Psychiatric Annals

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Chronic Cocaine Abuse: Evidence for Adverse Effects on Health and Functioning

Arnold M Washton, PhD; Mark S Gold, MD

Abstract

INTRODUCTION

Cocaine use has increased dramatically in the US in recent years. Surveys estimate that over 22 million Americans have used the drug and the number continues to soar at a rapid rate.1,2 With its increased use, cocaine-related health consequences have become more prevalent. On a national level, cocaine-related deaths and emergency room visits have increased over 200% since 1976 and cocaine-related admissions to government treatment programs have increased over 500%.5

Despite these disturbing trends, the popular belief that cocaine is a relatively benign drug with6, out significant hazards or addiction potential continues to be perpetuated. Such misconceptions are fostered by a lack of adverse publicity about cocaine and a paucity of published studies describing dysfunctional cocaine use. The tendency to underestimate cocaine's abuse potential and adverse effects is especially true for use of the drug by the intranasal route ("snorting") which is the most popular method of self-administration. Some authors have suggested that severity of cocaine problems is based mainly on route of administration with intranasal use being regarded as relatively safe as compared to smoking of cocaine free base or intravenous use.4 Risks associated with intranasal use have been minimized.

In response to the recent increase in cocaine abuse problems, we established a national telephone helpline, 800-COCAINE, to provide information, advice and referral to treatment on a 24hour per day, 7-day per week basis. We have now conducted a survey of 500 helpline callers which demonstrates addictive patterns of use and serious adverse effects in intranasal, free base, and intravenous users.

SUBJECTS AND METHODS

Our subjects were 500 cocaine abusers randomly selected from over 70,000 callers to 800COCAINE during its first 12 weeks of operation beginning on May 6, 1983. Subjects had learned of the helpline from television and radio broadcasts stating that 800-COCAINE could be called anonymously from anywhere in the US to obtain information or referral to treatment for a cocaine problem. Each subject voluntarily consented to a confidential 20 to 30-minute telephone interview conducted by an experienced drug abuse counselor. The interview included an extensive questionnaire on demographic variables, drug use, and adverse effects of cocaine use on specific aspects of the subject's health and psychosocial functioning.

RESULTS

The callers were from 37 different states in the US with the majority from New York/New Jersey (37%), California (17%), and Florida (12%). The sample consisted of 336 males (67%) and 164 females (33%) with a mean age of 30 years. Four hundred twenty-six (85%) were white and 74 (15%) were black or hispanic. Most callers were employed (76%) with 40% earning over $25,000 per year. They had an average of 14.1 years of education.

The average caller had been using cocaine for 4.9 years. Sixty-one percent were intranasal (IN) users, 21% were free base smokers (FB), and 18% were intravenous (IV) users. Among current FB and IV users, 89% said they had started using cocaine by the IN route. Forty-eight percent of the sample was currently using cocaine on a daily basis. At a street cost of $75 to $125 per gram, callers reported spending an average of $637 on cocaine during the week prior to calling the helpline. Sixty-eight percent said they were also using alcohol or sedativehypnotic drugs to reduce the "jittery" stimulant effects of cocaine or to relieve the unpleasant "crash" when the cocaine euphoria wore off. The subjective effects of cocaine deemed most desirable by the callers included: mood elevation to the point of euphoria (82%); increased energy, increased drive and mental capacity (53%), and enhanced sociability and sexual arousal (21%).

The average caller reported 12 of a possible 21 questionnaire items…

INTRODUCTION

Cocaine use has increased dramatically in the US in recent years. Surveys estimate that over 22 million Americans have used the drug and the number continues to soar at a rapid rate.1,2 With its increased use, cocaine-related health consequences have become more prevalent. On a national level, cocaine-related deaths and emergency room visits have increased over 200% since 1976 and cocaine-related admissions to government treatment programs have increased over 500%.5

Despite these disturbing trends, the popular belief that cocaine is a relatively benign drug with6, out significant hazards or addiction potential continues to be perpetuated. Such misconceptions are fostered by a lack of adverse publicity about cocaine and a paucity of published studies describing dysfunctional cocaine use. The tendency to underestimate cocaine's abuse potential and adverse effects is especially true for use of the drug by the intranasal route ("snorting") which is the most popular method of self-administration. Some authors have suggested that severity of cocaine problems is based mainly on route of administration with intranasal use being regarded as relatively safe as compared to smoking of cocaine free base or intravenous use.4 Risks associated with intranasal use have been minimized.

In response to the recent increase in cocaine abuse problems, we established a national telephone helpline, 800-COCAINE, to provide information, advice and referral to treatment on a 24hour per day, 7-day per week basis. We have now conducted a survey of 500 helpline callers which demonstrates addictive patterns of use and serious adverse effects in intranasal, free base, and intravenous users.

