Cocaine Abuse
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Cocaine is a powerfully addictive stimulant that directly
affects the brain. Cocaine has been labeled the drug of the 1980s and ‘90s,
because of its extensive popularity and use during this period. However, cocaine
is not a new drug. In fact, it is one of the oldest known drugs. The pure chemical,
cocaine hydrochloride, has been an abused substance for more than 100 years,
and coca leaves, the source of cocaine, have been ingested for thousands of
years.
Pure cocaine was first extracted from the leaf of the Erythroxylon coca bush,
which grows primarily in Peru and Bolivia, in the mid-19th century. In the early
1900s, it became the main stimulant drug used in most of the tonics/elixirs
that were developed to treat a wide variety of illnesses. Today, cocaine is
a Schedule II drug, meaning that it has high potential for abuse, but can be
administered by a doctor for legitimate medical uses, such as a local anesthetic
for some eye, ear, and throat surgeries.
There are basically two chemical forms of cocaine: the hydrochloride salt and
the “freebase.” The hydrochloride salt, or powdered form of cocaine, dissolves
in water and, when abused, can be taken intravenously (by vein) or intranasally
(in the nose). Freebase refers to a compound that has not been neutralized by
an acid to make the hydrochloride salt. The freebase form of cocaine is smokable.
Cocaine is generally sold on the street as a fine, white, crystalline powder,
known as “coke,” “C,” “snow,” “flake,” or “blow.” Street dealers generally
dilute it with such inert substances as cornstarch, talcum powder, and/or sugar,
or with such active drugs as procaine (a chemically-related local anesthetic)
or with such other stimulants as amphetamines.
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Crack is the street name given to the freebase form of cocaine that has been
processed from the powdered cocaine hydrochloride form to a smokable substance.
The term “crack” refers to the crackling sound heard when the mixture is smoked.
Crack cocaine is processed with ammonia or sodium bicarbonate (baking soda)
and water, and heated to remove the hydrochloride.
Because crack is smoked, the user experiences a high in less than 10 seconds.
This rather immediate and euphoric effect is one of the reasons that crack became
enormously popular in the mid 1980s. Another reason is that crack is inexpensive
both to produce and to buy.
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In 1997, an estimated 1.5 million Americans (0.7 percent of those age 12 and
older) were current cocaine users, according to the 1997 National Household
Survey on Drug Abuse (NHSDA). This number has not changed significantly since
1992, although it is a dramatic decrease from the 1985 peak of 5.7 million cocaine
users(3 percent of the population). Based upon additional data sources that
take into account users underrepresented in the NHSDA, the Office of National
Drug Control Policy estimates the number of chronic cocaine users at 3.6 million.
Adults 18 to 25 years old have a higher rate of current cocaine use than those
in any other age group. Overall, men have a higher rate of current cocaine use
than do women. Also, according to the 1997 NHSDA, rates of current cocaine use
were 1.4 percent for African Americans, 0.8 percent for Hispanics, and 0.6 percent
for Caucasians.
Crack cocaine remains a serious problem in the United States. The NHSDA estimated
the number of current crack users to be about 604,000 in 1997, which does not
reflect any significant change since 1988.
The 1998 Monitoring the Future Survey, which annually surveys teen attitudes
and recent drug use, reports that lifetime and past-year use of crack increased
among eighth graders to its highest levels since 1991, the first year data were
available for this grade. The percentage of eighth graders reporting crack use
at least once in their lives increased from 2.7 percent in 1997 to 3.2 percent
in 1998. Pastyear use of crack also rose slightly among this group, although
no changes were found for other grades.
Data from the Drug Abuse Warning Network (DAWN) showed that cocaine-related
emergency room visits, after increasing 78 percent between 1990 and 1994, remained
level between 1994 and 1996, with 152,433 cocaine-related episodes reported
in 1996.
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The principal routes of cocaine administration are oral, intranasal, intravenous,
and inhalation. The slang terms for these routes are, respectively, “chewing,”
“snorting,” “mainlining,” “injecting,” and “smoking” (including freebase and
crack cocaine). Snorting is the process of inhaling cocaine powder through the
nostrils, where it is absorbed into the bloodstream through the nasal tissues.
Injecting releases the drug directly into the bloodstream, and heightens the
intensity of its effects. Smoking involves the inhalation of cocaine vapor or
smoke into the lungs, where absorption into the bloodstream is as rapid as by
injection. The drug can also be rubbed onto mucous tissues. Some users combine
cocaine powder or crack with heroin in a “speedball.”
Cocaine use ranges from occasional use to repeated or compulsive use, with
a variety of patterns between these extremes. There is no safe way to use cocaine.
