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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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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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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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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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Cocaine

Cocaine

History

Introduction to the West

Coca-Cola

Early drug laws

After the 1960S

Crack

Biochemistry

Treatment and prevention

Resources

Cocaine is a colorless or white narcotic crystalline alkaloid derived from the leaves of the South American coca plant, Erythroxylum coca. Aside from its use as a local anesthetic, which has largely been supplanted by safer drugs, its medical applications failed to live up to the hopes of physicians and chemists of the late nineteenth century. They administered cocaine to themselves and others in the hope that it would be a cure-all wonder drug. After about two decades of wide use in prescription and patented medicine, the harmful effects of cocaine became manifest, and its use as a drug in medical practice was eventually banned.

It subsequently became an illegal drug used for its mood-altering effects, which include euphoria and bursts of short-lived physical energy. The high produced by cocaine lasts for a short time. The crash that follows leaves the user in need of another dose to get back to the former high. But each encounter produces diminished a high, so that increasing doses are required to recapture the initial experience. The physical and social consequences of cocaine addiction are devastating both to the individual and society. It leads to impoverishment and the destruction of the individuals health.

In the late 1970s cocaine was snorted, or sniffed through the nose, in its crystalline form, then known as snow. Because of its high cost, the number of users was limited. In order to get a faster and stronger high, cocaine was also taken by injection with a hypodermic needle. In the 1980s a cheaper version of pure cocaine made its appearance on the illegal market in the form of crack, which is smoked. In the form of crack, cocaine has reached a larger population, making it one of the chief drug problems of the twenty-first century.

History

Coca plants, which are the source for cocaine, are indigenous to Central and South America. The name of the plant is derived from the Inca word Kuka. Archaeological evidence points to the use of coca plants in South America as early as seven thousand years ago. They were used for many centuries by the Incas as part of their religious ceremonies. To help the dead in the afterworld, mounds of stored coca leaves were left at burial sites in the area of modern Peru. These sites are estimated to be about 4, 500 years old. The Incas may also have been using liquid coca leaf compounds to perform brainsurgery 3, 500 years ago. Inca records dating from the thirteenth through the sixteenth century indicate that coca was revered as a sacred object with magical powers. The magic plant of the Incas was chewed by priests to help induce trances that led them into the spirit world to determine the wishes of their gods. Artifacts dating back thousands of years to the earliest Incan periods show the cheeks of their high priests distended with what in all probability were the leaves of the coca plant.

Even before the Spanish conquest, Indians working in silver mines of the northern Andes chewed thecoca leaf to help overcome pain, fatigue, and the respiratory problems common at high altitudes. Early European explorers in the fifteenth century compared the common sight of Indians they saw chewing the coca leaves to cattle chewing cud. After the Spanish conquest the Church sought to ban the practice of chewing the coca leaf, mainly because of its association with Incan religious ceremonies. When the ban failed, the Spanish allowed the Incan survivors to continue their ancient practice of coca leaf chewing in order to maintain mining production. South American farmers, who are descendants of the Incas, continue the practice to the present day.

Introduction to the West

The main alkaloid in the leaves of the coca plant was extracted in 1859 by Albert Niemann (18341861), a German scientist, who gave it the name cocaine. Reports soon followed of therapeutic benefits of cocaine in the treatment of a number of physical and mental disorders. These reports also praised cocaine for being a highly effective stimulant, able to conquer the most severe cases of fatigue.

Sigmund Freud (18561939), two decades after Niemanns work, began experimenting with cocaine, thinking it could be used to treat nervous fatigue, an ailment many upper- and middle-class Viennese were diagnosed with. He gave his fiancée cocaine and also administered it to himself. Then he wrote a paper praising the curative powers of cocaine in the treatment of such problems as alcohol and morphine addiction, gastrointestinal disorders, anxiety, depression, and respiratory problems. In this paper, Freud completely dismissed the powerful addictive properties of the drug, insisting that the user would develop an aversion to, rather than a craving for, its continued use.

Freud shortly afterwards became aware of his mistake when he attempted to cure a friends morphine addiction with the use of cocaine. At first the treatment seemed to work, but he soon saw that the friend developed an addiction to cocaine instead. Soon afterwards Freuds friend suffered a complete nervous breakdown.

Unfortunately, there were other physicians and chemists who misjudged the properties of cocaine in the same way Freud had done. For example, a

neurologist and former surgeon general of the United States, William Hammond, also praised the healing powers of cocaine and pronounced it no more addictive than coffee or tea.

Coca-Cola

In the 1880s, John Pemberton (18311888), a pharmacist from Atlanta, concocted a drink called Coca-Cola from a prescription syrup that had been used to treat headache, hysteria, and depression. Pembertons elixir drink contained coca leaves, kola nuts, and a small amount of cocaine in a sugary syrup. His secret formula was picked up by Asa Chandler, who formed the Coca-Cola company. The drink was praised by the New York Times as the new wonder drug. At about the same time, cocaine was sold in a cigarette produced by the Parke-Davis pharmaceutical company. The cigarettes were marketed as a cure for infections of the throat.

Early drug laws

From all the nineteenth-century hopes for the possible medical uses of cocaine, the only practical application that held up was its use as a local anesthetic. All the other efforts to prove that cocaine was a wonder drug were dismal failures in light of the powerful addictive effects of the drug. By the early twentieth century, it had become clear that cocaine posed a serious hazard to any user.

