Cocaine Use Disorder:
In Cocaine use disorder, Cocaine is an alkaloid derive from the coca bush, Erythroxylum coca, found in Bolivia and Peru. It isolated by Albert Neimann in 1860 and was used by Karl Koller (a friend of Freud) in 1884 as the ﬁrst effective local anesthetic agent.
Common street name: Crack
Cocaine Use Disorder:
It can administer orally, intranasally, by smoking ( free basing) or parenterally, depending on the preparation available. Cocaine HCl is the commonest form use, follow by the free base alkaloid.
Both intravenous use and free base inhalation produce a ‘rush’ of pleasurable sensations. Cocaine is a central stimulant which inhibits the reuptake of dopamine, along with the reuptake of norepinephrine and serotonin.
In animals, cocaine is the most powerful reinforcer of the drug-taking behaviour. A typical pattern of cocaine use is cocaine ‘runs’ (binges), followed by the cocaine ‘crashes’ (interruption of use). Cocaine is sometimes use in combination with opiates like heroin (‘speed ball’) or at times ampheta mines. Previously uncommon, cocaine misuse appears to be recently a growing problem in the metros of India.
Acute cocaine intoxication is characterise by pupillary dilatation, tachycardia, hypertension, sweating, and nausea or vomiting.
A hypomanic picture with increased psychomotor activity, grandiosity, elation of mood, hypervigilance and increased speech output may be present. Later, judgement is impaired and there is impairment of social or occupational functioning.
Cocaine use produces a very mild physical, but a very strong psychological, dependence. A triphasic withdrawal syndrome usually follows an abrupt discontinuation of chronic cocaine use.
Phases in Cocaine Withdrawal Syndrome:
|I (Crash phase)||i||9 hours to||Agitation, depression, anorexia, craving+++|
|ii||4 days||Fatigue, depression, sleepiness, craving +|
|iii||After discontinuation||Exhaustion, hypersomnia with intermittent awakening, hyperphagia, craving ±|
|II||i||4 to 7 days||Normal sleep, improved mood, craving ±|
|ii||After discontinuation||Anxiety, anergia, anhedonia, craving ++|
|III (Extinction phase)|
After 7-10 days of discontinuation
|No withdrawal symptoms, increased vulnerability to relapse|
The complications of chronic cocaine use include;
- Acute anxiety reaction,
- Uncontrolled compulsive behaviour,
- Psychotic episodes (with persecutory delusions, and tactile and other hallucinations),
- Delirium and delusional disorder.
High doses of cocaine can often lead to;
- Respiratory depression,
- Cardiac arrhythmias,
- Coronary artery occlusion,
- Myocardial infarction,
- Lung damage,
- Gastrointestinal necrosis,
- Foetal anoxia,
- Perforation of nasal septum.
Before starting treatment, it is essential to diagnose (or rule out) co-existent psychiatric and/or physical disorder, and assess the motivation for treatment. Cocaine use disorder is commonly associate with mood disorder, particularly major depression and cyclothymia.
Treatment of Cocaine Overdose:
The treatment of overdose consists of oxygenation, muscle relaxants, and IV thiopentone and/or IV diazepam (for seizures and severe anxiety). IV propranolol, a speciﬁc antagonist of cocaineinduced sympathomimetic effects, can helpful, administere by a specialist. Haloperidol (or pimozide) can be used for the treatment of psychosis, as well as for blocking the cardio-stimulatory effects of cocaine. These must be administered very carefully by an expert specialist.
Treatment of Chronic Cocaine Use:
The management of underlying (or co-existent) psychopathology is probably the most important step in the management of chronic cocaine use. The pharmacological treatment includes the use of bromocriptine (a dopaminergic agonist) and amantadine (an antiparkinsonian) in reducing cocaine craving. Other useful drugs are desipramine, imipramine and trazodone (both for reducing craving and for antidepressant effect). The goal of the treatment is total abstinence from cocaine use. The psychosocial management techniques, such as supportive psychotherapy and contingent behaviour therapy, are useful in the post-withdrawal treatment and in the prevention of relapse.
A Short Textbook of Psychiatry by Niraj Ahuja / Ch 4.