Wednesday, August 19, 2015

Pregnancy and Substance Abuse | Substance Abuse Problems

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Substance Abuse Problems

Table of Contents

1. PREGNANCY AND SUBSTANCE ABUSE
2. Infant of a substance-abusing mother
3. Neonatal abstinence syndrome
4. Alcohol and pregnancy
5. HEROIN
6. Opiate withdrawal
7. Opioid intoxication
8. Heroin overdose
9. Methadone overdose
10. COCAINE
11. Substance use - cocaine
12. Cocaine withdrawal
13. Cocaine intoxication
14. How Is Cocaine Used?
15. DRUGS OF ABUSE: COCAINE
16. What is cocaine?
17. What is the scope of cocaine use in the United States?
18. How is cocaine abused?
19. How does cocaine produce its effects?
20. What are the short-term effects of cocaine use?
21. What are the long-term effects of cocaine use?
22. Are cocaine abusers at risk for contracting HIV/AIDS and Hepatitis B and C?
23. What are the effects of maternal cocaine use?
24. What treatments are effective for cocaine abusers?
25. Where can I get further information about cocaine?

01.- PREGNANCY AND SUBSTANCE ABUSE

When you are pregnant, you are not just "eating for two." You also breathe and drink for two, so it is important to carefully consider what you give to your baby. If you smoke, use alcohol or take illegal drugs, so does your unborn baby.
First, don't smoke. Smoking during pregnancy passes nicotine and cancer-causing drugs to your baby. Smoke also keeps your baby from getting nourishment and raises the risk of stillbirth or premature birth. Don't drink alcohol. There is no known safe amount of alcohol a woman can drink while pregnant. Alcohol can cause life-long physical and behavioral problems in children, including fetal alcohol syndrome. Don't use illegal drugs. Using illegal drugs may cause underweight babies, birth defects or withdrawal symptoms after birth.
If you are pregnant and you smoke, drink alcohol or do drugs, get help. Your health care provider can recommend programs to help you quit. You and your baby will be better off.
Dept. of Health and Human Services Office on Women's Health

02.- Infant of a substance-abusing mother

Maternal substance abuse may consist of any combination of drug, chemical, alcohol, and/or tobacco use during the pregnancy.
While in the womb, a fetus grows and develops due to nourishment from the mother via the placenta. However, along with nutrients, any toxins in the mother’s system may be delivered to the fetus. These toxins may cause damage to the developing fetal organs.
WHAT CAUSES SUBSTANCE ABUSE DURING PREGNANCY?
Unfortunately, many women use drugs and alcohol for recreation before they know they are pregnant. Others continue to use drugs while pregnant as a result of addictions or psychiatric problems.
WHAT ARE THE SIGNS AND SYMPTOMS SEEN IN AN INFANT OF A SUBSTANCE-ABUSING MOTHER?
Babies born to substance-abusing mothers may have short- or long-term effects. Short-term withdrawal symptoms vary from mild fussiness to significant issues with irritability, feeding, jitteriness, and diarrhea. Symptoms are different for different substances. The diagnosis for babies with clinical findings of withdrawal may be confirmed with results from drug testing the baby’s urine or stool.
More significant long-term developmental problems may be seen in babies who are born with growth failure or various organ problems. Infants born to mothers who drink alcohol, even in modest amounts, may be born with the fetal alcohol syndrome, which consists of growth problems, unusual facial features, and intellectual disability. Other drugs may cause malformations of the heart, brain, bowel, or kidneys that can have significant impact on long-term development and outcome. Babies who have been exposed to drugs, alcohol and/or cigarettes are at higher risk for SIDS (sudden infant death syndrome).
WHAT IS THE TREATMENT FOR AN INFANT OF A SUBSTANCE-ABUSING MOTHER?
Depending on the drugs the mother used, a baby's treatment may involve limiting stimulation, such as noise and bright lights, maximizing "TLC" (tender loving care), and possibly using medication. In the case of babies whose mothers used narcotics, a narcotic is usually given to the baby in a small dose that can be carefully adjusted and then slowly "weaned" or decreased over days to weeks. Sedatives are sometimes used as well. Infants with organ damage or neurodevelopmental issues may need medical or surgical therapy and long-term developmental assistance.

Alternative Names

IUDE; Intrauterine drug exposure; Maternal drug abuse

03.- Neonatal abstinence syndrome

Neonatal abstinence syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while in the mother’s womb.

Causes

Neonatal abstinence syndrome occurs because a pregnant woman takes opiate or narcotic drugs such as heroin, codeine, oxycodone (Oxycontin) methadone or buprenorphine.
These and other substances pass through the placenta that connects the baby to its mother in the womb. The baby becomes addicted along with the mother.
At birth, the baby is still dependent on the drug. Because the baby is no longer getting the drug after birth, symptoms of withdrawal may occur.
Alcohol and other drugs use during pregnancy can also cause problems in the baby.
Babies of mothers who use other addictive drugs (nicotine, amphetamines, barbiturates, cocaine, marijuana,) may have long-term problems. However, there is no clear evidence of a neonatal abstinence syndrome for these drugs.

Symptoms

The symptoms of neonatal abstinence syndrome depend on:
• The type of drug the mother used
• How the body breaks down the drug
• How much of the drug she was taking
• How long she used the drug
• Whether the baby was born full-term or early (premature)
Symptoms often begin within 1 - 3 days after birth, but may take up to a week to appear. Symptoms may include:
• Blotchy skin coloring (mottling)
• Diarrhea
• Excessive crying or high-pitched crying
• Excessive sucking
• Fever
• Hyperactive reflexes
• Increased muscle tone
• Irritability
• Poor feeding
• Rapid breathing
• Seizures
• Sleep problems
• Slow weight gain
• Stuffy nose, sneezing
• Sweating
• Trembling (tremors)
• Vomiting

Exams and Tests

Many other conditions can produce the same symptoms as neonatal abstinence syndrome. To help make a diagnosis, the doctor will ask questions about the mother's drug use. The mother may be asked about which drugs she took during pregnancy, and when she last took them.
Tests that may be done to diagnose withdrawal in a newborn include:
• Neonatal abstinence syndrome scoring system, which assigns points based on each symptom and its severity. The infant's score can help determine treatment.
• Toxicology screen of first bowel movements (meconium)
• Urine test (urinalysis)

Treatment

Treatment depends on:
• The drug involved
• The infant's overall health
• Whether the baby was born full-term or premature
The health care team will watch the newborn carefully for signs of withdrawal, feeding problems, and weight gain. Babies who vomit or who are very dehydrated may need to get fluids through a vein (IV).
Infants with neonatal abstinence syndrome are often fussy and hard to calm. Tips to calm the infant down include:
• Gently rocking the child
• Reducing noise and lights
• Swaddling the baby in a blanket
Some babies with severe symptoms need medicines such as methadone and morphine to treat withdrawal symptoms.
The goal of treatment is to prescribe the infant a drug similar to the one the mother used during pregnancy and slowly decrease the dose over time. This helps wean the baby off the drug and relieves some withdrawal symptoms. Breastfeeding may also be helpful.
Babies with this condition often have poor feeding or slow growth. These babies may need:
• A higher-calorie formula that provides greater nutrition
• Smaller portions given more often

Outlook (Prognosis)

Treatment helps relieve symptoms of withdrawal.

Possible Complications

Drug and alcohol use during pregnancy can lead to many health problems in the baby besides NAS. These may include:
• Birth defects
• Low birth weight
• Premature birth
• Small head circumference
• Sudden infant death syndrome (SIDS)
• Problems with development and behavior
Neonatal abstinence syndrome can last from 1 week to 6 months.

When to Contact a Medical Professional

Make sure your doctor or nurse knows about all the drugs you take during pregnancy.
Call your doctor or nurse if your baby has symptoms of neonatal abstinence syndrome.