SUBJECTS AND METHODS

Our subjects were 500 cocaine abusers randomly selected from over 70,000 callers to 800COCAINE during its first 12 weeks of operation beginning on May 6, 1983. Subjects had learned of the helpline from television and radio broadcasts stating that 800-COCAINE could be called anonymously from anywhere in the US to obtain information or referral to treatment for a cocaine problem. Each subject voluntarily consented to a confidential 20 to 30-minute telephone interview conducted by an experienced drug abuse counselor. The interview included an extensive questionnaire on demographic variables, drug use, and adverse effects of cocaine use on specific aspects of the subject's health and psychosocial functioning.

RESULTS

The callers were from 37 different states in the US with the majority from New York/New Jersey (37%), California (17%), and Florida (12%). The sample consisted of 336 males (67%) and 164 females (33%) with a mean age of 30 years. Four hundred twenty-six (85%) were white and 74 (15%) were black or hispanic. Most callers were employed (76%) with 40% earning over $25,000 per year. They had an average of 14.1 years of education.

The average caller had been using cocaine for 4.9 years. Sixty-one percent were intranasal (IN) users, 21% were free base smokers (FB), and 18% were intravenous (IV) users. Among current FB and IV users, 89% said they had started using cocaine by the IN route. Forty-eight percent of the sample was currently using cocaine on a daily basis. At a street cost of $75 to $125 per gram, callers reported spending an average of $637 on cocaine during the week prior to calling the helpline. Sixty-eight percent said they were also using alcohol or sedativehypnotic drugs to reduce the "jittery" stimulant effects of cocaine or to relieve the unpleasant "crash" when the cocaine euphoria wore off. The subjective effects of cocaine deemed most desirable by the callers included: mood elevation to the point of euphoria (82%); increased energy, increased drive and mental capacity (53%), and enhanced sociability and sexual arousal (21%).

The average caller reported 12 of a possible 21 questionnaire items for adverse psychological effects. In contrast to the acute subjective effects mentioned above, chronic cocaine use was associated with significant disruption to the user's mood and mental state, as indicated by the data in Table 1 . The typical caller reported feeling chronically depressed, irritable, and overwhelmed with problems. Cognitive deficits, lack of motivation, and absence of sex drive were also common complaints. Forty-six callers reported a cocaine-related suicide attempt.

The average caller reported 11 of a possible 22 questionnaire items for adverse physical effects. As shown in Table 2, the most commonly reported symptoms included sleep problems and chronic fatigue. IN users typically complained of runny noses, sinus headaches, and nasal sores and/or bleeding. FB smokers complained of chronic cough, sore throat, and chest congestion resulting from frequent inhalation of hot cocaine vapors. Perhaps the most serious physical symptom was cocaine-induced brain seizures with loss of consciousness.

Table

TABLEIINCIDENCEOFADVERSE PSYCHOLOGICAL EFFECtS (N=SOO)

TABLEI

INCIDENCEOFADVERSE PSYCHOLOGICAL EFFECtS (N=SOO)

Table

TABLE 2INCIDENCE OFADVERSE PHYSICAL EFFECTS

TABLE 2

INCIDENCE OFADVERSE PHYSICAL EFFECTS

Callers reported numerous social, familial, financial, and employment problems associated with their cocaine use. These included: loss of job (25%), loss of spouse (26%), loss of friends (51%), and loss of all monetary assets (42%). They also reported fighting and violent arguments (66%), threat of separation or divorce (27%), and absenteeism coupled with reduced productivity at work (40%). Fifty-seven callers (11%) reported having an automobile accident while high on cocaine. Callers also reported dealing cocaine (39%) and stealing from work, family, or friends (29%) to support their cocaine habit. Sixty callers (12%) said they had been arrested for a cocainerelated crime (dealing or possession).

Over half the callers said they felt addicted to cocaine (61%), could not limit their use (73%), and could not refuse cocaine when it was available (83%). They also reported feeling distressed without cocaine (52%) and said they experienced withdrawal symptoms when they tried to stop using it (57%). Despite repeated attempts to control their use, 67% said they were unable to remain abstinent from cocaine for as long as one month. They preferred cocaine to food (71%), sex (50%), friends (64%), family activities (72%), and recreational activities (76%).

