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Cocaine is an alkaloid of the coca shrub and exhibits anaesthetic, vasoconstrictor and central stimulant properties. It has effects on a number of neurotransmitter systems in the brain and is active at many anatomical sites within the central nervous system.
Cocaine is prepared from the coca plant and initially is in the form of a salt (cocaine hydrochloride). This salt can be inhaled into the nostril and absorbed into the bloodstream across the nasal mucosa.
The cocaine salt can also be converted to the free base of cocaine with volatile solvents which must then be carefully removed. The free base cocaine is then burnt with inhalation of the smoke resulting in very rapid and efficient absorption across the alveolar membranes of the lungs.
The third method of cocaine administration is intravenous injection of the cocaine salt.
It is generally considered that most cocaine users begin with intra-nasal administration and later progress to injecting use or inhalation of smoke.
Cocaine was only discovered in Western Europe in the 19th century but had been used for centuries by South American Indians. In the past two decades consumption of cocaine has increased in America, Western Europe and more recently in Australia.
In the mid-1980s ready made free base cocaine was marketed in the streets of American cities and became known as 'crack'. Crack, a much cheaper and more accessible version of cocaine, is widespread among lower socioeconomic groups particularly in the inner-city areas dominated by racial and ethnic minorities in the United States of America. In contrast, the users of the crystalline form of cocaine, which is inhaled, have generally been identified as those who are better educated and of a higher socioeconomic status. These socioeconomic differences, together with the different preparations of cocaine, pose problems when attempting to propose general treatment guidelines.
Fox and Mathews (1992) report that in the United States, 25 000 000 people have used cocaine at least once with 6 000 000 Americans admitting use within the previous month and 3 000 000 using the drug continuously. Furthermore, 10% of pregnant women admitted to cocaine use at least once in the antenatal period.
In Australia levels of use are much lower, with the Parliamentary Joint Committee on the National Crime Authority 1988-1989 reporting figures of 84 500 users in the past 12 months and 6640 regular users. Contrary to popular perception, patterns of cocaine use in Australia have remained relatively stable between the years of 1985 and 1991. This is probably a consequence of the relative lack of availability and expense of cocaine. The only group in Australia to show an increase in use, were women in their early twenties and early thirties (Fox and Mathews, 1992).
Cocaine is a highly addictive drug, although there is disagreement in the research as to whether cocaine produces physical withdrawal symptoms. In general, the research suggests that cocaine does not produce physical dependence and a withdrawal syndrome.
Generally, regular users of cocaine are a very small group in Australia and are largely
confined to the more affluent groups in the cities. Those most at risk could include:
The intensity, and sometimes the nature, of cocaine's effects are governed by:
Deaths from cocaine usually result from high sensitivity to the drug or massive
overdose. Deaths from overdose may occur regardless of route of administration. In most
cases the reported lethal dose of pure cocaine is approximately 1.2 grams to 1.4 grams.
Most common causes of death are:
Cocaine dependence occurs without the specific physiological withdrawal symptoms observed with the abstinence of alcohol, benzodiazepines and opiates. Cocaine dependence is likely to develop within a social/occupational context.
Initial tolerance to cocaine develops rapidly, but thereafter cocaine users seldom seem to develop tolerance for increased amounts. Tolerance may not be obvious because of the tendency to mix cocaine use with other drugs, in particular heroin (known as a speedball), to enhance effects.
Withdrawal from cocaine generally takes place in three phases. The first being 'the crash', which describes withdrawal symptoms experienced immediately after the cessation of use (usually the first 2-4 days of abstinence). Symptoms may include agitation, depression, high craving and fatigue. The second phase is that of withdrawal. This phase may last up to 10 weeks and is characterised by depression, lack of energy and anxiety, high craving and angry outbursts. The last phase, extinction, may last indefinitely and is characterised by episodic cravings for cocaine, usually in response to conditioned cues. Such cravings may surface many months or years after drug use has ceased (Gawin and Kleber, 1984).
Other symptoms experienced during withdrawal may include:
There are no specific methods of treatment for users of this drug and management follows the general principles of management of other drugs.
Treatment must take into account:
Often known as contingency contracting, this method focuses and magnifies cocaine's aversive effects. It consists of the negotiation of an agreement between the doctor or health worker and patient regarding the consequences following any further administration of cocaine.
The agreement usually takes the from of a written contract authorising the doctor or health worker to notify specific individuals eg employer, spouse of any confirmed consumption of cocaine.
The patient must also agree to participate in a urine-monitoring program. Metabolites of cocaine can be detected in the urine samples for 48-72 hours after use, although cocaine itself is metabolised from the body within 30 minutes of ingestion.
A problem with this approach is that few patients are willing to accept a contract which may link them with serious consequences following a relapse to cocaine use.
Psychodynamic treatment aims to understand the functions that cocaine has played in the abuser's life and to help him or her serve these functions without drugs.
Self-help groups provide structure, limits and a helping network.
Self-help groups modelled upon lines of Alcoholics Anonymous have been developed in the United States (called Cocaine Anonymous). At this time there are no specific self-help groups in Australia for cocaine users. However, cocaine users could be helped by groups like Narcotics Anonymous (refer Chapter 18, Community Support Services).
A combination of all three orientations behavioural, supportive and psychodynamic is probably the most common form of treatment for both inpatient and outpatient settings.
Present and future hazards of this drug should be outlined to the patient and a treatment plan worked out with them.
The use of tricyclic antidepressant drugs to reduce craving from cocaine has shown promise in experimental work in the United States. None of the other pharmacological approaches so far tested, however, appear to offer promise.
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