Additional information on cocaine-related disorders
Additional Information on Cocaine-Related Disorders
Associated Features and Disorders
Associated descriptive features and mental disorders.
Cocaine is a short-acting drug that produces rapid and powerful effects on the central nervous system, especially when taken intravenously or smoked. When injected or smoked, cocaine typically produces an instant feeling of well-being, confidence, and euphoria. Dramatic behavioral changes can rapidly develop, especially in association with dependence. Individuals with Cocaine Dependence have been known to spend thousands of dollars for the substance within very short periods of time, resulting in financial catastrophes in which savings or homes have been lost. Individuals may engage in criminal activities to obtain money for cocaine. Erratic behavior, social isolation, and sexual dysfunction are often seen in the context of long-term Cocaine Dependence. Aggressive behavior can result from the effects of cocaine; violence is also associated with the cocaine "trade." Promiscuous sexual behavior either as a result of increased desire or using sex for the purpose of obtaining cocaine (or for money to purchase cocaine) has become a factor in the spread of sexually transmitted diseases, including human immunodeficiency virus (HIV).
Acute Intoxication with high doses of cocaine may be associated with rambling speech, headache, transient ideas of reference, and tinnitus. There may also be paranoid ideation, auditory hallucinations in a clear sensorium, and tactile hallucinations ("coke bugs"), which the user usually recognizes as effects of cocaine. Extreme anger with threats or acting out of aggressive behavior may occur. Mood changes such as depression, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in attention and concentration are common, especially during Cocaine Withdrawal.
Individuals with Cocaine Dependence often have temporary depressive symptoms that meet symptomatic and duration criteria for Major Depressive Disorder (see Substance-Induced Mood Disorder, p. 405). Histories consistent with repeated Panic Attacks, social phobic-like behavior, and generalized anxiety-like syndromes are not uncommon (see Substance-Induced Anxiety Disorder, p. 479). Eating Disorders may also be associated with this substance. One of the most extreme instances of cocaine toxicity is Cocaine-Induced Psychotic Disorder (see p. 338), a disorder with delusions and hallucinations that resembles Schizophrenia, Paranoid Type. Mental disturbances that occur in association with cocaine use usually resolve within hours to days after cessation of use, although they can persist for as long as a month.
Individuals with Cocaine Dependence often develop conditioned responses to cocaine-related stimuli (e.g., craving on seeing any white powder-like substance)-a phenomenon that occurs with most drugs that cause intense psychological changes. These responses probably contribute to relapse, are difficult to extinguish, and typically persist long after detoxification is completed. Cocaine Use Disorders are often associated with other Substance Dependence or Abuse, especially involving alcohol, marijuana, heroin (a speedball), and benzodiazepines, which are often taken to reduce the anxiety and other unpleasant stimulant side effects of cocaine. Cocaine Dependence may be associated with Posttraumatic Stress Disorder, Antisocial Personality Disorder, Attention-Deficit/Hyperactivity Disorder, and Pathological Gambling.
Associated laboratory findings.
Most laboratories test for benzoylecgonine, a metabolite of cocaine that typically remains in the urine for 1-3 days after a single dose and may be present for 7-12 days in those using repeated high doses. Mildly elevated liver function tests can be seen in individuals who inject cocaine or use alcohol excessively in association with cocaine. Hepatitis, sexually transmitted diseases including HIV, and tuberculosis may be associated with cocaine use. Pneumonitis or pneumothorax are occasionally observed on chest X ray. Discontinuation of chronic cocaine use is often associated with EEG changes, alterations in secretion patterns of prolactin, and down-regulation of dopamine receptors.
Associated physical examination findings and general medical conditions.
A wide range of general medical conditions may occur that are specific to the route of administration of cocaine. Persons who use cocaine intranasally ("snort") often develop sinusitis, irritation and bleeding of the nasal mucosa, and a perforated nasal septum. Those who smoke cocaine are at increased risk for respiratory problems (e.g., coughing, bronchitis, and pneumonitis due to irritation and inflammation of the tissues lining the respiratory tract). Persons who inject cocaine have puncture marks and "tracks," most commonly on their forearms, as seen in those with Opioid Dependence. HIV infection is associated with Cocaine Dependence due to the frequent intravenous injections and the increase in promiscuous sexual behavior. Other sexually transmitted diseases, hepatitis, and tuberculosis and other lung infections are also seen. Cocaine Dependence (with any route of administration) is commonly associated with signs of weight loss and malnutrition because of its appetite-suppressing effects. Chest pain may also be a common symptom. Pneumothorax can result from performing Valsalva-like maneuvers that are done to better absorb cocaine that has been inhaled. Myocardial infarction, palpitations and arrhythmias, sudden death from respiratory or cardiac arrest, and stroke have been associated with cocaine use among young and otherwise healthy persons. These incidents are probably caused by the ability of cocaine to increase blood pressure, cause vasoconstriction, or alter the electrical activity of the heart. Seizures have been observed in association with cocaine use. Traumatic injuries due to disputes resulting in violent behavior are common, especially among persons who sell cocaine. Among pregnant females, cocaine use is associated with irregularities in placental blood flow, abruptio placentae, premature labor and delivery, and an increased prevalence of infants with very low birth weights.