In 1904, the cocaine was removed from the Coca-Cola syrup. In 1906 the Pure Food and Drug Act was enacted to stop the sale of patent medicines containing substances such as cocaine. Before that date, manufacturers were not required to list the ingredients of their patent medicines. The 1906 act made truthful labeling of patent medicines sold across state borders mandatory, but it did not stop the sale of cocaine products. New York State tried to curtail cocaine sales by passing a law in 1907 that limited the right to distribute cocaine to physicians. That law merely paved the way for the illicit street traffic. Dealers obtained cocaine from physicians and then sold it on the street.

The cocaine drug problem continued to rise until 1914, when the Harrison Act was passed. This legislation used the federal Treasury Department to levy taxes on all phases of cocaine trafficking and imposed further strict measures on the sale and distribution of cocaine. From that time to the 1960s, cocaine use dwindled, in part because of the rising popularity of amphetamines on the illegal market. The medical use of cocaine as a topical anesthetic and as an ingredient in cough medicines continued, while its illegal use was largely confined to the very rich.

After the 1960S

By the 1970s, when illegal drug use became more widespread in the general population, middle- and upper-class groups began to use cocaine in its white crystalline form. A mythology of its effectiveness as an aphrodisiac (a substance supposed to enhance the sex drive), a mental energizer, and a self-esteem booster began to develop. Along with benefits that active and ambitious middle-class people hoped for in their drug of choice, came reports of the relative safety of cocaine use in comparison to other drugs. The harsh lessons learned around the turn of the century were all but forgotten.

Crack

By the late 1970s, cocaine addiction in the United States had reached epidemic proportions. In the mid-1980s people started smoking cocaine after freebasing it, that is, dissolving the cocaine alkaloid from its white powder base to create a smokable form of pure cocaine. Ether is used to remove the hydrochloride base, which does not burn. The smoked cocaine goes straight into the bloodstream and gives a quicker and stronger high. Freebasing with ether can be dangerous because if any ether remains in the freebase cocaine, it can quickly ignite into flames when smoked. The comedian Richard Pryor, to mention one of the more famous cases, was severely burned when he freebased cocaine.

Besides freebase cocaine, there is another form of smokable cocaine, called crack, which also gives a fast and potent high. Crack is safer and easier to obtain than freebase cocaine because baking soda is used instead of ether to remove the hydrochloride. The baking soda produces pure forms of cocaine in small pellets that can be smoked in a pipe (where it makes the crackling sound that gave this form of cocaine its name). The cost of crack is so low that anybody, even a child, can afford it, and the drug soon began to wreak its devastations on the working classes. The widespread use of crack cocaine has led most visibly to rising crime rates, with gang wars erupting over control of territory and with users resorting to theft, prostitution, and other crimes to support their habits. Other consequences have been impaired workplace performance, new public health problems including such phenomena as crack babies, and a host of other social and economic evils.

Biochemistry

Used as a local anesthetic, cocaine constricts the blood vessels, thereby slowing down blood circulation. It also reduces the sensitivity of nerve endings, especially in the skin, eyes, and areas of the mouth. Because cocaine is a stimulant, it increases the heart and pulse rate and raises blood pressure, causing alertness, insomnia, loss of appetite, and dilated pupils.

Several theories have been proposed to explain the addictive effects of cocaine, which differs from other stimulants in its ability to trap the user in a cycle of continued use. Experiments using animals who are able to self-administer cocaine show that, once the need for cocaine is established, an animal will neglect its hunger and sex drives in order to satisfy the craving for the drug. Rats took cocaine until they died, while monkeys

KEY TERMS

Alkaloid A nitrogen-based chemical, usually of plant origin, also containing oxygen, hydrogen, and carbon. Many are very bitter and may be active if ingested. Common alkaloids include nicotine, caffeine, and morphine.

Amphetamines Stimulant drugs discovered in the 1930s that were widely prescribed as diet pills and became a staple in the illegal drug traffic.

Aphrodisiac A drug that is supposed to stimulate sexual impulses.

Coca leaves Leaves of the coca plant that were chewed by the Incas and are still used by farmers of certain regions in South America.

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

Dopamine The neurotransmitter believed to be responsible for the cocaine high.

Euphoria Feelings of elation and well being produced by drugs such as cocaine.

Freebasing Processes used to free drugs such as cocaine from their hydrochloride base.

Local anesthetic A pain killer that acts on a particular site of the body without affecting other sites or causing unconsciousness.

Snow The white powder of cocaine hydrochloride that is inhaled through the nostrils. This way of taking cocaine is called snorting and was popular in the 1970s before the advent of crack cocaine.

indulged until they exhibited such behaviors as paranoia, hyperactivity, convulsions, and heart failure.

Cocaine, like the opioids morphine and heroin, causes addiction by arousing an intense sense of pleasure. Certain parts of the brain induce pleasurable sensations when stimulated. Unlike the opioids, though, cocaine appears to have a greater access to those parts of the brain known as the limbic system, which controls the emotions. Cocaine stimulates the release of the neurotransmitter dopamine, which is responsible for the stimulation of the limbic system. The drug is therefore more potent than other drugs in being more psychologically rewarding. According to a recent theory, most of the mood and behavior changes brought about by cocaine use is due to the release of excess amounts of dopamine in the reward centers of the brain. The ensuing depression and craving for the drug are caused by dopamine depletion after the effects of the drug wear off.