Any route of administration can lead to absorption of toxic amounts of cocaine,
leading to acute cardiovascular or cerebrovascular emergencies that could result
in sudden death. Repeated cocaine use by any route of administration can produce
addiction and other adverse health consequences.
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A great amount of research has been devoted to understanding the way cocaine
produces its pleasurable effects, and the reasons it is so addictive. One mechanism
is through its effects on structures deep in the brain. Scientists have discovered
regions within the brain that, when stimulated, produce feelings of pleasure.
One neural system that appears to be most affected by cocaine originates in
a region, located deep within the brain, called the ventral tegmental area (VTA).
Nerve cells originating in the VTA extend to the region of the brain known as
the nucleus accumbens, one of the brain’s key pleasure centers. In studies using
animals, for example, all types of pleasurable stimuli, such as food, water,
sex, and many drugs of abuse, cause increased activity in the nucleus accumbens.
| Cocaine in the brain – In the normal communication process,
dopamine is released by a neuron into the synapse, where it can bind with
dopamine receptors on neighboring neurons. Normally dopamine then recycled
back into the transmitting neuron by a specialized protein called the dopamine
transporter. If cocaine is present, it attaches to the dopamine transporter
and blocks the normal recycling process, resulting in a build-up of dopamine
in the synapse which contributes to the pleasurable effects of cocaine. |
Researchers have discovered that, when a pleasurable event is occurring, it
is accompanied by a large increase in the amounts of dopamine released in the
nucleus accumbens by neurons originating in the VTA. In the normal communication
process, dopamine is released by a neuron into the synapse (the small gap between
two neurons), where it binds with specialized proteins (called dopamine receptors)
on the neighboring neuron, thereby sending a signal to that neuron. Drugs of
abuse are able to interfere with this normal communication process. For example,
scientists have discovered that cocaine blocks the removal of dopamine from
the synapse, resulting in an accumulation of dopamine. This buildup of dopamine
causes continuous stimulation of receiving neurons, probably resulting in the
euphoria commonly reported by cocaine abusers.
As cocaine abuse continues, tolerance often develops. This means that higher
doses and more frequent use of cocaine are required for the brain to register
the same level of pleasure experienced during initial use. Recent studies have
shown that, during periods of abstinence from cocaine use, the memory of the
euphoria associated with cocaine use, or mere exposure to cues associated with
drug use, can trigger tremendous craving and relapse to drug use, even after
long periods of abstinence.
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Short-term effects of cocaine
- Increased energy
- Decreased appetite
- Mental alertness
- Increased heart rate and
- blood pressure
- Constricted blood vessels
- Increased temperature
- Dilated pupils
Cocaine’s effects appear almost immediately after a single dose, and disappear
within a few minutes or hours. Taken in small amounts (up to 100 mg), cocaine
usually makes the user feel euphoric, energetic, talkative, and mentally alert,
especially to the sensations of sight, sound, and touch. It can also temporarily
decrease the need for food and sleep. Some users find that the drug helps them
to perform simple physical and intellectual tasks more quickly, while others
can experience the opposite effect.
The duration of cocaine’s immediate euphoric effects depends upon the route
of administration. The faster the absorption, the more intense the high. Also,
the faster the absorption, the shorter the duration of action. The high from
snorting is relatively slow in onset, and may last 15 to 30 minutes, while that
from smoking may last 5 to 10 minutes.
The short-term physiological effects of cocaine include constricted blood vessels;
dilated pupils; and increased temperature, heart rate, and blood pressure. Large
amounts (several hundred milligrams or more) intensify the user’s high, but
may also lead to bizarre, erratic, and violent behavior. These users may experience
tremors, vertigo, muscle twitches, paranoia, or, with repeated doses, a toxic
reaction closely resembling amphetamine poisoning. Some users of cocaine report
feelings of restlessness, irritability, and anxiety. In rare instances,
sudden death can occur on the
first use of cocaine or unexpectedly
thereafter. Cocaine-related
deaths are often a result of cardiac
arrest or seizures followed by respiratory
arrest.
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Long-term effects of cocaine
- Addiction
- Irritability and mood disturbances
- Restlessness
- Paranoia
- Auditory hallucinations
Cocaine is a powerfully addictive drug. Once having tried cocaine, an individual
may have difficulty predicting or controlling the extent to which he or she
will continue to use the drug. Cocaine’s stimulant and addictive effects are
thought to be primarily a result of its ability to inhibit the reabsorption
of dopamine by nerve cells. Dopamine is released as part of the brain’s reward
system, and is either directly or indirectly involved in the addictive properties
of every major drug of abuse.
