaine is smoked or injected into the veins. When the "high" is over, the user feels tired, sluggish, and "low."

This cycle can precipitate repeated cocaine use to try to recapture the first high. Oddly, the more often cocaine is used, the less intense the pleasure. This is called tolerance. If use continues to the point of addiction, users take cocaine just to feel "normal."

Heavy users and binge users can experience visual and auditory hallucinations. A tactile hallucination (a hallucination involving the sense of touch) called "cocaine bugs" causes users to feel imaginary bugs crawling under their skin. Users can scratch or use a knife to try to remove the "bugs" in reaction to this sensation. In 1999, two NIDA-funded studies confirmed that heavy cocaine use can cause long-lasting brain impairment. In one study, it was found that the user's problem-solving skills and cognitive skills lagged behind that of moderate or non-users. In a second study, a month after last use, heavy users performed much worse than moderate or non-users in tasks involving planning and reasoning. Users can become psychologically dependent on cocaine, using the drug to take the place of real-life experiences and problem-solving strategies. People who become dependent and then quit using cocaine often experience an intense craving for the drug long after the last use.

PHYSIOLOGICAL EFFECTS

Cocaine is a central nervous system (CNS) stimulant that causes a significant increase in heart rate, respiration, blood pressure, and body temperature. According to DAWN, one in thirteen cocaine users go to the hospital to be treated for severe reactions that could be life threatening. Sudden death can result from heart failure, respiratory failure, seizures, strokes, and cerebral hemorrhage. There is no antidote for cocaine overdose. Even if the adverse reactions do not result in death, they can do permanent damage to the body.

For years, scientists have known that cocaine interferes with the brain's dopamine system. Dopamine is a neurotransmitter—a chemical that passes nerve impulses from one nerve cell to another, and dopamine is associated with movement, emotional response, and the ability to experience pleasure. Research indicates that serotonin transporters are also inactivated with cocaine use. Serotonin is another neurotransmitter, and adequate levels are associated with well-being. Low levels of serotonin in the brain have been linked to depression. Inactivation of dopamine and serotonin transporters leads to receptor over-stimulation and the "high." Continued use of cocaine can result in long-term changes in the brain chemistry as receptors decrease in number. These changes can be persistent and even irreversible, and may be responsible for the feeling of depression that lasts long after withdrawal.

As late as the 1980s, there was a pervasive myth that cocaine is not addictive. This was because withdrawal symptoms were not thought to be physical. When a person addicted to a substance stops taking the substance, he or she experiences withdrawal symptoms. The withdrawal symptoms are unpleasant, and encourage the person to take the substance again in order to avoid the withdrawal. Cocaine withdrawal symptoms include an intense and irresistible craving for cocaine, depression or "crash," and sometimes paranoia. It is now known that cocaine is powerfully addictive. Research indicates that after repeated ingestion of cocaine, nearly 100% of monkeys and rats tested will self-administer the drug. Cocaine is one of the easiest drugs to get animals to take willingly.

Cocaine is metabolized very quickly by the body. Within minutes, enzymes in the blood and in the liver split the cocaine molecule into two halves, rendering it inactive. Cocaine and its metabolites are excreted in the urine. The body's efficient metabolism of cocaine causes the "high" to be relatively short-lived. This often causes cocaine users to take several doses of cocaine in a short time, which can increase the chances of an overdose.

Harmful side effects

The most serious effect of using cocaine is the possibility of sudden death. It can happen after the first use or anytime thereafter. Sudden death can occur with cocaine use alone, but it more commonly occurs when cocaine is combined with alcohol or other drugs. More common side effects include irreversible damage to the heart and liver, along with damage inflicted by strokes and seizures. Cocaine users are also at risk for addiction. Addiction is often viewed as a disease. It occurs when drug use is no longer a voluntary choice but an uncontrollable compulsion. Some crack users report addiction after just one use.

The point of ingestion determines the specific side effects. For instance, snorting powder cocaine over time will damage the septum and ulcerate the mucous membrane of the nose. Smoking crack cocaine can cause lung trauma and bleeding. Injecting cocaine into the veins often causes inflammation, infections, and carries a greater risk for contracting AIDS/HIV and hepatitis.

Cocaine use during pregnancy is especially dangerous. It can cause harm to both the mother and the baby. Cocaine causes spasms in the blood vessels, including those in the placenta. Sometimes placenta abruption (separation of the placenta from the wall of the uterus before the baby is born) and bleeding occurs, which can be fatal to the mother and baby. Children born to mothers who used cocaine during pregnancy are often termed "crack babies." These babies tend to be abnormally small. Because of their low birth weight, they are 20 times more likely to die in their first month of life than babies of normal weight. The babies have an increased risk of mental retardation, cerebral palsy, and vision and hearing disabilities. Cocaine-induced prenatal strokes can cause permanent brain damage. Another common abnormality of these babies is their unusually small head. While they seem to have normal intelligence, studies indicate more behavioral problems for exposed children than unexposed children.

Long-term health effects

Cocaine constricts blood vessels and decreases blood flow. Using imaging technology such as magnetic resonance angiography (MRA) and transcranial Doppler sonography (TDC), scientists can see both short-term and long-term blood flow deficits in the brains of cocaine users. Long-term cocaine use can also cause atherosclerosis, or thickening of the blood vessels. Because of this, cocaine abusers in their thirties can have arteries as constricted as non-abusers in their sixties. With reduced blood flow to the brain, some cocaine abusers have shown cognitive deficits in attention span, memory, and problem-solving. Other effects include serious damage to the heart, lungs, and liver.

Cocaine also has a reputation for being disinhibiting. Users may take unusual risks that can lead to long-term consequences. These risks can range from sexual encounters to automobile accidents caused by poor judgment or aggression.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Cocaine is almost always used with other drugs, including alcohol, heroin, amphetamines, and marijuana. Combining drugs increases the chances of overdose and serious side effects. The most common drug to be combined with cocaine is alcohol. Alcoholic beverages prolong the cocaine "high" and reduce drug-induced paranoia. This combination creates a new substance, cocaethylene. Cocaethylene is as potent as cocaine and lasts longer. However, it can be more toxic to the heart. The combination of cocaine and alcohol results in more deaths than any other illegal drug combination.

Combining cocaine with heroin is called a "speedball," "dynamite," or "whiz-bang." It is a very dangerous combination because cocaine speeds up the respiratory system while heroin depresses it. However, at high doses, cocaine can begin to depress the respiratory system, as well. In speedballing, cocaine and heroin are typically ingested at the same time. However, some users ingest the drugs alternately to feel either more "energetic" or more "relaxed." This combination can be more toxic than using either drug alone. Comedian John Belushi died using this combination in 1982.

Amphetamines are often combined with cocaine to extend the "high." Cocaine creates a "rush" but it is short-lived. Adding amphetamines extends the "high" for up to ten hours. Using these drugs together increases the chances of an overdose and increases toxic effects.

Cocaine is also frequently combined with marijuana. Called a "diablito" or "turbo," a cigar is filled with marijuana and crack and then smoked. This increases the risk to the cardiovascular system as both drugs speed up the heart and increase blood pressure.

Brompton's mixture

In the 1970s, a combination of cocaine, methadone, and alcohol was given to terminal cancer patients. The methadone and alcohol relieved the pain but induced a lethargic and clouded state for the patients. Cocaine was added to make patients more alert. New medications are more effective and cocaine is no longer used for cancer patients.

TREATMENT AND REHABILITATION

According to the 1997 National Association of State Alcohol and Drug Abuse Directors (NASADAD), excepting alcohol, the largest number of publicly funded drug treatment admissions were for cocaine. The biggest challenge to cocaine treatment and rehabilitation is preventing relapse (the return to using drugs) caused by a persistent and intense craving for cocaine. To this end, after detoxification, which can take less than a week, treatment programs often include deconditioning. Deconditioning exposes abstinent users to cues that produce powerful and pleasurable memories of cocaine use. By keeping the patients from reinforcing the memories with cocaine use, the cues eventually lose their power to produce a craving.

While cocaine addiction can be treated successfully, there is no one program that is effective for everyone. Principles of Effective Drug Treatment, published by NIDA, recommends a multi-faceted approach to treatment. It suggests behavioral therapies, medications, rehabilitation and social services. The idea is to treat the whole person.

Regarding medication, NIDA research reports that medications that act on both the dopamine and serotonin receptors might reduce the intense craving and depression. Behavior therapies can include group and/or individual counseling, popular 12-Step programs, therapeutic communities, and chemical dependency inpatient and outpatient programs. Rehabilitative treatment includes training focused on resolving problems related to jobs, home life, and the criminal justice system.

PERSONAL AND SOCIAL CONSEQUENCES

When cocaine use progresses to a point of dependence it can be devastating. At this stage, drug seeking often becomes the first priority. Suddenly, values such as love of family and commitment to work can take second place to finding, buying, and using cocaine.

Habitual users can lose the trust and respect of the people important to them. Lying, stealing, and isolating oneself all take a heavy toll on family, friends, and employment relationships.