Prevention

Discuss all medications, and alcohol and tobacco use with your health care provider. If you are using drugs, including alcohol or tobacco, ask your health care provider for help with stopping as soon as possible. If you are already pregnant, talk to your health care provider about the best way to stop using and keep you and the baby safe.

Alternative Names

NAS

References

Wong S, Ordean A, Kahan M; Maternal Fetal Medicine Committee; Family Physicians Advisory Committee; Medico-Legal Committee; Society of Obstetricians and Gynaecologists of Canada. Substance use in pregnancy.J Obstet Gynaecol Can.
Jansson LM, Velez M. Neonatal abstinence syndrome.Curr Opin Pediatr.
Bio LL, Siu A, Poon CY. Update on the pharmacologic management of neonatal abstinence syndrome.J Perinatol.
McQueen KA, Murphy-Oikonen J, Gerlach K, Montelpare W. The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Adv Neonatal Care.
Bencke M, Smith VC, Committee on Substance Abuse, Committee on Fetus and Newborn. American Academy of Pediatrics. Prenatal substance abuse: short- and long-term effects on the exposed fetus (technical report).Pediatrics.

04.- Alcohol and pregnancy

Pregnant women are strongly urged not to drink alcohol during pregnancy.
Drinking alcohol while pregnant has been shown to cause harm to a baby as it develops in the womb. Alcohol used during pregnancy may also lead to long-term medical problems and birth defects.

Information

When a pregnant woman drinks alcohol, the alcohol travels through her blood and into the baby's blood, tissues, and organs. Alcohol breaks down much more slowly in the baby's body than in an adult. That means the baby's blood alcohol level remains increased longer than the mother's. This can harm the baby and can sometimes lead to lifelong damage.
DANGERS OF ALCOHOL DURING PREGNANCY
Drinking a lot of alcohol during pregnancy can lead to a group of defects in the baby known as fetal alcohol syndrome. Symptoms can include:
• Behavior and attention problems
• Heart defects
• Changes in the shape of the face
• Poor growth before and after birth
• Poor muscle tone and problems with movement and balance
• Problems with thinking and speech
• Learning problems
These medical problems are lifelong and can range from mild to severe.
Complications seen in the infant may include:
• Cerebral palsy
• Premature delivery
• Miscarriage or stillbirth
HOW MUCH ALCOHOL IS SAFE?
There is no known "safe" amount of alcohol use during pregnancy. Alcohol use appears to be the most harmful during the first 3 months of pregnancy; however, drinking alcohol anytime during pregnancy can be harmful.
Alcohol includes beer, wine, wine coolers, and liquor.
One drink is defined as:
• 12 oz of beer
• 5 oz of wine
• 1.5 oz of liquor
How much you drink is just as important as how often you drink.
• Even if you don't drink often, drinking a large amount at one time can harm the baby.
• Binge drinking (5 or more drinks on one sitting) greatly increases a baby's risk of alcohol-related damage.
• Drinking moderate amounts of alcohol when pregnant may lead to miscarriage.
• Heavy drinkers (those who drink more than 2 alcoholic beverages a day) are at greater risk of giving birth to a child with fetal alcohol syndrome.
• The more you drink, the more you raise your baby's risk for harm.
DO NOT DRINK DURING PREGNANCY
Women who are pregnant or who are trying to get pregnant should avoid drinking any amount of alcohol. The only way to prevent fetal alcohol syndrome is to not drink alcohol during pregnancy.
If you did not know you were pregnant and drank alcohol, stop drinking as soon as you find out. The sooner you stop drinking alcohol, the healthier your baby will be.
Choose non-alcoholic versions of beverages you like.
If you cannot control your drinking, avoid being around other people who are using alcohol.
Pregnant women with alcoholism should join an alcohol abuse rehabilitation program. They should also be followed closely by a health care provider.
The following organizations may be of help:
• National Council on Alcoholism and Drug Dependency -- www.ncadd.org
• Substance Abuse Treatment Facility Locator -- 1-800-662-4357 (findtreatment.samhsa.gov/TreatmentLocator/)

Alternative Names

Drinking alcohol during pregnancy

References

Bandstra ES, Accornero VH. Infants of substance-abusing mothers. In: Martin RJ, Fanaroff AA, Walsh MC, eds.Fanaroff and Martin's Neonatal-Perinatal Medicine
Wallen LD, Gleason CA. Perinatal substance abuse. In: Gleason CA, Devaskar SU.Avery's Diseases of the Newborn
Bertrand J, Floyd LL, Weber MK. Guidelines for identifying and referring persons with fetal alcohol syndrome.MMWR Recomm Rep
Cunnigham FG, Leveno KL, Bloom SL, et al. Teratology and medications that affect the fetus. In: Cunnigham FG, Leveno KL, Bloom SL, et al, eds.Williams Obstetrics
Committee on Health Care for Underserved Women. Committee Opinion No. 496: At-risk drinking and alcohol dependence: Obstetric andgynecologic implications. Obstet Gynecol

05.- HEROIN

Also called: Black tar, H, Horse, Junk, Skag, Smack

Heroin is a white or brown powder or a black, sticky goo. It's made from morphine, a natural substance in the seedpod of the Asian poppy plant. It can be mixed with water and injected with a needle. Heroin can also be smoked or snorted up the nose. All of these ways of taking heroin send it to the brain very quickly. This makes it very addictive.
Major health problems from heroin include miscarriages, heart infections, and death from overdose. People who inject the drug also risk getting infectious diseases, including HIV/AIDS and hepatitis.
Regular use of heroin can lead to tolerance. This means users need more and more drug to have the same effect. At higher doses over time, the body becomes dependent on heroin. If dependent users stop heroin, they have withdrawal symptoms. These symptoms include restlessness, muscle and bone pain, diarrhea and vomiting, and cold flashes with goose bumps.
NIH: National Institute on Drug Abuse

06.- Opiate withdrawal

Opiate withdrawal refers to the wide range of symptoms that occur after stopping or dramatically reducing opiate drugs after heavy and prolonged use (several weeks or more).
Opiate drugs include heroin, morphine, codeine, Oxycontin, Dilaudid, methadone, and others.

Causes

About 9% of the population is believed to misuse opiates over the course of their lifetime, including illegal drugs like heroin and prescription pain medications such as Oxycontin.
These drugs can cause physical dependence. This means that a person relies on the drug to prevent symptoms of withdrawal. Over time, greater amounts of the drug become necessary to produce the same effect (drug tolerance).
The time it takes to become physically dependent varies with each individual.
When the person stops taking the drugs, the body needs time to recover, and withdrawal symptoms result. Withdrawal from opiates can occur whenever any chronic use is discontinued or reduced.
Some people even withdraw from opiates after being given such drugs for pain while in the hospital without realizing what is happening to them. They think they have the flu, and because they don't know that opiates would fix the problem, they don't crave the drugs.

Symptoms

Early symptoms of withdrawal include:
• Agitation
• Anxiety
• Muscle aches
• Increased tearing
• Insomnia
• Runny nose
• Sweating
• Yawning
Late symptoms of withdrawal include:
• Abdominal cramping
• Diarrhea
• Dilated pupils
• Goose bumps
• Nausea
• Vomiting
Opioid withdrawal reactions are very uncomfortable but are not life-threatening. Symptoms usually start within 12 hours of last heroin usage and within 30 hours of last methadone exposure.

