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COCAINE

 Cocaine 1

 

INTRODUCTION

 

Many individuals view drug abuse and addiction as a social problem.  They think that most people who take drugs are morally weak or that they have criminal tendencies.  It is also a common belief that drug abusers and addicts could stop using drugs if they really wanted to and were willing to change their behavior.  These myths have been disproved by data collected from the using sub-population; however, society changes its perceptions very slowly. Consequently, these and other similar myths still stereotype those with drug-related problems, as well as their families, communities, and the health care professionals who work with them.  It is abundantly clear that drug abuse and addictions comprise a public health problem that affects many and has wide-ranging social consequences.  It should be the substance abuse professionals goal to help society replace its myths and long-held mistaken beliefs about drug abuse and addiction with scientific evidence that proves that addiction is a chronic, relapsing, and beatable disease (with professional help).  Another fact that society should recognize is that this problem will not go away by its self.  We must work collectively to educate society on the facts regarding drug use and abuse and then work diligently with those individuals caught up in this quagmire to help them overcome this insidious and malignant attack on their life.

 

The addiction process starts with drug use and abuse when an individual makes a conscious choice to use drugs but addiction is more than drug abuse alone.  Researchers have provided overwhelming evidence that drugs interfere with normal brain functioning creating powerful feelings of pleasure.  Also, they have shown that drugs have long-term effects on the brain’s metabolism and activity.  At some point, changes occur in the brain that can turn drug abuse into addiction, a chronic, relapsing illness; consequently, drug users that have progressed to this stage are addicted to drugs and they suffer from compulsive drug craving and usage and usually cannot quit by themselves.  Treatment is necessary to end this compulsive behavior.

 

Cocaine 2COCAINE

 

Cocaine is an alkaloid that is obtained from the leaves of the coca plant.  It stimulates the Central Nervous System and creates a euphoric sense of happiness and increased energy.  Cocaine can also suppress appetite.  Cocaine is most often used for the aforementioned effects; however, it is also a topical anesthetic used in eye, throat, and nose surgery.  The name is derived from the name of the plant (coca) plus the alkaloid suffix-ine.

 

Cocaine is an ancient drug of abuse and became a problem in the United States in the early 1960s.  It has continued to present a significant threat to users into the 21st century.  Dealers commonly dilute it with inert substances such as cornstarch or talcum powder or with an active drug such as amphetamines. Regardless of how cocaine is used or how frequently, a user can experience acute cardiovascular or cerebrovascular medical emergencies, such as a heart attack or stroke, which can result in death.  Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.  There have been reports that death has occurred following the first time use of cocaine.

 

Cocaine is an addictive stimulant that disrupts normal brain activity.  Cocaine is one of the oldest known drugs and the pure chemical (cocaine hydrochloride) has been an abused substance for over 100 years.  It was extracted from the leaf of the coca bush in the mid-19th century. Also, South American natives have chewed the leaves for thousands of years to fight off fatigue, lessen hunger and increase endurance.  At present, over 80 percent of Indians living in coca-growing regions chew the leaves.  Visitors to native homes are often served pieces of coca leaves to chew before other beverages and foods are served. 

 

Cocaine was the primary stimulant used in most of the tonics/elixirs that were developed in the United States (early 1900s) to treat a wide variety of illnesses.  It was initially viewed as a wonder drug and it received wide acceptance.  It was also used in beverages and other non-medical applications. However, the true nature of cocaine (highly addictive stimulant that disrupts normal brain activity) was recognized shortly thereafter and the challenge to control or rid this substance has been ongoing ever since.  Today, cocaine is a schedule II drug, meaning that it has a high potential for abuse, but can be administered by a physician for legitimate medical uses, such as local anesthesia for some eye, ear and throat surgeries, as noted earlier.

 

There are two forms of cocaine: the hydrochloride salt and the freebase.  The hydrochloride salt (powered form of cocaine) dissolves in water and can be taken intravenously (injected in the vein) or intranasally (snorted in the nose).  Freebase refers to a compound that has not been neutralized by an acid to make the hydrochloride salt.  The freebase form of cocaine is smokable.

 

Cocaine is typically sold as a white, crystalline powder.  The street names include Coke, C, Snow, Flake and Blow.

