Doctor's Notes on Cocaine Abuse (Addiction)
Cocaine is a crystalline alkaloid obtained from coca leaves; originally used as a local anesthetic, the drug is used currently for its stimulant and euphoric effects that often result in a compulsive psychological need (addiction) for its use (abuse); it has many different street names such as nose candy, blow, toot and many others; when it is mixed with heroin, it is termed a speedball – when it is extracted from the powdered form, with baking soda and heat, it may be termed crack or crack cocaine. In addition, cocaine may be mixed with many other drugs. Cocaine may be inhaled, ingested, smoked, or IV injected. Signs and symptoms of cocaine abuse vary; euphoria may be experienced with increased energy, excitement and sociability – some people feel great sense of power and competence to such a high level that it is delusional and allows the person to engage in extremely risky activities. However, some individuals may have signs and symptoms such as dilated pupils, nausea, vomiting, headaches, vertigo, cold sweats, tremors, tooth grinding and hallucinations. More long-term symptoms include nasal problems like nasal septum perforation, lung problems that can result in difficulty breathing, cardiovascular problems including heart attacks, problems with pregnancy and increased miscarriages, infections, especially in IV drug users, liver damage and overdoses that result in severe headaches, seizures and/or death.
Other signs and symptoms that may be related to cocaine abuse and addiction are behavioral changes such as poor family communication, family conflicts, disruptive financial situations because of the high costs to purchase cocaine and the irritation/desperation, including lying and stealing, exhibited by individuals addicted to the drug when the drug euphoria wears off and the drug is not available.
Cocaine abuse and/or addiction is to be caused by a combination of genetic and environmental risk factors. Researchers suggest that repeated exposure to cocaine changes processes in the brain that lead to altered levels of dopamine that causes addiction. Some users only want the euphoria of cocaine abuse and that causes addiction. Social acceptance is sometimes based on drug use; this can cause drug use and/or abuse and addiction.
Cocaine Abuse (Addiction) 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 a 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) can be physiological effects of cocaine. With or even without increased amounts of coke, these can progress to excitement, flightiness, emotional instability, restlessness, irritability, apprehension, inability to sit still, cold sweats, tremors, twitching of small muscles (especially of the eyes and other face muscles, fingers, feet), and muscle jerks. The effects of cocaine on the teeth may include teeth grinding. The cocaine user may also experience 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, and loss of vital support functions (such as low blood pressure, slow heart rate, slow respiration, and death).
- Brain effects: The effects of cocaine on the brain include alteration of responsiveness of the brain to various chemicals. These chemicals are called neurotransmitters and include norepinephrine, dopamine, serotonin, acetylcholine, and gamma-aminobutyric acid; they are responsible for most of the complications of cocaine. Infants of cocaine-smoking parents have been brought to an emergency department because of seizures induced by secondhand cocaine smoking. One study 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, water pipes, 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, non-bloody 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, 40% complained of chest
pain -- themost common complaint -- and22% complained of shortness of breath or were unable to breathe.
- Cardiovascular (heart, blood vessels) effects: 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 many emergency departments.
- Other cardiovascular complications include abnormal heart rhythms or rapid heart rate, cardiomyopathy, which is a disease of the heart muscle, or aortic rupture or dissection in which there is a 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 the 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, heart attacks, and cardiac deaths have occurred in young users from 19-44 years of age.
- The overstimulation of the sympathetic system with the rapid heart rate, high blood pressure, and vasospasm also cause abnormal heart 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, 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. Abusers of this drug may also use other drugs, alcohol, and nicotine, which adversely affect the pregnancy as well. They have an increased rate of miscarriages and placental 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 non-sterile 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, 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 or AIDS.
- Body packers or stuffers: People smuggle processed cocaine across international borders. They often swallow drug-filled packets or stuff them into body openings such as the vagina or rectum. The "body packer" or "mule" can carry 50-200 tightly wrapped condoms or latex bags filled with high-grade cocaine hydrochloride. If the containers break or leak, the cocaine can be absorbed by the person's body. Most mules have no symptoms and may be apprehended by an astute official who notices some suspicious behavior. Some will become acutely ill when the packets leak or rupture, resulting in massive intoxication, seizures, and death. A similar problem may occur with "body stuffers." These are cocaine users or traffickers who swallow bags of cocaine when arrested so there is no evidence.
Cocaine Abuse (Addiction) Causes
Although there is no one single cause of cocaine addiction, addictive disease is generally believed to be the result of a combination of genetic background and environmental risk factors. Those from high-risk family environments are particularly susceptible to the development of addictive disease, and they need to be aware of this information during their preadolescent period. However, the presence of an addict in the family does not mean that a person can be certain to 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 lead 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.
- Social risk factors for cocaine abuse include low socioeconomic status and lower levels of education, peer pressure, easy availability of drugs, and living in an area that has high crime or drug use.
- Family risk factors for cocaine abuse include low parental supervision, inconsistent or harsh discipline, poor family communication, high family conflicts, and divorce.
- Individual risk factors for cocaine abuse can be male gender, Caucasian ethnicity, and late adolescent age. While men are more likely to develop cocaine abuse, women are thought to experience more cravings, depression, and social and family problems as a result of abusing cocaine. Women are more likely to seek treatment for this ailment compared to men. Early childhood aggression or other behavior problems; being the victim of abuse; and mental health, peer, or academic problems all increase the likelihood of cocaine abuse. Other individual risk factors include thrill-seeking behaviors and low recognition of the dangers of drug use.
Drug abuse, now also referred to as drug use disorders, refers to using substances, over-the-counter (OTC) medications, prescription drugs, or illegal street drugs for the purpose of getting high. Substance abuse can lead to significant, even life-threatening, health problems. It also increases the risk of accidents, suicide, unsafe sex, and violence. Teens are more likely to abuse substances if they suffer from depression, low self-esteem or impulse control, have a history of being abused, or family history of substance abuse. Teens who receive low parental supervision or communication, or who feel different than their peers are also at risk for drug abuse.
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Kasper, D.L., et al., eds. Harrison's Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.