Exams and Tests

Your doctor can often diagnose opiate withdrawal after performing a physical exam and asking questions about your medical history and drug use.
Urine or blood tests to screen for drugs can confirm opiate use.
Other testing will depend on the physician's concern for additional medical problems. These test may include:
• Blood chemistries and liver function tests such as CHEM-20
• CBC (complete blood count, measures red and white blood cells, and platelets, which help blood to clot)

Treatment

Treatment involves supportive care and medications. The most commonly used medication, clonidine, primarily reduces anxiety, agitation, muscle aches, sweating, runny nose, and cramping.
Other medications can treat vomiting and diarrhea.
Buprenorphine (Subutex) has been shown to work better than other medications for treating withdrawal from opiates, and it can shorten the length of detoxification (detox). It may also be used for long-term maintenance, like methadone.
Persons withdrawing from methadone may be placed on long-term maintenance. This involves slowly decreasing the dosage of methadone over time. This helps reduce the intensity of withdrawal symptoms.
Some drug treatment programs have widely advertised treatments for opiate withdrawal called detox under anesthesia or rapid opiate detox. Such programs involve placing you under anesthesia and injecting large doses of opiate-blocking drugs, with hopes that this will speed up the return the body to normal opioid system function.
There is no evidence that these programs actually reduce the time spent in withdrawal. In some cases, they may reduce the intensity of symptoms. However, there have been several deaths associated with the procedures, particularly when it is done outside a hospital.
Because opiate withdrawal produces vomiting, and vomiting during anesthesia significantly increases death risk, many specialists think the risks of this procedure significantly outweigh the potential (and unproven) benefits.

Support Groups

Support groups, such as Narcotics Anonymous and SMART Recovery, can be enormously helpful to persons addicted to opiates.

Outlook (Prognosis)

Withdrawal from opiates is painful, but usually not life-threatening.

Possible Complications

Complications include vomiting and breathing in stomach contents into the lungs. This is called aspiration, and can cause lung infection. Vomiting and diarrhea can cause dehydration and body chemical and mineral (electrolyte) disturbances.
The biggest complication is return to drug use. Most opiate overdose deaths occur in persons who have just withdrawn or detoxed. Because withdrawal reduces the person's tolerance to the drug, those who have just gone through withdrawal can overdose on a much smaller dose than they used to take.
Longer-term treatment is recommended for most persons following withdrawal. This can include self-help groups, like Narcotics Anonymous or SMART Recovery, outpatient counseling, intensive outpatient treatment (day hospitalization), or inpatient treatment.
Those withdrawing from opiates should be checked for depression and other mental illnesses. Appropriate treatment of such disorders can reduce the risk of relapse. Antidepressant medications should NOT be withheld under the assumption that the depression is only related to withdrawal, and not a pre-existing condition.
Treatment goals should be discussed with the person and recommendations for care made accordingly. If a person continues to withdraw repeatedly, methadone maintenance is strongly recommended.

When to Contact a Medical Professional

Call your doctor if you are using or withdrawing from opiates.

Alternative Names

Withdrawal from opioids; Dopesickness

References

Doyon S. Opiods. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds.Emergency Medicine: A Comprehensive Study Guide.
Plasencia AMA, Furbee RB. Opioids. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds.Harwood-Nuss' Clinical Practice of Emergency Medicine.

07.- Opioid intoxication

Opioid intoxication is a condition caused by use of opioid-based drugs, which include morphine, heroin, oxycodone, and the synthetic opioid narcotics. Prescription opioids are used to treat pain. Intoxication or overdose can lead to a loss of alertness, or unconsciousness.

Causes

In the United States, the most commonly abused opioids are heroin and methadone.

Symptoms

Symptoms depend on how much of the drug is taken.
Symptoms of opioid intoxication can include:
• Breathing problems - breathing may stop
• Extreme sleepiness or loss of alertness
• Small pupils
With repeated use of opioids, fibrotic lung disease may develop as a result of the talc, cornstarch or cellulose which is used to dilute or bind the opioid. The long-term effect may be reduced lung function and shortness of breath
Individuals who inject the drug will often develop abscesses at the injection site. These may be large enough to require incision and drainage, often in the operating room.

Exams and Tests

Testing will depend on the physician’s concern for additional medical problems.
• Blood chemistries and liver function tests such as CHEM-20
• CBC (complete blood count) measures red and white blood cells, and platelets, which help blood to clot
• Toxicology (poison) screening
A chest x-ray may be ordered to look for pneumonia, as well as an EKG (electrocardiogram, or heart tracing) looking for evidence of heart rhythm disturbances or heart attack.

Treatment

The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. The patient may receive:
• Breathing support, including supplemental oxygen
• Tube placed through the mouth into the lungs (endotracheal intubation)
• Medicine called naloxone, which helps block the effect of the drug on the central nervous system (such medicine is called a narcotic antagonist)
Since the effect of the narcotic antagonist is short-lived in most cases, the health care team will monitor the patient for 4 to 6 hours in the emergency department, although the optimal observation time after opioid intoxication has not been defined for most opioids. Those with moderate-to-severe intoxications will likely be admitted to the hospital for 24 to 48 hours.
A psychiatric evaluation is needed for all exposures with suicidal intent.

Alternative Names

Intoxication - opioids

References

Doyon S. Opiods. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds.Emergency Medicine: A Comprehensive Study Guide
Plasencia AMA, Furbee RB. Opioids. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds.Harwood-Nuss' Clinical Practice of Emergency Medicine

08.- Heroin overdose

Heroin is an illegal street drug that is very addictive. This article discusses overdose due to heroin. An overdose is when you take more than the normal or recommended amount of something, usually a drug. An overdose may result in serious, harmful symptoms or death.
In any given year, approximately 0.6% of 15 to 64 year olds in the United States use opiates (heroin/opium). If a user becomes dependent, then they are between 6 and 20 times more likely to die than someone in the general population.
This is for information only, and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.

Poisonous Ingredient

• Heroin

Where Found

Heroin is made from morphine. Morphine is a powerful drug, and it naturally occurs in the seedpods of Asian (opium) poppy plants. Street names for heroin include "junk," "smack," and "skag."
See also: Morphine overdose

Symptoms

Airways and lungs:
• No breathing
• Shallow breathing
• Slow and difficult breathing
Eyes, ears, nose, and throat:
• Dry mouth
• Extremely small pupils, sometimes as small as the head of a pin ("pinpoint pupils")
• Tongue discoloration
Heart and blood:
• Low blood pressure
• Weak pulse
Skin:
• Bluish-colored nails and lips
Stomach and intestines:
• Constipation
• Spasms of the stomach and intestinal tract
Nervous system:
• Coma
• Delirium
• Disorientation
• Drowsiness
• Muscle spasticity

Home Care

Seek immediate medical help. Do NOT make a person throw up unless told to do so by poison control or a health care professional.

Before Calling Emergency

Determine the following information:
• The patient's age, weight, and condition
• The name of the product (ingredients and strengths if known)

Poison Control

The National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.
This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.
See: Poison control center - emergency number

What to Expect at the Emergency Room

The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. The patient may receive:
• Blood and urine tests
• Breathing support, if needed
• Chest x-ray
• EKG (electrocardiogram, or heart tracing)
• Fluids through a vein (by IV)
• Medications to treat symptoms, including a narcotic antagonist, to counteract the effects of the heroin

Outlook (Prognosis)

If an antidote can be given, recovery from an acute overdose occurs within 24 - 48 hours. Heroin is often mixed with other substances (adulterants), which can cause additional symptoms and organ damage. Hospitalization may be necessary.
Because heroin is commonly injected into a vein, there are health concerns related to sharing contaminated needles. Sharing contaminated needles can lead to hepatitis, HIV infection, and AIDS.

