190 Cocaine Abuse and Dependence (305.6)

DSM-IV-TR criteria

A maladaptive pattern of cocaine use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12 month period:

1. Recurrent cocaine use resulting in a failure to fulfill major role obligations at work, school or home.

2. Recurrent cocaine use in situations in which it is physically hazardous

3. Recurrent cocaine-related legal problems

4. Continued cocaine use despite having a persistent or recurrent social or interpersonal problem caused or exacerbated by it use.

Or the symptoms have never met the criteria for Substance Dependence for this class of substance.

Associated features

• Intoxication of cocaine is accompanied with a number of symptoms. There is heightened alertness and euphoria associated with intoxication of cocaine. Behavioral changes such as hyperactivity, restlessness, impaired judgment and functioning, and anxiety are also associated with intoxication. People under a more severe intoxication will experience more agitation, confusion, and possibly seizures.
• Withdrawal symptoms can include a dysphoric or unpleasant mood, fatigue, unpleasant dreams, insomnia, psycho motor retardation, and increased appetite. When people are in this dysphoric mood, they think back to the euphoria they received from the cocaine high, which in turn increases their cravings to use cocaine again, to get out of the mood.
• Cocaine abusers experience a number of symptoms that affect every part of the body. First of all, cocaine affects the nervous system, which causes euphoria. It can also cause symptoms like hallucinations and muscle jerks. Cocaine also affects the brain, which makes it so addictive. Since cocaine is mostly sniffed or snorted through the nose, this causes serious effects on the sinuses and nose. Smoking cocaine can affect the lungs, much the way smoking cigarettes affect the lungs and breathing. Cocaine also has an effect on the heart. One of the main effects of cocaine is stimulating the sympathetic nervous system which is directly related to the heart and the “flight-or-fight” response. Cocaine abuse can cause increased heart rate, blood pressure, and decreasing the size of the blood vessels, which in turn restrict blood flow to the heart.
• People dependent to cocaine will do nearly anything to get cocaine. This can interfere with their job, schooling, and relationships. People dependent on cocaine have many of the same symptoms of intoxication. They have increased energy, weight loss, and not involved in normal activities, along with many other symptoms.

Child vs. adult presentation

There has not been much research done in the area of child vs. adult presentation. Children, however, can be affected by cocaine use in their parents. A fetus can be harmed when a mother is using cocaine while pregnant resulting in the baby having withdrawal symptoms when born. Women who are pregnant and using cocaine experience more miscarriages. Cocaine can affect the development of the fetus. Cocaine can cause certain areas of the brain to develop abnormally. It can cause problems later on in life with being able to pay attention, processing information and staying focused, compared with those who are not exposed to the drug. Newborns born to mothers who used cocaine during the pregnancy have lower birth weight, smaller head circumference, and are shorter than those babies who were born to mothers not using cocaine. These effects have a great impact on the child throughout their life. Children can also be affected by the second-hand smoke from parents who smoke cocaine. Overall, there is no research showing that children use cocaine. Mothers who use cocaine can affect the development of their children. Cocaine use generally begins in adolescence and the symptoms are the same as those experienced by adults using cocaine.

Gender and cultural differences in presentation

• There are not many differences in the presentation of intoxication or withdrawal symptoms across genders; however it has been found that women typically use cocaine for different reasons. It is usually a response to stress, hoping that the drug will make them feel better. In men, it has been found that they use cocaine to feel even better when already feeling good. More specifically, a study conducted in 2002, found that estrogen may have a role in sex-based addictions. The study found that women usually become dependent after using cocaine for shorter amounts of time as compared with men. Estrogen can affect the immediate response to cocaine as well as the long-term effects of the drug. Another study, published in 2005, tested women and men stress reactivity. These participants were dependent on cocaine. They were all given a psychological stress task, the Mental Arithmetic Task, and a Cold Pressor Task. The participants were measured on their physiological stress response (heart rate, etc.), their subjective stress responses (nervousness, etc.), and their cocaine cravings they experienced. The results showed that women demonstrated more subjective reactivity. They had higher ratings of nervousness, stress, and pain compared with the men in the study. The study showed that women seem to be more stressed overall when dependent on cocaine as compared to men. However, this was the first study that used the testing procedure that was used and none have been done since.
• Culturally there has been no research in the area of difference of presentation. The main differences that have been researched are differences in uses among different ethnic groups.

