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Cocaine Abuse
COCAINE ABUSE
Cocaine is presently the most abused major stimulant in America. In Lebanon, IDRAAC found that almost
1% of the population used cocaine in their lifetime (1). It is not a new drug of abuse but is now considered
the caviar of recreational drugs. Thus, this distinction is reflected in its description—champagne of drugs,
gold dust, Cadillac of drugs, status stimulant, yuppie drug, and others. And it can also express its method of
preparation, such as freebase. It is more popularly known simply as coke.
A common myth is that cocaine is not addictive because it lacks the physical withdrawal symptoms seen in
alcohol or heroin addiction. Cocaine has powerful psychological addictive properties. As more than one
user has reflected, “If it is not addictive, then why can’t I stop?” The trend in drug abuse in the United States
is presently multiple or polydrug abuse, and cocaine is no exception. Cocaine is often used with alcohol,
sedatives such as Valium, Ativan, or heroin, as an upper/downer combination. The other drug is also used
to moderate the side effects of the primary addiction. A common polydrug abuse problem, seen especially
in adolescents, is cocaine, alcohol, and marijuana.
Drug abuse, chemical dependency, and addictive behavior spare no one and are spread throughout society.
They do not respect age, profession, race, religion, or physical attributes.
History: Cocaine is a naturally occurring alkaloid usually extracted from the leaves of the coca shrub,
which was originally found in the Andes Mountains of Peru and Bolivia. With its appreciation as a lucrative
cash crop, it is now cultivated in Colombia, Argentina, Brazil, Mexico, the West Indies, Ecuador, and Java.
Coca leaves were mixed with lime and chewed by the Peruvian Indians as early as the sixth century to allay
the effects of cold, hunger, and fatigue. It is still used as such as a gift from the Sun God. In this sense, coca
is an important sociocultural tradition for Peruvian and Bolivian Indians and should not to be confused with
the cocaine snorting, smoking, and injecting of the Western abuser. Coca was later introduced to Europe,
where the alkaloid cocaine was isolated. Its medicinal effects on depression, alcohol and morphine addiction, fatigue, and as a local anesthetic were discovered. However, these discoveries were not without cost to
those who experimented with it. The result was addiction and dependency on the drug.
A brain tonic: In 1886, an elixir containing cocaine from the coca leaf and caffeine from the African
kola nut was marketed in Atlanta. It was sold as a brain tonic recommended for headaches, alcoholism,
morphine addiction, abdominal pain, and menstrual cramps. This elixir, appropriately named Coca-Cola,
rapidly became one of the most popular elixirs in the country. But because of the adverse effects of cocaine,
appreciated even then, the Coca-Cola Company agreed to use decocainized coca leaves in 1903.
Limited medical use: Cocaine has little medical use. Because of its anesthetic effect, it was used for eye
surgery. But because of its profound ability to vasoconstrict blood vessels (that is, make veins and arteries
narrow, thus stopping bleeding), it can lead to scarring and delayed healing of the cornea. It is still available
for use in the nose for surgery, stopping nosebleeds, and as a local anesthetic for cuts in children.
Methods of abuse: Coke in this hydrochloride salt form may be injected; swallowed; applied to oral,
vaginal, or even rectal mucous membranes; or mixed with liquor. Coke is most commonly used by snorting
or sniffing.
With snorting, the usual ritual is to place a line of coke, about 0.3 cm wide by 2.5 cm long, on a smooth
surface. The finely divided powder is then snorted (inhaled quickly) into a nostril through a plastic or glass
straw or a rolled currency bill. This ritual is usually repeated within a few minutes using the other nostril.
Special spoons and other paraphernalia are available for snorting cocaine.
Cocaine is generally not taken by mouth for recreational purposes. Toxic reactions, including death, have
occurred in people who swallow the drug to avoid police detection or border authorities. This smuggling
attempt is known as body packing. This crystalline white powder can be dissolved in water and used intravenously (“slammed”). In this form, it has a high melting point, so it cannot be smoked and is the most widely
used form of the drug.