Aside from theft, NIDA funded research shows that drug abusers cost employers about twice as much in medical and worker's compensation claims than drug-free workers. As a result, more and more businesses are requiring drug screening before hiring and are employing periodic drug-testing thereafter.

While a single dose of cocaine may cost as little as five or ten dollars, an addiction can cost hundreds of dollars a week. This can lead to financial ruin and often progresses to criminal activity. (Users desperate for more drugs may turn to illegal activity, including robbery or prostitution, in order to finance their habit.) Conviction of an illegal drug offense can trigger minimum mandatory prison sentences. Also, students convicted of cocaine possession can be disqualified from obtaining federal college grants and loans.

Though less than 2% of Americans use cocaine, it has profound national consequences. Health and human services related to drug and alcohol abuse cost taxpayers more than $294 billion dollars annually. This cost rose 50% from 1985 to 1992. A NIDA-funded study showed that cocaine use was the primary factor contributing to this increase.

LEGAL CONSEQUENCES

Under the Controlled Substance Act, cocaine is a Schedule II drug. This means that cocaine has a high potential for abuse and that abuse may lead to severe physical and psychological dependence. It also means that cocaine has accepted medical uses with severe restrictions. The only legal use of cocaine in the United States is as a local anesthetic.

The Anti-Drug Abuse Act of 1986 and 1988 established federal mandatory minimum drug sentencing guidelines. The punishment exacted by the federal law is substantially greater than the punishment imposed by most state laws. For example, someone convicted of cocaine possession that receives a 12-year sentence in the state system may be liable for a mandatory life term if tried in the federal system. Also, most state laws do not differentiate between powder cocaine and crack cocaine. Federal law carries a much harsher penalty for crack than for powder. Possession of five grams of crack or 500 grams of powder carries a mandatory first-offense penalty of not less than five years in prison.

Legal history

Cocaine accessed by chewing coca leaves has been a legal and common tradition in South America for over 4,000 years. It continues to be legal.

Purified powder cocaine was legal in Europe and the United States from its introduction in the 1860s until1914. During that time, cocaine use reached epidemic proportions. Medical reports of addiction and sudden death caused public opinion to move against cocaine use. In 1906, the Pure Food and Drug Act mandated that cocaine be listed as an ingredient in all medicines whether they were sold by individuals or drug companies. President William Taft declared cocaine as Public Enemy No. 1, and in 1914 Congress passed the Harrison Narcotics Act. Cocaine thus became one of the first drugs to be banned in the United States. That same year, all 48 states had laws banning cocaine. The only legal use for cocaine was as a local anesthetic.

While laws continued to be passed over the next seven decades, none proved to be as controversial as the Anti-Drug Abuse Act of 1986 and 1988. Like the Harrison Act, this law arose during an epidemic of cocaine use. This time, it was the 1980s epidemic fueled by crack. In 1986, the death of two promising young athletes, Len Bias and Don Rogers, added to public outrage. The new laws differentiated between powder cocaine and crack and were much harsher on the latter. These laws require 100 times as much powder cocaine possession as crack to trigger an identical minimum mandatory prison sentence. Ongoing controversy surrounds this law. Several bills have been introduced to reduce the disparity, but none have been passed into law as of early 2002.

Drug trafficking organizations in Columbia control the world's cocaine supply. The United States is actively engaged in fighting Columbia-based drug cartels. The U.S. Drug Enforcement Administration Congressional testimony of March 2, 2001 stated that targeting organized crime groups in Columbia will continue to be a priority and a matter of national security.

Federal guidelines, regulations, and penalties

Federal Trafficking Penalties, which are outlined in the Anti-Drug Abuse Act of 1986 and 1988, make a significant distinction between powder cocaine and crack cocaine. A first-time offender convicted for possession of 5–49 grams of crack cocaine will receive a mandatory minimum sentence of five years and not more than 40 years. Fines for individuals can be up to $2 million. The federal mandatory minimum sentences for powder cocaine begin at 500–4,999 grams and trigger the same sentence. Penalties for convicted second-time offenders are a minimum mandatory sentence of 10 years to life, with fines up to $4 million. This law is often referred to as the 100:1 law and has been challenged and reviewed several times.

RESOURCES

Books

Berger, Gilda. Crack, The New Drug Epidemic. Franklin Watts,1987.

Carroll, Marilyn. Cocaine and Crack. Enslow Publishers Inc.,1994.

Friedman, David P., and Sue Rusche. False Messengers: How Addictive Drugs Change the Brain. Harwood Academic Publishers, 1999.

Goldstein, Avram. Addiction: From Biology to Drug Policy. Oxford University Press, 2001.

Other

Center for Education and Information on Drugs and Alcohol. NSW+Health. Cocaine<http://www.ceida.net.au/tools_for_workers/drugs/cocaine.html>.

National Institute on Drug Abuse. National Institutes of Health. "Cocaine Abuse May Lead to Strokes and Mental Deficits." NIDA Notes 13, no. 3 (July 1998). <http://www.nida.nih.gov/NIDA_Notes/NNVol12N3/Cocaine.html>.

National Institute on Drug Abuse. National Institutes of Health. "Oops: How Casual Drug Use Leads to Addiction." NIDA NOTES<http://www.nida.nih.gov/Published_Articles/Oops.html>.

United States Department of Justice. Drug Enforcement Administration. Cocaine. <http://usdoj.gov/dea/concern/cocaine.html>.

United States Office of National Drug Control Policy. "Crack: The Perception." Pulse Check: Trends in Drug Abuse (November2001). <http://www.whitehousedrugpolicy.gov/publications/drugfact/pulsechk/fall2001/crack.html>.

United States Office of National Drug Control Policy. "Powder Cocaine: The Perception." Pulse Check: Trends in Drug Abuse (November 2001). <http://www.whitehousedrugpolicy.gov/publications/drugfact/pulsechk/fall2001/powder.html>.

Organizations

Cocaine Anonymous World Services, P.O. Box 2000, Los Angeles, CA, USA, 90049-8000, (310) 559-5833, [email protected], <http://www.ca.org>.

Cocaine Helpline, 1-800-662-HELP.

National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, [email protected]/Inforfax/cocaine.html, <http://www.drugabuse.gov/Inforfax/cocaine.html>.

Patty Jo Sawvel

Cocaine and Related Disorders

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Cocaine is extracted from the coca plant, which grows in Central and South America. The substance is processed into many forms for use as an illegal drug of abuse. Cocaine is dangerously addictive, and users of the drug experience a “high”—a feeling of euphoria or intense happiness, along with hypervigilance, increased sensitivity, irritablity or anger, impaired judgment, and anxiety.

Forms of the drug

In its most common form, cocaine is a whitish crystalline powder that produces feelings of euphoria when ingested. In powder form, cocaine is known by such street names as “coke,” “blow,” “C,” “flake,” “snow and “toot.” It is most commonly inhaled or snorted. It may also be dissolved in water and injected.

Crack is a form of cocaine that can be smoked and that produces an immediate, more intense, and more short-lived high. It comes in off-white chunks or chips called “rocks.”

In addition to their stand-alone use, both cocaine and crack are often mixed with other substances. Cocaine may be mixed with methcathinone to create a “wildcat.” Cigars may be hollowed out and filled with a mixture of crack and marijuana. Either cocaine or crack used in conjunction with heroin is called a “speedball.” Cocaine used together with alcohol represents the most common fatal two-drug combination.

Description

Cocaine-related disorders is a very broad topic. According to the mental health clinician’s handbook, Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (also known as the DSM-IV-TR), the broad category of cocaine-related disorders can be subdivided into two categories: cocaine use disorders and cocaine-induced disorders. Cocaine use disorders include cocaine dependence and cocaine abuse. Cocaine-induced disorders include:

• cocaine intoxication
• cocaine withdrawal
• cocaine intoxication delirium
• cocaine-induced psychotic disorder, with delusions
• cocaine-induced psychotic disorder, with hallucinations
• cocaine-induced mood disorder
• cocaine-induced anxiety disorder
• cocaine-induced sexual dysfunction
• cocaine-induced sleep disorder
• cocaine-related disorder not otherwise specified

Cocaine use disorders

COCAINE ABUSE

For the cocaine abuser, the use of the substance leads to maladaptive behavior over a 12-month period. The person may fail to meet responsibilities at school, work, or home. The cocaine abuse impairs the affected person’s judgment, and he or she puts him- or herself in physical danger to use the substance. For example, the individual may use cocaine in an unsafe environment. The person who abuses cocaine may be arrested or charged with possession of the substance, yet will continue to use cocaine despite all of the personal and legal problems that may result.

