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Cocaine and related disorders

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 1992the 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 medicationsgreater than twentyhave 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

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Cocaine

Cocaine

Definition

Cocaine is a highly addictive central nervous system stimulant extracted from the leaves of the coca plant, Erythroxylon coca.

Description

In its most common form, cocaine is a whitish crystalline powder that produces feelings of euphoria when ingested.

Now classified as a Schedule II drug, cocaine has legitimate medical uses as well as a long history of recreational abuse. Administered by a licensed physician, the drug can be used as a local anesthetic for certain eye and ear problems and in some kinds of surgery.

Forms of the drug

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 smokable form of cocaine that produces an immediate and more intense high. It comes in off-white chunks or chips called "rocks." Little crumbs of crack are sometimes called "kibbles & bits."

In addition to their stand-alone use, both cocaine and crack are often mixed with other substances. Cocaine may be mixed with methcathinone (a more recent drug of abuse, known as "cat," that is similar to methamphetamine) to create a "wildcat." A hollowed-out cigar filled with a mixture of crack and marijuana is known as a "woolah." And either cocaine or crack used in conjunction with heroin is called a "speed-ball." Cocaine used together with alcohol represents the most common fatal two-drug combination.

History

Cocaine is one of the oldest known psychoactive drugs. Coca leaves, the source of cocaine, were used by the Incas and other inhabitants of the Andean region of South America for thousands of years, both as a stimulant and to depress appetite and combat apoxia (altitude sickness ).

Despite the long history of coca leaf use, it was not until the latter part of the nineteenth century that the active ingredient of the plant, cocaine hydrochloride, was first extracted from those leaves. The new drug soon became a common ingredient in patent medicines and other popular products (including the original formula for cola). This widespread use quickly raised concerns about the drug's negative effects. In the early 1900s, several legislative steps were taken to address those concerns; the Harrison Act of 1914 banned the use of cocaine and other substances in non-prescription products. In the wake of those actions, cocaine use declined substantially.

The drug culture of the 1960s sparked renewed interest in cocaine. With the advent of crack in the 1980s, use of the drug had once again become a national problem. Cocaine use declined significantly during the early 1990s, but it remains a significant problem and is on the increase in certain geographic areas and among certain age groups. A mid-1990s government report said that Americans spend more money on cocaine than on all other illegal drugs combined.

Causes and symptoms

As with other forms of addiction, cocaine abuse is the result of a complex combination of internal and external factors. Genetic predisposition, family history, and immediate environment can affect a person's probability of becoming addicted.

As many as three to four million people are estimated to be chronic cocaine users. The 1997 National Household Survey on Drug Abuse reported an estimated 600,000 current crack users, showing no significant change since the late 1980s.

How cocaine affects the brain

Extensive research has been conducted to determine how cocaine works on the brain and why it is so addictive. Cocaine has been found to affect an area of the brain known as the ventral tegmental area (VTA), which connects with the nucleus accumbens, a major pleasure center. Like other commonly abused addictive drugs, cocaine's effects are related to the action of the neurotransmitter dopamine, which carries information between neurons. Cocaine interferes with the normal functioning of neurons by blocking the re-uptake of dopamine, which builds up in the synapses and is believed to cause the pleasurable feelings reported by cocaine users.

Short-term effects of use

The short-term effects of cocaine can include:

  • rapid heartbeat
  • constricted blood vessels
  • dilated pupils
  • increased temperature
  • increased energy
  • reduced appetite
  • increased sense of alertness
  • euphoria
  • death due to overdose

Long-term effects of use

The long-term effects of cocaine and crack use include:

  • dependence, addiction
  • irritability
  • mood swings
  • restlessness
  • weight loss
  • auditory hallucinations
  • paranoia

Cocaine use and pregnancy

The rise in cocaine use as well as the appearance of crack cocaine in the late 1980s spurred fears about its effects on the developing fetus and, since then, several research reports have suggested that prenatal cocaine use could be associated to a wide range of fetal, newborn, and child development problems. According to the Lindesmith Center-Drug Policy Foundation, many of these early reports had methodological flaws, and most researchers nowadays propose more cautious conclusions concerning prenatal cocaine effects. Much evidence would seem to point to the lack of quality prenatal care and the use of alcohol and tobacco as primary factors in poor fetal development among pregnant cocaine users. Research sponsored by the National Institute on Drug Abuse (NIDA) and the Albert Einstein Medical Center in Philadelphia corroborate the Lindensmith Center findings in reporting that the lack of quality prenatal care is associated with undesirable effects often attributed to cocaine exposure such as prematurity, low birth weight, and fetal or infant death. The Center for Disease Control and Prevention (CDC), however, reports that mothers who use cocaine early in pregnancy are five times as likely to have a baby with a malformation of the urinary tract as mothers who do not use the drug. Thus, cocaine use during pregnancy is inadvisable, especially since it is also often associated with the use of alcohol known to cause long-term developmental problems. Supporting the cocaine-exposed expecting mother so as to discourage cocaine use remains an important task for all health caregivers.

Diagnosis

Diagnosing cocaine addiction can be difficult. Many of the signs of short-term cocaine use are not obvious. Since cocaine users often also use other drugs, it may not be easy to distinguish the effects of one drug from another.

Cocaine use has been documented in significant numbers of eighth graders as well as older teens. Over all age groups, more men than women use the drug. The highest rate of cocaine use is found among adults 18 to 25 years old.