Treatment and prevention

Breaking a cocaine dependency is difficult, and treatment is costly and prolonged, involving treatment centers and support groups. Since addiction is a chronic disorder, the detoxification process is just the first step, and there is no final cure. Remissions can be expected, and the goal of treatment may have to be the control and reduction of use and dependency.

Prevention efforts in the United States have for a long time been focused primarily on stopping cocaine imports from South America, mainly Peru and Colombia, and these efforts have had some success in breaking up the powerful and wealthy cartels that control the cultivation and trade of the coca leaf. However, these producers are still sending coca to the United States and continue to seek other markets worldwide. The U.S.-backed war against coca growing in Latin America has also been criticized as having negative environmental and cultural effects, especially in countries such as Bolivia, where coca continues to be a major crop for non-cocaine purposes. Coca growing has been legal in Bolivia since shortly after a former coca-growers union member, Evo Morales, was elected President in 2005.

Studies have shown that a recent decline of cocaine usage in the United States is directly correlated to educational programs targeting young people and aiming to enhance their understanding of the dangers of cocaine use. Such educational programs are more likely to lead to results than interdiction efforts and provide the best hope of curtailing the current epidemic of cocaine abuse and preventing similar epidemics in the future.

Resources

BOOKS

Allen, Christian. An Industrial Geography of Cocaine. New York: Routledge, 2005.

Karch, Steven B. A Brief History of Cocaine. Boca Raton, FL: CRC, 2005.

Jordan P. Richman

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Cocaine

COCAINE

OFFICIAL NAMES: Powder cocaine, crack cocaine

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

DRUG CLASSIFICATIONS: Schedule II, stimulant


OVERVIEW

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

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

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

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

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

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

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

CHEMICAL/ORGANIC COMPOSITION

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

TYPES OF COCAINE

Anesthetic

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

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

Coca leaves

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

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

Coca paste

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

Powder cocaine

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

Free base

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

Crack cocaine

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

INGESTION METHODS

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

Mouth and stomach

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

Snorting

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

Injecting

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

Smoking

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

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

THERAPEUTIC USE

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

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

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

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

USAGE TRENDS

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

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

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

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

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

Scope and severity

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

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

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

Age, ethnic, and gender trends

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

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

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

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

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

MENTAL EFFECTS

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

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

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

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

PHYSIOLOGICAL EFFECTS

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

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

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

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

Harmful side effects

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

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

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

Long-term health effects

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

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

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

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

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

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

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

Brompton's mixture

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

TREATMENT AND REHABILITATION

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

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

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

PERSONAL AND SOCIAL CONSEQUENCES

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

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

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

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

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

LEGAL CONSEQUENCES

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

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

Legal history

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

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

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

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

Federal guidelines, regulations, and penalties

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

RESOURCES

Books

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

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

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

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

Other

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

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

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

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

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

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

Organizations

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

Cocaine Helpline, 1-800-662-HELP.

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

Patty Jo Sawvel

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Cocaine

Cocaine

The abuse of cocaine is a major public-health problem in the United States. In the 1970s, people began taking cocaine as a recreational drug . Experts believed that cocaine was harmless. Many movies and books from this decade show cocaine use as a popular, sophisticated social activity. By the mid-1980s, when many people were using cocaine in large quantities, experts and the public began to recognize the drug's dangers. Cocaine use can cause severe medical and psychological problems.

Cocaine (also known as "coke," "snow," "lady," "crack," and "ready rock"), is an alkaloid that can act both as a local anesthetic and as a stimulant. Users generally take cocaine in binges: They take the drug repeatedly for several days, and then use no cocaine for several days or weeks. Many users resist getting treatment. Users caught possessing or selling cocaine face stiff criminal penalties, but these punishments have not been effective at reducing the rate of heavy cocaine use. In fact, the number of people who used cocaine rarely or occasionally declined during the 1990s. However, the number of frequent or heavy users only decreased slightly.

Medical Uses of Cocaine

The major medical use of cocaine is as a local anesthetic, particularly for procedures that involve the nose, throat, or mouth. It is the only local anesthetic that causes vasoconstriction, or narrowing of the blood vessels. For this reason, cocaine is useful in surgeries that require a minimum of bleeding. In addition, cocaine shrinks membranes, giving the surgeon a better view. When used in appropriate doses for necessary surgeries, and with appropriate medical caution, cocaine appears to be both useful and safe as a local anesthetic.

Methods of Abuse

As an illegal drug, cocaine can be taken in a number of ways. These "routes of administration" include oral (by mouth), intranasal (through the nose), intravenous (by injection into the veins), and smoking. The effects of cocaine are similar no matter what the route. However, the way in which a person takes cocaine influences the likelihood that he or she will abuse it. This is because some methods of taking the drug act more quickly to increase levels of cocaine in the brain. The amount of cocaine in the brain determines the sensations that the user will feel. A person who gets the largest and quickest changes in cocaine brain levels is more likely to take the drug again.

Cocaine abusers do not take cocaine orally, because cocaine taken by mouth is absorbed into the brain slowly. By this method, it takes more than an hour to reach peak brain levels of cocaine. Abusers are more likely to inhale cocaine into the nose as a powder. By this method, the drug is quickly absorbed from the mucous membranes in the nose. Because of its local anesthetic actions, cocaine numbs or "freezes" the mucous membranes. A person buying cocaine on the street will test its purity by inhaling a small amount to see if this numbing occurs. When cocaine is inhaled, or "snorted," cocaine blood levels peak about twenty to thirty minutes later. Users who inhale cocaine report that they are ready to take a second dose of the drug within thirty to forty minutes after the first dose. Snorting was the most common way for people to use cocaine in the mid-1980s. Later, users discovered that smoking or injecting cocaine gets the drug to the brain faster. These became the preferred methods for taking the drug.

