Epidemiology. Cocaine is a derivative of the coca plant (Egthroxylon coca, birthplace – Central America), the leaves of which the Indians have long used to chew in order to obtain a stimulating effect and reduce hunger. Cocaine was part of the original formula of coca-cola drink and, until now, has medical use as a local anesthetic. In connection with the cheaper manufacturing process, cocaine use has been steadily increasing since the late 1970s. Psychological mechanisms predisposing to cocaine use, are the desire to improve their self-affirmation, social status and escape from depression.
Clinic. The main pharmacodynamic effect of cocaine is blockade of dopamine, serotonin and epinephrine receptors. The nature of its specific activation of mesocortical dopaminergic structures is unclear. Cocaine powder is more often inhaled through the nose, or when smoking (“crack”) its alkaloid form is inhaled. Subcutaneous and intravenous administration is also used. The drug gives an intense feeling of euphoria, lasting 15-30 minutes. after intravenous or intranasal administration.
In addition to the main ones (see below), signs of acute intoxication can be impulsive sexual and psychomotor agitation, often reminiscent of a hypomanic condition, decreased concentration, insomnia. Signs of intoxication are spontaneously stopped within 48 hours, however, the state of dysphoria and increased fatigue accompanying the reversal is easily removed by cocaine, alcohol or sedatives, which stimulates repeated abuse. A characteristic behavioral trait is the desire, being in a social environment, often retire to take the drug.
Many of the users of cocaine, while controlling its use, have long avoided physical dependence, but the opinion that cocaine does not cause it, which was widespread in the 1970s, turned out to be erroneous. The period of dependence formation is 4 years in adults and 1.5 years in adolescents. Psychological dependence develops very quickly and may appear after a single dose. Under experimental conditions, monkeys, which are given the opportunity to introduce themselves to cocaine, do this all the time, until death occurs against the background of suppression of the activity of the centers of the medulla oblongata. People often have a “drunken” stereotype of use – from several hours to several days with weight loss, dehydration, high risk of psychosis and death. Death, however, is more likely when cocaine is used to potentiate the effects of opiates.
Cocaine psychosis is clinically similar to amphetamine. Perhaps dangerous to others aggressive behavior. Tactile hallucinations are often accompanied by a feeling of insects crawling under the skin. This phenomenon is referred to as “crawling”, “cocaine insect” or Magnan symptom, which was first described in 1889. It is usually associated with the parenteral administration of cocaine.
With prolonged intranasal admission develops chronic rhinitis, ulceration of the nasal mucosa, up to necrosis of the nasal septum due to vascular spasm. Reducing serotonin levels contributes to the appearance of depression and suicidal tendencies on the background of withdrawal syndrome. The peak of the withdrawal syndrome occurs at 2-4 days after discontinuation, although some symptoms (depression, irritability) can persist for up to several weeks.
Cocaine has a generalized sympathomimetic effect on the vascular system, which can lead to cardiac arrhythmias and a high rise in blood pressure with hemorrhage in the brain as a possible complication. Other complications can be myocardial infarction and status epilepticus.
The diagnosis of acute intoxication is made on the basis of common for Fix. On the criteria, as well as: 1) the presence of at least one of the following mental symptoms: a) euphoria with a sense of energy surge, b) a feeling of increased vigor, c) a tendency to reassess one’s own personality, grandiosity of plans, d) conflict, aggressive behavior, e a) affective instability, e) repeatability, stereotyped behavior, g) auditory, visual or tactile illusions, h) hallucinations with intact orientation, and) paranoid ideas, j) reduced mental productivity and productivity; 2) the presence of at least two of the following somatic symptoms: a) tachycardia (sometimes bradycardia), b) cardiac arrhythmia, c) hypertension (sometimes hypotension), d) alternation of profuse sweat with a feeling of cold, e) nausea, vomiting, e) loss weight, g) pupil dilation, h) psychomotor anxiety (sometimes adynamia), and) muscle weakness, j) chest pain, l) convulsive seizures.
