Cocaine

<HTML>

<HEAD>

<TITLE>Cocaine</TITLE>

</HEAD>

Cocaine

History:  Despite its recent publicity, cocaine has been used in Western Europe and the United States since at least the late 19th century. The first major cocaine epidemic in the United States occurred in 1890.

Epidemiology: 5.8 million Americans polled admitted to using cocaine within the past 30 days v. 1.6 million several years ago. Those who used within the past year has gone up from 8 to 12 million. There has been a 26% reduction in cocaine-related ER visits, but the number who used every day or every week increased during that time period. There are an estimated 3 million cocaine users in the United States. 500,000 use crack cocaine, which is a highly addictive form because of the route of administration (inhalation). 80 tons of cocaine entered the United States in 1990. Crack cocaine is highy addictive yet less expensive than pure cocaine ($5 v. $100 per ounce). <DIR>

<DIR>

11% of women in 36 hospitals used illicit drugs during their pregnancy. 15-25% of babies are born with cocaine in their system, which may lead to jittery, nervous babies with increase in malformations, such as GU abnormalities. Cocaine may also be a risk factor for SIDS (sudden infant death syndrome). Cocaine can be in breast milk up to 60 hours after a mother stops using. </DIR>

</DIR>

Routes of administration: oral (chewing cocoa leaves), intranasal (snorting), and inhalation (free-basing v. crack cocaine). Intravenous route can also be used. Note that speed-balling is mixing heroine and cocaine, then injecting intravenously.

Neurobiology: dopaminergic system in the mesocorticolimbic areas of the brain -> powerful reinforcement. Cocaine prevents reuptake of dopamine presynaptically, as well as serotonin. Cocaine leads to upregulation of norepinephrine postsynaptic receptors.

Medical sequelae of use: myocardial infarction, stroke, crack lung (look likes pneumonia clinically, but without an infectious agent; treatment: antiinflammatory agents).

Intoxication:   Cocaine is a psychostimulant with effects very similar to those of amphetamines - elation, euphoria, grandiosity, and improvement on mental and motor tasks.   Animals will prefer cocaine to food, killing themselves to continue self-administration. It is also an analgesic and a peripheral vasoconstrictor.  The drug can also cause hypervigilance, paranoia, and frank psychosis.   Cocaine can heighten both sexual desire and aggression.   Tachycardia, pupillary dilation, elevated blood pressure, perspiration or chills, nausea or vomiting, and visual or tactile hallucinations are all possible elements of cocaine intoxication.   In high doses, cocaine can induce seizures and suppress medullary control of the heart and respiratory drive.  Syncope and myocardial infarctions may occur.

Withdrawal:  Withdrawal from cocaine is rarely life-threatening, but the patient may become intensely dysphoric and anergic (the so-called "crash").   They may become hypersomnolent and look as though they have major depression. The patient may also become agitated and unable to sleep (or conversely may sleep all day). Cocaine may last from 24 hours to 7 days after discontinuation of use. Craving may occur 24-72 hours after use.  Keep a high index of suspicion when a hospitalized cocaine dependent patient suddenly has an urgent desire for premature discharge or a pass off the ward. Note that a patient may have depression and sleep disturbance, as well as chills and muscle twitching, for up to 10 weeks after their last use.

Routes of administration:  Although expensive I.V. or snorted cocaine was the preferred route of administration in the 1980s, over the past several years "crack cocaine", which is smoked, has become widely available and very inexpensive (a patient can become intoxicated for as little as $10).  As a result, cocaine dependence now affects more socioeconomic groups than in the past.  Much crime is related to crack cocaine dependent people attempting to get money for more of the drug (dealing, stealing, and prostitution are common means of doing this).  If a patient does use I.V. injection, be sure to test for and counsel about the risks of HIV and other blood-borne diseases.

</HTML>