Epidemic free-base cocaine abuse. Case study from the Bahamas

Cocaine use and stroke

Stroke is the third most common cause of death in developed countries. In England and Wales, 1000 people under the age of 30 have a stroke each year. Cocaine is the most commonly used class A drug, and the first report of cocaine-induced stroke was in 1977. Since the development of alkaloidal "crack" cocaine in the 1980s, there has been a significant rise in the number of case reports describing both ischaemic and haemorrhagic stroke associated with cocaine use. Cocaine is a potent central nervous system stimulant, and acts by binding to specific receptors at pre-synaptic sites preventing the reuptake of neurotransmitters. The exact mechanism of cocaine-induced stroke remains unclear and there are likely to be a number of factors involved including vasospasm, cerebral vasculitis, enhanced platelet aggregation, cardioembolism, and hypertensive surges associated with altered cerebral autoregulation. The evidence surrounding each of these factors will be considered here.

The pathophysiology of cocaine abuse

Cocaine is a naturally occurring alkaloid that increases dopamine concentrations in the reward centers of the brain. There has been a marked increase in cocaine abuse over the last two decades. A neuropsychological stimulant, cocaine also reduces somnolence, increases alertness and improves concentration. However, cocaine abuse has many pathophysiological consequences. These fall broadly into four groups: pathology associated with a drug abusing lifestyle, pathology that occurs whilst intoxicated with (but not directly due to) the drug, pathology associated with drug administration and pathology resulting from pharmacological action of the drug. This review provides a detailed description of the physiological, pharmacological, and pathological effects of cocaine, and highlights the forensic and medicolegal implications of cocaine abuse.

Comparison of meconium and neonatal hair analysis for detection of gestational exposure to drugs of abuse

BACKGROUND

Meconium and hair are two biological markers of in utero exposure to illicit drugs.

OBJECTIVE

To compare the sensitivity of the two tests for different drugs.

SETTING

Motherisk laboratory which tests in utero drug exposure in Toronto.

METHODS

Cocaine, benzoylecgonine, opiates, cannabis, benzodiazepines, methadone, and barbiturates were measured in pairs of hair and meconium samples from the same neonates.

RESULTS

Meconium was marginally more sensitive than neonatal hair for detection of cocaine and cannabis, possibly because it may detect second trimester exposure whereas hair grows only during the third trimester of pregnancy. There was a significant correlation between hair and meconium concentrations of cocaine, cannabis, and opiates.

CONCLUSION

In cases of clinical suspicion and a negative neonatal urine test, both meconium and hair are effective biological markers of in utero illicit drug exposure. Meconium may be more sensitive, but neonatal hair is available for three months whereas meconium is available for only one or two days. In contrast, the use of meconium, being a discarded material, is more acceptable to some parents than hair testing, which entails cutting scalp hair from the newborn.

Relationship between extent of cocaine use and dependence among adolescents and adults in the United States

The relationships between intensity of cocaine use, route of administration and past year dependence were investigated in a nationally representative sample of past year cocaine users aged 12 and over (N = 2,349) from three aggregated surveys (1991-1993) of the National Household Survey on Drug Abuse (NHSDA). An approximate measure of DSM-IV dependence criteria was developed from self-reported symptoms of dependence and drug-related problems. The model and the data provided no basis for rejecting the hypothesis that the logit of the probability of dependence increased linearly with the logarithm of the frequency of cocaine use in the past year and with quantity of cocaine use in the past 30 days. The associations between frequency and quantity of cocaine use and cocaine dependence varied significantly by an age-by-gender interaction and race/ethnicity. African-American users, who had higher rates of cocaine dependence than whites, used cocaine more frequently, used it by more addictive routes (smoking or injection), and were more likely to use crack. Adolescent females, who reported higher rate of cocaine dependence than males, used cocaine more frequently and reported more symptoms at low doses of cocaine use. Multivariate logistic regressions indicated that frequency and quantity of use, as well as route of administration, retained unique associations with cocaine dependence. Implications of the findings for the epidemiological study of cocaine use and dependence are discussed.

Epidemic crack cocaine use linked with epidemics of genital ulcer disease and heterosexual HIV infection in the Bahamas: evidence of impact of prevention and control measures

BACKGROUND

Epidemic freebase/crack cocaine use began in the Bahamas in 1982, closely followed by epidemics of genital ulcer disease (GUD) and HIV infection. Numbers of new clients receiving ambulatory treatment for cocaine use in Nassau peaked in 1984.