COCAINE DEPENDENCE

Cocaine dependence is even more serious than cocaine abuse. Dependence is a maladaptive behavior that, over a three-month period, has caused the affected individual to experience tolerance for and withdrawal symptoms from cocaine. Tolerance is the need to increase the amount of cocaine intake to achieve the same desired effect. In other words, someone who is dependent on cocaine needs more cocaine to produce the same “high” that a lesser amount produced in the past. The dependent person also experiences cocaine withdrawal. Withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. The symptoms include irritable mood and two or more of the following symptoms: fatigue, nightmares, difficulty sleeping or too much sleep, elevated appetite, agitation (restlessness), or slowed physical movements. The onset of withdrawal symptoms can cause a person to use more cocaine to avoid these painful and uncomfortable symptoms. The dependent person uses larger amounts of cocaine for longer periods of time than intended. He or she cannot cut back on the use of the substance, often has a difficult time resisting cocaine when it is available, and may abandon work or school to spend more time acquiring and planning to acquire more cocaine. The individual continues to use the cocaine despite the negative effects it has on family life, work and school.

Cocaine-induced disorders

COCAINE INTOXICATION

Cocaine intoxication occurs after recent cocaine use. The person experiences a feeling of intense happiness, hypervigilance, increased sensitivity, irritability or anger, with impaired judgement, and anxiety. The intoxication impairs the person’s ability to function at work, school, or in social situations. Two or more of the following symptoms are present immediately after the use of the cocaine:

• enlarged pupils
• elevated heart rate
• elevated or lowered blood pressure
• chills and increased sweating
• nausea or vomiting
• weight loss
• agitation or slowed movements
• weak muscles
• chest pain
• coma
• confusion
• irregular heartbeat
• depressed respiration
• seizures
• odd postures
• odd movements

COCAINE WITHDRAWAL

As mentioned, withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. The symptoms include irritable mood and two or more of the following symptoms: fatigue, nightmares, difficulty sleeping or too much sleep, elevated appetite, agitation (restlessness), or slowed physical movements.

COCAINE-INDUCED DELIRIUM

According to the DSM-IV-TR, several criteria must be met in order for a health care professional to establish the diagnosis of cocaine-induced delirium. Patients have a disturbance of their level of consciousness or awareness, evidenced by drowsiness or an inability to concentrate or pay attention. Patients also experience a change in their cognition (ability to think) evidenced by a deficit in their language or their memory. For example, these patients may forget where they have placed an item, or their speech is confusing. These symptoms have rapid onset within hours or days of using cocaine and the symptoms fluctuate throughout the course of the day. These findings cannot be explained by dementia (state of impaired thought processes and memory that can be caused by various diseases and conditions) and the doctor must not be able to recognize some other physical reason that can account for the symptoms other than cocaine intoxication.

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH DELUSIONS

The person with this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience delusions (beliefs that the person continues to maintain, despite evidence to the contrary). In order for this state to be considered cocaine-induced psychotic disorder, these symptoms cannot be due to another condition or substance.

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH HALLUCINATIONS

This condition is the same as cocaine-induced psychotic disorder with delusions, except that this affected individual experiences hallucinations instead of delusions. Hallucinations can be described as hearing and seeing things that are not real.

COCAINE-INDUCED MOOD DISORDER

The person with this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience depressed, elevated, or irritable mood with apathy (lack of empathy for others, and lack of showing a broad range of appropriate emotions).

COCAINE-INDUCED ANXIETY DISORDER

The person this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience anxiety, panic attacks, obsessions, or compulsions. Panic attacks are discrete episodes of intense anxiety. Persons affected with panic attacks may experience accelerated heart rate, shaking or trembling, sweating, shortness of breath, or fear of going crazy or losing control, as well as other symptoms. An obsession is an unwelcome, uncontrollable, persistent idea, thought, image, or emotion that a person cannot help thinking even though it creates significant distress or anxiety. A compulsion is a repetitive, excessive, meaningless activity or mental exercise which a person performs in an attempt to avoid distress or worry.

COCAINE-INDUCED SEXUAL DYSFUNCTION

The person with this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience sexual difficulties, and these difficulties are deemed by the clinician to be due directly to the cocaine use. Substance-induced sexual difficulties can range from impaired desire, impaired arousal, impaired orgasm, or sexual pain.

COCAINE-INDUCED SLEEP DISORDER

This disorder is characterized by difficulty sleeping (insomnia ) during intoxication or increased sleep duration when patients are in withdrawal.

COCAINE-RELATED DISORDER NOT OTHERWISE SPECIFIED

This classification is reserved for clinicians to use when a cocaine disorder that the clinician sees does not fit into any of the above categories.

Causes and symptoms

Causes

BIOCHEMICAL/PHYSIOLOGICAL CAUSES

Twin studies have demonstrated that there is a higher rate of cocaine abuse in identical twins as compared to fraternal twins. This indicates that genetic factors contribute to the development of cocaine abuse. This finding also indicates, however, that unique environmental factors contribute to the development of cocaine abuse, as well. (If genes alone determined who would develop cocaine dependence, 100% of the identical twins with the predisposing genes would develop the disorder. However, because the results show only a relationship, or a correlation, between genetics and cocaine use among twins, these results indicate that other factors must be at work, as well.) Studies have also shown that disorders like attention deficit/hyperactivity disorder (ADHD), conduct disorder, and antisocial personality disorder all have genetic components, and since patients who abuse cocaine have a high incidence of these diagnoses, they may also be genetically predisposed to abusing cocaine.

REINFORCEMENT

Learning and conditioning also play a unique role in the perpetuation of cocaine abuse. Each inhalation and injection of cocaine causes pleasurable feelings that reinforce the drug-taking procedure. In addition, the patient’s environment also plays a role in cueing and reinforcing the experience in the patient’s mind. The association between cocaine and environment is so strong that many people recovering from cocaine addiction report that being in an area where they used drugs brings back memories of the experience and makes them crave drugs. Specific areas of the brain are thought to be involved in cocaine craving, including the amygdala (a part of the brain that controls aggression and emotional reactivity), and the prefrontal cortex (a part of the brain that regulates anger, aggression, and the brain’s assessment of fear, threats, and danger).

Symptoms

The following list is a summary of the acute (short-term) physical and psychological effects of cocaine on the body:

• blood vessels constrict
• elevated heart rate
• elevated blood pressure
• a feeling of intense happiness
• elevated energy level
• a state of increased alertness and sensory sensitivity
• elevated anxiety
• panic attacks
• elevated self-esteem
• diminished appetite
• spontaneous ejaculation and heightened sexual arousal
• psychosis (loss of contact with reality)

The following list is a summary of the chronic (long-term) physical and psychological effects of cocaine on the body:

• depressed mood
• irritability
• physical agitation
• decreased motivation
• difficulty sleeping
• hypervigilance
• elevated anxiety
• panic attacks
• hallucinations
• psychosis

Demographics

The patterns of cocaine abuse in the United States have changed much over the past thirty years. The patterns have also been changing in other parts of the world as well, including South America and Western Europe. In the United States, several studies have attempted to track drug abuse in many different populations. The studies include: the Monitoring the Future Study (MTF); the National Household Survey on Drug Abuse (NHSDA); the Drug Abuse Warning Network (DAWN), which gets reports from Emergency Rooms and medical examiners’ offices on drug-related cases and deaths; and Arrestee Drug Abuse Monitoring (ADAM), which gets information on urine samples obtained from people who have been arrested.

In the annual MTF study, cocaine use among high school seniors had declined from 13.1% in 1985 to 3.1% in 1992—the lowest it had been since 1975 when the survey was first implemented. The rate of cocaine use began to rise again and peaked at 5.5% in 1997. The NHSDA found that the levels of cocaine use declined over the same time period. The decline in the rates has been thought to be due in part to education about the risks of cocaine abuse.

The incidence of new crack cocaine users has also decreased. There was a minimal decline in the numbers of excessive cocaine users between the years 1985 and 1997. The Epidemiologic Catchment Area (ECA) studies done in the early 1980s combined cocaine dependence with cocaine abuse and found that one-month to six-month prevalence rates for cocaine abuse and dependence were low or could not be measured. The lifetime rate of cocaine abuse was 0.2%.

A 1997 study from The National Institute on Drug Abuse indicates that among outpatients who abuse substances, 55% abuse cocaine.

Cocaine abuse affects both genders and many different populations across the United States. Males are one-and-a-half to two times more likely to abuse cocaine than females. Cocaine began as a drug of the upper classes in the 1970s; now the socioeconomic status of cocaine users has shifted. Cocaine is more likely to be abused by the economically disadvantaged because it is easy for them to get, and it is inexpensive ($10 for a small bag of crack cocaine). These factors have led to increased violence (because people who are cocaine dependent often will become involved in illegal activity, such as drug dealing, in order to acquire funds for their habit) and higher rates of acquired immune deficiency (AIDS) among disadvantaged populations.

Diagnosis

If a mental health clinician suspects cocaine use, he or she may ask the patient specifically about swallowing, injecting, or smoking the substance. Urine and blood testing will also be conducted to determine the presence of the substance. Doctors may also talk to friends or relatives concerning the patient’s drug use, especially for cases in which the physician suspects that the patient is not being entirely honest about substance use. The clinician may also investigate a patient’s legal history for drug arrests that may give clues to periods of substance abuse to which the patient will not admit.