 

CRACK COCAINE

Cocaine 5CRACK COCAINE

Crack cocaine is an addictive stimulant that is derived from powdered cocaine using a simple conversion process.  It is produced by dissolving powdered cocaine in a mixture of water and ammonia or sodium bicarbonate (baking soda).  The mixture is boiled until a solid substance forms.  The solid is removed from the liquid, dried, and then broken into the rocks that are sold as crack cocaine.  Crack rocks are white (or near-white) and vary in size and shape. 

 

Crack cocaine emerged as a drug of abuse in the mid-1980s.  It is desired among users because it produces an immediate high and because it is easy and inexpensive to produce; consequently, it is readily available and affordable.  Crack is nearly always smoked and it delivers large quantities of the drug to the lungs, producing an immediate and intense euphoric effect.  Street names for crack include:  24-7, Hardball, Candy, Cloud, Jellybeans, Cookies, Nuggets, tornado and many others.

 

Crack cocaine is a schedule II substance under the controlled Substance Act.  Schedule II drugs have a high potential for abuse and may also lead to severe psychological or physical dependence.COCAINE USE IN THE UNITED STATES

 

In 2002 the National Survey on Drug Use and Health  (NSDUH) estimated 1.5 million Americans could be classified as dependent on or abusing cocaine in the past 12 months.  The same survey estimated that there are 2 million current (past month) users.  Cocaine initiation (first time users) steadily increased during the 1990s, reaching over 1 million in 2001.  Adults (18 to 25 years of age) have a higher rate of current cocaine use than those in any other age group.  Overall, men have a higher rate of current cocaine use than do women.  Also, according to the 2002 NSDUH, estimated rates of current cocaine users were 2.0 percent for American Indians or Alaskan Natives, 1.6 percent for Native Hawaiian or other Pacific Islanders, and 0.2 percent of Asians.

 

The 2003 Monitoring the Future Survey, which annually surveys teen attitudes and recent drug use, reports that crack cocaine use decreased among 10th graders in 30-day and annual use prevalence periods.  This was the only statistically significant change affecting cocaine in any form.  Past-year use rate increased form 1.8 percent to 2.3 percent, and this years decline brings it to approximately its 2001 level.

 

Data from the Drug Abuse Warning Network (DAWN) showed that cocaine-related emergency department visits increased 33 percent between 1995 and 2002, rising from 58 to 78 per 100,000 populations.

 

 

COCAINE-RELATED DISORDERS

 

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) includes a description of cocaine use disorders, as well as cocaine induced disorders.  The following excerpts were taken form DSM-IV.

 

Cocaine Dependence:

 

Cocaine has extremely potent effects, and individuals exposed to it can develop dependence after using the drug for very short periods of time. An early sign of Cocaine dependence is when the individual finds it increasingly difficult to resist using cocaine whenever it is available.  Because of its short half-life (time required for the body to eliminate one-half of the amount consumed) of about 30 to 50 minutes, there is a need for frequent dosing to maintain a high. Persons with cocaine dependence can spend extremely large amounts of money on the drug within a very short period of time.  As a result, the person using the substance may become involved in theft, prostitution, or drug dealing or may request salary advances to obtain funds to purchase the drug.  Individuals with cocaine dependence often find it necessary to discontinue use for several days to rest or to obtain additional funds.  Important responsibilities such as work or childcare may be grossly neglected to obtain or use cocaine.  Mental or physical complications of chronic use such as paranoid ideation, aggressive behavior, anxiety, depression, and weight loss are common.  Regardless of the route of administration, tolerance occurs with repeated use.  Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoric mood, can be seen and are likely to enhance craving and the likelihood of relapse.  The overwhelming majority of individuals with cocaine dependence have had signs of physiological dependence on cocaine (tolerance or withdrawal) at some time during the course of their substance use. 