GOAL

To assess interrelations among epidemics of crack use, GUD, and HIV infection.

STUDY DESIGN

The study was designed for review and comparison of temporal trends in ambulatory and inpatient treatment of cocaine users and in numbers of cases of sexually transmitted disease (STD) and HIV infection in the Bahamas. A retrospective case-control study of cocaine use and STDs was performed at the Comprehensive Dermatovenereology Clinic in Nassau.

RESULTS

Ambulatory visits and inpatient admissions for cocaine use peaked in 1984 and 1987, respectively. GUD cases increased 12-fold in the Bahamas from 1983 to the period of 1985-1987 and then declined. At the Comprehensive Dermatovenereology Clinic, gonorrhea cases outnumbered bacterial GUD cases approximately 10:1 in 1982 and 1983, but the latter increased to outnumber gonorrhea cases in 1985 and 1987-1988. Annual HIV seroprevalences at new-problem visits rose from less than 0.3% in 1986 to 12.9% by 1994 and then leveled off. Cocaine use among patients seen with STD from 1985 through 1990 was significantly associated with GUD (odds ratio [OR], 3.3; 95% CI, 2.1-5.1), secondary syphilis (OR 5.5; 95% CI, 2.4-12.6), and HIV infection (OR, 8.1; 95% CI, 4.3-15.2).

CONCLUSIONS

In temporally linked successive epidemics of cocaine use, GUD, and HIV infection, case-control analyses confirmed the association of cocaine use with GUD and with HIV infection. Declining GUD and HIV seroprevalence stabilization followed declines in cocaine use and implementation of syndromic management of GUD, as well as intensified partner-notification efforts.

Epidemic Lymphogranuloma venereum during epidemics of crack cocaine use and HIV infection in the Bahamas

BACKGROUND

Since the early 1980s, the Bahamas has experienced sequential epidemics of freebase/crack cocaine use, genital ulcer-inguinal adenopathy disease (GUD), and heterosexual HIV infection.

GOAL

To prospectively define the etiology of GUD in patients at the Princess Margaret Hospital during outbreaks of crack cocaine use, GUD, and HIV infection in the Bahamas.

STUDY DESIGN

In Nassau, 47 consecutive patients with GUD underwent serologic testing for syphilis and for infections with HIV, herpes simplex virus type 2 (HSV-2), and Chlamydia trachomatis. Genital ulcer specimens were tested by culture and/or polymerase chain reaction (PCR) assay for Haemophilus ducreyi; by PCR and/or antigen assay for HSV; and by PCR for C trachomatis. Lymph node aspirates were tested by PCR for C trachomatis and H ducreyi.

RESULTS

Twenty patients (43%) had HIV infection; eight had lymphogranuloma venereum (LGV), confirmed by PCR detection of C trachomatis sequences consistent with the L2 serovar; and nine others had possible LGV, on the basis of serum microimmunofluorescent C trachomatis antibody titers > or =256. Inguinal lymphadenopathy or bubo was present in 15 of 17 patients, who thus met the laboratory criteria for definite or possible LGV, and in 7 of 30 who did not meet such laboratory criteria (P < 0.001). Thirteen patients had confirmed genital herpes, seven had confirmed chancroid, and four had probable or possible primary syphilis.

CONCLUSIONS

The epidemics in the Bahamas of crack use, heterosexual HIV infection, and GUD apparently included epidemic transmission of LGV.

Cocaine: history, use, abuse

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Substance abuse: infant and childhood outcomes

Many children are born to women who consume drugs such as alcohol, cocaine, heroin, methadone, marijuana, and/or phencyclidine (PCP) during pregnancy. As a result, some children are growing up with both physical and developmental delays. Children with fetal alcohol syndrome have reported problems with growth, attention deficit disorder, and other medical problems. Impaired cognitive and neurologic functioning through the first 2 years of live has been documented for children exposed to methadone while in utero. Those children exposed to polydrug use including cocaine and marijuana seem to have difficulties with language development and verbal skills. Some of these deficiencies show improvement with early intervention and a nurturing environment, but in many cases the impairment continues throughout childhood. Because experimentation with drugs occurs at an early age, education related to drug prevention should begin early, possibly with school-aged children. Drug prevention education needs to be age and developmentally specific. The use of appropriate drug prevention strategies may help children make good decisions regarding drug use, especially during the teenage years when adolescent pregnancy may occur.