Medical complications

Cocaine has been linked to several serious health problems, including:

  • arrhythmia
  • heart attacks
  • chest pain
  • respiratory failure
  • strokes
  • seizures

Other complications may vary depending on how the drug is administered. Prolonged snorting, for example, can irritate the nasal septum, producing nosebleeds, chronic runny nose, and other problems. Intravenous users face an increased risk of infectious diseases such as HIV/AIDS and hepatitis.

Testing

Drug testing can be useful in diagnosing and treating cocaine abuse. Urine testing can detect cocaine; besides providing an objective alternative to reliance on what a patient says, such tests can also be used as a follow-up to treatment to confirm that the patient has remained drug-free.

Treatment

The last two decades have seen a dramatic rise in the number of cocaine addicts seeking treatment. But like all forms of drug abuse, cocaine abuse/addiction is a multifaceted phenomenon involving environmental, social, and familial as well as physiological factors. This greatly complicates the challenge of effectively treating cocaine addiction.

Pharmacological treatments

To date, no medications have been approved specifically for treating cocaine addiction. But several were under development at this writing. Selegeline, delivered either via a time-release pill or a transdermal patch, shows promise as a possible anti-cocaine medication. Clinical studies have shown the drug disulfiram (also used to treat alcoholics) to be effective in treating cocaine abusers. In addition, antidepressant medications are sometimes used to control the mood swings associated with the early stages of cocaine withdrawal. Research in 2004 was looking at new approachtreating cocaine addiction with a virus that helped clear the drug from the brain.

Behavioral approaches

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. Residential programs/therapeutic communities may also 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.

Alternative treatment

Various alternative or complementary approaches have been used in treating cocaine addiction, often in combination with more conventional therapies. In Japan, the herb acorus has been traditionally used both to assist early-stage cocaine withdrawal and in later recovery stages. Other herbs sometimes used to treat drug addictions of various kinds include kola nut, guarana seed and yohimbe (to boost short-term energy), and valerian root, hops leaf, scullcap leaf, and chamomile (to calm the patient). The amino acids phenylalanine and tyrosine have been used to reduce cocaine addicts' craving for the drug, and vitamin therapy may be used to help strengthen the patient. Gentle massage has been used to help infants born with congenital cocaine addiction. Other techniques, such as acupuncture, EEG biofeedback, and visualization, may also be useful in treating addiction.

Prognosis

Because addiction involves so many different factors, prospects for individual addicts vary widely. A 2004 study found that recovered drug addicts often crave the drug for years and are at risk for relapse. However, research also has consistently shown that treatment can significantly reduce both drug abuse and subsequent criminal activity. The comprehensive Services Research Outcomes Study (1998) found a 45% drop in cocaine use five years after treatment, compared to use during the five years before treatment. The study also found that females generally respond better to treatment than males, and older patients tend to reduce their drug use more than younger patients.

Some research also supports the idea that 12-step programs used in conjunction with other approaches can significantly enhance the prospects for a positive outcome. One study of people in outpatient drug-treatment programs found that participation in a 12-step program nearly doubled their chances of remaining drug-free.

KEY TERMS

Apoxia Apoxia refers to altitude sickness.

Arrhythmia Irregular heartbeat.

Central nervous system Part of the nervous system consisting of the brain, cranial nerves and spinal cord. The brain is the center of higher processes, such as thought and emotion and is responsible for the coordination and control of bodily activities and the interpretation of information from the senses. The cranial nerves and spinal cord link the brain to the peripheral nervous system, that is the nerves present in the rest of body.

Nasal septum The membrane that separates the nostrils.

Neurotransmitter A chemical that carries nerve impulses across a synapse.

Synapse The gap between two nerve cells.

Prevention

Despite significant variation over time, cocaine addiction has proven to be a persistent public health problem. Interdiction and source control are expensive and have failed to eliminate the problem, and some law enforcement officials are now recommending more emphasis on demand reduction through education and other measures to address the causes of cocaine addiction.

Resources

PERIODICALS

Avants, S. Kelly. "A Randomized Controlled Trial of Auricular Acupuncture for Cocaine Dependence." JAMA November 22, 2000.

"Craving for Cocaine May Last for Years after Recovery." Health & Medicine Week April 19, 2004: 846.

Goode, Erica. "Acupuncture Helps Some Quell Need for Cocaine." New York Times August 15, 2000: D7.

LeDuff, Charlie. "Cocaine Quietly Reclaims Its Hold as Good Times Return." New York Times August 21, 2000: 2.

"Treating Cocaine Addiction With Viruses." Ascribe Health News Service June 21, 2004.

ORGANIZATIONS

Cocaine Anonymous. 6125 Washington Blvd. Suite 202, Culver City, CA 90232. (800) 347-8998.

Nar-Anon Family Group Headquarters, Inc. P.O. Box 2562, Palos Verdes Peninsula, CA 90274. (310) 547-5800.

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Gregutt, Peter; Odle, Teresa. "Cocaine." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. 30 May. 2016 <http://www.encyclopedia.com>.