 

Cocaine Abuse

 

The intensity and frequency of cocaine administration is less in cocaine abuse as compared with dependence.  Episodes of problematic use, neglect of responsibilities, and inter-personal conflict often occur around paydays or special occasions, resulting in a pattern of brief periods (hours to a few days) of high-dose use followed by much longer periods (weeks to months) of occasional use or abstinence.  Legal difficulties may result from possession or use of the drug.  When the problems associated with use are accompanied by evidence of tolerance, withdrawal, or compulsive behavior related to obtaining and administering cocaine, a diagnosis of cocaine dependence rather than cocaine abuse should be considered.  However, since some symptoms of tolerance, withdrawal, or compulsive use can occur in individuals with abuse but not dependence, it is important to determine whether the full criteria for dependence are met.

 

Criteria for Diagnosis

 

The DSM-IV presents the following criteria for a diagnosis of Substance Dependence:

 

The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems.  In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior.  The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

 

(1)            tolerance, as defined by either of the following:

(a)            a need for markedly increased amounts of the substance to

achieve intoxication or desired effect

(b)            markedly diminished effect with continued use of the same amount of the substance

(2)            withdrawal as manifested by either of the following:

(a)    the characteristics withdrawal syndrome for the substance (b)  the same (or a closely related) substance is taken to relieve

        or avoid withdrawal symptoms

(3)            the substance is often taken in larger amounts or over a longer period than was intended

(4)            there is a persistent desire or unsuccessful efforts to cut down or control substance use

(5)            a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects

(6)            important social, occupational, or recreational activities are given up or reduced because of substance use

(7)            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 substance use (e.g., current marijuana use despite recognition of marijuana-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

 

The DSM-IV presents the following criteria for a diagnosis of Substance Abuse:

 

The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance.  In order of an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems.  Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences o repeated used. 

The criteria for Substance Abuse is:

A.    a maladaptive pattern or substance 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 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)recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

(4) 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 or intoxication, physical fights)

 

B.    The symptoms have never met the criteria for substance Dependence

for this class of substance.

 

 

THE ESSENCE OF ADDICTION

 

Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse provided the following insight into drug addiction.  He states: The word addiction calls up many different images and strong emotions.  But what are we reacting to?  Too often we focus on the wrong aspects of addiction so our efforts to deal with this difficult issue can be badly misguided.  Any discussion about psychoactive drugs inevitably moves to the question but is it really addicting?   The conversation then shifts to the so-called types of addiction whether the drug is physically or psychologically addicting.  The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field call physical dependence.

 

The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be.  Indeed, people always seem relieved to hear that a substance just produces psychological addiction, or has only minimal physical withdrawal symptoms.  Then they discount the dangers and they are wrong.

 

Defining addiction Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark, and a distraction from the real issue.  From both clinical and policy perspectives, it does not matter much what physical withdrawal symptoms occur.  Other aspects of addiction are far more important.  Physical dependence is not that important because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications.  Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances.

 

What does matter tremendously is whether or not a drug causes what we now know to be the essence of addiction:  uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.  This is the crux of how many professional organizations all define addiction, and how we all should use the term.  It is really only this expression of addiction uncontrollable, compulsive craving, seeking and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole.  These are the elements responsible for the massive health and social problems caused by drug addiction.

 

Essence of Addiction Drug craving and the other compulsive behaviors are the essence of addiction.  They are extremely difficult to control, much more difficult than any physical dependence.  They are principal target symptoms for most drug treatment programs.  For an addict, there is no motivation more powerful than drug craving.

 

Rethinking Addiction focusing on addiction as compulsive, uncontrollable drug use should help clarify everyones perception of nature of addiction and of potentially addicting drugs.  For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful and powerful concept of uncontrollable drug seeking and use.  The task of treatment is to regain control over drug craving, seeking and use.

 

Rethinking addiction also affects which drugs we worry about and the nature of our concerns.  The message from modern science is that in deciding which drugs are addicting and require what kind of societal attention, we should focus primarily on whether taking them causes uncontrollable drug seeking and use.  One important example is the use of opiates, like morphine to treat cancer pain.  In most circumstances, opiates are addicting.  However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here.  This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

Treating Addiction:  Follow The Science It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple.  We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough.  This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

 

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction.  We certainly will do a better job of serving everyone affected by addiction  – addicts, their families and their communities if we focus on what really matters to them.  As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.