Drug-induced hyperthermia

Drug-related causes of hyperthermia can often be overlooked in the setting of elevated body temperature. This article reviews the pathophysiology, presentation, and treatment of several drug-induced hyperthermia syndromes: malignant hyperthermia, neuroleptic malignant syndrome, sympathomimetic poisoning, and anticholinergic toxicity. Although the general approach is similar, specific management strategies may be required for each syndrome.

Neurovascular complications of cocaine

Use of cocaine in the USA, has reached epidemic proportions since 1983, when "crack" was introduced, its higher potency compared with cocaine HCl has been associated with a tremendous increase in the incidence of strokes. This study reports our experience with 55 cases of neurovascular events (25 ischemic and 30 hemorrhagic) related to cocaine use in 54 patients. Only 15 patients had other risk factors for stroke. Twenty six patients smoked "crack", 10 snorted cocaine and 12 injected it intravenously. Strokes occurred within 3 h of cocaine use in 15 patients with infarcts and 17 with hemorrhages. Ten infarcts occurred after an overnight binge. Of the hemorrhage group 9 were subarachnoid, 16 intracerebral (8 basal ganglia, 7 hemispheric and one brain stem) and 5 intraventricular. Computerized tomography (CT) showed an aneurysm of the anterior communicating artery, as well as one of the vein of Galen. Four aneurysms and 3 AVMs were identified on angiography. CT revealed 15 infarcts; it was normal in 7 patients with pure motor hemiparesis and in 3 with findings consistent with anterior spinal artery infarction. Several mechanisms may be responsible for the cerebrovascular complications. A sudden rise in systemic arterial pressure may cause hemorrhages, frequently in association with an underlying aneurysm or AVM. Vasospasm, arteritis, myocardial infarction with cardiac arrhythmias and increased platelet aggregation may provoke infarcts.

Human ecology and behavior and sexually transmitted bacterial infections

The three direct determinants of the rate of spread of sexually transmitted diseases (STDs) are sexual behaviors, the mean duration of infectiousness, and the mean efficiency of sexual transmission of each STD. Underlying ecological and behavioral factors that operate through one or more of these direct determinants lie on a continuum, ranging from those most proximate back to those more remote (in time or mechanism) from the direct determinants. Most remote and least modifiable are the historical stages of economic development that even today conspicuously influence patterns of sexual behavior. Next are the distribution and changing patterns of climate, hygiene, and population density; the global population explosion and stages of the demographic transition; and ongoing changes in human physiology (e.g., menarche at younger age) and culture (e.g., later marriage). More proximate on the continuum are war, migration, and travel; and current policies for economic development and social welfare. Most recent or modifiable are technologic and commercial product development (e.g., oral contraceptives); circumcision, condom, spermicide, and contraception practices; patterns of illicit drug use that influence sexual behaviors; and the accessibility, quality, and use of STD health care. These underlying factors help explain why the curable bacterial STDs are epidemic in developing countries and why the United States is the only industrialized country that has failed to control bacterial STDs during the AIDS era.

Smoked cocaine: patterns of use and pulmonary consequences

This article offers a perspective on the use of volatilized alkaloidal cocaine in its freebase and crack forms and on the pulmonary consequences of such use. The inhalational route of administration of freebase and crack cocaine exposes the lung to their combustion products, raising concern about possible adverse pulmonary effects. A brief historical review of cocaine and its methods of use precedes the presentation of data concerning current modes and patterns of use and some pulmonary complications of crack and freebase use. Results from a systematic study of a large sample of cocaine users document a high frequency of occurrence of acute respiratory symptoms in temporal association with cocaine smoking. No relationship was detected between the prevalence of acute pulmonary symptoms and identifiable aspects of techniques of cocaine administration. These results suggest that the respiratory consequences of alkaloidal cocaine are most likely attributable to the inhaled cocaine itself, rather than to variable characteristics of usage.

