Cocaine abuse in the United States peaked in the 1970s and 1980s, but it remains an enormous problem today. The stimulant directly affects brain function, and long-term addiction leads to extensive physiological and psychological problems.
Cocaine is a powerfully addictive stimulant that directly affects the brain.
Pure cocaine was first extracted from the leaf of the Erythroxylon coca bush in the mid-19th century. In the early 1900s it became the main stimulant drug used in most of the tonics and elixirs that were developed to treat a wide variety of illnesses. It quickly became popular as an ingredient in patented medicines (throat lozenges and tonics) and other products (such as Coca Cola, from which it was later removed).
Concern soon mounted due to instances of addiction, psychotic behavior, convulsion, and death. A series of steps, including passage of the Pure Food and Drug Act of 1906, were taken to combat health and behavioral problems associated with the use of cocaine. Finally, the Harrison Act of 1914 outlawed the use of cocaine in over-the-counter products and made it available only by prescription. Cocaine use soon dropped dramatically and remained at minimal levels for nearly half a century.
In the 1960s, illicit cocaine use rebounded, and by the late 1970s the drug had become popular among middle- and upper-middle-class Americans. By the mid-1980s, there was widespread evidence of physiological and psychological problems among cocaine users, with increased emergency-room episodes and admissions to treatment.
Today, cocaine is a Schedule II drug—it has high potential for abuse but can be administered by a doctor for legitimate medical uses, such as a local anesthetic for certain eye, ear, and throat surgeries.
There are two basic forms of cocaine: powdered and freebase. The powdered form is a hydrochloride salt that dissolves in water; freebase is a compound that has not been neutralized by an acid to make hydrochloride salt. The freebase form of cocaine can be smoked, as is "crack" cocaine that has been processed from cocaine hydrochloride to a freebase for smoking.
Cocaine is a stimulant that makes users feel euphoric, energetic, and mentally alert. Highly addictive, it can cause severe mental and physical problems. It is possible to overdose fatally.
The major routes of administration of cocaine are inhaling (or snorting), injecting, and smoking. There is great risk regardless of the method of use. It appears that compulsive cocaine use may develop even more rapidly if the substance is smoked rather than snorted. Smoking allows extremely high doses of cocaine to reach the brain very quickly and brings an intense and immediate high. The injecting drug user is at risk for acquiring or transmitting HIV infection/AIDS as well as Hepatitis C if needles or other injection equipment are shared.
Cocaine is a strong central nervous system stimulant that interferes with the reabsorption of dopamine, a chemical messenger associated with pleasure and movement. This buildup of dopamine, part of the brain's reward system, contributes to the high that characterizes cocaine consumption.
The duration of cocaine's immediate euphoric effects, which include hyperstimulation, reduced fatigue, and mental clarity, depends on the route of administration. The faster the cocaine is absorbed, the more intense the high. On the other hand, the faster the absorption, the shorter the duration of action. The high from snorting cocaine may last 15 to 30 minutes, while that from smoking may last 5 to 10 minutes. Increased use can reduce the period of stimulation.
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 milligrams), 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 experience the opposite effect.
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 sometime thereafter. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.
Long-term effects of cocaine use include addiction, irritability and mood disturbances, restlessness, paranoia, and auditory hallucinations.
Binge cocaine use, during which the drug is taken repeatedly and at increasingly higher 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.
Medical Complications of Cocaine Use
There can be severe medical complications associated with cocaine use. Some of the most frequent complications are cardiovascular effects, including disturbances in heart rhythm and heart attacks; respiratory effects such as chest pain and respiratory failure; neurological effects, including strokes, seizures, 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 fibrillations; accelerate heartbeat and breathing; and increase blood pressure and body temperature. Physical symptoms may include chest pain, nausea, blurred vision, fever, muscle spasms, convulsions, coma, and death.
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. Persons who inject cocaine have puncture marks and "tracks," most commonly in their forearms. Intravenous cocaine users may also experience allergic reactions, either to the drug or to some additive in street cocaine, which in severe cases can result 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, which 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.
Warning Signs of Use:
Cocaine is an "upper" (stimulant) that gives its user a false sense of limitless power and energy. When users come down, they are usually depressed, edgy, and craving more. No one can predict whether he or she will become dependent and addicted, or whether the next dose will be deadly.
There was 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 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. 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 emerging compounds are being investigated to assess their safety and efficacy. Topiramate and modafanil, two marketed medications, have shown promise. Additionally, baclofen, a GABA-B agonist, showed promise in a subgroup of cocaine addicts with heavy use patterns. Antidepressant drugs are of some benefit with regard to mood changes experienced during the early stages of cocaine abuse. Medical treatments are also being developed to deal with acute emergencies resulting from excessive cocaine abuse.
Many behavioral treatments have been found effective for cocaine addiction, including both residential and outpatient approaches. Indeed, behavioral therapies are often the only available effective treatment for many drug problems, including cocaine addiction. However, integration of both pharmacological and behavioral treatments may ultimately prove to be the most effective approach. Disulfiram (a medication that has been used to treat alcoholism), in combination with behavioral treatment, is effective in reducing cocaine abuse. It is important that patients receive services that match all of their treatment needs. For example, if a patient is unemployed, it may be helpful to provide vocational rehabilitation or career counseling. Similarly, if a patient has marital problems, it may be important to offer couples counseling. A behavioral therapy component that may be particularly useful for helping patients achieve initial abstinence from cocaine is contingency management. Some contingency management programs use a voucher-based system to give positive rewards for staying in treatment and remaining cocaine-free.
Cognitive-behavioral treatment is a focused approach to helping cocaine-addicted individuals abstain—and remain 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 and successfully cope with relapse. This approach attempts to help patients 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 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 (TCs), or residential programs with stays of 6 to 12 months, offer another alternative to those in need of treatment for cocaine addiction. TCs focus on resocialization of the individual, and can include on-site vocational rehabilitation and other supportive services. Of course, there is variation in the types of therapeutic processes offered in TCs.