Epidemiology

In 2007, the National Survey on Drug Use and Healthreported that 35.9 million Americans have used cocaine at least once in their life. In 2007, students who took the Youth Risk Behavior Surveillance System, 7.2% reported trying cocaine at least once. While only 3.3% reported having used cocaine in the past month. Nearly half of federal and state prisoners have tried cocaine once in their life. Research shows that nearly 75% of people that try cocaine will become addicted. Only 25% of people that are using cocaine will be able to stop without any help at all. Throughout the 1990’s to present-day, cocaine use has remained stable, with no significant increases or declines. The number of people trying cocaine has gone down since the 1980’s, however it has not been that significant. Adolescents show high rates of cocaine usage. Hispanic adolescents show the highest rates of cocaine use in the 30 days prior to taking the Youth Risk Behavior Survey. Caucasian adolescents report the next highest rate, then African American adolescents. Newer research has shown that drug use in adolescents has gone down since 2001. However, Hispanic adolescent drug use is still an area of concern. Currently, Hispanic adolescents are using cocaine more than Caucasian and African American adolescents. Additionally, research has shown that cocaine use is rising in European countries. One group of researchers believes that to combat this, a public health approach is necessary.

Etiology

Research has shown that repeated exposure to cocaine can cause a change in genes and this leads to an altered level of a protein that regulates dopamine levels. Dopamine is associated with the euphoria received from cocaine use. This causes many people to become addicted or dependent on cocaine. Cocaine is addictive and changes genes, making it hard to stop the addiction. It has also been found that if one has a family member using cocaine, they are more likely to do the same. While the nature of the drug is addictive, one’s environment can also have an effect on using cocaine.

Empirically supported treatments

While there is no cure for cocaine abuse or dependence, there are therapies and drugs that can help people be relieved of the symptoms of intoxication or help them make a life change to get off of the drug all together. However, there are no guarantees. First, psychosocial treatments provide support for behavioral change. About half of users in this setting can abstain from cocaine for about a month to a month and a half. However, the success of the program depends on the duration of the program and the specific designs of the program. Many use a 12-step approach to changing their behavior. This is based on getting help with being drug-free from a higher being. Another type of therapy is Relapse Prevention. This helps people understand their body and the cues they get so they can manage their use and relapse symptoms. Another psychosocial treatment is a Matrix Neurobehavioral Model Treatment. This involves many types of therapies including individual therapy, family education, and relapse prevention groups. This is also a 12-step program that can include meetings with mandatory urine tests to see if members are actually improving. Next, much research has been done regarding pharmacological treatments. However, while some initially have shown success, most have failed to show similar results when tested again. Drugs can be helpful for cocaine intoxication, though. Benzodiapines have shown to help people with intoxication symptoms that do not go away. Benzodiapines are also helpful to treat the withdrawal symptoms. Roughly 20 drugs have been tested in helping with cocaine dependence. There is no current evidence for any effective pharmacological treatment for cocaine dependence. Psychosocial treatment proves to be the most effective treatment, currently. In 2005, a group of researchers developed a system, called Cocaine Rapid Efficacy Screening Trial (CREST) which is a randomized method for testing and comparing the effect of pharmacological treatments on cocaine dependence. The CREST started out with a 2-4-week period of gathering information, then the 8-week treatment period. The participants were given urine tests, cocaine craving ratings, mood test, along with a few other tests and measures to track the progress of their treatment and the drug. This study was done in 4 major United States cities and 19 total drugs were tested for their effectiveness in treating cocaine dependence. Their findings showed three drugs (reserpine, cabergoline, and, tiagabine) that showed signs of effectiveness. These drugs were to be tested in a full-scale research experiment. No pharmacological treatments have been found to help people dependent on cocaine. They only help treat physical symptom associated with cocaine use. The only supported treatment is psychosocial therapy.

Links:

• Cocaine, Marijuana, Crack, Meth, Heroin Changes Brain ChemistryDrugs Damaging the Brain

DSM-V Proposed Changes: adding “Cocaine-Use Disorder”

DSM-V Cocaine-Use Disorder Criteria:

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)

4. tolerance, as defined by either of the following:

• a need for markedly increased amounts of the substance to achieve intoxication or desired effect
• markedly diminished effect with continued use of the same amount of the substance

(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. withdrawal, as manifested by either of the following:

• the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)
• the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

(Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. the substance is often taken in larger amounts or over a longer period than was intended

7. there is a persistent desire or unsuccessful efforts to cut down or control substance use

8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

9. important social, occupational, or recreational activities are given up or reduced because of substance use

10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

11. Craving or a strong desire or urge to use a specific substance.

Severity specifiers:

Moderate: 2-3 criteria positive

Severe: 4 or more criteria positive

Specify if:

• With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 4 or 5 is present)
• Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 4 nor 5 is present)

Course specifiers (see text for definitions):

• Early Full Remission
• Early Partial Remission
• Sustained Full Remission
• Sustained Partial Remission
• On Agonist Therapy
• In a Controlled Environment