Differential diagnosis

Differential diagnosis is the process of distinguishing one condition from other, similar conditions. The cocaine abuse disorder is easily confused with other substance abuse disorders and various forms of mental illness.

The symptoms of cocaine intoxication, such as increased talkativeness, poor sleep, and the intense feelings of happiness are similar to the symptoms for bipolar disorder, so the urine toxification screening test may play a key role in the diagnosis. Patients with cocaine intoxication with hallucinations and delusions can be mistaken for schizophrenic patients instead, further emphasizing the importance of the urine and blood screens. As part of establishing the diagnosis, the physician must also rule out PCP (phencyclidine ) intoxication and Cushing’s disease (an endocrine disorder of excessive cortisol production). Withdrawal symptoms are similar to those of the patient with major depression. For this reason, the clinician may ask the patient about his or her mood during times of abstinence from drug use to discern if any true mood disorders are present. If cocaine use is causing depression, the depression should resolve within a couple of weeks of stopping drug use.

Laboratory testing

The breakdown products of cocaine remain in the urine. The length of time that they remain depends on the dose of cocaine, but most doses would not remain in the urine longer than a few days. Cocaine can also be found in other bodily fluids such as blood, saliva, sweat, and hair, and these provide better estimates as to recent cocaine use. The hair can hold evidence that a patient has been using drugs for weeks to months. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) are different kinds of imaging studies. Both kinds of scans look at the amount of blood that is flowing to the brain.

When these images are taken of the brains of people who abuse cocaine, the resulting scans have revealed abnormalities in certain sections of the brain. The brains of people addicted to cocaine shrink, or atrophy.

Neuropsychological assessment

Neuropsychological testing is also an important tool for examining the effects of toxic substances on brain functioning. Some physicians may use neuropsychological assessments to reveal patients’ cognitive and physical impairment after cocaine use. Neuropsychological testing assesses brain functioning through structured and systematic behavioral observation. Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, and language. An example of a task that a physician might ask the patient to complete as part of a neuropsychological examination is to name as many words beginning with a particular letter as the patient can in one minute. Patients who abuse cocaine often have difficulty completing tasks, such as the one described, that require concentration and memory.

Treatments

Psychological and social interventions

TREATMENT SETTINGS

Not all patients who abuse cocaine need to resort to long-term treatment. Treatment length varies with the degree that a person is dependent on the substance. If the patient has other psychiatric conditions such as major depression or schizophrenia or has significant medical complications of cocaine abuse, then he or she is more likely to require higher-intensity treatment. Residential programs/therapeutic communities may be helpful, particularly in more severe cases. Patients typically spend six to 12 months in such programs, which may also include vocational training and other features. The availability of such treatment, as well as medical insurance’s ability to cover treatment, are all issues that affect the patient’s access to treatment.

PSYCHOTHERAPY

A wide range of behavioral interventions have been successfully used to treat cocaine addiction. The approach used must be tailored to the specific needs of each individual patient, however.

Contingency management rewards drug abstinence (confirmed by urine testing) with points or vouchers which patients can exchange for such things as an evening out or membership in a gym. Cognitive-behavioral therapy helps users learn to recognize and avoid situations most likely to lead to cocaine use and to develop healthier ways to cope with stressful situations.

Supportive therapy helps patients to modify their behavior by preventing relapse by taking actions such as staying away from drug-using friends and from neighborhoods or situations where cocaine is abundant.

Self-help groups like Narcotics Anonymous (NA) or Cocaine Anonymous (CA) are helpful for many recovering substance abusers. CA is a twelve-step program for cocaine abusers modeled after Alcoholics Anonymous (AA). Support groups and group therapy led by a therapist can be helpful because other addicts can share coping and relapse-prevention strategies. The group’s support can help patients face devastating changes and life issues. Some experts recommend that patients be cocaine-free for at least two weeks before participating in a group, but other experts argue that a two-week waiting period is unnecessary and counterproductive. Group counseling sessions led by drug counselors who are in recovery themselves are also useful for some people overcoming their addictions. These group counseling sessions differ from group therapy in that the people in a counseling group are constantly changing.

The National Institute of Drug Abuse conducted a study comparing different forms of psychotherapy : patients who had both group drug counseling and individual drug counseling had improved outcomes. Patients who had cognitive-behavioral therapy stayed in treatment longer.

Medications

Many medications—greater than twenty—have been tested but none have been found to reduce the intensity of withdrawal. Dopamine agonists like amantadine and bromocriptine and tricyclic antidepressants such as desipramine have failed in studies to help treat symptoms of cocaine withdrawal or intoxication.

Alternative therapy

Alternative techniques, such as acupuncture, EEG biofeedback, and visualization, may be useful in treating addiction when combined with conventional treatment approaches.

Prognosis

Not all cocaine abusers become dependent on the drug. However, even someone who only uses occasionally can experience the harmful effects (interpersonal relationship conflicts, work or school difficulties, etc.) of using cocaine, and even occasional use is enough to addict. In the course of a person’s battle with cocaine abuse, he or she may vary the forms of the drug that he or she uses. A person may use the inhaled form at one time and the injected form at another, for example.

KEY TERMS

Amygdala —An almond-shaped brain structure in the limbic system that is activated in acute stress situations to trigger the emotion of fear.

Coca plant —The plant that is the source of cocaine.

Crack —A slang term for a form of cocaine that is smokable.

Craving —An overwhelming need to seek out more drugs.

Physical dependence —A maladaptive behavior that over a three-month period has caused the individual to experience tolerance and withdrawal symptoms.

Tolerance —Progressive decrease in the effectiveness of a drug with long-term use.

Withdrawal —Symptoms experienced by a person who has become physically dependent on a drug, experienced when the drug use is discontinued.

Many studies of short-term outpatient treatment over a six-month to two-year period indicate that people addicted to cocaine have a better chance of recovering than people who are addicted to heroin. A study of veterans who participated in an inpatient or day hospital treatment program that lasted 28 days, revealed that about 60% of people who were abstinent at four months were able to maintain their abstinence at seven months.

Having a good social support network greatly improves the prognosis for recovery from cocaine abuse and dependence.

Prevention

Efforts to prevent cocaine abuse, as well as any substance abuse, begin with prevention programs that are based in schools, in the workplace, heath care clinics, criminal justice systems, and public housing. Programs such as Students Taught Awareness (STAR) are cost effective and have reduced the rates of substance abuse in the schools. These school-based programs also foster parental involvement and education about substance abuse issues. The juvenile justice system also implements drug prevention programs. Even many workplaces provide drug screening and treatment and counseling for those who test positive. Employers may also provide workshops on substance abuse prevention. The United States Department of Housing and Urban Development (HUD) also sponsors drug prevention programs.

See alsoAddiction; Detoxification; Disease concept of chemical dependency.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Jaffe, Jerome H., M.D. “Cocaine-Related Disorders.” In Comprehensive Textbook of Psychiatry, edited by Benjamin J. Sadock, M.D. and Virginia A. Sadock, M.D. 7th edition. Philadelphia: Lippincott Williams and Wilkins, 2000.

Matthews, John. “Substance-Related Disorders: Cocaine and Narcotics.” In Psychiatry Update and Board Preparation, edited by Thomas A. Stern, M.D. and John B. Herman, M.D. New York: McGraw Hill, 2000.

PERIODICALS

Adinoff, Byron, M.D. and others. “Limbic Response to Procaine in Cocaine Addicted Subjects.” American Journal of Psychiatry (March 2001): 390–398.

Held, Gale A., M.P.A. “Linkages Between Substance Abuse Prevention and Other Human Services Literature Review.” National Institute on Drug Abuse (NIDA) (June 1998).

Jacobsen, Leslie K., M.D. and others. “Quantitative Morphology of the Caudate and Putamen in Patients With Cocaine Dependence.” American Journal of Psychiatry (March 2000): 486–489.

Kampman, Kyle M., M.D. and others. “Amantadine in the Treatment of Cocaine-Dependent Patients With Severe Withdrawal Symptoms.” American Journal of Psychiatry (December 2000): 2052–2054.

ORGANIZATIONS

National Institute on Drug Abuse (NIDA). 6001 Executive Boulevard, Room 5213, Bethesda, MD, 20892-9561. (301) 443-1124. <http://www.nida.nih.gov>.

The American Academy of Addiction Psychiatry (AAAP). 7301 Mission Road, Suite 252, Prairie Village, KS, 66208. (913) 262-6161. <http://www.aaap.org>.

Cocaine Anonymous World Services (CAWS). 3740 Overland Ave. Ste. C, Los Angeles, CA, 90034. (310) 559-5833. <http://www.ca.org>.

OTHER

Leshner, Alan Ph.D. “Cocaine Abuse and Addiction.” National Institute on Drug Abuse Research Report Series NIH Publication Number 99-4342, Washington, D.C. Supt.of doc. U.S. Government Printing Offices, 1999.