Freebasing involves the conversion of cocaine hydrochloride into cocaine sulfate that is “free” of the additives and nearly 100% pure. It is not water soluble and has a low melting point, so it can be smoked. The
freebaser runs the risk of being burned by the conversion process because a highly volatile solvent, such as
ether, is being used.
Crack is extracted from coke using baking soda and heat—a relatively safe method compared with the ether
technique. The waxy base becomes rocks of cocaine, ready to be sold in vials. This rock cocaine is also
easy to smoke, the most common form of use in the streets. Cocaine sulfate is also available as coca paste
known as basuco, bazooka, piticin, pistol, pitillos, or tocos and is widely smoked in South America. Because
the freebase is resistant to destruction by heat, it can be smoked either in cigarettes, including marijuana
cigarettes, or in “coke pipes.” Smoking the freebase produces a more powerful effect more rapidly, but it
is also more dangerous because the safe dose can easily be exceeded. A user describes the comparison:
“Snorting coke is like driving 75 kilometres per hour. Smoking crack is like driving 200 kilometres per hour
without brakes!”
Why cocaine becomes addictive: Research with cocaine has shown that all laboratory animals can
become compulsive cocaine users. Animals will work more persistently at pressing a bar for cocaine than
for any drug, including opiates. An addicted monkey pressed the bar 12,800 times until it got a single dose
of cocaine. If the animal survives, it will return to the task of obtaining more cocaine.
The human response is similar to that of the laboratory animal. The cocaine-dependent human prefers it to
all other activities and will use the drug until the user or the supply is exhausted. These persons will exhibit
behavior entirely different from their previous lifestyle.
Cocaine-driven humans will compel themselves to perform unusual acts compared with their former standards of conduct. There are many stories of professionals, such as lawyers, physicians, bankers, artists and
athletes, with daily habits costing hundreds to thousands of dollars, with binges in the $20,000-$50,000
range. The result may be loss of job and profession, loss of family, bankruptcy, and death.
Lethal dose: Although this drug has been in use for more than 5000 years, the toxic dose or the amount
of cocaine that will cause death or some significant medical consequence is unknown. The average lethal
dose by the IV route or by inhalation is about 750-800 mg. This is subject to significant individual variation
because deaths have occurred in doctors’ offices with as little as 25 mg applied to the mucous membrane or
the snorting of a single line in recreational use where the average dose of 1 line is 20 mg.
Effects: The method of use dictates the onset of activity and duration of its effects. If snorted, the effects
will peak within 30 minutes with its duration of effect lasting 1-3 hours. If swallowed with alcohol, effects
peak in 30 minutes and last about 3 hours. If used intravenously or inhaled/smoked, the effects peak in
seconds to 2 minutes but last only 15-30 minutes. The breakdown products of the drug will be excreted
and can be detected in the urine for 24-72 hours. For chronic users, it can be detected for up to 2 weeks.
Cocaine Abuse Causes
Addictive disease is believed to be caused by genetic background and environment. Those from high-risk
family environments are particularly susceptible to the development of addictive disease, and they need to
know this in their pre-adolescent period. However, the presence of an addict in the family does not mean
that a person will become an addict.
Researchers supported by the National Institute on Drug Abuse have identified a process in the brain that
may help explain addiction to cocaine and other drugs of abuse. Their research indicates that repeated
exposure to cocaine causes a change in genes that leads to altered levels of a specific brain protein. This
protein regulates the action of a normally occurring brain chemical called dopamine. It is a chemical messenger in the brain associated with the cocaine’s pleasurable “rush”—the mechanism of addiction. Certainly,
more research is needed to unlock the mysteries of addiction, but this information adds one more link in
explaining how the brain adapts in the addiction process.