Alternative Names

Acetomorphine overdose; Diacetylmorphine overdose

References

Doyon S. Opioids. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds.Emergency Medicine: A Comprehensive Study Guide
. National Clearinghouse on Alcohol and Drug Information. October 1997. NIH Publications No. 05-4165. Revised May 2005.National Institute on Drug Abuse Research Report Series: Heroin Abuse and Addiction
Bardsley CH. Opioids. In: Marx JA, ed.Rosen's Emergency Medicine - Concepts and Clinical Practice

09.- Methadone overdose

Methadone is a very strong painkiller. It is also used to treat heroin addiction. Methadone overdose occurs when someone accidentally or intentionally takes more than the normal or recommended amount of this medication.
Methadone overdose can also occur if a person takes methadone with certain painkillers, such as oxycontin, hydrocodone (Vicodin), or morphine.
This is for information only and not for use in the treatment or management of an actual poison exposure. If you have an exposure, you should call your local emergency number (such as 911) or the National Poison Control Center at 1-800-222-1222.

Poisonous Ingredient

• Methadone

Where Found

• Dolophine
• Eptadone
• Methadone
• Methadose
• Physeptone
Note: This list may not include all sources of methadone, and includes preparations that are taken by mouth (orally) or injected into veins, muscle, or under the skin.

Symptoms

Eyes, ears, nose, and throat:
• Pinpoint pupils
Gastrointestinal:
• Constipation
• Nausea
• Spasms of the stomach or intestines
• Vomiting
Heart and blood:
• Low blood pressure
• Weak pulse
Lungs:
• Breathing difficulty
• Breathing - slow and labored
• Breathing - shallow
• No breathing
Nervous system:
• Coma (decreased level of consciousness and lack of responsiveness)
• Disorientation
• Dizziness
• Drowsiness
• Fatigue
• Muscle twitches (spasticity)
• Weakness
Skin:
• Blue fingernails and lips
• Cold, clammy skin

Home Care

Seek immediate medical help. Do NOT make a person throw up unless told to do so by Poison Control or a health care professional.

Before Calling Emergency

Determine the following information:
• Patient's age, weight, and condition
• Name of the product (ingredients and strengths, if known)
• Time it was swallowed
• Amount swallowed

Poison Control

The National Poison Control Center (1-800-222-1222) can be called from anywhere in the United States. This national hotline number will let you talk to experts in poisoning. They will give you further instructions.
This is a free and confidential service. All local poison control centers in the United States use this national number. You should call if you have any questions about poisoning or poison prevention. It does NOT need to be an emergency. You can call for any reason, 24 hours a day, 7 days a week.
Take the container with you to the hospital, if possible.
See: Poison control center- emergency number

What to Expect at the Emergency Room

The health care provider will measure and monitor your vital signs, including temperature, pulse, breathing rate, and blood pressure. Symptoms will be treated as appropriate. You may receive:
• Activated charcoal
• Breathing support, including tube through the mouth and breathing machine (ventilator)
• Chest x-ray
• EKG (heart tracing)
• Fluids through a vein (by IV)
• Laxative
• Medicine (narcotic antagonist) to reverse the effect of the medication
• Tube from the mouth into the stomach to empty the stomach (gastric lavage)

Outlook (Prognosis)

How well you do depends on the amount of poison swallowed and how quickly treatment is received. The faster you get medical help, the better chance for recovery.
If an antidote can be given, recovery from an acute overdose begins immediately. However, since methadone's effects can last for about a day, the patient is usually kept in the hospital overnight and may receive several doses of the antidote.
Persons who took a large overdose may not be breathing (respiratory arrest) and may have seizures if they do not get this medicine quickly. Complications, such as pneumonia, muscle damage from lying on a hard surface for a prolonged period of time, or brain damage from lack of oxygen, may result in permanent disability.

References

Yip L, Megarbane B, Borron SW. Opioids. In: Shannon MW, Borron SW, Burns MJ, eds.Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose
Bardsley CH. Opioids. In: Marx JA, Hockberger RS, Walls RM, et al., eds.Rosen's Emergency Medicine: Concepts and Clinical Practice

10.- COCAINE

Also called: Blow, C, Coca, Coke, Crack, Flake, Snow

Cocaine is a white powder. It can be snorted up the nose or mixed with water and injected with a needle. Cocaine can also be made into small white rocks, called crack. Crack is smoked in a small glass pipe.
Cocaine speeds up your whole body. You may feel full of energy, happy, and excited. But then your mood can change. You can become angry, nervous, and afraid that someone's out to get you. You might do things that make no sense. After the "high" of the cocaine wears off, you can "crash" and feel tired and sad for days. You also get a strong craving to take the drug again to try to feel better.
No matter how cocaine is taken, it is dangerous. Some of the most common serious problems include heart attack and stroke. You are also at risk for HIV/AIDS and hepatitis, from sharing needles or having unsafe sex. Cocaine is more dangerous when combined with other drugs or alcohol.
It is easy to lose control over cocaine use and become addicted. Then, even if you get treatment, it can be hard to stay off the drug. People who stopped using cocaine can still feel strong cravings for the drug, sometimes even years later.
NIH: National Institute on Drug Abuse

11.- Substance use - cocaine

Cocaine is made from the leaves of the coca plant. Cocaine comes as a white powder, which can be dissolved in water. It is available as a powder or liquid.
As a street drug, cocaine can be taken in different ways:
• Inhaling it through the nose (snorting)
• Dissolving it in water and injecting it into a vein (shooting up)
• Mixing with heroin and injecting into a vein (speedballing)
• Smoking it (this type of cocaine is called freebase or crack)
Street names for cocaine include blow, bump, C, candy, Charlie, coca, coke, flake, rock, snow, speedball, toot.

Cocaine's Effects on Your Brain

Cocaine is a strong stimulant. They make the messages between your brain and body move faster. As a result, you are more alert and physically active.
Cocaine also causes the brain to release dopamine. Dopamine is a chemical that is involved with mood and thinking. It is also called the feel-good brain chemical. Using cocaine may cause pleasurable effects such as:
• Joy (euphoria, or a "flash" or "rush") and less inhibition, similar to being drunk
• Feeling as if your thinking is extremely clear
• Feeling more in control, self-confident
• Wanting to be with and talk to people (more sociable)
• Increased energy
How fast you feel the effects of cocaine depends on how it is used:
• Smoking: Effects start right away and are intense and last 5 to 10 minutes.
• Injecting into a vein: Effects start within 15 to 30 seconds and last 20 to 60 minutes.
• Snorting: Effects start in 3 to 5 minutes, are less intense than smoking or injecting, and last 15 to 30 minutes.

Harmful Effects of Cocaine

Cocaine can harm the body in many ways and lead to health problems such as:
• Appetite decrease and weight loss
• Heart problems, such as fast heart rate, irregular heartbeat, increased blood pressure
• High body temperature and skin flushing
• Memory loss and problems thinking clearly
• Mood and emotional problems, such as aggressive or violent behavior
• Restlessness and tremors
• Sleep problems
Persons who use cocaine have a high chance of getting HIV and hepatitis B and C due to activities such as sharing used needles with someone who is already infected with one of these diseases. Other risky behaviors that can be linked to drug use, such as having unsafe sex, can also increase the chance of becoming infected with one of these diseases.
Using too much cocaine can cause an overdose. This is known as cocaine intoxication. Symptoms can include enlarged pupils of the eye, sweating, tremors, confusion, and sudden death.

Cocaine Can Be Addictive

Persons who use cocaine can get addicted to it. This means their mind is dependent on cocaine. They are not able to control their use of it and they need (crave) it to get through daily life.
Addiction can lead to tolerance. Tolerance means you need more and more cocaine to get the same high feeling. If you try to stop using the drug, you may have reactions. These are called withdrawal symptoms and may include:
• Strong cravings for the drug
• Mood swings that can make a person feel depressed, then agitated or anxious
• Not able to concentrate
• Physical reactions such as headaches, aches and pains, increased appetite, not sleeping well

Treatment Options

Treatment begins with recognizing there is problem. Once you decide you want to do something about your cocaine use, the next step is to get help and support.
Treatment programs use behavior modification techniques through counseling (talk therapy). The techniques get you to understand your behaviors and why you use cocaine. Involving family and friends during counseling can help support you and keep you from going back to using (relapsing) the drug.
If you have severe withdrawal symptoms, you may need to stay at a residential treatment program. There, your health and safety can be monitored as you recover.
At this time, there is no medicine that can help reduce the use of cocaine by blocking its effects, although scientists are researching such medicines.

