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1. SOURCE

Cocaine is a powerful Central Nervous System stimulant, produced from the leaves of the Erythroxylon Coca Tree. This plant grows mainly in Peru and Bolivia.

2. MODES OF ADMINSTRATION

Cocaine, in the form of its salt Cocain Hydrochloride, can be inhaled, sniffed ("snorted") or injected (under the skin, into the muscle or intravenously).
Cocaine base, in the form of "rock" or "crack" is smoked. It is to be noted that Cocaine Hydrochloride loses¡ 90% of its effect when smoked hence the attempts at extracting pure cocaine base from the salt. This method, known as "free-basing", uses highly inflammable solvents such as ether and chloroform in its process, resulting in serious burns even fatalities, when the mixture ignites or explodes. Recently a safe method, using non-inflammable "bicarbonate", has been discovered. This method results in the production of pure cocaine base in the form of small hard pellets known as "rock" or "crack" (the latter name because of the "crackling" noise made when these pellets are smokes.)

3. APPEARANCE

Cocaine hydrochloride is an odourless white crystalline powder with a bitter numbing taste. It is very soluble in water and alcohol. Street cocaine is often adulterated with other substances to give it its bitter taste and numbing effect.

A common pattern of use is sniffing 20-30milligrams of cocaine at the time ("lines" of cocaine) and to repeat this two or three times per hour for several hours.

Heavy users are known to use up to 10-gramme per-day, but the usual cocaine dependent uses 2-3 grammes 3 to 4 times weekly.

Because of the present world glut of cocaine, street purity varies from 45% to 55%.

4. SIGNS AND SYMPTOMS OF INTOXICATION

Because of its very potent euphoric and energy-increasing properties, cocaine has an extremely high dependence producing liability.

1. Short term effects

A sense of well being, euphoria and postponement of mental and physical fatigue is experienced.

There is a loss of appetite, insomnia and an exaggerated feeling of self-confidence.

Pupils are dilated; a reflex increased and there is a general "racing" of activities.

Heart rate increases together with blood pressure. There is constriction of blood vessels.

There is increased respiration rate. As dosages are increased the patient experiences tremors, vertigo, severe agitation with paranoid features. There are headaches, pallor, sweating and a rapid weak pulse. Convulsions may occur and coma can supervene. A cocaine toxic psychosis is frequently precipitated by the patient going on a "cocaine spree" where he takes large amounts in excess of several grammes over several hours. He may continue such a "spree" for several days.

With the use of "crack" severe aggression and violence are common.

2. Long Term Effects

Nervousness, excitability, agitation and paranoid thinking are common features. There are mood swings, memory disturbances, insomnia and impotence.

There may be confusion and severe exhaustion (because of lack of sleep) and loss of appetite leading to marked loss of weight. Physical complications may occur and can be fatal (e.g. Cardiac arrest; cerebral hemorrhage). Repeated "snorting" often leads to perforation of the nasal septum, due to necrosis of cartilage as a result of the constriction of blood supply.

5. SIGNS AND SYMPTOMS OF COCAINE WITHDRAWAL

True tolerance to the stimulant effect of cocaine has not been demonstrated. Users may consistently use the same dosage to experience the same pleasurable effect. Others frequently increase their dosage (up to 10 grammes daily) presumably in an attempt to experience an intensified and prolonged effect.

After abrupt termination of cocaine use there is exhaustion, severe depression extended but very restless sleep and hunger on awakening. The severe depression which occurs, and which can last for moths, is one of the major features of cocaine withdrawal. It is accompanied by severe craving and obsessional urge to obtain cocaine.

This obsessive craving, led an American colleague to remark recently" The treatment of cocaine dependence, is to keep them away from cocaine".

6. TREATMENT

1. Acute intoxication and overdosage

Treatment is essentially medical emergency intervention to deal with coma, respiratory failure and cardiac arrest.

In cases presenting with severe agitation, paranoid delusions and features of toxic psychosis adequate sedation is required.

2. Cocaine withdrawal syndrome

All the general principles of sedation, anti-convulsants and concurrent treatment apply as discussed under heroin withdrawal management.

A specific feature in the cocaine withdrawal syndrome is the occurrence of severe depression.

Indeed this depression makes suicide the presenting problem in cocaine withdrawal management. Whilst a certain amount of withdrawal depression occurs in the treatment of all drug dependents (including alcohol) it cannot be compared to the intensity, severity and persistence of the depression encountered in cocaine withdrawal.

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