Cocaine Abuse Symptoms
The effects of cocaine can be divided into what goes on in the central nervous system, in the brain, and in
the rest of the body. The effects of the drug vary greatly, depending on the route of administration, amount,
purity, and effects of the added ingredients. The effect also varies with the user’s emotional state while taking
the drug. This is based on the user’s attitude toward the drug, the physical setting in which the drug is being
used, his or her physical condition, and whether or not the person is a regular user. Because cocaine affects
every organ system, from the brain to the skin, the following discussion will cover signs (what doctors find
by physical examination) and symptoms (what you feel) for major organ systems.
Central nervous system and psychiatric effects: Users who have pleasurable experiences report
varying degrees of euphoria; increased energy, excitement, and sociability; less hunger and fatigue; a
marked feeling of increased physical and mental strength; and decreased sensation of pain. Some will feel
a great sense of power and competence that may be associated with the delusion or false sense of grandeur,
known as cocainomania. There can be talkativeness, good humor, and laughing. Dilated pupils, nausea,
vomiting, headache, or vertigo (the sensation of your surroundings or yourself moving or spinning). With or
even without increased amounts of coke, these can progress to excitement, flightiness, emotional instability,
restlessness, irritability, apprehension, inability to sit still, teeth grinding, cold sweats, tremors, twitching of
small muscles (especially of face, fingers, feet), muscle jerks, hallucinations (cocaine bugs, snow lights, voices
and sounds, smells), and cocaine psychosis. Cocaine psychosis resembles paranoid schizophrenia and can
bring on paranoia, mania, and psychosis.
Major effects that usually cause a cocaine abuser to go to an emergency department are severe headache,
seizures, loss of consciousness that can be caused by not breathing or bleeding in the brain, stroke, hyperthermia (increased body temperature), coma, loss of vital support functions (such as low blood pressure,
slow heart rate, slow respirations, and death).
Brain effects: The use of cocaine causes the alteration of responsiveness of the brain to various chemicals.
These chemicals or neurotransmitters, such as norepinephrine, dopamine, serotonin, acetylcholine, and
gamma-aminobutyric acid, are responsible for most of the complications of cocaine. Infants of cocainesmoking parents have been brought to an emergency department because of seizures induced by secondhand cocaine smoking. One study (in the USA) of people who sought care in an emergency department
reported that 22% complained of anxiety, 13% dizziness, 10% headache, 9% nausea, 9% psychosis, and
9% confusion.
Ear, nose, and throat effects: Because the majority of users sniff or snort cocaine through their nose,
there are a variety of nasal and sinus diseases. Many users complain of nasal irritation, nasal crusting, recurrent nosebleeds, nasal stuffiness, facial pain caused by sinusitis, and hoarseness.
The mucous membrane of both sides of the septum (the cartilage that separates the nostrils) can be damaged
by decreased blood supply, along with drying, crusting, and nose picking. This results in a perforation or
hole in the septum with more crusting, foul secretions, nosebleeds, and whistling with nasal breathing, the
so-called coke nose.
Because nasal obstruction is a common complaint, many users self-treat with over-the-counter nasal decongestants, such as Afrin, which adds to the problem because it also closes or narrows the blood vessels. Many
users have also realized that this easily recognized and accepted form of self-medication with a nasal spray
is a way to administer cocaine in public. After all, who is going to check that it is not a common nasal spray
in the dispenser?
Lung effects: The direct effects of smoking cocaine are responsible for most lung and breathing complications. The large surface area of the lungs and its great blood supply cause rapid and profound brain
stimulation known as the head rush.
Smoking the freebase, crack, or paste is done using a glass pipe, waterpipes, or cigarettes, which are heated by butane lighters or matches. The residue from the tars, matches, cocaine contaminants, and additives,
such as marijuana, often cause chronic bronchitis, chronic coughing, and coughing up black, nonbloody
phlegm. These conditions can cause shortness of breath and chest pain.
Utilizing the technique of deep inhalation and breath holding to maximize the amount of cocaine inhaled
and absorbed can cause the lung to collapse. These cocaine users will complain of sharp chest pain, often
worse with deep breathing, neck pain, difficult or painful swallowing, and air under the skin in the neck
that feels like Rice Krispies under the skin when touched (subcutaneous emphysema). Though unusual, the
user’s lungs can fill with fluid (pulmonary edema) causing extreme shortness of breath, sometimes respiratory failure, and death.