An appreciable tolerance to cocaine’s high may develop, with many addicts reporting
that they seek but fail to achieve as much pleasure as they did from their first
experience. Some users will frequently increase their doses to intensify and
prolong the euphoric effects. While tolerance to the high can occur, users can
also become more sensitive (sensitization) to cocaine’s anesthetic and convulsant
effects, without increasing the dose taken. This increased sensitivity may explain
some deaths occurring after apparently low doses of cocaine.
Use of cocaine in a binge, during which the drug is taken repeatedly and at
increasingly high doses, leads to a state of increasing irritability, restlessness,
and paranoia. This may result in a full-blown paranoid psychosis, in which the
individual loses touch with reality and experiences auditory hallucinations.
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Medical consequences of cocaine abuse
- Cardiovascular effects
- disturbances in heart rhythm
- heart attacks
- Respiratory effects
- chest pain
- respiratory failure
- Neurological effects
- strokes
- seizures and headaches
- Gastrointestinal complications
There are enormous medical complications associated with cocaine use. Some
of the most frequent complications are cardiovascular effects, including disturbances
in heart rhythm and heart attacks; such respiratory effects as chest pain and
respiratory failure; neurological effects, including strokes, seizure, and headaches;
and gastrointestinal complications, including abdominal pain and nausea.
Cocaine use has been linked to many types of heart disease. Cocaine has been
found to trigger chaotic heart rhythms, called ventricular fibrillation; accelerate
heartbeat and breathing; and increase blood pressure and body temperature. Physical
symptoms may include chest pain, nausea, blurred vision, fever, muscle spasms,
convulsions and coma.
Different routes of cocaine administration can produce different adverse effects.
Regularly snorting cocaine, for example, can lead to loss of sense of smell,
nosebleeds, problems with swallowing, hoarseness, and an overall irritation
of the nasal septum, which can lead to a chronically inflamed, runny nose. Ingested
cocaine can cause severe bowel gangrene, due to reduced blood flow. And, persons
who inject cocaine have puncture marks and “tracks,” most commonly in their
forearms. Intravenous cocaine users may also experience an allergic reaction,
either to the drug, or to some additive in street cocaine, which can result,
in severe cases, in death. Because cocaine has a tendency to decrease food intake,
many chronic cocaine users lose their appetites and can experience significant
weight loss and malnourishment.
Research has revealed a potentially dangerous interaction between cocaine and
alcohol. Taken in combination, the two drugs are converted by the body to cocaethylene.
Cocaethylene has a longer duration of action in the brain and is more toxic
than either drug alone. While more research needs to be done, it is noteworthy
that the mixture of cocaine and alcohol is the most common two-drug combination
that results in drug-related death.
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Yes. Cocaine abusers, especially those who inject, are at increased risk for
contracting such infectious diseases as human immunodeficiency virus (HIV/AIDS)
and hepatitis. In fact, use and abuse of illicit drugs, including crack cocaine,
have become the leading risk factors for new cases of HIV. Drug abuse-related
spread of HIV can result from direct transmission of the virus through the sharing
of contaminated needles and paraphernalia between injecting drug users. It can
also result from indirect transmission, such as an HIV-infected mother transmitting
the virus perinatally to her child. This is particularly alarming, given that
more than 60 percent of new AIDS cases are women. Research has also shown that
drug use can interfere with judgement about risk-taking behavior, and can potentially
lead to reduced precautions about having sex, the sharing of needles and injection
paraphernalia, and the trading of sex for drugs, by both men and women.
Additionally, hepatitis C is spreading rapidly among injection drug users;
current estimates indicate infection rates of 65 to 90 percent in this population.
At present, there is no vaccine for the hepatitis C virus, and the only treatment
is expensive, often unsuccessful, and may have serious side effects.
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The full extent of the effects of prenatal drug exposure on a child is not
completely known, but many scientific studies have documented that babies born
to mothers who abuse cocaine during pregnancy are often prematurely delivered,
have low birth weights and smaller head circumferences, and are often shorter
in length.
Estimating the full extent of the consequences of maternal drug abuse is difficult,
and determining the specific hazard of a particular drug to the unborn child
is even more problematic, given that, typically, more than one substance is
abused. Such factors as the amount and number of all drugs abused; inadequate
prenatal care; abuse and neglect of the children, due to the mother’s lifestyle;
socio-economic status; poor maternal nutrition; other health problems; and exposure
to sexually transmitted diseases, are just some examples of the difficulty in
determining the direct impact of perinatal cocaine use, for example, on maternal
and fetal outcome.
Many may recall that “crack babies,” or babies born to mothers who used cocaine
while pregnant, were written off by many a decade ago as a lost generation.