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Gregutt, Peter; Odle, Teresa. "Cocaine." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved May 30, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451600397.html

Cocaine and Crack Cocaine

COCAINE AND CRACK COCAINE

Cocaine, extracted from the leaves of the coca plant (Erythroxylon coca ), is the most potent naturally occurring central nervous system stimulant. Cocaine is classified as a Schedule II drug due to its high potential for abuse (U.S. Controlled Substance Act 21 U.S.C., Section 802 [1996]), but it can be administered by a doctor for legitimate medical reasons, such as a local anesthetic for some eye, ear, and throat surgeries. There are two primary forms of chemical cocaine: the hydrochloride salt form, a powdered form of cocaine that is approximately 99 percent pure cocaine, and the "freebase" form. Hydrochloride salt dissolves in water and can be taken intravenously or intranasally. The freebase form of cocaine has not been neutralized by an acid to make a hydrochloride salt and can be smoked. It is processed with ammonia or sodium bicarbonate (baking soda) and water, and heated to remove the hydrochloride.

Crack cocaine, or simply "crack," is essentially the same end product as freebase cocaine, but the result of a cheaper and safer chemical method of preparing a smokable form of cocaine. The term "crack" refers to the crackling sound heard when the mixture is heated or smoked.

DISTRIBUTION AND EFFECTS

Illicit cocaine is generally distributed on the street as a fine, white, crystalline powder or as an off-white chunky material. Street dealers most often dilute it with inert substances such as sugar, cornstarch, and/or talcum powder; or with other active drugs, including local anesthetics such as lidocaine or procaine, or other stimulants such as amphetamines. The primary routes of cocaine administration are oral, intranasal, intravenous, and inhalation. However, there is no safe way to use cocaine, and any route of administration can lead to absorption of toxic amounts of cocaine, resulting in acute cardiovascular or cerebrovascular emergencies that sometimes result in death. Cocaine-related deaths are commonly the result of cardiac arrest or seizures followed by respiratory arrest.

Small amounts of cocaine may make the user feel euphoric, energetic, talkative, and mentally alert, especially to sensations of sight, sound, and touch. The duration of these effects depends upon the route of administration. The faster the absorption, the more intense the highbut the shorter the duration of action. Short-term physiological effects of cocaine include constricted blood vessels, dilated pupils, and increased heart rate, blood pressure, and body temperature. Longer-term effects of cocaine use include tolerance and addiction, irritability and mood disorders, restlessness, paranoia, and auditory hallucinations. The most frequent medical consequences of cocaine use are cardiovascular effects, including disturbed heart rhythms and heart attacks; respiratory effects, including chest pain and respiratory failures; neurological effects, such as strokes, seizures, and headaches; and gastrointestinal complications, including abdominal pain and nausea.

The combination of cocaine and alcohol is especially potent and dangerous. When taken in combination, the body converts the two into cocaethylene, which has a longer duration of action in the brain and is more toxic than either drug alone. The combination of alcohol and cocaine is the most common two-drug combination that results in drug-related deaths.

COCAINE USE

The United States witnessed a dramatic increase in cocaine use during the 1980s when, due to its high cost, it was glamorized as a symbol of status and material success by celebrities, the entertainment industry, and the media. The problem was further complicated when crack cocaine was introduced in 1985. A smokable and cheaper form of the drug, crack extended the problems of cocaine dependence to urban ghettos and to members of society who might not have been able to afford cocaine itself. Cocaine use in the United States peaked between 1982 and 1985, at which time between 5.7 and 10.4 million Americans (3 to 5.6 percent of the population) reported cocaine use. Since then, it has decreased, but remains a significant problem. According to the 1999 National Household Survey on Drug Abuse (NHSDA), there were 14.8 million illicit drug users in the United States in 1998. Of these 14.8 million, approximately 1.5 million people were using cocaine (0.7 percent of the household population over twelve years of age), and 413,000 people were using crack. According to the Office of National Drug Control Policy, by including data from additional sources that take into account users underrepresented by the NHSDA, the number of chronic cocaine users has recently been estimated at 3.6 million. The annual number of new users of any form of cocaine increased from 1994 to 1998, and data from both the NHSDA and the 1999 Monitoring the Future survey indicated increases in the rate of cocaine initiation among youths ages twelve to seventeen in particular.

Information about cocaine use outside the United States is less readily available, although the United Nations Drug Control Program estimates that approximately 13 million people worldwide abuse cocaine. Abuse remains highest in the United States, despite declines since the mid-1980s peak and increased levels of both cocaine and "bazuco" (coca paste) abuse in Latin American countries. Cocaine, along with other coca-derived substances, is the second most widely abused illicit drug in the Americas, and accounts for a majority of the demand for treatment. Data from the Report of the International Narcotics Control Board for 1999 showed increased cocaine seizures in Europe, largely in Spain and the Netherlands. While an upward trend is apparent across nearly all of Europe, it is especially pronounced in Spain, Ireland, and the United Kingdom.

COCAINE PRODUCTION

Columbia, Peru, and Bolivia are the first, second, and third largest illicit coca producing countries in the world, respectively. The United Nations Office for Drug Control and Crime Prevention estimates that they collectively account for more than 90 percent of illicit coca. Interpol data suggests there was an increase in coca production in 1999, despite increased efforts of national drug services to break down and disable drug trafficking organizations. Interpol statistics indicate that nearly 50 percent of the cocaine seized in 1999 occurred in Central and South America and the Caribbean, approximately 40 percent in North America, and the remaining 10 percent in Europe.