Susan Hobbs, M.D.
Peter Gregutt

Cocaine and related disorders

Definition

Cocaine is extracted from the coca plant, which grows in Central and South America. The substance is processed into many forms for use as an illegal drug of abuse. Cocaine is dangerously addictive, and users of the drug experience a "high"—a feeling of euphoria or intense happiness, along with hypervigilance, increased sensitivity, irritablity or anger, impaired judgment, and anxiety.

Forms of the drug

In its most common form, cocaine is a whitish crystalline powder that produces feelings of euphoria when ingested. In powder form, cocaine is known by such street names as "coke," "blow," "C," "flake," "snow" and "toot." It is most commonly inhaled or "snorted." It may also be dissolved in water and injected.

Crack is a form of cocaine that can be smoked and that produces an immediate, more intense, and more short-lived high. It comes in off-white chunks or chips called "rocks."

In addition to their stand-alone use, both cocaine and crack are often mixed with other substances. Cocaine may be mixed with methcathinone to create a "wildcat." Cigars may be hollowed out and filled with a mixture of crack and marijuana. Either cocaine or crack used in conjunction with heroin is called a "speedball." Cocaine used together with alcohol represents the most common fatal two-drug combination.

Description

Cocaine-related disorders is a very broad topic. According to the mental health clinician's handbook, Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revised (also known as the DSM-IV-TR ), the broad category of cocaine-related disorders can be subdivided into two categories: cocaine use disorders and cocaine-induced disorders. Cocaine use disorders include cocaine dependence and cocaine abuse. Cocaine-induced disorders include:

• cocaine intoxication
• cocaine withdrawal
• cocaine intoxication delirium
• cocaine-induced psychotic disorder, with delusions
• cocaine-induced psychotic disorder, with hallucinations
• cocaine-induced mood disorder
• cocaine-induced anxiety disorder
• cocaine-induced sexual dysfunction
• cocaine-induced sleep disorder
• cocaine-related disorder not otherwise specified

Cocaine use disorders

COCAINE ABUSE. For the cocaine abuser, the use of the substance leads to maladaptive behavior over a 12-month period. The person may fail to meet responsibilities at school, work, or home. The cocaine abuse impairs the affected person's judgment, and he or she puts him- or herself in physical danger to use the substance. For example, the individual may use cocaine in an unsafe environment. The person who abuses cocaine may be arrested or charged with possession of the substance, yet will continue to use cocaine despite all of the personal and legal problems that may result.

COCAINE DEPENDENCE. Cocaine dependence is even more serious than cocaine abuse. Dependence is a maladaptive behavior that, over a three-month period, has caused the affected individual to experience tolerance for and withdrawal symptoms from cocaine. Tolerance is the need to increase the amount of cocaine intake to achieve the same desired effect. In other words, someone who is dependent on cocaine needs more cocaine to produce the same "high" that a lesser amount produced in the past. The dependent person also experiences cocaine withdrawal. Withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. The symptoms include irritable mood and two or more of the following symptoms: fatigue , nightmares, difficulty sleeping or too much sleep, elevated appetite, agitation (restlessness), or slowed physical movements. The onset of withdrawal symptoms can cause a person to use more cocaine to avoid these painful and uncomfortable symptoms. The dependent person uses larger amounts of cocaine for longer periods of time than intended. He or she cannot cut back on the use of the substance, often has a difficult time resisting cocaine when it is available, and may abandon work or school to spend more time acquiring and planning to acquire more cocaine. The individual continues to use the cocaine despite the negative effects it has on family life, work, and school.

Cocaine-induced disorders

COCAINE INTOXICATION. Cocaine intoxication occurs after recent cocaine use. The person experiences a feeling of intense happiness, hypervigilance, increased sensitivity, irritability or anger, with impaired judgment, and anxiety. The intoxication impairs the person's ability to function at work, school, or in social situations. Two or more of the following symptoms are present immediately after the use of the cocaine:

• enlarged pupils
• elevated heart rate
• elevated or lowered blood pressure
• chills and increased sweating
• nausea or vomiting
• weight loss
• agitation or slowed movements
• weak muscles
• chest pain
• coma
• confusion
• irregular heartbeat
• depressed respiration
• seizures
• odd postures
• odd movements

COCAINE WITHDRAWAL. As mentioned, withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. The symptoms include irritable mood and two or more of the following symptoms: fatigue, nightmares, difficulty sleeping or too much sleep, elevated appetite, agitation (restlessness), or slowed physical movements.

COCAINE-INDUCED DELIRIUM. According to the DSM-IV-TR, several criteria must be met in order for a health care professional to establish the diagnosis of cocaine-induced delirium. Patients have a disturbance of their level of consciousness or awareness, evidenced by drowsiness or an inability to concentrate or pay attention. Patients also experience a change in their cognition (ability to think) evidenced by a deficit in their language or their memory. For example, these patients may forget where they have placed an item, or their speech is confusing. These symptoms have rapid onset within hours or days of using cocaine and the symptoms fluctuate throughout the course of the day. These findings cannot be explained by dementia (state of impaired thought processes and memory that can be caused by various diseases and conditions) and the doctor must not be able to recognize some other physical reason that can account for the symptoms other than cocaine intoxication.

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH DELUSIONS. The person suffering from this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience delusions (beliefs that the person continues to maintain, despite evidence to the contrary). In order for this state to be considered cocaine-induced psychotic disorder, these symptoms cannot be due to another condition or substance.

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH HALLUCINATIONS. This condition is the same as cocaine-induced psychotic disorder with delusions, except that this affected individual experiences hallucinations instead of delusions. Hallucinations can be described as hearing and seeing things that are not real.

COCAINE-INDUCED MOOD DISORDER. The person suffering from this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience depressed, elevated, or irritable mood with apathy (lack of empathy for others, and lack of showing a broad range of appropriate emotions).

COCAINE-INDUCED ANXIETY DISORDER. The person suffering from this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience anxiety, panic attacks, obsessions, or compulsions. Panic attacks are discrete episodes of intense anxiety. Persons affected with panic attacks may experience accelerated heart rate, shaking or trembling, sweating, shortness of breath, or fear of going crazy or losing control, as well as other symptoms. An obsession is an unwelcome, uncontrollable, persistent idea, thought, image, or emotion that a person cannot help thinking even though it creates significant distress or anxiety. Acompulsion is a repetitive, excessive, meaningless activity or mental exercise which a person performs in an attempt to avoid distress or worry.

COCAINE-INDUCED SEXUAL DYSFUNCTION. The person suffering from this disorder has experienced intoxication or withdrawal from cocaine within a month from the time he or she begins to experience sexual difficulties, and these difficulties are deemed by the clinician to be due directly to the cocaine use. Substance-induced sexual difficulties can range from impaired desire, impaired arousal, impaired orgasm, or sexual pain.

COCAINE-INDUCED SLEEP DISORDER. This disorder is characterized by difficulty sleeping (insomnia ) during intoxication or increased sleep duration when patients are in withdrawal.

COCAINE-RELATED DISORDER NOT OTHERWISE SPECIFIED. This classification is reserved for clinicians to use when a cocaine disorder that the clinician sees does not fit into any of the above categories.

Causes and symptoms

Causes

BIOCHEMICAL/PHYSIOLOGICAL CAUSES. Twin studies have demonstrated that there is a higher rate of cocaine abuse in identical twins as compared to fraternal twins. This indicates that genetic factors contribute to the development of cocaine abuse. This finding also indicates, however, that unique environmental factors contribute to the development of cocaine abuse, as well. (If genes alone determined who would develop cocaine dependence, 100% of the identical twins with the predisposing genes would develop the disorder. However, because the results show only a relationship, or a correlation, between genetics and cocaine use among twins, these results indicate that other factors must be at work, as well.) Studies have also shown that disorders like attention-deficit/hyperactivity disorder (ADHD), conduct disorder , and anti-social personality disorder all have genetic components, and since patients who abuse cocaine have a high incidence of these diagnoses, they may also be genetically predisposed to abusing cocaine.

REINFORCEMENT. Learning and conditioning also play a unique role in the perpetuation of cocaine abuse. Each inhalation and injection of cocaine causes pleasurable feelings that reinforce the drug-taking procedure. In addition, the patient's environment also plays a role in cueing and reinforcing the experience in the patient's mind. The association between cocaine and environment is so strong that many people recovering from cocaine addiction report that being in an area where they used drugs brings back memories of the experience and makes them crave drugs. Specific areas of the brain are thought to be involved in cocaine craving, including the amygdala (a part of the brain that controls aggression and emotional reactivity), and the prefrontal cortex (a part of the brain that regulates anger, aggression, and the brain's assessment of fear, threats, and danger).

