Cocaine is white powder that comes from the leaves of the South American coca plant. It belongs to a class of drugs known as stimulants. Cocaine may be "snorted" through the nose, smoked, or injected (usually into the veins). Regardless of the route of administration, cocaine is highly addictive. Most people who use cocaine use it only occasionally; fewer than ten percent of those who ever try the drug use it once a week or more. The social use of cocaine is generally termed abuse.
With repeated usage of cocaine, tolerance occurs. Tolerance is an increased resistance to the drug's effects, which necessitates larger doses of the drug to maintain the "high." Cocaine dependence begins with episodic use (abuse), which may involve using the drug two or three days a week, or bingeing, during which the user may consume a significant amount of cocaine in a short period, stopping only when the cocaine supply ends or from exhaustion.
Criteria for cocaine dependence includes evidence of tolerance, characteristic withdrawal symptoms, persisting with drug use despite clear evidence of overtly harmful consequences, and progressive neglect of alternative pleasures or interests in favor of substance use. Cocaine is psychologically addicting. The drug is central to the person's thoughts, emotions, and activities, and they suffer severe depression if the drug is unavailable, which lifts only when they take it again.
"Crack cocaine" is a form of cocaine that has been chemically altered so that it can be smoked and offers users an intense "high" without the risks associated with injecting the drug. By going directly to the lungs, this form of cocaine permits greater absorption and the most rapid delivery of the drug to the brain. Although cocaine is generally used illegally, when used as a legitimate drug it is used on a limited basis as a local anesthetic for eye, ear, and throat surgery.
How is it diagnosed?
History: Individuals who have been using cocaine for a long period of time may suffer from restlessness, extreme excitability, and insomnia. Repeated use of high doses of cocaine in some individuals may reveal a toxic psychosis characterized by mounting anxiety, paranoia, and auditory, visual, and tactile hallucinations. "Cocaine bugs" might develop in which the user feels like there are insects crawling under the skin.
Physical exam: On physical exam, the individuals will have enlarged (dilated) reactive pupils, an increase in heart rate and blood pressure, rapid breathing, increased perspiration and jitters.
The individual should be examined for a perforated nasal septum (from snorting cocaine), along with needle marks and abscesses (indicative of use by injection).
Blood pressure, respiration and temperature should be taken as they are all increased with cocaine intoxication.
Weight should be measured as prolonged use of cocaine causes considerable weight loss due to a decreased appetite.
A mental status examination may reveal signs of confusion, paranoia, hallucinations, impulsivity, agitation, and hyperactivity.
Upon withdrawal of occasional cocaine use, physical symptoms will be minimal, if they occur at all, and may include abdominal cramps, nausea, diarrhea, fever, chills, and exhaustion. However, with chronic use, abrupt cessation will result in depression, sleep disturbances, sluggishness (lethargy), muscle aches, and a tremendous craving for the drug.
Symptoms of a cocaine overdose include an elevated temperature, shallow respirations, and increased heart rate and blood pressure. The person may experience hallucinations, paranoia, hyperactivity and confusion.
Tests: A polydrug screen should be ordered to confirm cocaine use and the approximate amount used. It should also be done to determine if the individual is using drugs other than cocaine, which occurs frequently.
Both blood and urine samples may be used, however urine is generally the method of choice. A positive drug screen should always be confirmed by a second test since it may result in serious consequences for the individual.
Psychological testing may also be done as it can offer useful insights into underlying psychopathology in the individual dependent on cocaine.
How is it treated?
Abstinence is the treatment goal. Cocaine abuse generally does not require treatment unless it has affected the person's life in an extreme manner, such as the loss of home or job.
The first step in treatment is detoxification (ridding the body of the drug). It takes about a week to detoxify from cocaine and another four weeks to ten months until the body chemistry settles down. Drugs that are available that may help alleviate the cravings associated with withdrawal include dopamine antagonists and certain tricyclic antidepressants. Combining a dopamine antagonist and tricyclic is considerably more effective than either drug alone.
Acupuncture has also been shown to reduce withdrawal symptoms as well as counteract the craving for cocaine.
Treatment services include individual psychotherapy, family therapy, drug education, acupuncture, and relaxation training. These services are implemented on an inpatient (residential) or outpatient basis.
The only clearly accepted factor indicating need for inpatient cocaine abuse treatment are individuals with severe depression or psychotic symptoms lasting beyond one to three days after abstinence as well as repeated outpatient failures. However, hospitalization may be necessary if the individual is violent towards others, suicidal, or is having severe withdrawal symptoms during detoxification.
Many employers have instituted Employee Assistance Programs (EAPs), which is a work-based intervention strategy by which employee substance abuse problems are dealt with through a broad-based employee problem identification policy. Ongoing structured self-help programs such as Cocaine Anonymous and Rational Recovery are recommended as an adjunct to treatment services.
Regular but random drug screens should be part of the treatment process. It should also be understood that relapse is often part of the recovery process.
What might complicate it?
Complications of cocaine use may include sinusitis, runny nose (rhinitis), perforated nasal septum, nosebleeds, lung damage, and respiratory paralysis.
Users who inject the drug risk not only overdose, but also infections from non-sterile needles, such as skin abscesses, inflammation of the membranes of the spinal cord or brain (meningitis) as well as hepatitis or acquired immune deficiency syndrome (AIDS) from sharing needles with others.
The most common cardiac complications of cocaine use are heart attack (myocardial infarction), irregular or abnormal heart rhythm (cardiac arrhythmias), stroke, and rupture of the ascending aorta and sudden cardiac death.
Other complications include polydrug abuse. The most common drugs used with cocaine are alcohol, tranquilizers, marijuana, and heroin.
The natural history of cocaine abuse/dependence includes periodic relapses to drug use, therefore the recovering person will require assistance in discerning warning signs of an impending relapse so that it may be avoided.
Those who abuse cocaine on an occasional basis are generally able to maintain abstinence without any difficulty. However, as use of the drug becomes more frequent, many users complain of sleep and eating disorders, depression and anxiety, and the craving for cocaine compels them to take it again.
Nevertheless, some heavy users have been able to quit on their own. Experience demonstrates that most cocaine addicts have been using the drug for two to four years before their situation forces them to enter some type of treatment.
Cocaine overdoses are not usually fatal, but, when this does occur, it is typically due to respiratory depression following convulsions or cardiovascular collapse.
The long-term effects of cocaine (such as restlessness, extreme excitability, insomnia, and paranoia) are often identical to amphetamine psychosis and very similar to paranoid schizophrenia. The individual using cocaine may be suffering from a psychiatric disorder along with the substance abuse disorder. This is called dual diagnosis. The individual may be self-medicating another psychiatric illness, such as affective disorder, attention deficit disorder, schizophrenia, or postraumatic stress disorder.
However the most common concurrent psychiatric illness with cocaine dependence is depression, which is found significantly more often in individuals using cocaine than among opiate and depressant abusers. There is clearly overlap that makes differential diagnosis challenging at best. Because chronic use of cocaine can magnify or even produce psychiatric symptoms, it is often difficult to determine which of these symptoms represent independent psychiatric disorders versus drug-induced/organic conditions, however most of the psychiatric disorders observed in cocaine addicts occur after the addiction begins and are, by definition, secondary disorders.
If substance abuse predates the onset of affective symptoms, then primary substance abuse with a secondary mood disorder would be diagnosed.
Physician, psychologist, nurses, social worker, and recovering substance abuser, and psychiatrist.