 

ADDICTION PROCESS

 

The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs.  The hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life.  It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use.  The objectives are for the clinician involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs.  For example, as it is beneficial for an insulin dependent diabetic to be educated on all aspects of diabetes, it is equally important for an individual who abuses cocaine to be educated on all aspects of cocaine use including impulse control, distorted cognitive ability and the consequences of poor decision-making.

  

Figure 1 depicts a typical addiction process and identifies the major functional blocks of the process.  The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings and influences of his family, friends, peers and other during his or her early life) it leads to that individual having a distorted cognitive ability.  That, in turn, enables an individual to continue to use and will ultimately result in unmanageability of his or her life (if the cycle is not disrupted).  The following paragraphs describe each block and how it impacts the users life.

 

cocaine 3

                                                             Figure 1

                                                      Addiction Process

Value/Belief System

 

An individuals value/belief system reflects his/her perception of self and represents values, judgments and myths that he/she believes to be true.  A persons value/belief system is fairly well established by an early age and is refined and honed as lifes experiences make us into the person we are at any given time in our life.   It is the major control and decision-making guide and helps us to chose between right and wrong and things we do versus things we dont do.  Most individuals have a value/belief system about:

 

              Religion

              Alcohol and other drugs use/abuse

              Sexuality

              Race

              Peer pressure/social acceptance

              Social involvement

              Family roles

 

A clinician should explore a clients value/belief system to better understand what they believe about various topics including topics related to drug use.  An area I like to explore is the environment they were exposed to during their early life.  For example, I want to determine if their parents or caregivers had a permissive attitude toward drugs.  I also want to know if they had friends who used drugs and what was the norm regarding use of alcohol and other drugs.  Other questions might include:

  

              Were you exposed to limits or restrictions as a youth?

              Did your parents use drugs?

              Were you allowed to drink, smoke or use drugs with your parents?

              At what age did you start to drink or smoke?

              Was there a permissive attitude (toward alcohol and other drug used) in your home/neighborhood?

              Did you have a detailed schedule as a youth?

              Did your parents involve themselves with your friends?

              Did your parents monitor your activities?

 

Obviously, this is an attempt to assess the risk factors the individual was exposed to during his or her early life.  Generally, a permissive attitude/environment will provide early opportunities to experiment with alcohol, tobacco and other drugs.  This liberal, permissive environment also enables a young person to form a positive image of most activities and/or to establish a distorted mental picture of specific activity (such as use of alcohol and other drugs).   To give an example of how our belief/values work in the life of a cocaine user, lets suppose a person forms a concept of a problem user as one who is unemployed and has an arrest record.  Now, lets suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act.  In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem.  The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use.  It should also be noted that an individuals belief system about drug use might change in response to his or her own experiences and influences from clinicians and other treatment modalities.  The cycle may also be disrupted by other factors (generally a crisis) in the users life.

 

 

Distorted Cognitive Ability

 

A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions for themselves.  With respect to the use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use.  It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities.  When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial.  The most common forms of denial are:

 

              Rationalizing:  Making excuses for cocaine use.  Example,  all of my friends use more than me

              Minimizing: Indicating his/her use is less serious than it really is.  Example: Sure I use, but not that much; I only use on weekends, real users use every day

              Blaming: I use cocaine because all of my friends do.  The user admits involvement but the responsibility for it lies with some else

 

An important challenge facing most compulsive users it to break though denial and accept the reality of their situation.  The challenge in counseling situations is to help the individual through this process.  This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adapt new coping strategies and new ways to divert himself or herself away from his or her former lifestyle.   Learning new concepts is usually met with rsistance, as most individuals dont want to change and will only change in response to pain or other strong motivator.   Distorted cognitive activity or impaired thoughts mask the reality of most situations.  A cocaine user can gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

 

 

              Most frequently used form of denial (with respect to cocaine use) is: ______________________________________________

      (rationalizing, minimizing, blaming or others)

 

              Most frequently processed impaired thought:  ______________________________________________

 

              Im not a problem user because: ______________________________________________

 

 

If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with cocaine and they are in need of professional help. The key to any cognitive change is that the individual be open and honest and willing to accept that change is needed.  If they have a good attitude, it is easier for them to accept the perils associated with compulsive use.  The net is that people can change but in most cases the change must be initiated at the cognitive level.  If one is in denial regarding a problem there is very little that anyone else can do to help that individual.