Symptoms

The following list is a summary of the acute (short-term) physical and psychological effects of cocaine on the body:

• blood vessels constrict
• elevated heart rate
• elevated blood pressure
• a feeling of intense happiness
• elevated energy level
• a state of increased alertness and sensory sensitivity
• elevated anxiety
• panic attacks
• elevated self-esteem
• diminished appetite
• spontaneous ejaculation and heightened sexual arousal
• psychosis (loss of contact with reality)

The following list is a summary of the chronic (long-term) physical and psychological effects of cocaine on the body:

• depressed mood
• irritability
• physical agitation
• decreased motivation
• difficulty sleeping
• hypervigilance
• elevated anxiety
• panic attacks
• hallucinations
• psychosis

Demographics

The patterns of cocaine abuse in the United States have changed much over the past thirty years. The patterns have also been changing in other parts of the world as well, including South America and Western Europe. In the United States, several studies have attempted to track drug abuse in many different populations. The studies include: the Monitoring the Future Study (MTF); the National Household Survey on Drug Abuse (NHSDA); the Drug Abuse Warning Network (DAWN), which gets reports from Emergency Rooms and medical examiners' offices on drug-related cases and deaths; and Arrestee Drug Abuse Monitoring (ADAM), which gets information on urine samples obtained from people who have been arrested.

In the annual MTF study, cocaine use among high school seniors had declined from 13.1% in 1985 to 3.1% in 1992—the lowest it had been since 1975 when the survey was first implemented. The rate of cocaine use began to rise again and peaked at 5.5% in 1997. The NHSDA found that the levels of cocaine use declined over the same time period. The decline in the rates has been thought to be due in part to education about the risks of cocaine abuse.

The incidence of new crack cocaine users has also decreased. There was a minimal decline in the numbers of excessive cocaine users between the years 1985 and 1997. The Epidemiologic Catchment Area (ECA) studies done in the early 1980s combined cocaine dependence with cocaine abuse and found that one-month to six-month prevalence rates for cocaine abuse and dependence were low or could not be measured. The lifetime rate of cocaine abuse was 0.2%.

A 1997 study from The National Institute on Drug Abuse indicates that among outpatients who abuse substances, 55% abuse cocaine.

Cocaine abuse affects both genders and many different populations across the United States. Males are one-and-a-half to two times more likely to abuse cocaine than females. Cocaine began as a drug of the upper classes in the 1970s; now the socioeconomic status of cocaine users has shifted. Cocaine is more likely to be abused by the economically disadvantaged because it is easy for them to get, and it is inexpensive ($10 for a small bag of crack cocaine). These factors have led to increased violence (because people who are cocaine dependent often will become involved in illegal activity, such as drug dealing, in order to acquire funds for their habit) and higher rates of acquired immune deficiency (AIDS) among disadvantaged populations.

Diagnosis

If a mental health clinician suspects cocaine use, he or she may ask the patient specifically about swallowing, injecting, or smoking the substance. Urine and blood testing will also be conducted to determine the presence of the substance. Doctors may also talk to friends or relatives concerning the patient's drug use, especially for cases in which the physician suspects that the patient is not being entirely honest about substance use. The clinician may also investigate a patient's legal history for drug arrests that may give clues to periods of substance abuse to which the patient will not admit.

Differential diagnosis

Differential diagnosis is the process of distinguishing one condition from other, similar conditions. The cocaine abuse disorder is easily confused with other substance abuse disorders and various forms of mental illness.

The symptoms of cocaine intoxication, such as increased talkativeness, poor sleep, and the intense feelings of happiness are similar to the symptoms for bipolar disorder , so the urine toxification screening test may play a key role in the diagnosis. Patients with cocaine intoxication with hallucinations and delusions can be mistaken for schizophrenic patients instead, further emphasizing the importance of the urine and blood screens. As part of establishing the diagnosis, the physician must also rule out PCP (phencyclidine) intoxication and Cushing's disease (an endocrine disorder of excessive cortisol production). Withdrawal symptoms are similar to those of the patient with major depression. For this reason, the clinician may ask the patient about his or her mood during times of abstinence from drug use to discern if any true mood disorders are present. If cocaine use is causing depression, the depression should resolve within a couple of weeks of stopping drug use.

Laboratory testing

The breakdown products of cocaine remain in the urine. The length of time that they remain depends on the dose of cocaine, but most doses would not remain in the urine longer than a few days. Cocaine can also be found in other bodily fluids such as blood, saliva, sweat, and hair, and these provide better estimates as to recent cocaine use. The hair can hold evidence that a patient has been using drugs for weeks to months. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) are different kinds of imaging studies . Both kinds of scans look at the amount of blood that is flowing to the brain. When these images are taken of the brains of people who abuse cocaine, the resulting scans have revealed abnormalities in certain sections of the brain. The brains of people addicted to cocaine shrink, or atrophy.

Neuropsychological assessment

Neuropsychological testing is also an important tool for examining the effects of toxic substances on brain functioning. Some physicians may use neuropsychological assessments to reveal patients' cognitive and physical impairment after cocaine use. Neuropsychological testing assesses brain functioning through structured and systematic behavioral observation. Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, and language. An example of a task that a physician might ask the patient to complete as part of a neuropsychological examination is to name as many words beginning with a particular letter as the patient can in one minute. Patients who abuse cocaine often have difficulty completing tasks, such as the one described, that require concentration and memory.

Treatments

Psychological and social interventions

TREATMENT SETTINGS. Not all patients who abuse cocaine need to resort to long-term treatment. Treatment length varies with the degree that a person is dependent on the substance. If the patient has other psychiatric conditions such as major depression or schizophrenia or has significant medical complications of cocaine abuse, then he or she is more likely to require higher-intensity treatment. Residential programs/therapeutic communities may be helpful, particularly in more severe cases. Patients typically spend six to 12 months in such programs, which may also include vocational training and other features. The availability of such treatment, as well as medical insurance's ability to cover treatment, are all issues that affect the patient's access to treatment.

PSYCHOTHERAPY. A wide range of behavioral interventions have been successfully used to treat cocaine addiction. The approach used must be tailored to the specific needs of each individual patient, however.

Contingency management rewards drug abstinence (confirmed by urine testing) with points or vouchers which patients can exchange for such things as an evening out or membership in a gym. Cognitive-behavioral therapy helps users learn to recognize and avoid situations most likely to lead to cocaine use and to develop healthier ways to cope with stressful situations.

Supportive therapy helps patients to modify their behavior by preventing relapse by taking actions such as staying away from drug-using friends and from neighborhoods or situations where cocaine is abundant.

Self-help groups like Narcotics Anonymous (NA) or Cocaine Anonymous (CA) are helpful for many recovering substance abusers. CA is a twelve-step program for cocaine abusers modeled after Alcoholics Anonymous (AA). Support groups and group therapy led by a therapist can be helpful because other addicts can share coping and relapse-prevention strategies. The group's support can help patients face devastating changes and life issues. Some experts recommend that patients be cocaine-free for at least two weeks before participating in a group, but other experts argue that a two-week waiting period is unnecessary and counterproductive. Group counseling sessions led by drug counselors who are in recovery themselves are also useful for some people overcoming their addictions. These group counseling sessions differ from group therapy in that the people in a counseling group are constantly changing.

The National Institute of Drug Abuse conducted a study comparing different forms of psychotherapy : patients who had both group drug counseling and individual drug counseling had improved outcomes. Patients who had cognitive-behavioral therapy stayed in treatment longer.

Medications

Many medications—greater than twenty—have been tested but none have been found to reduce the intensity of withdrawal. Dopamine agonists like amantadine and bromocriptine and tricyclic antidepressants such as desipramine have failed in studies to help treat symptoms of cocaine withdrawal or intoxication.

Alternative therapy

Alternative techniques, such as acupuncture , EEG biofeedback , and visualization, may be useful in treating addiction when combined with conventional treatment approaches.

Prognosis

Not all cocaine abusers become dependent on the drug. However, even someone who only uses occasionally can experience the harmful effects (interpersonal relationship conflicts, work or school difficulties, etc.) of using cocaine, and even occasional use is enough to addict. In the course of a person's battle with cocaine abuse, he or she may vary the forms of the drug that he or she uses. A person may use the inhaled form at one time and the injected form at another, for example.

Many studies of short-term outpatient treatment over a six-month to two-year period indicate that people addicted to cocaine have a better chance of recovering than people who are addicted to heroin. A study of veterans who participated in an inpatient or day hospital treatment program that lasted 28 days, revealed that about 60% of people who were abstinent at four months were able to maintain their abstinence at seven months.

Having a good social support network greatly improves the prognosis for recovery from cocaine abuse and dependence.

Prevention

Efforts to prevent cocaine abuse, as well as any substance abuse, begin with prevention programs that are based in schools, in the workplace, heath care clinics, criminal justice systems, and public housing. Programs such as Students Taught Awareness (STAR) are cost effective and have reduced the rates of substance abuse in the schools. These school-based programs also foster parental involvement and education about substance abuse issues. The juvenile justice system also implements drug prevention programs. Even many workplaces provide drug screening and treatment and counseling for those who test positive. Employers may also provide workshops on substance abuse prevention. The United States Department of Housing and Urban Development (HUD) also sponsors drug prevention programs.

See also Addiction; Detoxification; Disease concept of chemical dependency

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

Jaffe, Jerome H., M.D. "Cocaine-Related Disorders." In Comprehensive Textbook of Psychiatry, edited by Benjamin J. Sadock, M.D. and Virginia A. Sadock, M.D. 7th edition. Philadelphia: Lippincott Williams and Wilkins, 2000.