COCAINE CONTROL PROGRAMS

The primary strategy for controlling the cocaine problem is a global effort to reduce the illicit drug supply, and thereby illicit drug demand, including cocaine. Coordinated by the United Nations Office for Drug Control and Crime Prevention, the three components of the drug supply strategy include law enforcement, alternative development, and crop monitoring. Regional and national law enforcement agencies each have their own legislative, administrative, and social measures to address illicit drug production, possession, and distribution. International organizations such as the UN and Interpol unify these national efforts to address the global issues of drug demand and supply.

Another tactic aimed at reducing drug supply is alternative development. As defined by the United Nations Drug Control Program, alternative development is "a process to prevent and eliminate the illicit cultivation of plants containing narcotic drugs and psychotropic substances through specifically designed rural development measures in the context of sustained national economic growth and sustainable development efforts in countries taking action against drugs, recognizing the particular sociocultural characteristics of the target communities and groups, within the framework of a comprehensive and permanent solution to the problem of illicit drugs" (UN 1998). These programs focus on local knowledge, skills, interests, and needs to replace drug-crop cultivation with licit, sustainable, and profitable crops, offering farmers and communities an alternative means of survival.

The third component of the UN strategy is a global monitoring program of illicit crops. This program combines aerial surveillance, on-the-ground assessment, and satellite sensing, enabling governments to better target and assess the impact of programs directed at crop reduction, and provide feedback to the international community. The objective of the program is to apply the feedback internationally in order to gain insight and develop new strategies on how to curb the flow of drugs from region to region.

Robert S. Gold

Blakeley Pomietto

(see also: Addiction and Habituation; Substance Abuse, Definition of )

Bibliography

Levinthal, C. F. (1999). Drugs, Behavior, and Modern Society. Boston: Allyn and Bacon.

U.S. Department of Health and Human Services, National Institutes of Health (1999). Cocaine Abuse and Addiction. Bethesda, MD: National Institute on Drug Abuse.

(2000). Monitoring the Future: National Results on Adolescent Drug Use, 1999. Bethesda, MD: National Institute on Drug Abuse.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (2000). National Household Survey on Drug Abuse. Bethesda, MD: Office of Applied Studies.

U.S. Department of Justice, Drug Enforcement Administration (2001). Cocaine. Available at http://www.dea.gov/concern/cocaine.htm.

United Nations (1998). Resolutions Adopted by the General Assembly: An Action Plan Against Illicit Manufacture, Trafficking and Abuse of Amphetamine-Type Stimulants and Their Precursors. Available at http://www.undcp.org/resolution_199809-08_3.html#E.

United Nations Publications, Office for Drug Control and Crime Prevention (1999). Report of the International Narcotics Control Board for 1999. Vienna, Austria: International Narcotics Control Board.

(2001). Who Is Using Drugs? Available at http://www.undcp.org/drug_demand_who.html.

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Gold, Robert S.; Pomietto, Blakeley. "Cocaine and Crack Cocaine." Encyclopedia of Public Health. 2002. Encyclopedia.com. 30 May. 2016 <http://www.encyclopedia.com>.

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Cocaine

Cocaine

Cocaine is a powerful drug that stimulates the body's central nervous system. Prepared from the leaves of the coca shrub that grows in South America, it increases the user's energy and alertness, reduces appetite and the need for sleep, and heightens feelings of pleasure. Although United States law makes its manufacture and use for nonmedical purposes illegal, many people are able to obtain it illegally.

A powerful stimulant

Aside from a few extremely limited medical uses, cocaine has no other purpose except to give a person an intense feeling of pleasure known as a "high." While this may not seem like such a bad thing, the great number of physical side effects that accompany that high, combined with the powerful psychological dependence it creates, makes it an extremely dangerous drug to take. As a very powerful stimulant, cocaine not only gives users more energy, it makes them feel confident and even euphoric (pronounced yew-FOR-ik)meaning they are extremely elated or happy, usually for no reason. This feeling of elation and power makes users believe they can do anything, yet when this high wears off, they usually feel upset, depressed, tired, and even paranoid.

Cocaine has a very interesting history: It has gone from being considered a mild stimulant and then a wonder drug, to a harmless "recreational" drug, and finally to a powerfully addictive and very dangerous illegal drug. Although cocaine has, in fact, been all of these things at one time or another, we know it today to be an addictive drug that can wreck a person physically, mentally, and socially. It can also easily kill people.

History and European discovery

Cocaine is extracted from the leaves of the coca shrub (Erythroxylum coca ), which grows in the tropical forests on the slopes of the Andes Mountains of Peru. A second species, Erythroxylum novagranatense, grows naturally in the drier mountainous regions of Columbia. For thousands of years, the native populations of those areas chewed the leaves of these plants to help them cope with the difficulty of living at such a high altitude. Chewing raw coca leaves (usually combined with ashes or lime) reduced their fatigue and suppressed their hunger, making them better able to handle the hard work they had to do to live so high up in the mountains. The coca leaves were also used during religious ceremonies and for rituals such as burials. The feelings that the leaves gave to their chewers made them consider the coca plant to be a gift from the gods.

