Specific, consequences of cocaine abuse on health and psycho-social functioning were assessed in 55 cocaine-abusing subjects who called a telephone “helpline.” Results showed a high incidence and wide range of adverse consequences including: (a) impairment of job functioning, interpersonal relationships, and financial status; (b) disturbances of mood and cognitive functioning; (c) psychiatric symptoms of depression, paranoia, and increased suicidal/violent tendencies; and (d) physical symptoms of exhaustion, weight loss, sleep problems, and seizures. Cocaine-related automobile accidents, suicide attempts, and violent acts, including a cocaine-related homicide, were also reported. Intranasal users reported no fewer and no less severe adverse consequences than free-base smokers or intravenous users. Our findings challenge popular notions that cocaine is a benign “recreational” drug and that the intranasal route of administration guarantees protection against addictive patterns of use and adverse effects.
Cocaine use has escalated to epidemic proportions in the U.S. in recent years. Nationwide surveys estimate that over 22 million American have used cocaine and the numbers continue to soar at an alarming rate. Moreover, cocaine use has spread considerably into the middle-class and working-class segments of American society. It is no longer a drug used only by the wealthy or elite.
Health consequences of escalating cocaine use are reflected in figures showing more than a 200% increase in cocaine-related deaths and emergency room visits and more than a 500% increase in cocaine-related admissions to federally funded treatment programs between 1976 and 1981. Despite these alarming trends, the popular belief that cocaine is a benign “recreational” drug continues to be perpetuated. Recent studies of cocaine use have focused primarily on “social-recreational” users () or on individual case reports of dysfunctional use (). Such reports tend to underestimate the prevalence of dysfunctional cocaine use and resulting adverse consequences. This is especially true for intranasal use which is commonly regarded as much safer than free-base smoking or intravenous use.
We now report data on specific adverse effects of cocaine use on health and psychosocial functioning in a sample of intranasal, free-base, and intravenous users.
Subjects and Methods
A telephone “helpline” for cocaine abusers was established at out facility in February 1983. Local television and radio stations publicized the helpline by informing cocaine users that they would call anonymously for information, advice or referral to treatment. We conducted a 20-30 minute telephone interview and administered an extensive questionnaire to the callers to obtain data on demographic variables, drug use, psychiatric history, and particularly on consequences of cocaine use within specific areas of physical health and psychosocial functioning. Consequences were grouped into several categories each containing a checklist of specific items, as follows: (1) Physical Consequences – nausea/vomiting, sweating, nasal sores/bleeding, headaches, persistent cough/sore throat, feel run down and Weak, sleep problems, chills, hands tremble, double vision, seizures/loss of consciousness; (2) “Major” Psychological or Behavioral Consequences – paranoid ideation, physically injured someone, hallucinations; (3) “Minor” Psychological or Behavioral Consequences – irritable, short-tempered, depressed, anxious, lazy, low on energy, difficulty concentrating, confused thoughts, memory problems, loss of sex drive; (4) Vocational Consequences – lateness, absence, reduced productivity at Work; (5) Interpersonal Consequences – increased discord with spouse/ mate, spouse leaves or threatens to leave, impairment of social life and friendships, impaired sexual relationship; (6) Legal, Consequences – arrests for possesion or sale of cocaine or related crimes; (7) Financial Consequences – depleted bank acounts, unable to keep up with bills, no extra money, accumulated debts; (8) Automobile Accidents – any cocaine-related auto accident involving damage to property and/or persons.
Over 2,000 calls Were received on the helpline during its first eight weeks of operation and calls continue to be received at a rate of 25-100 per day. Approximately 70% of the calls are from cocaine abusers themselves and the remainder from concerned family members, friends, or professionals. Data presented here are fran the first 55 cocaine abusers who were interviewed on the helpline.