Matthews, John. "Substance-Related Disorders: Cocaine and Narcotics." In Psychiatry Update and Board Preparation, edited by Thomas A. Stern, M.D. and John B. Herman, M.D. New York: McGraw Hill, 2000.

PERIODICALS

Adinoff, Byron, M.D. and others. "Limbic Response to Procaine in Cocaine Addicted Subjects." American Journal of Psychiatry March 2001: 390-398.

Held, Gale A., M.P.A. "Linkages Between Substance Abuse Prevention and Other Human Services Literature Review." National Institute on Drug Abuse (NIDA) June 1998.

Jacobsen, Leslie K., M.D. and others. "Quantitative Morphology of the Caudate and Putamen in Patients With Cocaine Dependence." American Journal of Psychiatry March 2000: 486-489.

Kampman, Kyle M., M.D. and others. "Amantadine in the Treatment of Cocaine-Dependent Patients With Severe Withdrawal Symptoms." American Journal of Psychiatry December 2000: 2052-2054.

ORGANIZATIONS

The American Academy of Addiction Psychiatry (AAAP). 7301 Mission Road, Suite 252, Prairie Village, KS, 66208. (913) 262-6161.<http://www.aaap.org >.

Cocaine Anonymous World Services (CAWS). 3740 Overland Ave. Ste. C, Los Angeles, CA, 90034. (310) 559-5833. <http://www.ca.org>.

National Institute on Drug Abuse (NIDA). 6001 Executive Boulevard, Room 5213, Bethesda, MD, 20892-9561.(301) 443-1124.<http://www.nida.nih.gov>.

OTHER

Leshner, Alan Ph.D. "Cocaine Abuse and Addiction." National Institute on Drug Abuse Research Report Series NIH Publication Number 99-4342, Washington, D.C. Supt.of doc. US. Govt. Print. Off., 1999.

Susan Hobbs, M.D.

Peter Gregutt

COCAINE

The abuse of cocaine has become a major public-health problem in the United States since the 1970s. During that period it emerged from relative obscurity, described by experts as a harmless recreational drug with minimal toxicity. By the mid-1980s, cocaine use had increased substantially and its ability to lead to drug taking at levels that caused severe medical and psychological problems was obvious. Cocaine (also known as "coke," "snow," "lady," "Crack" and "ready rock"), is an Alkaloid with both local anesthetic and Psychomotor Stimulant properties. It is generally taken in binge cycles, with periods of hours to days in which users take the drug repeatedly, alternating with periods of days to weeks when no cocaine is used. Many users are recalcitrant to treatment, and the introduction of substantial criminal penalties associated with its possession and sale have not yet been effective in reducing its prevalence of heavy use. In fact, although occasional use of cocaine diminished somewhat by the early 1990s, heavier use did not.

HISTORY

Cocaine is extracted from the Coca Plant (Erythroxylon coca ), a shrub now found mainly in the Andean highlands and the northwestern parts of the Amazon in South America. The history of coca plant use by the cultures and civilizations who lived in these areas (including the Inca) goes back more than a thousand years, with evidence of use found archeologically in their burial sites. The Inca called the plant a "gift of the Sun god" and believed that the leaf had supernatural powers. They used the leaves much as the highland Indians of South America do today. A wad of leaves, along with some ash, is placed in the mouth and both chewed and sucked. The ash helps in the extraction of the cocaine from the coca leaf—and the cocaine is efficiently absorbed through the mucous membranes of the mouth.

During the height of the Inca Empire (11th-15th centuries) coca leaves were reserved for the nobility and for religious ceremonies, since it was believed that coca was of divine origin. With the conquest of the Inca Empire by the Spanish in the 1500s, coca use was banned. The Conquistadors soon discovered, however, that their Indian slaves worked harder and required less food if they were allowed to chew coca. The Catholic church began to cultivate coca plants, and in many cases the Indians were paid in coca leaves.

Although glowing reports of the stimulant effects of coca reached Europe, coca use did not achieve popularity. This was no doubt related to the fact that coca plants could not be grown in Europe and the active ingredient in the coca leaves did not survive the long ocean voyage from South America. After the isolation of cocaine from coca leaves by the German chemist Albert Niemann in 1860 and the subsequent purification of the drug, it became more popular. It was aided in this regard by commercial endeavors in which cocaine was combined with wine (e.g., Vin de Coca), products for which there appeared many enthusiastic and uncritical endorsements by notables of the time.

Both interest in and use of cocaine spread to the United States, where extracts of coca leaves were added to many patent medicines. Physicians began prescribing it for a variety of ills including dyspepsia, gastrointestinal disorders, headache, neuralgia, toothache, and more—and use increased dramatically. By the beginning of the twentieth century, cocaine's harmful effects were noted and caused a reassessment of its utility. As part of a broader regulatory effort, the U.S. government began to control its manufacture and sale. In 1914, the Harrison Narcotic Act forbade use of cocaine in over-the-counter medications and required the registration of those involved in the importation, manufacture, and sale of either coca or opium products. This had the effect of substantially reducing cocaine use in the United States, which remained relatively low until the late 1960s, when it moved into the spotlight once again.

MEDICAL UTILITY

Cocaine is a drug with both anesthetic and stimulant properties. Its local anesthetic and vasoconstriction effects remain its major medical use. The local anesthetic effect was established by Carl Koller in the mid-1880s, in experiments on the eye, but because it has been found to cause sloughing of the cornea, it is no longer used in eye surgery. Because it is the only local anesthetic capable of causing intense vasoconstriction, cocaine is beneficial in surgeries where shrinking of the mucous membranes and the associated increased visualization and decreased bleeding are necessary. Therefore, it remains useful for topical administration in the upper respiratory tract. When used in clinically appropriate doses, and with medical safeguards in place, cocaine appears to be a useful and safe local anesthetic.

PHARMACOKINETICS

Cocaine can be taken by a number of routes of administration—oral, intranasal, intravenous, and smoked. Although the effects of cocaine are similar no matter what the route, route clearly contributes to the likelihood that the drug will be abused. The likelihood that cocaine will be taken for nonmedical purposes is assumed to be related to the rate of increase in cocaine brain level (as measured by blood levels) associated with those routes that provide the largest and most rapid changes in brain level being associated with greater self-administration. The oral route of administration, not a route used by cocaine abusers, is characterized by relatively slow absorption and peak levels that do not appear until approximately an hour after ingestion. Cocaine, however, is quickly absorbed from the nasal mucosa when it is inhaled into the nose as a powder (cocaine hydrochloride). Because of its local anesthetic properties, cocaine numbs or "freezes" the mucous membranes, a quality used by those purchasing the drug on the street to test for purity. When cocaine is used intranasally ("snorting"), cocaine blood levels, as well as subjective and physiological effects, peak at about 20 to 30 minutes, and reports of a "rush" are minimal. Intranasal users report that they are ready to take a second dose of the drug within 30 to 40 minutes after the first dose. Although this route was the most common way for people to use cocaine in the mid-1980s, it is not as efficient in getting the drug to the brain as either smoking or intravenous injection, and it has declined in popularity.

When taken intravenously, venous blood levels peak virtually immediately and subjects report a substantial, dose-related rush. This route was, until the mid-1980s, traditionally the choice of the experienced user, since it provided a rapid increase in brain levels of cocaine with a parallel increase in subjective effects. Blood levels of cocaine dissipate in parallel with subjective effects, and subjects report that they are ready for another intravenous dose within about 30 to 40 minutes. Users of intravenous cocaine are also more likely to combine their cocaine with Heroin (e.g., a "speedball") than are users by other routes.

In the mid-1980s, smoked cocaine began to achieve popularity. Freebase, or "crack," is cocaine base, which is not destroyed at temperatures required to volatilize it. As with intravenous cocaine, blood levels peak almost immediately and, as with intravenous cocaine, a substantial rush ensues after smoking it. Users can prepare their own free-base from the powdered form they purchase on the street, or they can purchase it in the form of crack, or "ready-rock." The development of a smokable form of cocaine provided a more socially acceptable route of drug administration (both Nicotine and Marijuana cigarettes provided the model for smoking cocaine), resulting in a drug that was both easy to use and highly toxic, since the route allowed for frequent repeated dosing with a readily available and relatively inexpensive drug. The use of intravenous cocaine, in contrast, was limited to those able to acquire the paraphernalia and willing to put a needle in a vein. The toxicity of the smoked route of administration is in part related to the fact that a potent dose of cocaine is available to anyone who can afford it.

Cocaine is frequently taken in combination with other drugs such as alcohol, marijuana, and Opiates. In fact, almost 75 percent of cocaine deaths reported in 1989 involved co-ingestion of other drugs. When taken in combination with alcohol, a metabolite—Cocaethylene—is formed, which appears to be only slightly less potent than cocaine in its behavioral effects. It is possible that some of the toxicity reported after relatively low doses of cocaine might well be due to the combination of cocaine and alcohol.