 

 

Cycle Of Use

 

The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This on-going activity results in addiction (again, compulsive, uncontrolled drug craving, seeking and use).  This lifestyle is problematic and typically follows a well-established pattern (Reference Individual Addiction Cycle).  At this phase of use, his or her drug related choices begin to disrupt normal activities with family, work, school and community.  His or her use is increasing in importance to where it is interfering with most other activity/relationships.  It generally results in behavioral problems or unmanageability of ones life.

 

 

Unmanageability

 

As the use continues, the individual begins to encounter the negative consequences of his/her behavior.  In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help.  The hypothesis is that deeply imbedded in human nature is the tendency to resist all change until we finally pain and then we may stop to look at the cause of the pain.  This process may manifest itself in any of the following:

            

          Physical (health problems, increased risk taking)

          Social problems (family, work, school, community)

          Emotional (feelings of guilt, shame or depression)

          Spiritual (low self esteem, feeling empty, isolated)

          Financial (heavy debt load; inability to manage)

 

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her use.  This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decisions (related to  use). 

 

 

INDIVIDUAL ADDICTION CYCLE

 

Figure 2 depicts an individual addiction cycle for a cocaine user and identifies the major blocks associated with the cycle.   Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).

 

Cocaine 7

 

Preoccupation

 

To preoccupy is defined as to absorb wholly the mind or attention of or occupy beforehand or before another. It can be viewed as a locked in mind state, where in addictions the main focus is on obtaining his or her drug of choice.  Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration and frequency.  The initial onset may be mild but generally get more intense as time passes without satisfying the impulse.   The intensity of the state also varies depending on how long the individual has been a drug user as all individuals are creatures of habit and we program ourselves to expect resolution within a predetermined timeframe or the mind will increase the desire to satisfy the impulse.   An approach to understanding this phase of use is to ask the user a series of questions such as:

 

What thoughts did you focus on when you initially began using cocaine?

Was your intent (reason for use) to overcome fatigue, increase alertness or control appetite? 

Did you use due to social pressures or the influence of friends?

How did your attitude toward drugs change as the compulsion to use increased?

What are your thoughts like at present?

What do you think regarding using again?

 

Remember that it takes time to break old habits and to re-program our minds to desire different things.   Also, remember the urge to continue or use will be very strong when an individual initially stops.  Individuals must be resilient in their efforts to break the cycle.  This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.   Again, the mind wants to continue to do those things that bring pleasure.  Consequently, a  drug binge, big shopping spree or  hanging out with former using buddies are positive events in a user’s mind and they want to repeat them.  Consequently, there is a strong drive to set aside or dismiss concepts that would limit us doing what we want to do.  I have often stated in-group sessions that using is an extremely selfish action.  It basically says I will do what I want to do without any consideration for my health, family or other considerations.  Unfortunately, we all know there is the negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other (positive) thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds.  I often use the phrase, when one makes the decision (for example, to use cocaine) they also accept the consequences.  Sometimes good (pleasure) happens, but most of the time bad and sometimes catastrophic event can occur.

 

 

Habits/Ritual

 

The second part of the individualized addiction cycle is a set of habits that typically lead to cocaine use.  Some counselors may refer to this as ritualistic or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking.  The preceding cycle (Figure 1) discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (ritual) that are typically completed without thought.

 

A using ritual is the behavior that leads to use.  For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously included drug use (concert).  It may also be triggered by an argument with a spouse; loss of a job or other catastrophic events or it could be as insignificant as driving through a neighborhood where his or her former supplier lived.  In any event, it is something that triggers a thought in our minds that initiates a chain of events that lead to using.  This is another view of compulsivity.  Its also important to note that when a ritual is initiated, it is very difficult to stop the process.  For a compulsive cocaine user, it is virtually impossible without professional help.

 

Another assignment for the addicted individual is to describe what keys their use. List and analyze the activities and behaviors leading to use.  The objective is that the better we understand what motivates an individual; the easier it is to interrupt the cycle.  The second part of the exercise is to identify what could be done to disrupt the process.   This may be as simple as planning an evening of entertainment at home with the family.  Whatever the case may be, the better one understands themselves, the easier it is to manage their lives and to make better decisions.