When taken by intravenous injection, cocaine reaches peak blood levels immediately, and users experience a "rush." Brain levels of cocaine increase quickly, so the user feels the drug's effects just as quickly. As blood levels of cocaine decrease, so do the effects, and users are ready for another intravenous dose within thirty to forty minutes. Users who inject cocaine are more likely to combine their cocaine with heroin (a combination known as a "speedball") than are users who take it in other ways.

The smokable form of cocaine came into widespread use in the mid-1980s. Freebase, or crack, is a form of cocaine that is not destroyed when heated. As with injected cocaine, blood levels peak almost immediately and the user feels a strong rush. Users can prepare their own freebase from the powdered form they buy on the street, or they can buy it in the form of crack.

Freebase and crack offer an instant high. They are easier to use than other forms of the drug and also less expensive. As a result, users tend to take the drug repeatedly. Repeated high doses of cocaine are very toxic, or poisonous, causing serious damage to the user's health.

Cocaine is frequently taken in combination with other drugs such as alcohol, marijuana, and heroin. In fact, almost 75 percent of cocaine deaths reported in 1989 involved the use of other drugs. Relatively low doses of cocaine can be highly toxic when taken together with alcohol.

Medical Complications from Cocaine Use

Cocaine use leads to a broad range of medical complications affecting nearly every one of the body's organ systems. At low doses, cocaine causes increases in heart rate, blood pressure, respiration (breathing), and body temperature. A person intoxicated by cocaine can suffer from heart attacks, stroke, contractions of blood vessels (which interferes with blood flow), and cardiac arrhythmia (irregular heartbeat).

When taken repeatedly over long periods, cocaine can cause changes in behavior, including irritability, hypervigilance (being overly watchful or alert), paranoid thinking, excessive activity, and eating and sleep disturbances. Repeated cocaine use can also cause severe mental disturbances. The user may develop a psychosis in which he or she feels paranoid and anxious and has hallucinations. Some users display unpredictable, odd behavior that may become violent. Stopping cocaine use after a binge often causes a crash, in which the user becomes depressed , feels tired, and has eating and sleep disturbances. At first during the crash, the person does not crave more cocaine. But as time goes on, the user may think of little else other than finding the next dose.

How Cocaine Affects Behavior

A major effect of cocaine on human behavior is its ability to change a person's moods. The user's desire to feel this effect again is what makes cocaine a drug of abuse. Research shows that cocaine produces a feeling of euphoria, or intense well-being. People feel more energetic and friendly when on cocaine. These effects occur whether a person injects or smokes cocaine.

A person who takes cocaine repeatedly will develop tolerance to many of its behavioral effects. When the original dose no longer has much of an effect, the user must take increasingly larger amounts of cocaine to achieve the high. These larger doses present greater risks to the user's heart and blood vessels.

Users of cocaine and other stimulant drugs claim that the drug improves their performance of many activities. No evidence exists to support this claim. In general, cocaine has little effect on performance except when a person is unable to perform up to usual standards because of fatigue. In this situation, cocaine can enable the person to perform as if he or she were not tired. But this effect lasts for only a short time.

see also Coca Plant; Cocaine: Withdrawal; Cocaine Treatment: Behavioral Approaches; Cocaine Treatment: Medications; Complications from Injecting Drugs; Crack; Users.


DID YOU KNOW?

Cocaine was first synthesized in 1855. It was not until 1880, however, that the medical world studied its effects. In 1886 John Pemberton included cocaine as the main ingredient in his new soft drink, Coca-Cola, contributing to public acceptance of cocaine. It was cocaine's energizing effect on the consumer that was initially responsible for Coca-Cola's popularity.

Public disapproval over the use of that substance forced Pemberton to remove cocaine from Coca-Cola in 1903. Eventually people became so concerned about the dangers of cocaine that it was outlawed in 1920. Today cocaine in any form is illegal.


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Cocaine

Cocaine

Cocaine is a colorless or white narcotic crystalline alkaloid derived from the leaves of the South American coca plant—Erythroxylum coca. Aside from its use as a local anesthetic, which has largely been supplanted by safer drugs, its medical applications failed to live up to the hopes of physicians and chemists of the late nineteenth century. They administered cocaine to themselves and others in the hope that it would be a cure-all wonder drug. After about two decades of wide use in prescription and patented medicine, the harmful effects of cocaine became manifest, and its use as a drug in medical practice was eventually banned.

It subsequently became an illegal drug used for its mood-altering effects, which include euphoria and bursts of short-lived physical energy . The "high" produced by cocaine lasts for a short time. The "crash" that follows leaves the user in need of another "fix" to get back to the former high. But each encounter produces diminished highs, so that increasing doses are required to recapture the initial experience. The physical and social consequences of cocaine addiction are devastating both to the individual and society. It leads to impoverishment and the destruction of the individual's health. When young people begin to use cocaine, communities begin to feel the effects of increased crime, violence, and social decay.

In the late 1970s cocaine was "snorted," or sniffed through the nose, in its crystalline form, then known as "snow." Because of its high cost, the number of users was limited. In order to get a faster and stronger high, cocaine was also taken by injection with a hypodermic needle. By the 1980s a cheaper version of pure cocaine made its appearance on the illegal market in the form of "crack," which is smoked, primarily in the "crack houses" where it is produced. In the form of crack, cocaine has reached a larger population, making it one of the chief drug problems of the present.