Frequency of coronary artery disease and left ventricle dysfunction in cocaine users

To evaluate the spectrum of coronary artery disease (CAD) in cocaine users, coronary angiograms obtained from 33 patients (26 men [79%] and 7 women [21%], mean age 37 years) with history of cocaine use and cardiac symptoms were retrospectively reviewed. Clinical indications for coronary angiograms included chest pain (n = 28), congestive failure (n = 4) and complete heart block (n = 1). Coronary angiograms were reviewed independently by 2 angiographers unaware of patient's clinical status. Thirteen patients (40%) had normal coronary angiograms, and 20 (60%) had CAD; 7 (21%) had mild CAD (less than or equal to 70% diameter stenosis), and 13 (40%) had significant CAD (greater than 70% diameter stenosis). Of 13 patients with significant CAD, 7 had 1-vessel, 4 had 2-vessel and 2 had 3-vessel CAD. There was enzymatic evidence of myocardial infarction in 12 of 33 patients (36%); all 12 had CAD (10 with significant and 2 with mild CAD). Mean age and number of risk factors (serum total cholesterol, cigarette smoking, systemic hypertension, diabetes mellitus, family history of CAD, and obesity) in patients with CAD (mild or significant) and with normal coronary angiograms were not statistically different. Left ventricular ejection fraction was normal in 15 patients (45%) and depressed in 18 (55%). All patients with CAD and low ejection fractions (n = 12) had regional wall motion abnormalities, whereas all those with normal coronary arteries and low ejection fraction (n = 6) had global hypokinesia.

Cardiovascular complications of cocaine

Cocaine use is escalating in the United States. Cocaine produces sympathomimetic effects and causes generalized vasoconstriction involving multiple organ systems. Its cardiovascular complications may be life-threatening and include myocardial infarction, myocarditis, cardiomyopathy, arrhythmias, and aortic dissection. Accurate diagnosis and prompt management can be life-saving. This review focuses on the current information available on the cardiovascular complications of cocaine and suggests guidelines regarding their management strategies.

Medical complications of cocaine: changes in pattern of use and spectrum of complications

We sought to determine whether changes in patterns of cocaine use, characterized by widespread abuse of cocaine alkaloid, have altered the nature and severity of medical complications over the past decade. Infectious complications, almost invariably associated with intravenous use, accounted for nearly all hospital admissions in the early 1980s. Cardiovascular, neurologic and psychiatric complications rose dramatically after 1987 both in absolute number and as a proportion of total complications. This rise parallelled increases in the absolute number and proportion of hospitalized patients smoking cocaine alkaloid or using intranasal cocaine, both disproportionately associated with non-infectious complications. While infectious complications were often local in nature, serious neurologic and cardiovascular sequelae were observed. These data indicate that changes in patterns of cocaine use have altered the nature and increased the severity of medical complications with a shift from infectious to cardiovascular, neurologic and psychiatric complications which may be life-threatening and associated with substantial morbidity.

Cocaine: the newest risk factor for cardiovascular disease

Cocaine-related cardiovascular events escalated during the 1980s as cocaine became purer, cheaper, and easier to obtain. Cocaine abuse is a risk factor for myocardial ischemia and/or infarction, cardiac arrhythmias, pulmonary edema, ruptured aortic aneurysm, cerebral infarction, infective endocarditis, vascular thrombosis, myocarditis, and dilated cardiomyopathy. As medical and social complications of cocaine have become evident, and with the growing negative image of cocaine, the number of first-time users has begun to decline. Cocaine abuse is seen on all levels of our society and has emerged as an issue of significant medical and public health importance. All routes and forms of cocaine abuse are potentially cardiotoxic and can be lethal. Fatal cardiac complications can occur in a first-time user. All physicians should be alert for cocaine abuse when confronted with unexplained cardiac symptoms. Cocaine is the newest and sometimes unrecognized risk factor for cardiovascular disease in young individuals otherwise free of cardiovascular risk factors.

A simple test of cocaine craving and related responses

This study evaluated a self-rated instrument for assessing perceived craving, mood, energy, and health levels in patients who are withdrawing from cocaine addiction. The instrument consisted of four 20-centimeter line scales. Twenty-five patients in a 28-day inpatient addictions treatment unit were chosen at random points in their treatment and given a chance to rate themselves on each scale by making a mark on a line that corresponded to their self-perception. Each patient performed two self-assessment, one day apart. The scores for each scale were correlated and found to be highly reliable. Surprisingly, none of the other three scale scores had a strong relationship with craving, and possible reasons for this result are discussed.

The cardiovascular effects of cocaine

Cocaine use and abuse continue to overwhelm urban economic, social, and health care systems. Patients frequently present to the emergency department with life-threatening manifestations of cocaine use, including trauma, acquired immune deficiency syndrome, psychomotor agitation, and cardiovascular collapse. Adequate treatment of the cocaine-intoxicated patient requires a critical understanding of the risk-to-benefit ratios for pharmacologic, toxicologic, and surgical or obstetric interventions. The pharmacologic and physiologic bases for the vascular manifestations of cocaine toxicity and experimental evidence for treatment strategies are reviewed.