 

 

Compulsivity

 

The third block of Figure 2 is compulsivity.  Compulsive actions are related to an irresistible impulse to perform an irrational act.  In essence, the user has an impulse control problem and/or is susceptible to relapse. Consequently, compulsivity is characterized as continued use of the substance despite significant substance-related problems.  Some clinicians refer to this phase as when the user begins to experience the consequences of his use.  Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop.  This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future.  The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria.  Unfortunately, the opposite emotions, of fear, hopelessness and helplessness, shame, guilt, depression and despair are often encountered.  One must remember that our minds retain the positive memorizes and have a tendency to set aside the negative ones.   The individual expects he/she will experience a high, when the negative feelings of shame and guilt develop the user is remorseful.  I think one of the root causes of severe depression is when the individual is expecting an unrealistic outcome and finally realizes he/she has to deal with a set of negative consequences.

 

 

Despair

 

Despair is the end result of addiction and is where feelings of hopelessness abound.  This block represents the consequences of compulsive use (negative impact on family, work, society, health) and the user generally has feelings of shame and guilt following episodes of use.   However, the addicted individuals mind attempts to soften his/her despair by processing thoughts such as I will never use again; things will be different in the future.  The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing the neutralizing thoughts.  So, instead of facing the addiction, the individuals mind has found another way to deny the addiction; consequently, the cycle continues.

 

 

WHY DO PEOPLE USE COCAINE

 

Adults generally begin to use cocaine in social settings with and a goal to fit into a social group.  Also, some begin to use to fight off fatigue, increase alertness and to suppress appetite.  Few if any users start out with the goal of becoming an addict; unfortunately, most are not aware of how easily and quickly they can get hooked on cocaine.  As mentioned earlier, problematic use and severe health problems may arise upon very early use.

 

 

MEDICAL COMPLICATIONS OF COCAINE ABUSE

 

Medical complications associated with cocaine abuse include cardiovascular effects, disturbances in heart rhythm and heart attacks; respiratory effects such as chest pain and respiratory failure; neurological effects, including strokes, seizures, and headaches; and gastrointestinal complications such as abdominal pain and nausea (1).

 

Cocaine use has been linked to many types of heart disease.  Cocaine has been found to trigger chaotic heart rhythms, called ventricular fibrillation; accelerated heartbeat and breathing; and increase blood pressure and body temperature.  Physical symptoms may include chest pain, nausea, blurred vision, fever, muscle spasms, convulsions, coma and death.

 

Different routes of cocaine administration can produce different adverse effects.  Regularly snorting cocaine, for example, can lead to the loss of the sense of smell, nosebleeds, problems with swallowing, hoarseness, and an overall irritation of the nasal septum, which can lead to a chronically inflamed, runny nose.  Ingested cocaine can cause severe bowel gangrene, due to reduced blood flow.  Persons who inject cocaine have puncture marks and tracks most commonly in their forearms.  Intravenous cocaine users may also experience an allergic reaction, either to the drug, or to some additive in street cocaine, which can result, in severe cases, in death.  Cocaine has a tendency to decrease food intake therefore many chronic cocaine users lose their appetites and can experience significant weight loss and malnourishment. (NIDA, Research Report Series)

 

Research has revealed a potentially dangerous interaction between cocaine and alcohol.  Taken in combination, the two drugs are converted by the body to coca ethylene.  Coca ethylene has a longer duration of action in the brain and is more toxic than either drug alone.  While more research needs to be done, it is noteworthy that the mixture of cocaine and alcohol is the most common two-drug combination that results in drug-related death.

 

It should also be noted for intravenous cocaine users that if they share drug equipment (needles) they are at risk of contracting HIV (the virus that causes AIDS). 