Our sample was: 78% male, 22% female, ages 22-59 years (X=33 yrs); 56% were white, 35% black, 9% Hispanic. Mean level of education was 14.1 years, range 9-18 years. Forty-nine percent had annual incomes over $25,000; 53% had occupations in the categories of white collar, professional, or self-employed business owner. Preferred route of cocaine administration was: intranasal (IN) 51%; free-base smoking (FB) 22%; and intravenous (IV) 27%. Estimates of weekly cocaine use ranged from 1-32 gram/week with a mean of 8.2 grams. Forty-eight Percent used 6 grams or more per week. Frequency of cocaine use averaged 5.7 days/week; 56% used at least 5 days/week. At prices of $100-$125 per gram, the average amount of money spent per week on cocaine was over $800 and ranged fran $109 to $3,150. No differences were found between the IN, FB, and IV groups with regard to weekly dose estimates or frequency of cocaine use.
Percentages who responded “yes” to each of the following statements about their cocaine use were: (a) psychologically addicted to cocaine – 92%; (b) have lost control over cocaine use – 91%; (c) crave cocaine and feel a compulsion to use it -81%; (d) want to stop using cocaine – 80%; and (e) feel unable to stop using cocaine without help – 75%. Sixty-four percent reported no concurrent regular use of drugs other than cocaine; the remaining 36% reported using tranquilizers, marijuana, alcohol, or heroin to reduce the stimulant effects of cocaine or to relieve the dysphoric “crash” when cocaine effects wore off.
A high incidence and wide range of adverse consequences of cocaine use were reported. The percentage of subjects reporting at least one, but usually several consequences within each category were as follows: (a) Physical Health – 98%; (b) Interpersonal – 93%; (c) “Minor” Psychological – 93%; (d) “Major” Psychological – 56%; (e) Vocational – 64%; (f) Financial – 84%; (g) Legal – 13%; and, (h) Auto Accident – 6%. A characteristic pattern of disruptive functioning was reported by most subjects, consisting of: (a) absenteeisn and reduced effectiveness at work; (b) increased discord with spouse/mate leading to actual separation or threat to separate; (c) diminished or exhausted financial resources and accumulation of debts; and, (d) feeling depressed, anxious, irritable, and overwhelmed with problems. The incidence of specific consequences within areas of physical health and psychological functioning is shown in Table Incidence of reported consequences of cocaine use (n =55):
|PHYSICAL HEALTH||# S’s||% S’s|
|Exhausted and weak||33||60%|
|Significant weight loss||18||33%|
|Seizure and loss of consciousness||6||11%|
|Physically injured someone||6||11%|
|Depressed, bad mood||36||65%|
|Loss of sex drive||24||44%|
The most common physical complaints were exhaustion and excessive sleeping following a binge of cocaine use. Nasal problems and headaches were characteristic of IN users with one reporting a perforated nasal septum. Persistent cough and sore throat was characteristic of FB smokers. The most disturbing physical consequence was seizure with loss of consciousness which reportedly occurred on at least several occasions of high-dose cocaine use in some of our subjects. Reported “minor” psychological consequences included mood disturbances, loss of sex drive, and impaired cognitive functioning. Among “major” psychological consequences, the most commonly reported was paranoid ideation consisting of exaggerated concerns about intruders as well as extreme mistrust of family members, friends, and neighbors. Two subjects reported symptoms of cocaine-induced psychosis characterized by eleaborate paranoid delusions with ideas of reference and persecution, as well as auditory and visual hallucinations. Increased violent and suicidal feelings or behaviors were reported in some cases. One subject reported committing a murder while high on cocaine. No consistent relationship was found between the incidence of reported consequences and either dose or frequency of cocaine use. A substantial number of consequences were consistently reported across a Wide range of doses and frequencies of cocaine use. Also, the IN, FB, and IV groups did not differ with regard to the incidence or type of reported consequences. Contrary to expectation, IN users reported no fewer and no less severe consequences than FB or IV users. The psychoactive, mood-altering effects of cocaine considered most desirable by our subjects included: feelings of elation, mastery, confidence, self-control, and sexual arousal; increased talkativeness, physical energy, and contentment; and, elimination of boredom, fatigue, and stress. However, almost without exception these desirable effects diminished or disappeared entirely With continued, chronic use and were eventually replaced by an increasing number of adverse effects such as depression, irritability, loss of sex drive, and intense guilt. In a futile attempt to recapture the desirable effects and to Ward off the unpleasant “crash,” behavior Was driven toward continued and intensified patterns of cocaine use. Our subjects found themselves progressively drawn into a powerful, vicious cycle of obtaining, using, and recuperating from cocaine. The accumulated adverse consequences of cocaine use and resulting psychological distress are what ultimately led them to call our helpline for assistance.