Table

TABLE 3MEAN NUMBER OF REPORTED CONSEQUENCES IN EACH CATEGORY IN=SOO)

TABLE 3

MEAN NUMBER OF REPORTED CONSEQUENCES IN EACH CATEGORY IN=SOO)

Table

TABLE 4INCIDENCE OF SELECTED CONSEQUENCES

TABLE 4

INCIDENCE OF SELECTED CONSEQUENCES

All three routes of cocaine administration were associated with a high incidence and wide range of adverse effects. However, as compared to IN users, FB and IV users generally reported a greater number of cocaine- related symptoms (Table 3) and a higher incidence of certain consequences (Table 4).

DISCUSSION

Our survey findings reflect the increasing prevalence of cocaine abuse in the US, particularly among white, middle-class males who are otherwise not heavily involved in drugs or alcohol. Not only are more persons using cocaine, but increasing numbers are escalating to addictive patterns of use and suffering serious consequences. The popular belief that cocaine is a relatively benign drug, especially if used by the intranasal route, is challenged by our findings that all three routes of cocaine administration were associated with severe drug dependence and drug-related dysfunction. Although IN users often feel exempt from adverse consequences, our findings and others,5 including reports of death from IN cocaine use,6 underscore the fact that this route of administration offers no guarantee of safety. However, FB and IV users do tend to suffer more numerous and more severe drug-related consequences. The sharp rise in cocaine plasma levels following FB and IV administration7 increases the abuse potential and threat of adverse reactions. As compared to IN administration, FB and IV use produce a more rapid onset of effects, a more intense euphoria, and a more intense rebound dysphoria. These characteristics drive the individual user toward more exaggerated patterns of use.

Our findings do not indicate that occasional cocaine use inevitably leads to severe drug dependency and major dysfunction. Our sample consisted of self-defined problematic users and our results must be interpreted accordingly. However, it also cannot be concluded that occasional or socalled "recreational" cocaine use is harmless. Given the extremely potent reinforcing effects of cocaine there is always a very real potential for an individual's use to escalate. It is the oftimes sudden and unpredictable escalation from occasional to regular and compulsive use patterns that is of greatest concern. The question of why some cocaine users escalate to compulsive patterns is of substantial clinical importance, but remains largely unanswered at present. It may be that stressful life events, certain psychological factors, social encouragement, and ready access to cocaine combine to create the potential for escalating use.

Although an extreme psychological addiction to cocaine undoubtedly develops in some users, whether cocaine also produces a true physical addiction remains unclear. Cessation of chronic cocaine use usually does not lead to a clearly definable withdrawal syndrome as with opiates or barbiturates. However, the generalized dysphoria and other feelings of malaise following cocaine use may be viewed as a withdrawal state especially since they are often associated with drug craving and drug-seeking behavior and are relieved by resumption of drug use. A temporary depletion of brain catecholamines and serotonin8 may serve as the biochemical basis of abstinence symptoms following cocaine use. The tolerance that develops to cocaine's euphorigenic effects also suggests that there may be a physiological component underlying cocaine dependence. Increased tolerance may explain why some heavy users can self-administer as much as 1 0 grams per day without severe toxic or lethal reactions.

Patterns of more frequent and escalating cocaine use are promoted to some extent by the drug's pharmacologic properties. Cocaine is an extremely potent reinforcer with highly desired subjective effects including euphoria and feelings of enhanced physical, mental, and sexual capabilities. These effects are rapid in onset and rather short-lived such that administration of the drug must be repeated every 20 to 30 minutes in order to maintain the "high" and avoid the rebound dysphoria. With increased dose and frequency of use, and especially when the cocaine is injected or smoked as free base, the "high" and the "crash" are intensified, leaving the user with a powerful craving for more cocaine. Many users take as much of the drug as they are able to obtain until they exhaust their drug supplies, money, or collapse from physical exhaustion. With continued use, the pleasurable effects of cocaine diminish and are replaced by an increasing number of adverse effects which can be alleviated only by cessation of use. Thus patterns of escalating cocaine use can be seen to arise from an almost obsessive desire to recapture the ephemeral euphoric state, an attempt to avoid the unpleasant rebound dysphoria, and an attempt to medicate oneself in response to acute or chronic stressors which may include certain psychiatric disorders.9

Chronic cocaine use typically leads to chronic depression, fatigue, irritability, and impotence or loss of sexual desire. The probability of adverse reactions to cocaine is primarily a function of dosage. Repeated administration within short intervals of time can lead to cumulation of cocaine in plasma12 and increase the risk of medical sequelae. Individual sensitivities to the adverse effects of any drug may vary widely so that a "safe" dose for one person may be a dangerous one for another. In some cases continued high-dose abuse may lead to chronic toxicity characterized by extreme agitation, paranoia, panic anxiety, and ultimately to a psychotic state almost indistinguishable from paranoid schizophrenia. 10 Acute toxic reactions may be characterized by muscle twitching, increased deep tendon reflexes, increased blood pressure and pulse rate, cardiac arrhythmia, and occasionally convulsions and respiratory failure. The clinical management of cocaine toxicity has been described elsewhere.11

A potentially serious but often overlooked consequence of cocaine abuse is its tendency to foster the abuse of other drugs or alcohol. Many cocaine users report heavy use of sedative-hypnotics, alcohol, and in some cases heroin to reduce the stimulant effects of cocaine and relieve the unpleasant "crash." This can lead to overdose reactions and to violent or suicidal behavior.