Once European explorers started coming to the Americas in the late fifteenth century, it was only a matter of time until invaders, such as the Spanish, came to the New World seeking riches. By the time the Spanish arrived in what is now Peru, the people of that land, known as the Incas, were already a civilization in decline, and they were easily subdued and conquered. The Spaniards eventually learned that giving coca leaves to native workers enabled them to force the workers to do enormous amounts of work in the gold and silver mines that were located in high altitudes. For the next two hundred years, although some coca plants were taken back to Europe, they were not popular or well-known since they did not travel well and were useless if dried out. Further, the Europeans did not like all the chewing and spitting required to get at the plant's active ingredient, and until this part of the plant could be isolated, coca leaves were not very much in demand.

Words to Know

Coca leaves: Leaves of the coca plant from which cocaine is extracted.

Crack: A smokable and inexpensive form of pure cocaine sold in the form of small pellets or "rocks."

Euphoria: A feeling of elation.

Active part isolated

All of this changed by the middle of the nineteenth century when German physician Albert Niemann perfected the process of isolating the active part of the drug and improved the process of making it. Niemann extracted a purified form of cocaine from the coca leaves, and wrote about the anesthetic or numbing feeling obtained when he put it on his tongue. Cocaine then began its inevitable introduction into medicine, drink, and finally drug abuse. First it was considered by many doctors to be a wonder drug, and they began prescribing it for all sorts of physical and mental problems. By the 1880s, cocaine was even added to a very popular "medicinal" wine called Vin Mariani. The famous Austrian physician Sigmund Freud (18561939), who would become the founder of psychoanalysis, published a paper in 1884 that made many wrong medical claims for cocaine. Although he would later withdraw his claims, Freud did write at the time, "The use of coca in moderation is more likely to promote health than to impair it."

Popular use

In 1888, a soft drink named "Coca-Cola" was developed in America that contained cocaine and advertised itself as "the drink that relieves exhaustion." By 1908, however, the makers of Coca-Cola realized their mistake and removed all the cocaine from it, using only caffeine as a stimulant. By then, the initial enthusiasm for cocaine was seen to be undeserved, and many cases of overuse and dependence eventually forced lawmakers to take action against it. Consequently, in 1914 the United States introduced the Harrison Narcotic Act, which made cocaine illegal. After that, cocaine use was popular only with a fairly small number of artists, musicians, and the very rich, until the 1970s. In that decade, cocaine use skyrocketed as many young people who had earlier smoked marijuana

took to cocaine as a drug they believed had no side effects, was safe, and was not addictive.

Popular overuse

All of these beliefs were eventually seen to be terribly untrue, as a cocaine epidemic in the 1980s claimed many lives, such as that of comedian John Belushi, and wrecked numerous other lives, such as that of the comedian Richard Pryor. Once it is understood what happens to a person's nervous system when he or she ingests or takes in cocaine, it is not surprising that the results are often bad and sometimes tragic. The cocaine sold on the streets is usually a white crystalline powder or an off-white chunky material. It is usually diluted with other substances, like sugar, and is introduced into a person's body by sniffing, swallowing, or injecting it. Most people "snort" the powder or inhale it through their nose, since any of the body's mucous membranes will absorb it into the bloodstream. Injecting the drug means that it must first be turned into a liquid. Both ways create an immediate effect. Smoking "crack" cocaine delivers a more potent high, since crack is distilled cocaine. In its "rock" form it cannot be snorted, but is smoked in pipes. The name "crack" comes from the crackling sound these rock crystals make when heated and burned.

Effects on the brain

However the active part of the drug gets into the body, it delivers the same effect to the person's central nervous system, depending on the amount taken and the user's past drug experience. Usually within seconds, it travels to the brain and produces a sort of overall anesthetic effect because it interferes with the transmission of information from one nerve cell to another. Since this interference is going on within the reward centers of the brain, the user experiences a fairly short-term high that is extremely pleasurable. Physically, the user's heart is racing, and his blood pressure, respiration, and body temperature also increase. The user feels temporarily more alert and energetic. The problem is that these feelings do not last very long, and the user must do more cocaine to recapture them.

In tests with experimental animals, cocaine is the only drug that the animals will repeatedly and continuously demand on their own to the point of killing themselves. Although cocaine is not physically addictive the way heroin is (meaning that the user physically craves the drug and suffers withdrawal when off it), it nonetheless creates a profound psychological dependence in which the mind craves the ecstasy that comes with the drug. Further, since the user experiences fatigue and depression when he or she stops, there is little reason to want to quit. Over time, these cravings get stronger and stronger, and the user can only think of how to get another "hit." This obviously makes them unable to live a normal life without the drug, which has by now taken over their lives.

Effects of abuse

Severe and heavy overuse can make the abuser suffer dizziness, headache, anxiety, insomnia, depression, hallucinations, and have problems moving about. The increase in blood pressure can cause bleeding in the brain as well as breathing problems, both of which have killed many a user. Often, even physically fit people like Len Bias, the All-American basketball star from the University of Maryland, can suddenly die from ingesting cocaine. The medical risks associated with this drug are great, especially since there is no antidote for an overdose. Taking cocaine also has legal consequences, and besides the disorder and dysfunction it brings to a person's life, it can also land them in jail. Many American schools also have a zero-tolerance policy, as do many companies and other organizations.

Overall, despite the glamour that some people see in the drug, the disadvantages far outweigh the temporary advantages, and rather than improving a person's life, it can only do the opposite.

[See also Addiction ]

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cocaine

cocaine (kōkān´, kō´kān), alkaloid drug derived from the leaves of the coca shrub. A commonly abused illegal drug, cocaine has limited medical uses, most often in surgical applications that take advantage of the fact that, in addition to its anesthetic effect, it constricts small arteries, lessening bleeding. There are many street names for cocaine, including coke, C, toot, flake, and snow.