Specific Culture, Age, and Gender Features
Cocaine use and its attendant disorders affect all race, socioeconomic, age, and gender groups in the United States. Although the current cocaine epidemic started in the 1970s among more affluent individuals, it has shifted to include lower socioeconomic groups living in large metropolitan areas. Rural areas that previously had been spared the problems associated with illicit drug use have also been affected. Roughly similar rates have been noted across different racial groups. Males are more commonly affected than females, with a male-to-female ratio of 1.5-2.0:1.
Prevalence
As with most drugs, the prevalence of cocaine use in the United States has fluctuated greatly over the years. After a peak in the 1970s, the proportion of the population who have used cocaine in any of its forms gradually decreased until the early 1990s, after which the pace of diminution continued but at a slower rate of decline. A 1996 national survey of drug use reported that 10% of the population had ever used cocaine, with 2% reporting use in the last year and 0.8% reporting use in the last month. Crack use was much less prevalent, with around 2% of the population reporting lifetime use, 0.6% reporting use in the prior year, and 0.3% reporting use in the prior month. Individuals between ages 26 and 34 years reported the highest rates of lifetime use (21% for cocaine and 4% for crack). However, the age group with the highest rate over the past year (5% for cocaine and 1% for crack) was 18- to 25-year-olds. It should be noted that because these surveys measured patterns of use rather than disorders, it is not known how many of those in the survey who used cocaine had symptoms that met the criteria for Dependence or Abuse.
The lifetime rate of Cocaine Abuse or Dependence was reported to be almost 2% in a 1992 community survey conducted in the United States, with a prevalence in the prior 12 months of about 0.2%.
Course
As with amphetamines, Cocaine Dependence is associated with a variety of patterns of self-administration, including episodic or daily (or almost daily) use. In the episodic pattern, the cocaine use tends to be separated by 2 or more days of nonuse (e.g., intense use over a weekend or on one or more weekdays). "Binges" are a form of episodic use that typically involve continuous high-dose use over a period of hours or days and are often associated with Dependence. Binges usually terminate only when cocaine supplies are depleted. Chronic daily use may involve high or low doses and may occur throughout the day or be restricted to only a few hours. In chronic daily use, there are generally no wide fluctuations in dose on successive days, but there is often an increase in dose over time.
Cocaine smoking and intravenous use tend to be particularly associated with a rapid progression from use to abuse or dependence, often occurring over weeks to months. Intranasal use is associated with a more gradual progression, usually occurring over months to years. Dependence is commonly associated with a progressive tolerance to the desirable effects of cocaine leading to increasing doses. With continuing use, there is a diminution of pleasurable effects due to tolerance and an increase in dysphoric effects. Few data are available on the long-term course of Cocaine Use Disorders.
Differential Diagnosis
For a general discussion of the differential diagnosis of Substance-Related Disorders, see p. 207. Cocaine-Induced Disorders may be characterized by symptoms (e.g., depressed mood) that resemble primary mental disorders (e.g., Major Depressive Disorder versus Cocaine-Induced Mood Disorder, With Depressive Features, With Onset During Withdrawal). See p. 210 for a discussion of this differential diagnosis. The marked mental disturbances that can result from the effects of cocaine should be distinguished from the symptoms of Schizophrenia, Paranoid Type, Bipolar and other Mood Disorders, Generalized Anxiety Disorder, and Panic Disorder.
Amphetamine Intoxication and Phencyclidine Intoxication may cause a similar clinical picture and can often only be distinguished from Cocaine Intoxication by the presence of cocaine metabolites in a urine specimen or cocaine in plasma. Cocaine Intoxication and Cocaine Withdrawal are distinguished from the other Cocaine-Induced Disorders (e.g., Cocaine-Induced Anxiety Disorder, With Onset During Intoxication) because the symptoms in these latter disorders are in excess of those usually associated with Cocaine Intoxication or Cocaine Withdrawal and are severe enough to warrant independent clinical attention.