Cocaine abuse has a potentially devastating impact not only on the individual user, but on society as well. Some abusers admit to being a hazard while driving under the influence of cocaine and report having serious automobile accidents. Also, many hold jobs with significant responsibility for the health and well-being of others. Callers to 800-COCAINE have included airline employees, physicians, nurses, dentists, psychologists, school bus drivers, attorneys, railroad signal operators, automobile mechanics, and prison guards. The negative impact of cocaine abuse is also being felt by American industry in the form of employee absenteeism, impaired work performance, and increased medical costs.13

There is presently no specific treatment for cocaine abuse with demonstrated long-term efficacy. Our clinical experience suggests that some form of supportive counseling, peer-support group, and urine monitoring seems to be essential for treatment success. As in other drug or alcohol dependencies, treatment will be ineffective as long as the patient continues to abuse cocaine and thus the first goal of treatment must be cessation of cocaine use and a strong commitment to maintaining abstinence. Some cocaine abusers are able to do this on an outpatient basis while others require a period of hospitalization because of medical problems, psychosis, acting-out behavior, polydrug addiction, or inability to stop using cocaine on an outpatient basis.

The large volume of calls to our helpline, which now receives as many as 1,000 calls per day from across the US, suggests that cocaine abuse is a massively escalating problem that has been largely hidden from scientific or public analysis. With increased use of cocaine, health consequences have become more prevalent and the personal and social costs have grown. Cocaine is an insidious drug, thought of as harmless by many people, but it often leads to severe consequences for those who abuse it. If cocaine were more readily available and at a lower cost, or if social sanctions and scientific information failed to caution against the potential dangers, dysfunctional cocaine use might become more prevalent.

REFERENCES

I. National Institute on Drug Abuse: National Household Survey on Drug Abuse, i982. Rockville, MD, National Clearinghouse for Drug Abuse Information, 1982.

2. Andersen K: Fighting cocaine's grip: Millions of users, billions of dollars. Time April 1983; 11:22-31.

3. Centers for Disease Control: National surveillance of cocaine use and related health consequences. MMWR 1982; 31:265-275.

4. Van Dyke C, Byck R: Cocaine. Sci Am 1982; 246: 128-141.

5. Helfrich AA, Crowléy TJ, Atkinson CA, et al: A clinical profile of 1 36 cocaine abusers, in Harris LS (ed): Problems of Drug Dependence, 1982. US Dept of Health and Human Services publication (ADM) 83-1264. Government Printing Office, 1983.

6. Wetli CV, Wright RK: Death caused by recreational cocaine use. JAMA 1979; 241:2519-2522.

7. Perez-Reyes M, DiGuiseppi BS, Ondrusek G, et al: Free base cocaine smoking. Clin Pharmacol Ther 1982: 32:459-465.

8. Blum K: Depressive states induced by drugs of abuse: Clinical evidence, theoretical mechanisms, and proposed treatment. Part II. Journal of Psychedelic Drugs 1976; 8:235-262.

9. Khantzian EJ: An extreme case of cocaine dependence and marked improvement with methylphenidate treatment. Am iPsychiatry 1983; 140:784-785.

10. Post RM: Cocaine psychosis: A continuum model Am J Psychiatry 1975; 132:225-231.

11. Gay GR: Clinical management of acute and toxic cocaine poisoning. Ann Emerg Med 1982; 11:562-572.

12. Barnett G, Hawks R, Resnick R: Cocaine pharmacokinetics in humans. / Ethnopharmacol 1981; 3:350-366.

13. Brecher J: Drugs on die job. Newsweek August 22, 1983; 22:52-60.

TABLEI

INCIDENCEOFADVERSE PSYCHOLOGICAL EFFECtS (N=SOO)

TABLE 2

INCIDENCE OFADVERSE PHYSICAL EFFECTS

TABLE 3

MEAN NUMBER OF REPORTED CONSEQUENCES IN EACH CATEGORY IN=SOO)

TABLE 4

INCIDENCE OF SELECTED CONSEQUENCES

10.3928/0048-5713-19841001-09

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