They were predicted to suffer from severe, irreversible damage, including reduced
intelligence and social skills. It was later found that this was a gross exaggeration.
Most crack-exposed babies appear to recover quite well. However, the fact that
most of these children appear normal should not be over-interpreted as a positive
sign. Using sophisticated technologies, scientists are now finding that exposure
to cocaine during fetal development may lead to subtle, but significant, deficits
later, especially with behaviors that are crucial to success in the classroom,
such as blocking out distractions and concentrating for long periods of time.
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There has been an enormous increase in the number of people seeking treatment
for cocaine addiction during the 1980s and 1990s. Treatment providers in most
areas of the country, except in the West and Southwest, report that cocaine
is the most commonly cited drug of abuse among their clients. The majority of
individuals seeking treatment smoke crack, and are likely to be poly-drug users,
or users of more than one substance. The widespread abuse of cocaine has stimulated
extensive efforts to develop treatment programs for this type of drug abuse.
Cocaine abuse and addiction is a complex problem involving biological changes
in the brain as well as a myriad of social, familial, and environmental factors.
Therefore, treatment of cocaine addiction is complex, and must address a variety
of problems. Like any good treatment plan, cocaine treatment strategies need
to assess the psychobiological, social, and pharmacological aspects of the patient’s
drug abuse.
There are no medications currently available to treat cocaine addiction specifically.
Consequently, NIDA is aggressively pursuing the identification and testing of
new cocaine treatment medications. Several newly emerging compounds are being
investigated to assess their safety and efficacy in treating cocaine addiction.
For example, one of the most promising anti-cocaine drug medications to date,
selegeline, is being taken into multi-site phase III clinical trials in 1999.
These trials will evaluate two innovative routes of selegeline administration:
a transdermal patch and a time-released pill, to determine which is most beneficial.
Disulfiram, a medication that has been used to treat alcoholism, has also been
shown, in clinical studies, to be effective in reducing cocaine abuse. Because
of mood changes experienced during the early stages of cocaine abstinence, antidepressant
drugs have been shown to be of some benefit. In addition to the problems of
treating addiction, cocaine overdose results in many deaths every year, and
medical treatments are being developed to deal with the acute emergencies resulting
from excessive cocaine abuse.
Many behavioral treatments have been found to be effective for cocaine addiction,
including both residential and outpatient approaches. Indeed, behavioral therapies
are often the only available, effective treatment approaches to many drug problems,
including cocaine addiction, for which there is, as yet, no viable medication.
However, integration of both types of treatments is ultimately the most effective
approach for treating addiction. It is important to match the best treatment
regimen to the needs of the patient. This may include adding to or removing
from an individual’s treatment regimen a number of different components or elements.
For example, if an individual is prone to relapses, a relapse component should
be added to the program. A behavioral therapy component that is showing positive
results in many cocaine-addicted populations, is contingency management. Contingency
management uses a voucher-based system to give positive rewards for staying
in treatment and remaining cocaine free. Based on drug-free urine tests, the
patients earn points, which can be exchanged for items that encourage healthy
living, such as joining a gym, or going to a movie and dinner.
Cognitive-behavioral therapy is another approach. Cognitivebehavioral coping
skills treatment, for example, is a shortterm, focused approach to helping cocaine-addicted
individuals become abstinent from cocaine and other substances. The underlying
assumption is that learning processes play an important role in the development
and continuation of cocaine abuse and dependence. The same learning processes
can be employed to help individuals reduce drug use. This approach attempts
to help patients to recognize, avoid, and cope; i.e., recognize the situations
in which they are most likely to use cocaine, avoid these situations when appropriate,
and cope more effectively with a range of problems and problematic behaviors
associated with drug abuse. This therapy is also noteworthy because of its compatibility
with a range of other treatments patients may receive, such as pharmacotherapy.
Therapeutic communities, or residential programs with planned lengths of stay
of 6 to 12 months, offer another alternative to those in need of treatment for
cocaine addiction.
Therapeutic communities are often comprehensive, in that they focus on the
resocialization of the individual to society, and can include on-site vocational
rehabilitation and other supportive services. Therapeutic communities typically
are used to treat patients with more severe problems, such as co-occurring mental
health problems and criminal involvement.
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NIDA
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Addiction: A chronic, relapsing disease characterized by compulsive
drug-seeking and use and by neurochemical and molecular changes in the brain.
Anesthetic: An agent that causes insensitivity to pain.
Antidepressants: A group of drugs used in treating depressive
disorders.
Cocaethylene: Potent stimulant created when cocaine and alcohol
are used together.
Coca: The plant, Erythroxylon, from which cocaine is derived.
Also refers to the leaves of this plant.
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