Effects and Addictive Nature

Cocaine blocks pain sensation and stimulates the central nervous system, producing a sudden increase in heart rate, temperature, and blood pressure. In the brain, it blocks the synaptic reabsorption of certain neurotransmitters (in particular dopamine). The resultant buildup of neurotransmitters causes pleasurable sensations to be passed along the neural pathways over and over again, creating a feeling of profound well-being, self-confidence, and alertness. It is accompanied by lack of hunger. The effect lasts for 10 to 30 minutes, and the user begins to crave more immediately as the neurotransmitter supply is exhausted. This pattern has led to cocaine's being described as "neuropsychologically addicting" in recognition that traditional definitions of physical vs. psychological addiction do not neatly fit in this case. Most cocaine addicts in treatment report some control over their use for the first two to four years, giving them the illusion that addiction will not develop.

Addiction is characterized by binges (usually of 4 to 24 hours, one to seven times per week), movement to intravenous use or smoking, extreme euphoria, and disregard for anything other than the drug, including food, sleep, sex, family, and survival. The behavior is limited only by the high cost of the drug and its limited availability. Abstinence after a cocaine binge leads to crashing (anxiety, depression, suspiciousness, sleep craving) and withdrawal (absence of pleasure in all things, lack of motivation, and boredom). Many users take other drugs (alcohol, marijuana, heroin) to attenuate these effects. A dangerous combination of cocaine and heroin, known as a "speedball," is used by some. Withdrawal usually results in further use, often spurred by a conditioned cue such as a specific smell or location linked with cocaine use. If the drug is not taken again there is a gradual lessening of the craving, although conditioned cues may exert an effect years afterward. Long-term use can result in digestive disorders, weight loss, general physical deterioration, and marked deterioration of the nervous system. Most drug-related emergency room visits are cocaine-related.

Modes of Administration; Crack Cocaine

Cocaine is either snorted (sniffed), swallowed, injected, or smoked. Habitual snorting can result in serious damage to the nasal mucous membranes; shared needles put the user at increased risk of HIV infection. The street drug comes in the form of a white powder, cocaine hydrochloride. The hydrochloride salt and the cutting agents are removed to create the pure base product "freebase." Freebase is smoked and reaches the brain in seconds. "Crack" cocaine, also called "rock," is a form of freebase that comes in small lumps and makes a crackling sound when heated. It is relatively inexpensive, but must be repeated often.

Crack cocaine magnifies the effects of cocaine and is considered to be more highly and more quickly addictive than snorted cocaine. It causes a very abrupt increase in heart rate and blood pressure that can lead to heart attack and stroke even in young people with no history of vascular disease, sometimes the first time the drug is used. It also crosses the placental barrier; babies born to crack-addicted mothers go through withdrawal and are at a higher risk of stroke, cerebral palsy, and other birth defects.

Treatment

Treatment focuses on disruption of the addict's pattern of binges, followed by prevention of relapses. Counseling combined with treatments such as acupuncture and administration of antidepressants (e.g., desipramine) has met with some success. Treatment is often complicated by underlying social problems, mental illness, and the use of multiple drugs.

Production and Distribution

Most coca is grown in Colombia, Peru, and Bolivia. The farmers, for whom it is a relatively well-paying crop, harvest and dry the leaves, which are then processed into coca paste. Cocaine base is extracted from the paste in informal laboratories. Further processing produces cocaine hydrochloride, a white powder, which is exported. Once in the United States, the cocaine is cut (diluted) with ingredients such as lactose, and sold or further processed into crack.

Import and production have been controlled by enormously powerful cartels such as the Medellín and Cali cartels in Colombia; the highly armed cartels have infiltrated governments and corrupted officials and have been held responsible for assassinations of public officials. Drug trafficking reached the highest levels of government and was at least in part responsible for the U.S. invasion of Panama in 1989 and the arrest and subsequent conviction of Panama's de facto leader, Manuel Noriega.

History of Cocaine Use

Andean Indians have long chewed leaves of the coca plant to decrease hunger and increase their stamina for work. Chewing the leaves produces no "high." Cocaine was first extracted from coca in the 19th cent. and was at first hailed as a miracle drug. By the 1880s in the United States it was freely prescribed by physicians for such maladies as exhaustion, depression, and morphine addiction and was available in many patent medicines. After users and physicians began to realize its dangers and various regulations were enacted, its use decreased, and by the 1920s the epidemic had abated.

Another epidemic began in the United States in the 1970s and peaked in the mid-1980s; again the drug was at first considered harmless. With the latter epidemic and its accompanying crack epidemic (beginning in 1985 and peaking in 1988) violence in crack-infested neighborhoods increased dramatically. Young people with few other opportunities were lured by the power and money of being crack dealers; most carried guns and many were murdered in drug-gang wars that ensued. By the late 1990s the cocaine and crack epidemic had subsided as heroin regained popularity among illicit drug users.

Bibliography

See publications of the Drugs & Crime Data Center and Clearinghouse, the Bureau of Justice Statistics Clearinghouse, and the National Clearinghouse for Alcohol and Drug Information.