The diagnosis of withdrawal syndrome is made on the basis of common criteria for Flx.3, the presence of affective disorders (for example, depression or anhedonia), as well as at least two of the following symptoms: a) feeling of increased fatigue, b) psychomotor retardation or anxiety, c) craving for cocaine, d) increased appetite, e) insomnia or increased sleepiness, f) freakish or unpleasant dreams.
Treatment. In case of acute cocaine intoxication, oxygenation of the lungs (if necessary under pressure) in the Trendelenburg pose is prescribed. In the presence of seizures, intravenous diazepam (5-10 mg). The latter is also indicated in the presence of anxiety with hypertension and tachycardia. It is also possible to introduce an antagonist of the sympathomimetic effect of cocaine – propranolol (every minute / 1 mg to 8 minutes), although it is not a defense against lethal doses or a treatment for severe overdose.
Emerging psychotic symptoms is an indication for the appointment of neuroleptics. A stationary stay when taken out of a state of intoxication has, inter alia, The goal is to prevent access to the drug and control suicidal tendencies. Sleep therapy (lorazepam) aims to better subjectively tolerate withdrawal symptoms. In some cases, tricyclic antidepressants, MAO inhibitors, and lithium (with an affect cycle) are effective for maintaining abstinence.
Psychotherapy and rehabilitation is carried out as in alcoholism. Significantly contributing to the substitution of the illusory psychological effect of cocaine more realistic self-affirmation of the patient in social life. Interpersonal therapy focuses on the analysis of communicative behavior, specific situations that are the starting points for anesthesia. In a state of cocaine abstinence, substitution alcoholism is fraught with a relapse of cocaine.
Mental and behavioral disorders resulting from the use of other stimulants, including caffeine
Clinic. The most well-known nervous system stimulants are amphetamine dextroamphetamine (dexedrine), methamphetamine (methedrine), methylphenidate (Ritalin). The pharmacodynamic effect is ensured by interfering with the metabolism of serotonin, norepinephrine and (more so than cocaine) dopamine. Stimulants are usually taken by mouth, although intravenous administration is also used. Small doses cause a rapid improvement in health, an increase in mental productivity, a decrease in feelings of fatigue and hunger, and a reduction in the pain threshold. This justifies the medical use of drugs for concentration disorders in children and adults, obesity and potentiation of the action of antidepressants.
High-risk groups of abuse: patients undergoing obesity treatment, professional athletes, drivers on long-haul flights. With an increase in tolerance, the daily dose can reach 1 g; conditionally lethal dose is 120 mg. The symptoms of acute intoxication and withdrawal are generally identical to those of cocaine use (see F14). In addition to the main somatic symptoms, in a state of intoxication can be observed: the game of vasomotors, cyanosis, minor hemorrhages, subfebrile, bruxism (gnashing of teeth), difficulty breathing, tremor, ataxia; in severe cases, coma. Here are often observed t. amphetamine stereotypes are essentially purposeless repetitive actions, such as the constant cleaning of shoes or the assembly and disassembly of electrical appliances. Mental manifestations may include anxiety, dysphoria, irritability, internal stress, logorei, insomnia, disturbances of the body, anxiety, confusion.
A characteristic sign of caffeine withdrawal may be a persistent or throbbing headache that develops 15–18 hours after the last dose. Death from overdose occurs on the background of hyperthermia, seizures, and cardiovascular insufficiency. The most dangerous and characteristic symptom of withdrawal is depression with suicidal tendencies. In contrast to schizophrenia, psychotic intoxication episodes characterize hyperactivity, hypersexuality, the prevalence of visual hallucinations over the auditory, less pronounced disorders of thinking.
Treatment. With overdose therapy, the oxidation of urine (ammonium chloride) contributes to the acceleration of the drug from the body. When treating withdrawal syndrome, hospitalization may be necessary to control suicidal and socially dangerous behavior. The high degree of dependence on the drug makes psychotherapy especially difficult here.