The large volume of calls to our helpline appear to reflect the increasing prevalence of cocaine dependence in the U.S., especially among White, middle-class males who are otherwise not heavily involved in drugs. Not only are more people using cocaine, but increasing numbers are developing addictive patterns of use and suffering serious disruption to their functioning. The popular belief that cocaine is a non-addictive, social drug, With low abuse potential, especially if used by the intranasal route, is challenged by our findings that all three routes of administration (snorting, smoking, injecting) were associated With compulsive use patterns characterized by loss of control over use, persistent craving and compulsion to use cocaine, and continued use despite serious adverse consequences. Although addictive patterns might develop more rapidly with free-base smoking or intravenous use, our findings and others () demonstrate that intranasal users are not exempt from uncontrollable use or from adverse consequences. Recent reports of death from intranasal use () underscore the fact that toxic blood levels of cocaine can be achieved by this route. Individuals With epilepsy, hypertension, or cardiovascular disease might be especially prone to fatal reactions.
Admittedly, our sample was biased since all subjects were problematic users as self-defined by their calling the helpline. Moderate users, by definition, tend not to suffer medical or psychological consequences. Nonetheless, it cannot be concluded that even moderate levels of intranasal use guarantee protection against eventual dependence and other adverse effects. Most of our subjects began with occasional use and were rather surprised at how quickly and intensely their use escalated to compulsive patterns especially because they had thought cocaine was non-addictive. The question of why some users escalate to addictive patterns is of substantial clinical importance, but remains largely unanswered at present. Comparison of social-recreational users with compulsive users might elucidate some important individual differences.
Although psychological dependence on cocaine does occur, whether cocaine produces true physical dependence remains a question. After cessation of chronic cocaine use, the user usually does not experience a clearly definable withdrawal syndrome as with heroin or barbiturates. However, the generalized dysphoria and feelings of malaise following cocaine use may be viewed as a withdrawal state especially since they are associated with drug craving and drug-seeking behavior and are relieved by resumption of cocaine use. Furthermore, our findings suggest that with chronic use of cocaine tolerance develops to many of its effects.
The large volume of anonymous calls to our helpline suggests that a substantial portion of cocaine abuse is otherwise hidden from scientific or public analysis. Estimates of the prevalence and consequences of cocaine abuse based on death rates, emergency-room visits, and treatment admissions may grossly underestimate the current extent of the problem. Nearly all our subjects had no history of treatment for any aspect of drug abuse, especially the more middle-class abusers who had dismissed the idea of seeking help in the usual type of drug abuse clinic that is known to treat mainly heroin addicts. There is currently no specific treatment for cocaine abuse with demonstrated efficacy. A number of pharmacologic agents (e.g., desipramine, methylphenidate, lithium carbonate) are being evaluated in the treatment of cocaine abusers at our outpatient facility and elsewhere (). Preliminary findings suggest the potential usefulness of these medications in selected patients when combined with frequent contact and supportive counseling or psychotherapy. Some cocaine abusers require hospitalization because of psychosis, acting-out behavior, or inability to refrain from cocaine use.
It is likely that adverse consequences of cocaine use will become increasingly prevalent and visible during the next few years. Cocaine’s reputation as a relatively safe recreational drug has already contributed to more widespread abuse. If cocaine were more readily available and at a substantially lower cost, or if social sanctions and scientific information failed to caution against intensified use, even larger numbers Would suffer serious consequences from this very seductive drug. It is imperative, therefore, that accurate information be gathered and disseminated about specific consequences of cocaine abuse.
There is a pressing need for expanded research and treatment efforts to combat the current epidemic of cocaine abuse in the U.S. and prevent it from escalating further.
Selections from the book: “Problems of Drug Dependence, 1983. Proceedings of the 45th Annual Scientific Meeting, the Committee on Problems of Drug Dependence, Inc.” Louis S. Harris, Ph.D., ed. A collection of papers which together record a year’s advances in drug abuse research; also includes reports on tests of new compounds for efficacy and dependence liability. National Institute on Drug Abuse Research Monograph 49, March 1984.