   

 

 

PREVENTION/TREATMENT

 

Cocaine abuse and addiction are complex problems involving biological changes in the brain, as well as a myriad of social, familial and environmental factors. Although almost exclusively handled in a residential or outpatient setting with no medical detox required, the treatment challenge is more demanding for cocaine than most other drugs and cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patents drug abuse.  There was an enormous increase in the number of people seeking treatment in the 1980s and 1990s in the United States.  Treatment providers in most areas of the country report that cocaine is the most commonly cited drug of abuse among their clients.  The majority of individuals seeking treatment smoke crack, and are likely to be polydrug users, or users of more than one substance.   

 

Pharmacological Approaches

 

There are no medications available to treat cocaine addiction, specifically.  Various agencies are aggressively pursuing the identification and testing of new cocaine treatment medications.  At present, there are several compounds that are being investigated to assess their safety and efficacy in treating this addiction.  Topiramate and modafanil have both shown promise as potential cocaine treatment agents.  Also, baclofen showed promise in a subgroup of cocaine addicts with heavy use patterns.  Antidepressant drugs have also shown to be of some benefit during early treatment.  Medications are also being developed to deal with the acute emergencies resulting from excessive cocaine abuse.  Although some medications appear promising, it is safe to say that a silver bullet to stop cocaine abuse is yet to be found.

 

 

Behavioral Interventions

 

Cognitive Behavioral Therapy (CBT) shows promising results for cocaine addicts when coupled with other programs such as Cocaine Anonymous.  Also, new evidence has been found in support of the hypothesis that a cocaine abusers personal characteristics effect what kind of treatment will work to reduce his or her drug use.  The evidence surfaced in a study in a clinic at the San Francisco Veterans Affairs Medial Center (VAMC), where investigators at the University of California, San Francisco (UCSF), compared the efficacy of CBT with 12-step facilitation (12SF). (Barbara Shine, NIDA Notes).  CBT theory holds that our surroundings strongly influence our thinking and behavior, so CBT introduces their patients to new ways of acting and thinking in response to their environment.  In the case of CBT counseling patients are urged to avoid situations that lead to drug use and to practice drug refusal strategies.

 

The 12-step recovery program is credited with helping many cocaine addicts in achieving long-term abstinence.  These fellowship programs have limited statistically measurable effects, as they do not release any quantifiable measure of its success rates.  There are, however many recovering addicts who claim this program has aided them.  They provide a type of fellowship and mutual support through regular group meetings as a path toward recovery from addiction.  The 12-step program is not affiliated with any religious group, there is a spiritual component-belief in a power greater than one’s self that helps members achieve and maintain abstinence.

 

 

RELAPSE PREVENTION

 

Probably the greatest challenge facing recovering cocaine addicts (and the substance abuse counselors who work with the clients) is to avoid relapse.  This CEU will present a prevention technique developed by Marlott and Gordon.  They described a comprehensive relapse prevention technique for alcohol and other drug addicts.  This treatment application will also help the problematic cocaine user.   Marlott and Gordon suggested an approach where high-risk situations were assessed and then coping strategies were developed for each situation.  The following factors were analyzed for each situation:

 

 

  1.           Self-Efficacy:  The individuals perception of his/her ability to cope with situations.
  2.           Expectations:  What is the consequence to the user of a specific behavior?
  3.           Attribute:  Why an individual exhibits a specific behavior.
  4.           Decision-Making:  Methodology used when the individual chooses a specific action.

 

Once this analysis is complete, Marlatt and Gordon suggest the following intervention strategies:

 

          Self-Monitoring:  Maintaining a log of urges/needs to use cocaine.  Additional information such as intensity of urge and coping strategy employed may also be documented.

         

          Direct Observation:     The individual rates the degree of temptation due to various situations.  The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters.

         

          Coping Skills:      This analytical tool is used to document the clients ability to cope once a high-risk behavior is encountered.  This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement.

         

          Decision Matrix:  The matrix is used to document the consequences of a specific decision or action.  It may be used to gather immediate, as well as delayed consequences and can document both positive and negative outcomes.

         

          Behavioral Commitment:    This tool is intended to establish limits on drug use (if any).  It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using.

 

          Reminder Questions:   They are used to key specific avoidance actions in the event of a strong urge.