In one study of the cocaine abusers who came to an emergency department in the USA, 40% complained
of chest pain—the most common complaint—and 22% complained of shortness of breath or were unable
to breathe.
Cardiovascular (heart, blood vessels): The major effect of cocaine is to stimulate the sympathetic
nervous system. This system is responsible for the “fight or flight response” and is controlled primarily by
adrenaline or epinephrine. The effects include increased heart rate, blood vessel narrowing, and high blood
pressure. Angina or the chest pain that is felt with decreased blood supply to the heart and heart attack have
accounted for more reports in medical journals than any other complication of cocaine intoxication. Chest
pain associated with cocaine use is now a common problem in urban emergency departments.
Other cardiovascular complications include abnormal heart rhythms or rapid heart rate, cardiomyopathy
or disease of the heart muscle, or aortic rupture or dissection where there is weakening of the walls of the
aorta. The acute use, despite the amount or route, causes narrowing of the arteries to the heart and vasospasm resulting in decreased blood flow to the heart. This causes angina, which can lead to a heart attack
that means death of heart tissue. Chronic use of cocaine, again regardless of the route, leads to accelerated
hardening and subsequent narrowing of the coronary arteries. Therefore, angina and heart attacks and
cardiac deaths have been found in young users from ages 19-44 years.
The overstimulation of the sympathetic system with the rapid heart rate, high blood pressure, and vasospasm
also cause the abnormal rhythms. Those rhythms may be ventricular tachycardia and ventricular fibrillation
and may cause sudden death. Chest pain has been the most common complaint to the emergency department, up to 40% of people, 21% complain of palpitations or the sensation that their hearts are racing or
going fast.
Pregnancy effects: Cocaine use during pregnancy can increase the complications of pregnancy and
affect the fetus directly. These abusers may also use other drugs, alcohol, and nicotine, which adversely affect the pregnancy. They have an increased rate of miscarriages, placenta abruption in which the placenta
separates from the wall of the uterus and results in stillbirth. There is increasing information that cocaine may
cause birth defects with increased rates of malformation, low birth weights, and behavioral abnormalities.
Infections: The infectious complications related to IV use of cocaine are not unique to cocaine. All IV drug
users are at risk for infections such as cellulitis (soft tissue infection at the injection site), abscesses at the
injection sites, tetanus or lockjaw, lung or brain abscesses, or infection of the heart valves. These are due to
nonsterile techniques of IV injections. Contagious viruses such as hepatitis B, hepatitis C, and HIV (AIDS virus) are transmitted by sharing IV needles. The abuser may complain of pain and swelling and redness at the
injection site or fever. Abusers may also complain of jaundice or turning yellow, abdominal pain, nausea,
vomiting, loss of appetite, or the multitude of complaints that accompany hepatitis and AIDS.
When to Seek Medical Care
If you have a psychiatrist who knows of your drug use, and if your symptoms are psychiatric in nature (such
as mania, paranoia, violence, suicidal, major depression, homicidal, or hallucinations), call or have someone call your doctor.
Call your doctor if the following conditions develop:
• If you have foul, itchy, or bloody discharge, or facial pain that seems like sinusitis
• If your chronic cough is associated with a mild fever, more phlegm production, or foul phlegm
• If you are pregnant and have premature labor pain, vaginal bleeding, or ankle swelling with high blood pressure.
• If you notice redness with mild swelling and mild pain at an injection site
• Severe headache, generalized seizures, loss of consciousness, signs of a stroke (loss of vision, seeing
double, inability to speak or slurred speech, weakness of extremities), or coma are all symptoms that demand emergency care. Call 140 for an ambulance as opposed to bringing someone by car to a hospital
emergency department.