Your Ongoing Recovery

As you recover, focus on the following to help prevent relapse:
• Keep going to your treatment sessions.
• Find new activities and goals to replace the activities that involved your drug use.
• Spend more time with family and friends you lost touch with while you were using. Consider not seeing friends who are still drug users.
• Exercise and eat healthy foods. Taking care of your body helps it heal from the harmful effects of cocaine use. You will feel better, too.
• Avoid triggers. These can be people you used cocaine with. Triggers can also be places, things, or emotions that can make you want to use cocaine again.

Resources

• The Partnership at Drugfree.org - www.drugfree.org
• LifeRing - www.lifering.org
• SMART Recovery - www.smartrecovery.org
Your workplace employee assistance program (EAP) is also a good resource.

When to Call the Doctor

Call for an appointment with your health care provider if you or someone you know is addicted to cocaine and needs help to stop using. Also call if you are having withdrawal symptoms that concern you.

Alternate Names

Substance abuse - cocaine; Drug abuse - cocaine; Drug use - cocaine

References

Kowalchuk A, Reed BC. Drug abuse. Rakel RE, Rakel DP, eds.Textbook of Family Medicine
National Institute on Drug Abuse. Drugs, brains, and behavior: the science of addiction. Revised August 2010. http://www.drugabuse.gov/publications/science-addiction.Accessed on April 29, 2014.
National Institute on Drug Abuse. Research report series: Cocaine. Revised September 2010. http://www.drugabuse.gov/sites/default/files/cocainerrs.pdf.Accessed on April 29, 2014.

12.- Cocaine withdrawal

Cocaine withdrawal occurs when a heavy cocaine user cuts down or quits taking the drug. Complete abstinence and a serum drug level of zero are not required.

Causes

Cocaine produces a sense of extreme joy by causing the brain to release higher than normal amounts of some biochemicals. However, cocaine's effects on other parts of the body can be very serious or even deadly.
When cocaine use is stopped or when a binge ends, a crash follows almost immediately. This crash is accompanied by a strong craving for more cocaine. Additional symptoms include fatigue, lack of pleasure, anxiety, irritability, sleepiness, and sometimes agitation or extreme suspicion or paranoia.
Cocaine withdrawal often has no visible physical symptoms like the vomiting and shaking that accompanies the withdrawal from heroin or alcohol.
In the past, people underestimated the how addictive cocaine can be. However, cocaine is addictive when addiction is defined as a desire for more of the drug, despite negative consequences.
The level of craving, irritability, delayed depression, and other symptoms produced by cocaine withdrawal rivals or exceeds that felt with other withdrawal syndromes.
See also:
• Drug abuse
• Drug abuse and dependence
• Stroke secondary to cocaine

Symptoms

Primary symptoms may include:
• Agitation and restless behavior
• Depressed mood
• Fatigue
• Generalized malaise
• Increased appetite
• Vivid and unpleasant dreams
• Slowing of activity
The craving and depression can last for months following cessation of long-term heavy use (particularly daily). Withdrawal symptoms may also be associated with suicidal thoughts in some people.
During withdrawal, there can be powerful, intense cravings for cocaine. However, the "high" associated with ongoing use becomes less and less pleasant, and can produce fear and extreme suspicion rather than joy (euphoria). Just the same, the cravings may remain powerful.

Exams and Tests

A physical examination and history of cocaine use are sufficient to diagnose this condition.
A toxicology (poison) screen may be performed to see if other drugs may have been taken.
Other routine tests may include:
• Blood chemistries and liver function tests such as CHEM-20
• Cardiac enzymes (look for evidence of heart damage or heart attack)
• CBC (complete blood count, measures red and white blood cells, and platelets, which help blood to clot)
• EKG (heart tracing)
• Chest x-ray
• Urinalysis

Treatment

The withdrawal from cocaine may not be as unstable as withdrawal from alcohol. However, the withdrawal from any chronic substance abuse is very serious. There is a risk of suicide or overdose.
Symptoms usually disappear over time. People who have cocaine withdrawal will often use alcohol, sedatives, hypnotics, or anti-anxiety medications such as diazepam (Valium) or lorazepam (Ativan)to treat their symptoms. Use of these drugs is not recommended because it simply shifts addiction from one substance to another.
At least half of all people addicted to cocaine also have a mental disorder (particularly depression and attention-deficit disorder). These conditions should be suspected and treated. When diagnosed and treated, relapse rates are dramatically reduced. All prescription drug use should be monitored carefully in patients who abuse substances.

Support Groups

The 12-step support groups, such as Cocaine Anonymous or Narcotics Anonymous, have helped many people addicted to cocaine. Alternative groups such as SMART recovery should be recommended for those who do not like the 12-step approach.

Outlook (Prognosis)

Cocaine addiction is difficult to treat, and relapse can occur. However, the rates of achieving stabilization are as good as those for other chronic illnesses like diabetes and asthma.
Treatment should start with the least restrictive option and move up if necessary. Outpatient care is as effective as inpatient care for most people addicted to cocaine, according to research.
Presently there are no effective medications for reducing craving, although some are being tested. Some studies have reported that medications such as amantadine and bromocriptine may help to reduce patient's craving, increase energy, and normalize sleep, particularly among those with the most seriously addicted.

Possible Complications

• Depression
• Craving and overdose
• Suicide
Because many users will abuse more than one drug, other withdrawal syndromes, such as alcohol withdrawal, need to be ruled out.

When to Contact a Medical Professional

Call your health care provider if you use cocaine and need help to stop using it.

Prevention

Avoid cocaine use. If you have previously used cocaine and wish to stop, try to avoid people, places, and things you associate with the drug. If you find yourself considering the euphoria produced by cocaine, force yourself to think of the negative consequences that follow its use. Group participation is helpful for many people.

References

Doyon S. Opiods. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds.Emergency Medicine: A Comprehensive Study Guide
Wax PM, Barrera, R. . Drug Withdrawal. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds.Harwood-Nuss' Clinical Practice of Emergency Medicine

13.- Cocaine intoxication

Cocaine is an illegal stimulant drug that affects your central nervous system. It is derived from the Erythroxylum coca plant, which is found in abundance in Central America, South America, the West Indies, and Indonesia. It produces a sense of extreme joy by causing the brain to release higher than normal amounts of some biochemicals. However, cocaine's effects on other parts of the body can be very serious, or even deadly.
See also:
• Drug abuse
• Drug abuse and dependence
• Drug abuse first aid
• Cocaine withdrawal

Causes

Cocaine intoxication may be caused by:
• Taking too much cocaine, or too concentrated a form of cocaine
• Using cocaine on hot weather days, which leads to more harm and side effects because of dehydration
• Using cocaine with certain other drugs
• Severe intoxication and death can occur in "drug mules" or "body packers" who intentionally swallow packets of cocaine

Symptoms

Symptoms of cocaine intoxication include:
• Anxiety and agitation
• Chest pain or pressure
• Enlarged pupils
• Feeling of being "high" (euphoria),
• Increased heart rate and blood pressure
With higher doses, sweating, tremors, confusion, hyperactivity and muscle damage, hyperthermia (seriously elevated body temperature), kidney damage, seizures, stroke, irregular heart beats, and sudden death can occur.