History

Coca plants, which are the source for cocaine, are indigenous to Central and South America . The name of the plant is derived from the Inca word Kuka. Archaeological evidence points to the use of coca plants in South America as early as seven thousand years ago. They were used for many centuries by the Incas as part of their religious ceremonies. To help the dead in the afterworld, mounds of stored coca leaves were left at burial sites in the area of modern Peru. These sites are estimated to be about 4,500 years old. The Incas may also have been using liquid coca leaf compounds to perform brain surgery 3,500 years ago. Inca records dating from the thirteenth through the sixteenth century indicate that coca was revered as a sacred object with magical powers. The magic plant of the Incas was chewed by priests to help induce trances that led them into the spirit world to determine the wishes of their gods. Artifacts dating back thousands of years to the earliest Incan periods show the cheeks of their high priests distended with what in all probability were the leaves of the coca plant.

Even before the Spanish conquest, Indians working in silver mines of the northern Andes chewed the coca leaf to help overcome pain , fatigue, and the respiratory problems common at high altitudes. Early European explorers in the fifteenth century compared the common sight of Indians they saw chewing the coca leaves to cattle chewing cud. After the Spanish conquest the Church sought to ban the practice of chewing the coca leaf, mainly because of its association with Incan religious ceremonies. When the ban failed, the Spanish allowed the Incan survivors to continue their ancient practice of coca leaf chewing in order to maintain mining production. South American farmers, who are descendants of the Incas, continue the practice to the present day.

Introduction to the West

The main alkaloid in the leaves of the coca plant was extracted in 1859 by Albert Niemann, a German scientist, who gave it the name cocaine. Reports soon followed of therapeutic benefits of cocaine in the treatment of a number of physical and mental disorders. These reports also praised cocaine for being a highly effective stimulant, able to conquer the most severe cases of fatigue.

Sigmund Freud, two decades after Niemann's work, began experimenting with cocaine, thinking it could be used to treat "nervous fatigue," an ailment many upper- and middle-class Viennese were diagnosed with. He gave his fiancée cocaine and also administered it to himself. Then he wrote a paper praising the curative powers of cocaine in the treatment of such problems as alcohol and morphine addiction, gastrointestinal disorders, anxiety , depression , and respiratory problems. In this paper, Freud completely dismissed the powerful addictive properties of the drug, insisting that the user would develop an aversion to, rather than a craving for, its continued use.

Freud shortly afterwards became aware of his mistake when he attempted to cure a friend's morphine addiction with the use of cocaine. At first the treatment seemed to work, but he soon saw that the friend developed an addiction to cocaine instead. Soon afterwards Freud's friend suffered a complete nervous breakdown.

Unfortunately, there were other physicians and chemists who misjudged the properties of cocaine in the same way Freud had done. For example, a neurologist and former surgeon general of the United States, William Hammond, also praised the healing powers of cocaine and pronounced it no more addictive than coffee or tea.


Coca-Cola

In the 1880s, John Pemberton, a pharmacist from Atlanta, concocted a drink called Coca-Cola from a prescription syrup that had been used to treat headache, hysteria, and depression. Pemberton's elixir drink contained coca leaves, kola nuts, and a small amount of cocaine in a sugary syrup. His secret formula was picked up by Asa Chandler, who formed the Coca-Cola company. The drink was praised by the New York Times as the new wonder drug. At about the same time, cocaine was sold in a cigarette produced by the Parke-Davis pharmaceutical company. The cigarettes were marketed as a cure for infections of the throat.

Early drug laws

From all the nineteenth-century hopes for the possible medical uses of cocaine, the only practical application that held up was its use as a local anesthetic. All the other efforts to prove that cocaine was a wonder drug were dismal failures in light of the powerful addictive effects of the drug. By the early twentieth century, it had become clear that cocaine posed a serious hazard to any user.

In 1904 the cocaine was removed from the Coca-Cola syrup. In 1906 the Pure Food and Drug Act was enacted to stop the sale of patent medicines containing substances such as cocaine. Before that date, manufacturers were not required to list the ingredients of their patent medicines. The 1906 act made truthful labeling of patent medicines sold across state borders mandatory, but it did not stop the sale of cocaine products. New York State tried to curtail cocaine sales by passing a law in 1907 that limited the right to distribute cocaine to physicians. That law merely paved the way for the illicit street traffic. Dealers obtained cocaine from physicians and then sold it on the street.

The cocaine drug problem continued to rise until 1914, when the Harrison Act was passed. This legislation used the federal Treasury Department to levy taxes on all phases of cocaine trafficking and imposed further strict measures on the sale and distribution of cocaine. From that time to the 1960s, cocaine use dwindled, in part because of the rising popularity of amphetamines on the illegal market. The medical use of cocaine as a topical anesthetic and as an ingredient in cough medicines continued, while its illegal use was largely confined to the very rich.


After the 1960s

By the 1970s, when illegal drug use became more widespread in the general population, middle- and upper-class groups began to use cocaine in its white crystalline form. A mythology of its effectiveness as an aphrodisiac (a substance supposed to enhance the sex drive), a mental energizer, and a self-esteem booster began to develop. Along with benefits that active and ambitious middle-class people hoped for in their drug of choice, came reports of the relative safety of cocaine use in comparison to other drugs. The harsh lessons learned around the turn of the century were all but forgotten.


