Cocaine Use Disorder
Cocaine is a stimulant drug that is frequently abused. Cocaine makes users feel euphoric, energetic, and mentally alert. Highly addictive, it can cause severe mental and physical problems. Cocaine abuse in the United States peaked in the 1970s and 1980s, but remains a significant problem today. The stimulant directly affects brain function, and long-term addiction leads to extensive physiological and psychological problems.
Pure cocaine was first extracted from the leaf of the Erythroxylum coca bush in the mid-19th century. In the early 1900s, people were lacing tonics and elixirs with the stimulant in hopes of treating a wide range of illnesses. Cocaine quickly became popular as an ingredient in patented medicines (such as throat lozenges and tonics) and other products (such as Coca-Cola, from which it was later removed).
Concern soon mounted due to increased instances of addiction, erratic behavior, convulsion, and death. The Pure Food and Drug Act, passed in 1906, required that dangerous ingredients such as cocaine be listed on product labels. The Harrison Act of 1914 outlawed the use of cocaine altogether in over-the-counter products and made it available only by prescription. Cocaine use 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, researchers found widespread evidence of physiological and psychological problems among cocaine users, with increased emergency-room episodes and admissions for treatment.
Today, cocaine is regulated as a Schedule II drug—it has a 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. The rate of cocaine use is highest among people ages 18 to 25.
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 in "crack" cocaine, processed from cocaine hydrochloride to a freebase for smoking.
The major routes of administration of cocaine are inhaling (or snorting), injecting, and smoking. There is great risk regardless of the method of use, and it is possible to overdose fatally. 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/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 resulting buildup of dopamine contributes to the high that characterizes cocaine use.
Cocaine's immediate euphoric effects include a state of hyperstimulation, reduced fatigue, and mental clarity. The duration of the effects depends on the route of administration. The faster the cocaine is absorbed, the more intense the high. However, 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 of the stimulant (several hundred milligrams or more) intensify the user's high, but may also lead to bizarre, erratic, or violent behavior. Those using cocaine in such amounts 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, in which the drug is taken repeatedly and at increasingly higher doses, leads to a state of increasing irritability, restlessness, and paranoia. It may result in a full-blown paranoid psychosis in which the individual loses touch with reality and experiences auditory hallucinations.
Cocaine use produces short-term effects and long-term effects. Short-term effects include:
- Fast heartbeat and breathing
- Elevation of blood pressure and body temperature
- Erratic or violent behavior
- Blurred vision, chest pain, nausea, fever, muscle spasms, convulsions, and death from convulsions, heart failure, or brain failure.
Long-term effects include:
- Dependence and depression
- Feelings of restlessness, irritability, mood swings, paranoia, sleeplessness, and weight loss
- Emotional problems and isolation from family and friends
- Psychosis, paranoia, depression, anxiety disorders, and delusions
- Damage to the nose and inflamed nasal passages
- Increased risk of hepatitis and HIV
- Severe respiratory infections
- Heart attacks, chest pain, respiratory failure, strokes, and abdominal pain and nausea
The National Institute of Drug Abuse identifies the warning signs of use:
- Red, bloodshot eyes
- A runny nose or frequent sniffing
- A change in eating or sleeping patterns
- A change in groups of friends
- A change in behavior
- Acting withdrawn, depressed, tired, or careless about personal appearance
- Losing interest in school, family, or activities previously enjoyed
- Frequently needing money.
Cocaine abuse falls under the umbrella of stimulant-related disorders. According to DSM-5, the diagnosis of stimulant-related disorders can be made when the pattern of cocaine, amphetamine, or other stimulant use leads to clinically significant impairment or distress, as manifested by at least two of the following during a 12-month period:
- The stimulant is taken in larger amounts or over a longer period than intended
- There is a persistent desire or unsuccessful efforts to cut down or control stimulant use
- A great deal of time is devoted to obtaining the stimulant, using it, or recovering from its effects
- Craving, or a strong desire to use the stimulant
- Recurrent stimulant use that interferes with other responsibilities
- Continued use of the stimulant despite problems caused by or exacerbated by its effects
- Reduced or discontinued participation in important social, occupational, or recreational activities as a result of stimulant use
- Recurrent use of stimulant despite physical dangers
- Continued use despite awareness of physical or psychological problems caused by the stimulant
- Tolerance, defined by a need for markedly increased amounts of the stimulant to achieve the desired effect or by markedly diminished effect with continued use of the same amount of the stimulant
- Withdrawal, manifested by either the presence of withdrawal symptoms associated with the stimulant or use of the stimulant or a substitute to relieve or avoid withdrawal symptoms
There can be severe medical complications associated with cocaine use. Some of the most frequent complications are cardiovascular, including disturbances in heart rhythm and frank heart failure; 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 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, coma, and death.
Different routes of cocaine administration can produce different adverse effects. Regularly snorting cocaine, for example, can lead to the loss of the sense of smell, nosebleeds, problems swallowing, hoarseness, and an overall irritation of the nasal septum, which can result in 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 appetite and can experience significant weight loss and malnourishment.
There is a potentially dangerous interaction between cocaine and alcohol. Taken in combination, the two drugs are converted by the body to cocaethylene, which has a prolonged duration of action in the brain and is more toxic than either drug alone. The mixture of cocaine and alcohol is the most common two-drug combination that results in drug-related death.
Cocaine is an "upper" (stimulant) that gives its user a false sense of power and energy, making the user feel euphoric, confident, and less inhibited. When users come down from the high, they are usually depressed, edgy, and craving more drugs. No one can predict whether they will become dependent and addicted, or whether the next dose will be deadly.
Cocaine and other substance abuse disorders are complex, involving biological systems as well as myriad social, familial, and environmental factors. Therefore, treatment of cocaine and stimulant abuse can be complex. As with any disorder, treatment strategies need to assess the biological, social, emotional, and pharmacological aspects of the individual's drug abuse.
Many behavioral treatments have been found effective for stimulant abuse, including in both residential and outpatient situations. Behavioral therapies are often the only available effective treatment for many drug use problems, including cocaine use.
Cognitive-behavioral treatment is a focused approach to helping cocaine abusers cut down or abstain, and remain abstinent, from abusing cocaine and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of substance abuse. The same learning processes can be employed to help individuals reduce drug use and successfully cope with relapse. Cognitive-behavioral therapy aims to help patients recognize the situations in which they are most likely to use cocaine, avoid the situations when appropriate, and cope more effectively with a range of problems associated with drug abuse. CBT is also compatible with a range of other treatments, including pharmacotherapy.
Another approach to treatment is harm reduction, whereby psychotherapeutic strategies are aimed at reducing the negative consequences associated with substance abuse without requiring the individual to commit to abstinence. Such an approach may eventually lead users to abstinence, and data shows that it often does, but its primary goal is to improve users' quality of life whether or not they are immediately willing to aim for abstinence.
There are no medications currently available to treat cocaine abuse specifically. Consequently, the National Institute on Drug Abuse (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. Two medicines currently marketed for other conditions, topiramate and modafinil, have shown promise. Additionally, baclofen, a GABA-B agonist, has shown 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.
Medications are sometimes used in combination with behavioral therapy. Disulfiram (a medication that has been used to treat alcohol abuse) in combination with behavioral treatment, has been successful in reducing cocaine abuse.
It is important that patients undergoing treatment for substance use 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.
Therapeutic communities or residential programs with stays of several months are also on offer for treatment for those who abuse cocaine. Therapeutic communities focus on the resocialization of the individual and can include on-site vocational rehabilitation and an array of other supportive services.
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.