Cocaine is broken down rapidly by enzymes (esterases) in the blood and liver. The major metabolites of this action (all relatively inactive) are Benzoylecgonine, ecgonine, and ecgonine methyl ester, all of which are excreted in the urine. Cocaethylene is an additional metabolite when cocaine and alcohol are ingested in combination. People with deficient plasma cholinesterase activity—fetuses, infants, pregnant women, patients with liver disease, and the elderly—are all likely to be sensitive to cocaine and therefore at higher risk for adverse effects than are others.

PHARMACOLOGY

Research has been focused on the neurochemical and neuroanatomical substrates that mediate cocaine's reinforcing effects. Although a number of Neurotransmitter systems are involved, there is growing evidence that cocaine's effects on dopaminergic neurons in the mesolimbic and/or mesocortical neuronal systems of the brain are most closely associated with its reinforcing and other behavioral effects. The initial site of action in the brain for its reinforcing effects has been hypothesized to be the dopamine transporter of mesolimbocortical neurons. Cocaine action at the Dopamine transporter has the effect of inhibiting dopamine re-uptake, resulting in higher levels of dopamine at the synapse. These dopaminergic pathways may mediate the reinforcing effects of other stimulants and opiates as well. A substantial body of evidence suggests that dopamine plays a major role in mediating cocaine's reinforcing effects, although it is clear that cocaine affects not only the dopamine but also the Serotonin and noradrenaline systems.

TOXICITY

In addition to blocking the re-uptake of several neurotransmitters, cocaine use results in central nervous system stimulation and local anesthesia. This latter effect may be responsible for the neural and myocardial depression seen after taking large doses. Cocaine use has been implicated in a broad range of medical complications covering virtually every one of the body's organ systems. At low doses, cocaine causes increases in heart rate, blood pressure, respiration, and body temperature. There have been suggestions that cocaine's cardiovascular effects can interact with ongoing behavior, resulting in increased toxicity. Cocaine intoxication has been associated with cardiovascular toxicity, related to both its local anesthetic effects and its inhibition of neuronal uptake of catecholamines, including heart attacks, stroke, vasospasm, and cardiac arrhythmias.

Cocaine is generally taken in binges, repeatedly, for several hours or days, followed by a period in which none is taken. When taken repeatedly, chronic cocaine intoxication can cause a psychosis, characterized by paranoia, anxiety, a stereotyped repetitive behavior pattern, and vivid visual, auditory, and tactile hallucinations. Less severe behavioral reactions to repeated cocaine use include irritability, hypervigilance, paranoid thinking, hyperactivity, and eating and sleep disturbances. In addition, when a cocaine binge ceases, there appears to be a crash response, characterized by depression, fatigue, and eating and sleep disturbances. Initially, the crash is accompanied by little cocaine craving, but as time increases since the last dose of cocaine, compulsive drug seeking can occur in which users think of little else but the next dose.

BEHAVIORAL EFFECTS

Nonhuman Research Subjects.

One of cocaine's characteristics, as a Psychomotor Stimu-Lant, is its ability to elicit increases in the motor behavior of animals. Single low doses produce increases in exploration, locomotion, and grooming. With increasing doses, locomotor activity decreases and stereotyped behavior patterns emerge (continuous repetitious chains of behavior). When administered repeatedly, cocaine produces increased levels of locomotor activity, increases in stereotyped behavior, and increases in susceptibility to drug-induced seizures (i.e., "kindling"). This sensitization occurs in a number of different species and has been suggested as a model for psychosis or schizophrenia in humans. Although sensitization to cocaine's unconditioned behavioral effects generally occurs, such effects are related to dose, environmental context, and schedule of cocaine administration. For example, sensitization occurs more readily when dosing is intermittent rather than continuous and when dosing occurs in the same environment as testing.

Learned behaviors, typically generated in the laboratory using operant schedules of reinforcement in which animals make responses that have consequences (e.g., press a lever to get food), generally show a rate-dependent effect of cocaine. As with Amphetamine, cocaine engenders increases in low rates of responding and decreases in high rates of responding. Environmental variables and behavioral context can modify this effect. For example, responding maintained by food delivery was decreased by doses of cocaine that either had no effect or increased comparable rates of responding maintained by shock avoidance. Cocaine's effects can also be modified by drug history. Although repeated administration can result in the development of sensitization to cocaine's effects on unlearned behaviors, repeated administration generally results in tolerance to cocaine's effects on schedule-controlled responding. This decrease in effect of the same dose after repeated dosing is influenced by behavioral as well as pharmacological factors.

Human Research Subjects.

A major behavioral effect of cocaine in humans is its mood-altering effect, generally believed related to its potential for abuse. Traditionally, subjective effects have provided the basis for classifying a substance as having abuse potential—and the cocaine-engendered profile of subjective effects is prototypic of stimulant drugs of abuse. Thus, cocaine produces dose-related reports of "high," "liking," and "euphoria"; increases in stimulant-related factors, such as increases on Vigor and Friendliness scale scores; ratings of "stimulated"; and decreases in various sedation scores. Subjective effects correlate well with single intravenous or smoked doses of cocaine, peaking soon after administration and dissipating in parallel with decreasing plasma concentrations. When cocaine is administered repeatedly, tolerance develops rapidly to many of its subjective effects and the same dose no longer exerts much of an effect. This means that the user must take increasingly larger amounts of cocaine to achieve the same effect. Tolerance to the cardiovascular effects of cocaine is less complete; the result here is a potential for drug-induced toxicity, since more and more drug is taken when the subjective effects are not present but the disruptions in cardiovascular function are still present.

Although users of stimulant drugs claim that their performance of many activities is improved by cocaine use, the data do not support their assertions. In general, cocaine has little effect on performance except under conditions in which performance has deteriorated from fatigue. Under those conditions, cocaine can bring it back to nonfatigue levels. This effect, however, is relatively short-lived, since cocaine has a half-life of less than one hour.

TREATMENT

Despite substantial efforts directed toward treatment of cocaine abuse, in the mid-1990s we are still unable to treat successfully many of the cocaine abusers who seek treatment. For many years the only approach to treating these people was psychological or behavioral. As of 1994, the most promising of these include behavioral therapy, relapse prevention, rehabilitation (e.g., vocational, educational, and social-skills training) and supportive psychotherapy. A major problem with these treatment approaches is related to their lack of selectivity. Rather than tailoring programs to an individual's background, drug-use history, psychiatric state, and socioeconomic level, individuals receive the treatment being delivered by the particular program they happen to attend. Treatment programs that focus on specific target populations will be far more successful than those which cover all who apply. For example, patients with relatively mild symptoms might do quite well in a behavioral intervention with some relapse-prevention instructions but those with more severe problems might require the addition of pharmacotherapy.

Pharmacological approaches to treating cocaine abusers have focused on potential neurophysiological changes related to chronic cocaine use. Thus, because dopamine appears to mediate cocaine's reinforcing effects, dopamine agonists such as Am-Antadine and bromocriptine have been tried. Methylphenidate, a stimulant, has been suggested as a possible substitution medication, and Antidepressants such as desipramine have been studied because of their actions on the dopaminergic system. In addition, because cocaine blocks re-uptake of Serotonin at nerve terminals, serotonin-uptake blockers, such as fluoxetine, have also been tested. Although most of the potential medications have been shown to be successful in some patients under open label conditions, none have been clearly successful in double blind placebo-controlled clinical trials.

Clearly, no medication yet exists for the treatment of cocaine abuse. It may well be that different medications may be effective for the various target populations and that variations in dosages and durations of treatment might be required, depending on a variety of patient characteristics. In fact, several medications have been shown to be effective only for small and carefully delineated populations (e.g., lithium for cocaine abusers diagnosed with concurrent bipolar manic-depressive or cyclothymic disorders). An artificial enzyme has been developed that inactivates cocaine as soon as it enters the blood-stream by binding the cocaine and breaking it into two inactive metabolites, and this has the potential for destroying much of the cocaine before it reaches the brain. As of 1994, this technique is unavailable for human use. In addition, and most importantly, cocaine abuse (and drug abuse in general) is a behavioral problem, and it is unlikely that any medication will be effective unless it is combined with an appropriate behavioral intervention.

(See also: Cocaine, Treatment Strategies ; Colombia As Drug Source ; Epidemics of Drug Abuse ; Epidemiology of Drug Abuse ; National Household Survey on Drug Abuse ; Treatment: Cocaine )

BIBLIOGRAPHY

Bock, G., & Whelan, J. (1992). Cocaine: Scientific and social dimensions. Ciba Foundation Symposium 166. Chichester: Wiley.

Johanson, C. E., & Fischman, M. W. (1989). Pharmacology of cocaine related to its abuse. Pharmacological Reviews, 41, 3-52.

Kleber, H. D. (1989). Treatment of drug dependence: What works. International Review of Psychiatry, 1, 81-100.

Landry, D. W., et al. (1993). Antibody-catalyzed degradation of cocaine. Science, 259, 1899-1901.

Marian W. Fischman