Exams and Tests

• Blood chemistries and liver function tests such as CHEM-20
• Cardiac enzymes (to look for evidence of heart damage or heart attack)
• CBC (complete blood count, measures red and whilte blood cells, and platelets, which help blood to clot)
• Toxicology (poison) screening
• EKG (heart tracing)
• Chest x-ray
• Urinalysis

Treatment

The health care provider will measure and monitor the patient's vital signs, including temperature, pulse, breathing rate, and blood pressure.
Symptoms will be treated as appropriate. A class of medications called benzodiazepines are given to calm slow a rapid heart beat, and lower blood pressure, and treat anxiety and/or agitation. The medicines include diazepam and lorazepam. Fluids will be administered through a vein. Heart, brain, muscle and kidney complications will be treated with additional medications.
Long-term treatment requires drug counseling in combination with medical therapy.

Alternative Names

Intoxication - cocaine

References

Perrone J, Hoffman RS. Cocaine, amphetamines, caffeine, and nicotine. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds.Emergency Medicine: A Comprehensive Study Guide
Shih RD, Hollander JE. Cocaine. In: Wolfson AB, Hendey GW, Ling LJ, et al, eds.Harwood-Nuss' Clinical Practice of Emergency Medicine

14.- How Is Cocaine Used?

Cocaine is a powerfully addictive stimulant drug made from the leaves of the coca plant native to South America. It produces short-term euphoria, energy, and talkativeness in addition to potentially dangerous physical effects like raising heart rate and blood pressure.
The powdered form of cocaine is either inhaled through the nose (snorted), where it is absorbed through the nasal tissue, or dissolved in water and injected into the bloodstream.
Crack is a form of cocaine that has been processed to make a rock crystal (also called “freebase cocaine”) that can be smoked. The crystal is heated to produce vapors that are absorbed into the blood-stream through the lungs. (The term “crack” refers to the crackling sound produced by the rock as it is heated.)
The intensity and duration of cocaine’s pleasurable effects depend on the way it is administered. Injecting or smoking cocaine delivers the drug rapidly into the bloodstream and brain, producing a quicker and stronger but shorter-lasting high than snorting. The high from snorting cocaine may last 15 to 30 minutes; the high from smoking may last 5 to 10 minutes.
In order to sustain their high, people who use cocaine often use the drug in a binge pattern—taking the drug repeatedly within a relatively short period of time, at increasingly higher doses. This practice can easily lead to addiction, a chronic relapsing disease caused by changes in the brain and characterized by uncontrollable drug-seeking no matter the consequences.

How Does Cocaine Affect the Brain?

Cocaine is a strong central nervous system stimulant that increases levels of the neurotransmitter dopamine in brain circuits regulating pleasure and movement.
Normally, dopamine is released by neurons in these circuits in response to potential rewards (like the smell of good food) and then recycled back into the cell that released it, thus shutting off the signal between neurons. Cocaine prevents the dopamine from being recycled, causing excessive amounts to build up in the synapse, or junction between neurons. This amplifies the dopamine signal and ultimately disrupts normal brain communication. It is this flood of dopamine that causes cocaine’s characteristic high.
With repeated use, cocaine can cause long-term changes in the brain’s reward system as well as other brain systems, which may lead to addiction. With repeated use, tolerance to cocaine also often develops; many cocaine abusers report that they seek but fail to achieve as much pleasure as they did from their first exposure. Some users will increase their dose in an attempt to intensify and prolong their high, but this can also increase the risk of adverse psychological or physiological effects.

What Are the Other Health Effects of Cocaine?

Cocaine affects the body in a variety of ways. It constricts blood vessels, dilates pupils, and increases body temperature, heart rate, and blood pressure. It can also cause headaches and gastrointestinal complications such as abdominal pain and nausea. Because cocaine tends to decrease appetite, chronic users can become malnourished as well.
Most seriously, people who use cocaine can suffer heart attacks or strokes, which may cause sudden death. Cocaine-related deaths are often a result of the heart stopping (cardiac arrest) followed by an arrest of breathing.
People who use cocaine also put themselves at risk for contracting HIV, even if they do not share needles or other drug paraphernalia. This is because cocaine intoxication impairs judgment and can lead to risky sexual behavior.
Some effects of cocaine depend on the method of taking it. Regular snorting of cocaine, for example, can lead to loss of the sense of smell, nosebleeds, problems with swallowing, hoarseness, and a chronically runny nose. Ingesting cocaine by the mouth can cause severe bowel gangrene as a result of reduced blood flow. Injecting cocaine can bring about severe allergic reactions and increased risk for contracting HIV, hepatitis C, and other blood-borne diseases.
Binge-patterned cocaine use may lead to irritability, restlessness, and anxiety. Cocaine abusers can also experience severe paranoia—a temporary state of full-blown paranoid psychosis—in which they lose touch with reality and experience auditory hallucinations.
Cocaine is more dangerous when combined with other drugs or alcohol (poly-drug use). For example, the combination of cocaine and heroin (known as a “speedball”) carries a particularly high risk of fatal overdose.

15.- DRUGS OF ABUSE: COCAINE

Cocaine is a powerfully addictive stimulant that directly affects the brain.
Cocaine abuse and addiction continue to plague our Nation. In 2008, almost 15 percent of Americans had tried cocaine, with 6 percent having tried it by their senior year of high school. Recent discoveries about the inner workings of the brain and the harmful effects of cocaine offer us unprecedented opportunities for addressing this persistent public health problem.
Genetic studies continue to provide critical information about hereditary influences on the risk of addiction to psychoactive substances, including cocaine. But genetic risk is far less rigid than previously thought. More recent epigenetic research has begun to shed light on the power of environmental factors (e.g., nutrition, chronic stress, parenting style) to influence gene expression and thus, genetic risk. Furthermore, sophisticated imaging technologies have allowed scientists to visualize the brain changes that result from chronic drug exposure or that occur when an addicted person is exposed to drug-associated “cues” that can trigger craving and lead to relapse. By mapping genetic factors, epigenetic mechanisms, and brain regions responsible for the multiple effects of cocaine, we are gaining fundamental insights that can help us identify new targets for treating cocaine addiction.
NIDA remains vigilant in its quest for more effective strategies to address the serious public health issues linked to cocaine abuse. We not only support a wide range of basic and clinical research, but also facilitate the translation of these research findings into real-world settings. To this end, we strive to keep the public informed of the latest scientific advances in the field of addiction. We hope that this compilation of scientific information on cocaine abuse will inform readers and bolster our efforts to tackle the personal and social devastation caused by drug abuse and addiction.

16.- What is cocaine?

Cocaine is a powerfully addictive stimulant that directly affects the brain. Cocaine was labeled the drug of the 1980s and 1990s because of its extensive popularity and use during that period. However, cocaine is not a new drug. In fact, it is one of the oldest known psychoactive substances. Coca leaves, the source of cocaine, have been chewed and ingested for thousands of years, and the purified chemical, cocaine hydrochloride, has been an abused substance for more than 100 years. In the early 1900s, for example, purified cocaine was the main active ingredient in most of the tonics and elixirs that were developed to treat a wide variety of illnesses.
Pure cocaine was originally extracted from the leaf of the Erythroxylon coca bush, which grew primarily in Peru and Bolivia. After the 1990s, and following crop reduction efforts in those countries, Colombia became the nation with the largest cultivated coca crop. Today, cocaine is a Schedule II drug, which means that it has high potential for abuse but can be administered by a doctor for legitimate medical uses, such as local anesthesia for some eye, ear, and throat surgeries.
Cocaine is generally sold on the street as a fine, white, crystalline powder and is also known as “coke,” “C,” “snow,” “flake,” or “blow.” Street dealers generally dilute it with inert substances such as cornstarch, talcum powder, or sugar, or with active drugs such as procaine (a chemically related local anesthetic) or amphetamine (another stimulant). Some users combine cocaine with heroin—in what is termed a “speedball.”
There are two chemical forms of cocaine that are abused: the water-soluble hydrochloride salt and the water-insoluble cocaine base (or freebase). When abused, the hydrochloride salt, or powdered form of cocaine, can be injected or snorted. The base form of cocaine has been processed with ammonia or sodium bicarbonate (baking soda) and water, and then heated to remove the hydrochloride to produce a smokable substance. The term “crack,” which is the street name given to freebase cocaine, refers to the crackling sound heard when the mixture is smoked.

