Scope of the problem

Cocaine abuse and addiction continues to be a problem that plagues our nation. In 1997, for example, an estimated 1.5 million Americans age 12 and older were chronic cocaine users. Although this is an improvement over the 1985 estimate of 5.7 million users, we still have a substantial distance to go in reducing the use of this addictive stimulant. Science is helping. We now know more about where and how cocaine acts in the brain, including how the drug produces its pleasurable effects and why it is so addictive.

Through the use of sophisticated technology, scientists can actually see the dynamic changes that occur in the brain as an individual takes the drug. They can observe the different brain changes that occur as a person experiences the "rush," the "high," and, finally, the craving of cocaine. They can also identify parts of the brain that become active when a cocaine addict sees or hears environmental stimuli that trigger the craving for cocaine. Because these types of studies pinpoint specific brain regions, they are critical to identifying targets for developing medications to treat cocaine addiction.

What is cocaine?

Cocaine is a powerfully addictive stimulant that directly affects the brain. Cocaine has been labeled the drug of the 1980's and 1990's, 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 coca bush, which grows primarily in Peru and Bolivia, in the mid-19th century. In the early 1900's, 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 it 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 other stimulants such as amphetamines.

What is crack?

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 immediate and euphoric effect is one of the reasons that crack became enormously popular in the mid 1980's. Another reason is that crack is inexpensive both to produce and to buy.

What is the extent of cocaine use in the United States?

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.

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. 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.

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 was 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. Past-year use of crack also rose slightly among this group, although no changes were found for other grades.

Trends in 30-day prevalence of cocaine abuse among eighth, tenth and twelfth graders. 1991-1998

How is cocaine used?

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.

How does cocaine produce its effects?

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.

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.

The path to healing

Reaping the benefits of treatment begins by recognizing the signs of cocaine addiction. The next step is to be evaluated by a qualified professional. Although cocaine addiction can be diagnosed by primary care physicians, most often the physician will refer the patient to a psychiatrist, psychologist, clinical social worker, or other professionals specializing in addictions. Treatment is a partnership between the patient and the health care provider. It is important that informed consumers understand their treatment options and discuss all concerns with a treatment provider as they arise. Cocaine addiction represents a challenge to treatment professionals.

Cocaine addicts are more prone to relapse and are often the most difficult clients to treat effectively because of their many problems. Dual diagnosis patients require a comprehensive treatment approach that recognizes their special needs and provides integrated treatment for the multiple disorders identified.

Serenity Lane is a total care facility for treating the whole person. We directly address the physical and psychological elements of dependency disorders, as well as the defeating beliefs that accompany addiction. Thirty years of experience has provided us with an expertise to treat patients who are suffering from addictions and those complicated by a psychiatric disorder.

PART 2

What are the short-term effects of cocaine use?

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.

What are the long-term effects of cocaine use?

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.

What are the medical complications of cocaine abuse?

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; 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, accelerated heartbeat and breathing, and increased 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. 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. It is noteworthy that the mixture of cocaine and alcohol is the most common two-drug combination that results in drug-related death.

Are cocaine abusers at risk for contracting HIV/AIDS?

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 judgment 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.

What is the effect of maternal cocaine use?

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, socioeconomic status, poor maternal nutrition and other health problems are just some examples of the difficulty in determining the direct impact of cocaine use.

Many may recall that "crack babies," or babies born to mothers who used cocaine while pregnant, were written off 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 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.

What treatments are effective for cocaine abusers?

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 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 psychological, social, and pharmacological aspects of the patient's drug abuse.

Pharmacological approaches

There are no medications currently available to treat cocaine addiction specifically. Consequently, the National Institute on Drug Abuse (NIDA) is 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, was taken into multi-site phase III clinical trials in 1999. These trials evaluated two innovative routes of selegeline administration: a transdermal patch and a time-released pill, to determine which was 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.

Behavioral interventions

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.

Cognitive-behavioral therapy is another approach. Cognitive-behavioral coping skills treatment, for example, is a short-term, 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.

Longer term halfway house 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.

For further information on Serenity Lane's treatment of cocaine addiction, call (541) 687-1110 or toll free 1-800-543-9905