 

It follows that a primary goal of any prevention program is to enable the individual to cope with future, inevitable urges to use cocaine.  The initial step is to identify the coping strategies that can be used in high-risk situations.  It is also important to discuss an implementation plans for how these skills will be used.  Some have referred to this process as setting up a self-management program.  According to Ricky George (1990), The goals of self-management programs are to teach the individual how to anticipate and cope with the problem of relapse.  This approach generally combines behavioral skills training, cognitive interventions and lifestyle changes to help the individual modify their behavior.

 

RECOVERY MODEL

 

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, and socially related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving ones level of functioning while striving to remain drug-free.  A brief overview of a recovery process follows:

 

          Pre-treatment phase:  The individual experiences or becomes aware of:

 

>Unpleasant consequences associated with drug use (family problems, loss of friends, loss of job, loss  of freedom, financial problems)

>Loss of control of their life; and emotional pain (may motivate individual to decide to enter treatment)

 

           Initial stabilization:

 

>Stop use of cocaine; avoid former using buddies

>Professionally managed coping and emotional strategies (to ease the   

  discontent associated with urges to resume using)

>Help with controlling impulsive behavior (counseling)

 

Phase 1:    Recovery (Getting Started)

 

       >Helps individual to accept and comprehend the addiction process

       >Identify use triggers:  Develop a plan to avoid and control impulses

       >Learn problem solving, stress management, and anger management skills

       >Accept personal responsibility for self (choices, decisions, behaviors, and consequences)

       >Express feelings 

 

Phase 2:    Recovery (Early)

 

       >Accepts need for recovery

       >Accepts responsibility for management of cocaine use

       >Begins to develop a drug-free self-image

       >Acknowledges the need for lifestyle changes; new friends

       >Adjusts to non-use behavior apply new problem solving skills as needed

       >May struggle with peer and family issues as drug-free lifestyle is demonstrated

       >Improved self-image.

 

Phase 3 (Middle)

 

       >Changed behavior and cognitive awareness aligned with new self-concept.

       >Accepts responsibility for own recovery.

       >Recognizes and embraces success of recovery.

       >Incorporates problem-solving skills into new lifestyle.

       >Comfortable with lifestyle changes.

       >Continues to struggle with peer and family issues.

       >Learns to balance and control life.

 

Phase 4 (Advanced)

 

      >Focus on learning coping skills to help deal with peers and family

      >Increases scope of life; starts to fulfill potential.

      >Develops balance and takes control of life.

      >Develops independence from the treatment program develops self-initiative.

      >Accepts identity as a recovering individual.

 

After Care

 

       >Positive experiences fuel personal growth.

       >Focus on total person (activities, spiritual growth and independence).

 

Keys to Avoid A Return to Problematic cocaine use:

 

       >High Activity Level: An idle mind often wanders in the wrong direction.

       >Generate To Do lists to guide daily activities.

       >Goal setting to acknowledge and reward success.

       >Individual reward system:  Work toward a specific individualized reward. 

         For example, new car, trip, clothes.

       >Plan pleasurable activities:  Hobbies, travel, reading, etc.

       >Plan self-improvement activities: Items that will help the individual feel good

          about themselves.

                  -Exercise/ active lifestyle

          -Nutrition program

          -Rest/relaxation time

        >Manage stress

        >Think positive.

        >Avoidance of high risk situations and activities

          -Events that previously led to use;

          -Avoid people/functions whose focus is on drug use.

          -Avoid things that have triggered previous relapses.

        >Develop mind-management techniques: Block negative thought processes. 

          The mind always leads the physical act (i.e., an individual thinks positive

          regarding an activity before they do the activity).  If we could train our minds

          to detect wrong thinking (about drug use), then we could alter or disrupt

          those thoughts and focus on different things or thought processes to avoid

          actually using.

               >Avoid over confident feelings, such as, I am in control and I have this problem

                 licked.  Generally, overconfidence leads to high-risk behavior and poor

                 decision-making.

              >Avoid out-of-balance emotional states.  Either feeling too good (overconfident)

                 or too bad

        (depression) can lead to resumption of use.

 

It is important for the user not to forget or rational away the pain and anguish of the former lifestyle.  The mind will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences.  At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.)  When they return to that lifestyle, they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained and one must realize that the mind can be misleading in some cases.  Teach your clients to think positive; act positive and surround themselves with positive people.