Crack

By the late 1970s, cocaine addiction in the United States had reached epidemic proportions. In the mid-1980s people started smoking cocaine after "freebasing" it, that is, dissolving the cocaine alkaloid from its white powder base to create a smokable form of pure cocaine. Ether is used to remove the hydrochloride base, which does not burn. The smoked cocaine goes straight into the bloodstream and gives a quicker and stronger high. Free-basing with ether can be dangerous because if any ether remains in the freebase cocaine, it can quickly ignite into flames when smoked. The comedian Richard Pryor, to mention one of the more famous cases, was severely burned when he freebased cocaine.

Besides freebase cocaine, there is another form of smokable cocaine, called "crack," which also gives a fast and potent high. Crack is safer and easier to obtain than freebase cocaine because baking soda is used instead of ether to remove the hydrochloride. The baking soda produces pure forms of cocaine in small pellets that can be smoked in a pipe (where it makes the crackling sound that gave this form of cocaine its name). The cost of crack is so low that anybody, even a child, can afford it, and the drug soon began to wreak its devastations on the working classes. The widespread use of crack cocaine has led most visibly to rising crime rates, with gang wars erupting over control of territory and with users resorting to theft, prostitution, and other crimes to support their habits. Other consequences have been impaired workplace performance, new public health problems including such phenomena as crack babies, and a host of other social and economic evils.

Biochemistry

Used as a local anesthetic, cocaine constricts the blood vessels, thereby slowing down blood circulation. It also reduces the sensitivity of nerve endings, especially in the skin, eyes, and areas of the mouth. Because cocaine is a stimulant, it increases the heart and pulse rate and raises blood pressure , causing alertness, insomnia , loss of appetite, and dilated pupils.

Several theories have been proposed to explain the addictive effects of cocaine, which differs from other stimulants in its ability to trap the user in a cycle of continued use. Experiments using animals who are able to self-administer cocaine show that, once the need for cocaine is established, an animal will neglect its hunger and sex drives in order to satisfy the craving for the drug. Rats took cocaine until they died, while monkeys indulged until they exhibited such behaviors as paranoia, hyperactivity, convulsions, and heart failure.

Cocaine, like the opioids morphine and heroin, causes addiction by arousing an intense sense of pleasure. Certain parts of the brain induce pleasurable sensations when stimulated. Unlike the opioids, though, cocaine appears to have a greater access to those parts of the brain known as the limbic system, which controls the emotions. Cocaine stimulates the release of the neurotransmitter dopamine , which is responsible for the stimulation of the limbic system. The drug is therefore more potent than other drugs in being more psychologically rewarding. According to a recent theory, most of the mood and behavior changes brought about by cocaine use is due to the release of excess amounts of dopamine in the reward centers of the brain. The ensuing depression and craving for the drug are caused by dopamine depletion after the effects of the drug wear off.


Treatment and prevention

Breaking a cocaine dependency is difficult, and treatment is costly and prolonged, involving treatment centers and support groups. Since addiction is a chronic disorder, the detoxification process is just the first step, and there is no final cure. Remissions can be expected, and the goal of treatment may have to be the control and reduction of use and dependency.

Prevention efforts in the United States have for a long time been focused primarily on stopping cocaine imports from South America, mainly Peru and Colombia, and these efforts have had some success in breaking up the powerful and wealthy cartels that control the cultivation and trade of the coca leaf. However, these producers are still sending coca to the United States and continue to seek other markets worldwide for their deadly crop.

Studies have shown that a recent decline of cocaine usage in the United States is directly correlated to educational programs targeting young people and aiming to enhance their understanding of the dangers of cocaine use. Such educational programs are more likely to lead to results than interdiction efforts and provide the best hope of curtailing the current epidemic of cocaine abuse and preventing similar epidemics in the future.


Resources

books

Flynn, John C. Cocaine. New York: Carol Publishing, 1991.

Gold, Mark S. Cocaine. New York: Plenum Publishing, 1993.

Rice-Licare, Jennifer, and Katharine Delaney-McLaughlin. Cocaine Solutions. Binghamton: Haworth Press, 1990.

Washton, Arnold M., and Mark S. Gold. Cocaine: A Clinician's Handbook. New York: Guilford Press, 1987.


Jordan P. Richman

KEY TERMS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alkaloid

—A nitrogen-based chemical, usually of plant origin, also containing oxygen, hydrogen, and carbon. Many are very bitter and may be active if ingested. Common alkaloids include nicotine, caffeine, and morphine.

Amphetamines

—Stimulant drugs discovered in the 1930s that were widely prescribed as diet pills and became a staple in the illegal drug traffic.

Aphrodisiac

—A drug that is supposed to stimulate sexual impulses.

Coca leaves

—Leaves of the coca plant that were chewed by the Incas and are still used by farmers of certain regions in South America.

Crack

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

Dopamine

—The neurotransmitter believed to be responsible for the cocaine high.

Euphoria

—Feelings of elation and well being produced by drugs such as cocaine.

Freebasing

—Processes used to free drugs such as cocaine from their hydrochloride base.

Local anesthetic

—A pain killer that acts on a particular site of the body without affecting other sites or causing unconsciousness.

Snow

—The white powder of cocaine hydrochloride that is inhaled through the nostrils. This way of taking cocaine is called "snorting" and was popular in the 1970s before the advent of crack cocaine.