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Cocaine

Cocaine

Cocaine is a powerful drug of the stimulant-euphoriant class that is obtained from an alkaloid in the leaves of the coca plant, a shrub or tree that grows in the South American countries of Peru and Bolivia. The processed drug is a white, crystalline compound called benzoylmethylecgonine. It is a central nervous system stimulant, which means it temporarily produces euphoria (a feeling of well-being), prevents drowsiness and fatigue, increases physical energy, heart rate and body temperature, decreases appetite, and increases talkativeness. Cocaine can also cause the user to become irritable, and have hallucinations (strange visions). An overdose of cocaine can cause trembling, vomiting, convulsions, and a depression of the central nervous system. This depression can cause breathing to stop or heart failure. Because it is so highly addictive, cocaine is classified as a narcotic and is controlled by federal drug abuse laws in the United States.

The Indians of South America have chewed the leaves of the coca plant for many generations to help them overcome fatigue and hunger, stay alert, and have greater stamina in the high elevations of the Andes Mountains; the leaves also numb the mouth and stomach. Coca leaves were chewed by Inca runners who carried messages long distances over the mountains and probably by workers who built the Inca road system. Many pottery figurines of early South America show men and women chewing coca leaves, often with expressions of great pleasure on their faces.

Early Research

Albert Niemann (1880-1921) separated the alkaloid cocaine from the dried leaves of the coca plant in 1860. He studied the white powder and named it cocaine, also noting the temporary numbing effect the compound had on his tongue. During the 1880s in Vienna, Austria, Sigmund Freud (1856-1939) studied cocaine as a treatment for morphine addiction. Freud suggested the possible use of cocaine as a local anesthetic to Viennese colleagues Leopold Königstein, a professor of ophthalmology (the medical study of the eye and diseases of the eye), and Carl Koller (1857-1944), a young ophthalmologist (doctor specializing in eye diseases).

Koller experimented on animals and then presented his findings to the Congress of Ophthalmology in Heidelberg, Germany, in 1884. He demonstrated the successful use of cocaine as a local anesthetic during eye surgery. Koller's findings were accepted enthusiastically. Koller himself emigrated to the United States in 1888 and established practice in New York City, where he died in 1944. Cocaine was used widely for ophthalmological procedures until it was discovered that it causes damage to the cornea (the transparent part of the eye that covers the iris and the pupil). This combined with its potential for drug abuse has resulted in cocaine's being used today only as a topical (given for one part of the body) anesthetic, mainly in the upper respiratory passages (nose and throat).

Local Anesthesia

American doctor William Halsted soon followed up on Koller's work by experimenting with cocaine injection into nerves to produce local anesthesia. By the end of 1885, Halsted had performed over 1,000 operations using cocaine as an anesthetic. Unfortunately, Halsted also discovered another of cocaine's properties. He became addicted to the substance and spent many years overcoming his dependence. Harvey Cushing (1869-1939), a student of Halsted's, coined the term "regional anesthesia" for this use of cocaine, in contrast to the "general anesthesia" produced by ether, a gas formerly used for anesthesia in surgery. Later in 1855, Leonard Corning (1855-1939), a New York neurologist, injected a cocaine solution as a spinal anesthesia. German doctor Carl L. Schleich (1859-1922) of Berlin used a cocaine solution for infiltration anesthesia in 1892.

Cocaine and Addiction

For many years, the addictive properties of cocaine went unrecognized. As a pain reliever and stimulant, the drug was a common ingredient in the very popular patent medicines of the late 1800s and early 1900s. Doctors freely prescribed cocaine for any number of ailments. Once the addictive dangers became known, scientists concentrated on developing synthetic substitutes for the anesthetic properties of cocaine. One of the first of these was Novocain. Today cocaine is only occasionally used medically, as a local anesthetic applied to the surface of the skin for some kinds of surgery. It is not prepared for internal use or for injection as medicine.

Today most cocaine is purchased and used illegally. Cocaine hydrochloride, a dry white powder also called "coke" or "snow" is often inhaled ("snorted") through a thin tube or straw inserted into the nostril. It is absorbed into the bloodstream through the nasal (nose) mucous membranes. Cocaine is sometimes injected into a vein and sometimes smoked in a purified form through a water pipe, called "freebasing." The most potent form of cocaine, "crack," is shaped into pellets and smoked using special equipment. The widespread use of cocaine and the resulting increase in violence associated with drug dealing was an important factor in stimulating the "war on drugs" in the United States that has continued since the 1980s, when cocaine abuse was at its peak.

Long-term use of cocaine can lead to skin sores, damage to the septum of the nose, weight loss, and damage to the nervous system. Bad mental effects include restlessness, anxiety, irritability, and sometimes paranoid psychosis. When a person stops using cocaine, he or she will experience craving for the drug, long periods of sleep, depression, fatigue, and exhaustion. Because withdrawal from cocaine does not produce extreme and dangerous physical symptoms like those caused by withdrawal from barbiturates, doctors consider cocaine to be more psychologically addictive than physically addictive.

[See also Anesthesia ]

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Cocaine and Psychoanalysis

COCAINE AND PSYCHOANALYSIS

Cocaine is an alkaloid extracted from coca leaves, which has been used in medicine for its analgesic and anesthetic properties. Cocaine dependency is an addiction to this narcotic. The relation between cocaine and psychoanalysis goes back to Freud's research in which he used the substance as an ophthalmic anesthetic.