• Someone with severe depression, violent behavior, paranoia, suicidal, or homicidal behavior should
certainly be brought to the hospital, especially if a psychiatrist is easily reached. Police may be needed to
subdue the violent, paranoid, suicidal, or homicidal person.
Go to an emergency department if the following conditions develop:
• A brisk nosebleed that cannot be stopped by direct pressure for 10 minutes
• Facial pain or headache with a fever
• Severe chest pain, difficulty breathing, shortness of breath, or foul or bloody phlegm with fever
• High blood pressure, especially with symptoms of headache, chest pain, or shortness of breath
• Chest pain, usually described as pressure or squeezing in nature, which maybe accompanied by difficulty
breathing, nausea, vomiting, and sweatiness
• Vaginal bleeding, premature labor pains, and suspicion of miscarriage
• Significant swelling, pain, redness, red lines leading from the injection site, and accompanied by fever
• Severe abdominal pain, persistent vomiting, vomiting blood
• If you think that one of your packets you have swallowed or stuffed in a body orifice (vagina, rectum) is
leaking or has broken
• Cocaine-induced headache diagnoses can include such conditions as tension headache, stroke (bleed in
head), sinusitis, meningitis, or brain abscess.
• Cocaine-induced seizures might indicate more serious problems such as bleeding in the brain, meningitis,
very high blood pressure with organ injury, or low blood pressure, respiratory failure, and heart problems.
Infants may experience seizures caused by parents’ smoking cocaine in their presence. It is important to note
that this is a form of child abuse.
• Psychiatric problems caused by cocaine abuse may include cocainomania, anxiety, hallucinations, paranoia, psychoses, violence, major depression, suicidal or homicidal tendencies, or attempted suicide.
• Nasal and throat complications of cocaine abuse will include diagnoses of nasal itching, post-nasal drip,
nosebleed, sinusitis, laryngitis, and perforated nasal septum.
• Pulmonary diagnoses may include pneumonia, bronchitis, COPD (chronic obstructive pulmonary disease
or emphysema), asthma or reactive airway disease, or a collapsed lung.
• Cardiovascular diagnoses include heart problems such as chest pain, heart attack, abnormal heart rhythms,
and various heart conditions that can lead to sudden death.
• Pregnancy diagnoses may include vaginal bleeding, threatened abortion, incomplete abortion, or spontaneous abortion, or miscarriage. Ultrasound may be used in this diagnosis.
• Infectious diagnoses may include cellulitis, shooter’s abscess, lung abscess, brain abscess, septic shock,
hepatitis, and any of the opportunistic infections associated with AIDS if you are HIV infected.
Cocaine Abuse Treatment
If you or a loved one suffers from cocaine abuse/addiction, please do not hesiatte to contact a MIND specialist for a confidential consultation.
Prevention
Prevention should start early in the preadolescent years for those who are at risk. This would include children
in families with a history of any addiction such as alcoholism and drug use. However simplistic the concept,
teaching youngsters to say “no” to smoking, alcohol, and drugs is an excellent prevention tool. If we can
keep the children and our future generations from the gateway drugs of nicotine, alcohol, and marijuana,
then we may be able to prevent the escalation to harder drugs such as cocaine.
Outlook
The prognosis for minor complications of cocaine use is good if further drug use can be stopped completely.
This will be a significant challenge to the addicted person and may require professional and support group
interaction. The majority of the cocaine abusers who come to the hospital for medical care will usually do
well and are often sent home. They may be seen or referred to chemical dependency counselors for followup as outpatients.
(1) Degenhardt L, Chiu WT, Sampson N, Kessler RC, Anthony JC, Angermeyer M, Bruffaerts R, de Girolamo G, Gureje O, Huang Y,
Karam AN, Kostyuchenko S, Lepine JP, Medina Mora ME, Neumark Y, Ormel J, Pinto-Meza A, Posada-Villa J, Stein DJ, Takeshima
T, Wells JE (2008). Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental
Health Surveys. PLoS Medicine 5(7):e141.
If you need further information, please do not hesitate to contact us
Obtained from www.webmd.com and edited by IDRAAC