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Cocaine

Cocaine



Cocaine is one of the best known and most dangerous of the many illegal drugs that have been popular in the United States since the twentieth century. It is derived from the coca plant, which grows in some areas of Latin America. When ingested by humans, it usually produces feelings of great well-being, confidence, and mental clarity. The effect is short-lived, however, and the aftermath of cocaine use is often characterized by irritability, anxiety, paranoia—and the intense desire for more cocaine. The drug is habit-forming to many and addictive to some. The effects of its long-term abuse include nasal and sinus deterioration, brain damage, increased likelihood of strokes, and, in some cases, death. Some susceptible persons, like college basketball star Len Bias (1963–1986), can die as a result of their first experience with cocaine.

Concentrated cocaine was first extracted from coca leaves around 1860. It soon appeared as an ingredient in a variety of foods, beverages, medicines, and personal-care products. A cocaine-laced wine called Vin Mariani was introduced in 1863 and proved very popular. Its consumers are believed to have included Queen Victoria (1819–1901), Thomas Edison (1847–1931), and at least one pope. Coca-Cola (see entry under 1900s—Food and Drink in volume 1) gets its name from the cocaine that was part of its original formula (which has long since been changed).

Eventually, cocaine's addictive properties and adverse health effects started to be noticed, and various states passed laws against it, beginning in 1887. At the same time, the drug began to develop a negative public image, often being associated in the press and in popular fiction with pimps, prostitutes, thieves, and racial minorities. In 1914, the federal government designated the drug a Class I Narcotic, which meant it was illegal except by prescription.

Cocaine use began to decline in the 1920s, partly due to its illegality but also because of the ready supply of another stimulant—amphetamines. These were legal, cheap, and produced a "high" that some said was superior to cocaine. Cocaine's decline continued until the 1960s, when amphetamines were also outlawed. The ban sent both drug abusers and drug dealers back to cocaine, which formed the basis for the cocaine problem that continues to plague the United States.

That problem was made worse around 1980 when "crack" cocaine—known on the street as "rock"—was developed. Made by mixing cocaine with baby powder or a similar substance, crack is a paste that hardens easily. It can then be broken into small bits that are usually smoked in small glass pipes. Crack is substantially more powerful than powdered cocaine, producing a faster high and consequently a deeper let-down. It is thus ferociously addictive. Crack use has become a particularly serious concern in many of America's inner cities. Its related social problems include domestic abuse and neglect, robbery and prostitution committed for drug money, and warfare between rival gangs (see entry under 1980s—The Way We Lived in volume 5) over the immense profits to be made from the crack trade.

Popular-culture depictions of cocaine use have largely reflected the drug's status in society. When cocaine was legal, many publications regularly carried advertisements for products that featured the drug as a major ingredient. But by the start of the twentieth century, shocking stories began to appear in magazines and novels about the horrible crimes committed by cocaine addicts. These accounts were often tainted with the racism common at the time, suggesting that blacks, in particular, were being turned into violent degenerates by cocaine use.

New entertainment media quickly began to ring the anticocaine alarm. A 1928 silent film, The Pace That Kills, shows farm boy Eddie moving to the big city and being introduced to cocaine by his new girlfriend. They both become addicts and end up committing suicide. The exact same film was remade in 1935 as a "talkie."

This trend in negative depictions of cocaine use continued in the following decades, reaching a peak in the 1980s when cocaine became a popular recreational drug among some young urban professionals, known as yuppies (see entry under 1980s—The Way We Lived in volume 5). A series of popular novels depicted cocaine-related anxiety among the yuppie set, including Bright Lights, Big City (1984; filmed in 1988) by Jay McInerney (1955–), Less than Zero (1985; filmed in 1987) by Bret Easton Ellis (1964–), and The Mysteries of Pittsburgh (1988) by Michael Chabon (1963–). Cocaine dealers were convenient villains in fiction and film. None was more depraved or evil than Tony Montana, the Cuban immigrant played by Al Pacino (1940–) in 1983's Scarface, directed by Brian DePalma (1940–).

In the 1990s, a conspiracy theory surfaced that the CIA had helped introduce crack into America's ghettos to distract black Americans from agitating against racism and social injustice. Although endorsed by the Nation of Islam's Louis Farrakhan (1933–), the theory remains unsubstantiated. It is true that penalties for the use of crack are harsher than those involving powdered cocaine, which is more likely to be abused by whites. The next decade saw several major films about cocaine, including the award-winning Traffic (2000) and Blow (2001), profiling George Jung, the modern era's first major cocaine kingpin.

—Justin Gustainis

For More Information

Erickson, Patricia G. The Steel Drug: Cocaine and Crack in Perspective. New York: Lexington Books, 1994.

Flynn, John C. Cocaine: An In-Depth Look at the Facts, Science, History, and Future of the World's Most Addictive Drug. Secaucus, NJ: Carol Publishing Group, 1991.

Inciardi, James A., and Karen McElrath. The American Drug Scene: AnAnthology. Los Angeles: Roxbury Publications, 1998.

McFarland, Rhoda. Cocaine. New York: Rosen Group, 1997.

Narcanon. Cocaine Facts.http://www.cocaineaddiction.com/cocaine.html (accessed April 4, 2002).

Starks, Michael. Cocaine Fiends and Reefer Madness: An Illustrated History of Drugs in the Movies. New York: Cornwall Books, 1982.

Washton, Arnold M., and Donna Boundy. Cocaine and Crack: What YouNeed to Know. Hillside, NJ: Enslow, 1989.

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Cocaine

Cocaine


What Kind of Drug Is It?