17.- What is the scope of cocaine use in the United States?

The National Survey on Drug Use and Health (NSDUH) estimates that in 2008 there were 1.9 million current (past-month) cocaine users, of which approximately 359,000 were current crack users. Adults aged 18 to 25 years have a higher rate of current cocaine use than any other age group, with 1.5 percent of young adults reporting past month cocaine use. Overall, men report higher rates of current cocaine use than women.
The 2009 Monitoring the Future survey, which annually surveys teen attitudes and drug use, reports a significant decline in the 30-day prevalence of powder cocaine use among 8th-, 10th-, and 12th-graders from its peak use in the late 1990s, as well as significant declines in past-month use among 10th- and 12th-graders from 2008-2009.
Repeated cocaine use can produce addiction and other adverse health consequences. In 2008, according to the NSDUH, nearly 1.4 million Americans met the Diagnostic and Statistical Manual of Mental Disorders criteria for dependence or abuse of cocaine (in any form) in the past 12 months. Further, data from the 2008 Drug Abuse Warning Network (DAWN) report showed that cocaine was involved in 482,188 of the nearly 2 million visits to emergency departments for drug misuse or abuse. This translates to almost one in four drug misuse or abuse emergency department visits (24 percent) that involved cocaine.

18.- How is cocaine abused?

Powdered Cocaine
The principal routes of cocaine administration are oral, intranasal, intravenous, and inhalation. Snorting, or intranasal administration, is the process of inhaling cocaine powder through the nostrils, where it is absorbed into the bloodstream through the nasal tissues. The drug also can be rubbed onto mucous tissues. Injecting, or intravenous use, releases the drug directly into the bloodstream and heightens the intensity of its effects. Smoking involves inhaling cocaine vapor or smoke into the lungs, where absorption into the bloodstream is as rapid as by injection. This rather immediate and euphoric effect is one of the reasons that crack became enormously popular in the mid-1980s.
Freebase Cocaine
Cocaine use ranges from occasional to repeated or compulsive use, with a variety of patterns between these extremes. Other than medical uses, there is no safe way to use cocaine. Any route of administration can lead to absorption of toxic amounts of cocaine, possible acute cardiovascular or cerebrovascular emergencies, and seizures—all of which can result in sudden death.

19.- How does cocaine produce its effects?

Research has led to a clear understanding of how cocaine produces its pleasurable effects and why it is so addictive. Scientists have discovered regions within the brain that are stimulated by all types of reinforcing stimuli such as food, sex, and many drugs of abuse. One neural system that appears to be most affected by cocaine originates in a region of the midbrain called the ventral tegmental area (VTA). Nerve fibers originating in the VTA extend to a region known as the nucleus accumbens, one of the brain's key areas involved in reward. Animal studies show that rewards increase levels of the brain chemical (or neurotransmitter) dopamine, thereby increasing neural activity in the nucleus accumbens. In the normal communication process, dopamine is released by a neuron into the synapse (the small gap between two neurons), where it binds to specialized proteins (called dopamine receptors) on the neighboring neuron and sends a signal to that neuron. Dopamine is then removed from the synapse to be recycled for further use. Drugs of abuse can interfere with this normal communication process. For example, scientists have discovered that cocaine acts by blocking the removal of dopamine from the synapse, which results in an accumulation of dopamine and an amplified signal to the receiving neurons (see image "Cocaine in the brain"). This is what causes the initial euphoria commonly reported by cocaine abusers.
Cocaine in the brain: In the normal communication process, dopamine is released by a neuron into the synapse, where it can bind to dopamine receptors on neighboring neurons. Normally, dopamine is then recycled back into the transmitting neuron by a specialized protein called the dopamine transporter. If cocaine is present, it attaches to the dopamine transporter and blocks the normal recycling process, resulting in a buildup of dopamine in the synapse, which contributes to the pleasurable effects of cocaine.

20.- What are the short-term effects of cocaine use?

Cocaine's effects appear almost immediately after a single dose and disappear within a few minutes or within an hour. Taken in small amounts, cocaine usually makes the user feel euphoric, energetic, talkative, and mentally alert, especially to the sensations of sight, sound, and touch. It can also temporarily decrease the need for food and sleep. Some users find that the drug helps them perform simple physical and intellectual tasks more quickly, although others experience the opposite effect.
The duration of cocaine's euphoric effects depends upon the route of administration. The faster the drug is absorbed, the more intense the resulting high, but also the shorter the duration. The high from snorting is relatively slow to arrive but it may last 15 to 30 minutes; in contrast, the effects from smoking are more immediate but may last only 5 to 10 minutes.
The short-term physiological effects of cocaine use include constricted blood vessels; dilated pupils; and increased body temperature, heart rate, and blood pressure. Large amounts of cocaine may intensify the user's high but can also lead to bizarre, erratic, and violent behavior. Some cocaine users report feelings of restlessness, irritability, anxiety, panic, and paranoia. Users may also experience tremors, vertigo, and muscle twitches. There also can be severe medical complications associated with cocaine abuse. Some of the most frequent are cardiovascular effects, including disturbances in heart rhythm and heart attacks; neurological effects, including strokes, seizures, headaches, and coma; and gastrointestinal complications, including abdominal pain and nausea. In rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.
In addition research has also revealed a potentially dangerous interaction between cocaine and alcohol.

21.- What are the long-term effects of cocaine use?

Cocaine is a powerfully addictive drug. Thus, it is unlikely that an individual will be able to reliably predict or control the extent to which he or she will continue to want or use the drug. And, if addiction takes hold, the risk for relapse is high even following long periods of abstinence. Recent studies have shown that during periods of abstinence, the memory of the cocaine experience or exposure to cues associated with drug use can trigger tremendous craving and relapse to drug use.
Brain images showing decreased dopamine2 receptors in the brain of a person addicted to cocaine versus a nondrug user. The dopamine system is important for conditioning and motivation, and alterations such as this are likely responsible, in part, for the diminished sensitivity to natural rewards that develops with addiction.Brain images showing decreased dopamine (D2) receptors in the brain of a person addicted to cocaine versus a nondrug user. The dopamine system is important for conditioning and motivation, and alterations such as this are likely responsible, in part, for the diminished sensitivity to natural rewards that develops with addiction.
With repeated exposure to cocaine, the brain starts to adapt, and the reward pathway becomes less sensitive to natural reinforcers and to the drug itself. Tolerance may develop—this means that higher doses and/or more frequent use of cocaine is needed to register the same level of pleasure experienced during initial use. At the same time, users can also become more sensitive (sensitization) to cocaine's anxiety-producing, convulsant, and other toxic effects.
Users take cocaine in "binges," during which the cocaine is used repeatedly and at increasingly higher doses. This can lead to increased irritability, restlessness, panic attacks, and paranoia—even a full-blown psychosis, in which the individual loses touch with reality and experiences auditory hallucinations. With increasing dosages or frequency of use, the risk of adverse psychological or physiological effects increases.
Different routes of cocaine administration can produce different adverse effects. Regularly snorting cocaine, for example, can lead to loss of sense of smell; nosebleeds; problems with swallowing; hoarseness; and an overall irritation of the nasal septum, which could result in a chronically inflamed, runny nose. Ingested cocaine can cause severe bowel gangrene, due to reduced blood flow. Persons who inject cocaine have puncture marks called "tracks," most commonly in their forearms, and may experience allergic reactions, either to the drug or to some additive in street cocaine, which in severe cases can result in death. Many chronic cocaine users lose their appetite and experience significant weight loss and malnourishment.