Cocaine was first used as an anesthetic agent in Vienna in 1884. Freud conducted research into the physiological action of the drug with a view to using it for therapeutic purposes. It was nevertheless his colleague, Carl Köller, who continued this work and to whom we attribute the discovery of the anesthetic properties of cocaine, based on its use in eye surgery. Years later Freud described the situation in these terms: "A side interest, though it was a deep one, had led me in 1884 to obtain from Merck some of what was then the little-known alkaloid cocaine and to study its physiological action....I suggested, however, to my friend Köningstein, the ophthalmologist, that he should investigate the question of how far the anaesthetizing properties of cocaine were applicable in diseases of the eye" (1925d, pp. 14-15). Ernest Jones (1953) reports that in 1884 Freud administered injections of cocaine to his friend Ernst von Fleischl in order to wean him off his morphine addiction and to ease his terrible trigeminal neuralgia. One year later he observed that the massive doses of cocaine required by Fleischl had led to chronic intoxication. He thus discovered the toxicity of cocaine, which stood in the way of its being used medically. Coca leaves and cocaine had been used in the Americas as stimulants to fight fatigue and hunger, but their use led to neurochemical and physiological effects as well as severe addiction problems.

Psychoanalysis has studied the underlying dynamics and the unconscious fantasies that drive patients to seek out the chemical and physiological effects of cocaine in a compulsive manner. Cocaine addiction is normally difficult to cure. Classification of the pathological structures underlying cocaine addiction seems to suggest that a process of pathological mourning or manic-depressive behavior can be found in many patients. Patients sometimes seek out this toxic substance as a stimulant or an anti-depressant in order to conceal states of depression. Some drug addicts unable to work through their grief develop pathological mourning wherein they identify with the lost dead object(s), thus unconsciously putting their lives in grave danger. Their repeated risk taking allows them to feel as if they are conquering death and are being resuscitated. This fantasied resurrection represents success to these addicts, in whose mental state the psychological notions of danger, death, and suicide do not exist. The psychoanalytic interpretation therefore must direct itself to the uncovering and interpreting of their resurrection fantasies and thus lead them to give up living within a dead object or give up identifying with a dead person.

David Rosenfeld

See also: Addiction; Alienation; Anorexia nervosa; Borderline conditions; Dependence; Fantasy (reverie); Indications and counterindications for psychoanalysis; Transitional object.

Bibliography

Freud, Sigmund. (1925d). An autobiographical study. SE, 20: 1-74.

Jones, Ernest. (1953). Sigmund Freud. Life and work. London: Hogarth.

Rosenfeld, David. (1992). The psychotic aspects of the personality. London-New York: Karnac Books.

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Cocaine

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 leafand 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 moreand 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 administrationoral, 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 metaboliteCocaethyleneis 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 activityfetuses, infants, pregnant women, patients with liver disease, and the elderlyare 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 potentialand 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

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cocaine

cocaine White, crystalline alkaloid extracted from the leaves of the coca plant. Once used as a local anaesthetic and an early ingredient in Coca-Cola, it is now primarily an illegal narcotic, with stimulant and hallucinatory effects. It is psychologically habit-forming, and the body does not develop tolerance. Habitual use of cocaine results in physical and nervous deterioration, and subsequent withdrawal results in severe depression. The street drug crack is a cocaine derivative.

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cocaine

cocaine (kŏ-kayn) n. an alkaloid, derived from the leaves of the coca plant (Erythroxylon coca) or prepared synthetically, sometimes used as a local anaesthetic in ear, nose, and throat surgery. Since it may lead to psychological dependence, cocaine has largely been replaced by safer anaesthetics.

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cocaine

co·caine / kōˈkān; ˈkōˌkān/ • n. an addictive drug, C17H21NO4, derived from coca or prepared synthetically, used as an illegal stimulant and sometimes medicinally as a local anesthetic.

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cocaine

cocaine A drug obtained from Erythroxylum coca. See ERYTHROXYLUM.

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MICHAEL ALLABY. "cocaine." A Dictionary of Plant Sciences. 1998. Encyclopedia.com. 30 May. 2016 <http://www.encyclopedia.com>.

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cocaine

cocaineabstain, appertain, arcane, arraign, ascertain, attain, Bahrain, bane, blain, brain, Braine, Cain, Caine, campaign, cane, chain, champagne, champaign, Champlain, Charmaine, chicane, chow mein, cocaine, Coleraine, Coltrane, complain, constrain, contain, crane, Dane, deign, demesne, demi-mondaine, detain, disdain, domain, domaine, drain, Duane, Dwane, Elaine, entertain, entrain, explain, fain, fane, feign, gain, Germaine, germane, grain, humane, Hussein, inane, Jain, Jane, Jermaine, Kane, La Fontaine, lain, lane, legerdemain, Lorraine, main, Maine, maintain, mane, mise en scène, Montaigne, moraine, mundane, obtain, ordain, pain, Paine, pane, pertain, plain, plane, Port-of-Spain, profane, rain, Raine, refrain, reign, rein, retain, romaine, sane, Seine, Shane, Sinn Fein, skein, slain, Spain, Spillane, sprain, stain, strain, sustain, swain, terrain, thane, train, twain, Ujjain, Ukraine, underlain, urbane, vain, vane, vein, Verlaine, vicereine, wain, wane, Wayne •watch chain • mondaine • Haldane •ultramundane • Cellophane •novocaine • sugar cane • marocain

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