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

Overview

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

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

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

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

Drug Classifications: Schedule II, stimulant

A Longtime South American Tradition

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



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

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

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

Cure-All or Curse?

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

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

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

Usage Decreases until the 1970s

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

The Real Thing


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

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


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

What Is It Made Of?

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

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

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

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

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

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

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

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

Crack Cocaine: The Drug of the Eighties

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


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

How Is It Taken?

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

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

Snorted, Injected, or Smoked—They Are All Addicting

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


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

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

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

Are There Any Medical Reasons for Taking This Substance?

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

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

Only Acceptable Use Is as an Anesthetic

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

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

Did You Know?


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

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

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

Usage Trends

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

The Era of Prohibition

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

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

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


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

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

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

User Characteristics

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

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

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

Effects on the Body

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

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

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

Harm to the Brain

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

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

Cocaine Bugs


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

The Dopamine Connection

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

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

The Myth of Nonaddiction

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

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

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

And There Is More.…

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


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

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

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

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

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

Reactions with Other Drugs or Substances

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

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

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

Treatment for Habitual Users

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

Addicts and Addiction


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

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

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

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

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


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

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


A Simple but Promising New Treatment Approach

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

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

Consequences

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

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

The Law

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

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

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

For More Information

Books

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

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

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

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

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

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

Periodicals

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

Web Sites

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

"Brief Encounters Can Provide Motivation to Reduce or Stop Drug Abuse." National Institutes of Health: NIH News (press release). http://www.nih.gov/news/pr/jan2005/nida-05.htm (accessed June 30, 2005).

"Cocaine." bbc.co.uk, A to Z of Drugs. http://www.bbc.co.uk/crime/drugs/cocaine.shtml (accessed June 30, 2005).

"Cocaine." U.S. Department of Justice, Drug Enforcement Administration.http://www.usdoj.gov/dea/concern/cocaine.html (accessed June 30, 2005).

"Comparing Methamphetamine and Cocaine." National Institute on Drug Abuse, NIDA Notes.http://www.nida.nih.gov/NIDA_notes/NNVol13N1/Comparing.html (accessed June 30, 2005).

"Crack." bbc.co.uk, A to Z of Drugs.http://www.bbc.co.uk/crime/drugs/crack.shtml (accessed June 30, 2005).

"Crack and Cocaine." National Institute on Drug Abuse, NIDA Info Facts.http://www.nida.nih.gov/Infofax/cocaine.html (accessed June 30, 2005).

"Drugs and Chemicals of Concern: Cocaine." U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program.http://www.deadiversion.usdoj.gov/drugs_concern/cocaine/cocaine.htm (accessed June 30, 2005).

"Four Tonnes of Cocaine Seized in Joint Operation with UK, Spain, and Portugal." Tackling Drugs, Changing Lives: Drugs.gov.uk, January 7, 2005. http://www.drugs.gov.uk/News/1117623830 (accessed June 30, 2005).

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

Mathias, Robert. "Study Finds Significant Mental Deficits in Toddlers Exposed to Cocaine before Birth." National Institute on Drug Abuse, NIDA Notes.http://www.nida.nih.gov/NIDA_notes/NNVol17N5/Study.html (accessed June 30, 2005).

Monitoring the Future.http://www.monitoringthefuture.org/ and http://www.nida.nih.gov/Newsroom/04/2004MTFDrug.pdf (both accessed June 30, 2005).

National Institute on Drug Abuse.http://www.nida.nih.gov/ and http://www.drugabuse.gov (both accessed June 30, 2005).

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

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

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

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

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

See also: Alcohol; Amphetamines; Heroin; Marijuana

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Cocaine and Related Disorders

Cocaine and Related Disorders

Definition

Description

Causes and symptoms

Demographics

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

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

Forms of the drug

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

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

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

Description

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

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

Cocaine use disorders

COCAINE ABUSE

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

COCAINE DEPENDENCE

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

Cocaine-induced disorders

COCAINE INTOXICATION

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

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

COCAINE WITHDRAWAL

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

COCAINE-INDUCED DELIRIUM

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

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH DELUSIONS

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

COCAINE-INDUCED PSYCHOTIC DISORDER, WITH HALLUCINATIONS

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

COCAINE-INDUCED MOOD DISORDER

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

COCAINE-INDUCED ANXIETY DISORDER

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

COCAINE-INDUCED SEXUAL DYSFUNCTION

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

COCAINE-INDUCED SLEEP DISORDER

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

COCAINE-RELATED DISORDER NOT OTHERWISE SPECIFIED

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

Causes and symptoms

Causes

BIOCHEMICAL/PHYSIOLOGICAL CAUSES

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

REINFORCEMENT

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

Symptoms

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

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

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

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

Demographics

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

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

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

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

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

Diagnosis

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

Differential diagnosis

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

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

Laboratory testing

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

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

Neuropsychological assessment

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

Treatments

Psychological and social interventions

TREATMENT SETTINGS

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

PSYCHOTHERAPY

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

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

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

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

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

Medications

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

Alternative therapy

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

Prognosis

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

KEY TERMS

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

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

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

Craving —An overwhelming need to seek out more drugs.

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

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

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

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

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

Prevention

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

See alsoAddiction; Detoxification; Disease concept of chemical dependency.

Resources

BOOKS

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

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

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

PERIODICALS

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

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

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

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

ORGANIZATIONS

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

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

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

OTHER

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

Susan Hobbs, M.D.
Peter Gregutt

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