22.- Are cocaine abusers at risk for contracting HIV/AIDS and Hepatitis B and C?

Yes, cocaine abusers are at increased risk for contracting such infectious diseases as human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) and viral hepatitis. This risk stems not only from sharing contaminated needles and drug paraphernalia but also from engaging in risky behaviors as a result of intoxication. Research has shown that drug intoxication and addiction can compromise judgment and decisionmaking, and potentially lead to risky sexual encounters, needle sharing, and trading sex for drugs—by both men and women. In fact, some studies are showing that among drug abusers, those who do not inject drugs are contracting HIV at rates equal to those who do inject drugs, further highlighting the role of sexual transmission of HIV in this population.
Additionally, hepatitis C (HCV) has spread rapidly among injecting drug users. Risk begins with the first injection, and within 2 years, nearly 40 percent of injection drug users (IDUs) are exposed to HCV. By the time IDUs have been injecting for 5 years, their chances of being infected with HCV are between 50 and 80 percent. Although treatment for HCV is not effective for everyone and can have significant side effects, medical followup is essential for all those who are infected. There is no vaccine for the hepatitis C virus, and it is highly transmissible via injection; thus, HCV testing is recommended for any individual who has ever injected drugs.

23.- What are the effects of maternal cocaine use?

The full extent of the effects of prenatal cocaine exposure on a child is not completely known, but many scientific studies have documented that babies born to mothers who abuse cocaine during pregnancy are often prematurely delivered, have low birth weights and smaller head circumferences, and are shorter in length than babies born to mothers who do not abuse cocaine.
Nevertheless, it is difficult to estimate the full extent of the consequences of maternal drug abuse and to determine the specific hazard of a particular drug to the unborn child. This is because multiple factors—such as the amount and number of all drugs abused, including nicotine; extent of prenatal care; possible neglect or abuse of the child; exposure to violence in the environment; socioeconomic conditions; maternal nutrition; other health conditions; and exposure to sexually transmitted diseases—can all interact to impact maternal, fetal, and child outcomes.
Some may recall that "crack babies" or babies born to mothers who abused crack cocaine while pregnant, were at one time written off as a lost generation. They were predicted to suffer from severe, irreversible damage, including reduced intelligence and social skills. It was later found that this was a gross exaggeration. However, the fact that most of these children appear normal should not be overinterpreted to indicate that there is no cause for concern. Using sophisticated technologies, scientists are now finding that exposure to cocaine during fetal development may lead to subtle, yet significant, later deficits in some children, including deficits in some aspects of cognitive performance, information processing, and attention to tasks—abilities that are important for the realization of a child's full potential.

24.- What treatments are effective for cocaine abusers?

In 2007, cocaine accounted for about 13 percent of all admissions to drug abuse treatment programs. The majority of individuals (72 percent in 2007) who seek treatment for cocaine abuse smoke crack and are likely to be polydrug abusers, or users of more than one substance. The widespread abuse of cocaine has stimulated extensive efforts to develop treatment programs for cocaine. As with any drug addiction, this is a complex disease that involves biological changes in the brain as well as myriad social, familial, and other environmental problems. Therefore, treatment of cocaine addiction must be comprehensive, and strategies need to assess the neurobiological, social, and medical aspects of the patient's drug abuse. Moreover, patients who have a variety of addictions often have other co-occurring mental disorders that require additional behavioral or pharmacological interventions.

Pharmacological Approaches

Presently, there are no FDA-approved medications to treat cocaine addiction. Consequently, NIDA is working aggressively to identify and test new medications to treat cocaine addiction safely and effectively. Several medications marketed for other diseases (e.g., vigabatrin, modafinil, tiagabine, disulfiram, and topiramate) show promise and have been reported to reduce cocaine use in controlled clinical trials. Among these, disulfiram (used to treat alcoholism) has produced the most consistent reductions in cocaine abuse. On the other hand, new knowledge of how the brain is changed by cocaine is directing attention to novel targets for medications development. Compounds that are currently being tested for addiction treatment take advantage of underlying cocaine-induced adaptations in the brain that disturb the balance between excitatory (glutamate) and inhibitory (gamma-aminobutyric acid) neurotransmission. Also, dopamine D3 receptors (a subtype of dopamine receptor) constitute a novel molecular target of high interest. Medications that act at these receptors are now being tested for safety in humans. Finally, a cocaine vaccine that prevents entry of cocaine into the brain holds great promise for reducing the risk of relapse. In addition to treatments for addiction, medical treatments are being developed to address the acute emergencies that result from cocaine overdose each year.

Behavioral Interventions

Many behavioral treatments for cocaine addiction have proven to be effective in both residential and outpatient settings. Indeed, behavioral therapies are often the only available and effective treatments for many drug problems, including stimulant addictions. However, the integration of behavioral and pharmacological treatments may ultimately prove to be the most effective approach.
Presently, there are no proven medications to treat cocaine addiction. Consequently, NIDA is working aggressively to identify and test new medications.
One form of behavioral therapy that is showing positive results in cocaine-addicted populations is contingency management, or motivational incentives (MI). MI may be particularly useful for helping patients achieve initial abstinence from cocaine and for helping patients stay in treatment. Programs use a voucher or prize-based system that rewards patients who abstain from cocaine and other drug use. On the basis of drug-free urine tests, the patients earn points, or chips, which can be exchanged for items that encourage healthy living, such as a gym membership, movie tickets, or dinner at a local restaurant. This approach has recently been shown to be practical and effective in community treatment programs.
Cognitive-behavioral therapy (CBT) is an effective approach for preventing relapse. CBT is focused on helping cocaine-addicted individuals abstain—and remain abstinent—from cocaine and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of cocaine abuse and addiction. These same learning processes can be harnessed to help individuals reduce drug use and successfully prevent relapse. This approach attempts to help patients recognize, avoid, and cope; that is, they recognize the situations in which they are most likely to use cocaine, avoid these situations when appropriate, and cope more effectively with a range of problems and problematic behaviors associated with drug abuse. This therapy is also noteworthy because of its compatibility with a range of other treatments patients may receive.
Therapeutic communities (TCs), or residential programs, offer another alternative to persons in need of treatment for cocaine addiction. TCs usually require a 6- or 12- month stay and use the program's entire "community" as active components of treatment. They can include onsite vocational rehabilitation and other supportive services and focus on successful reintegration of the individual into society.
Community-based recovery groups—such as Cocaine Anonymous—that use a 12-step program, can also be helpful to people trying to sustain abstinence. Participants may benefit from supportive fellowship and from sharing with those experiencing common problems and issues.
It is important that patients receive services that match all of their treatment needs. For example, if a patient is unemployed, it may be helpful to provide vocational rehabilitation or career counseling along with addiction treatment. If a patient has marital problems, it may be important to offer couples counseling.

25.- Where can I get further information about cocaine?

To learn more about cocaine and other drugs of abuse, visit the NIDA Web site at www.drugabuse.gov or contact the DrugPubs Research Dissemination Center at 877-NIDA-NIH (877-643-2644; TTY/TDD: 240-645-0228).

What's on the NIDA Web Site

• Information on drugs of abuse and related health consequences
• NIDA publications, news, and events
• Resources for health care professionals
• Funding information (including program announcements and deadlines)
• International activities
• Links to related Web sites (access to web sites of many other organizations in the field)
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Disclaimer: The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

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