Inhalational administration of cocaine in sheep

A pipe for administration of inhaled cocaine and its pyrolytic products in laboratory animals was developed and tested. In-vitro trials showed 30.0 +/- 5.2% (mean +/- SE) recovery of cocaine in solvent. Five non-pregnant ewes were instrumented with tracheal T-tubes and vascular catheters. After surgical recovery, ewes received three doses of cocaine (free base) in a randomized fashion; 2 mg/kg and 4 mg/kg both by inhalation, and 2 mg/kg intravenously. Arterial blood samples were collected and assayed for cocaine and its major metabolites by high performance liquid chromatography. Blood pressure and heart rate were continuously recorded. Cocaine administered by inhalation was eliminated with a half-life of 1.6 +/- 0.5 min (mean +/- SE) compared to 3.4 +/- 0.9 following intravenous administration (p less than 0.03). Likewise, clearance values were greater following inhalation, 5532 +/- 1756 ml/min/kg, than following intravenous administration, 163 +/- 20.6 ml/min/kg (p less than 0.04). Both routes of administration led to significant elevations in blood pressure, 7.5% increase after smoking vs 20% increase after intravenous administration. No correlation was found between inhalational dose of cocaine and peak plasma cocaine concentration.

Experience of Crack Use: Findings from a Community Based Sample in Toronto

This paper presents Canadian data on crack use collected from a community-based study of seventy-nine crack users in Toronto, and compares these findings with popular images of crack and its users. Crack was portrayed in the media and police reports as extremely dangerous because of the quick and intense high from smoking it and its powerful addictive property. Data from the study show that, while the quick and intense high was what crack users liked most, adverse physical, psychological and financial consequences of crack addiction have also cautioned users. The overall frequencies of use in the past month, past year, and lifetime were quite low, suggesting that crack use is not necessarily compulsive. The major factor affecting level of use was perceived risk of harm. Crack users were likely to be powder cocaine users as well, and they did not differ significantly from powder users with respect to sociodemographic characteristics. Treatment and prevention implications of the findings are discussed.

Freebase cocaine and memory

Despite the seriousness of acute medical and psychological consequences of cocaine abuse, little knowledge exists about the chronic effects of the drug. Investigation of a sample of abstinent freebase (crack) abusers in the Bahamas provides the first research evidence that prolonged cocaine abuse may result in persistent short-term memory disturbances.

A method for delivery of precise doses of smoked cocaine-base to humans

Despite increasing smoked cocaine-base use, there have been relatively few parametric studies in this area. The major reason for the limited number of studies is the lack of a simple procedure for the administration of precise doses of smoked cocaine-base to human volunteers. This paper describes a new method that allows for the delivery of precise doses of smoked cocaine-base. A complete description of the method and the precision of the administration procedure are presented. Furthermore, a study is described which was undertaken to determine: 1) the reproducibility of peak blood cocaine levels when the same dose of cocaine was given on two separate occasions; and 2) the dose-related effects on smoking topography, biochemical, physiological and subjective measures. Subjects (N = 5) were administered three doses of cocaine-base (10, 20 and 40 mg). Four subjects were given repeated doses of cocaine-base. Subjects were blind to the dose and in most cases randomly assigned to different doses. The results showed: 1) a significant correlation of peak whole blood cocaine concentrations among similar doses within subjects (r = .99); 2) no significant effects of dose on smoking topography; and 3) significant dose effects for whole blood cocaine concentrations, heart rate and systolic blood pressure.

Cocaine-related medical problems: consecutive series of 233 patients

PURPOSE

Little information describing common cocaine-related medical problems is available. This study examined the nature, frequency, treatment, incidence of complications, and emergency department deaths of patients seeking medical care for acute and chronic cocaine-associated medical problems.

PATIENTS AND METHODS

A consecutive series of 233 hospital visits by 216 cocaine-using patients over a 6-month period during 1986 and 1987 was studied. Medical records were retrospectively reviewed to determine patient characteristics, nature of complications, treatment, and outcome.

RESULTS

Patients most commonly used cocaine intravenously (49%), but freebase or crack use was also common (23.3%). Concomitant abuse of other intoxicants, especially alcohol, was frequently seen (48.5%). The vast majority of complaints were cardiopulmonary (56.2%), neurologic (39.1%), and psychiatric (35.8%); multiple symptoms were often present (57.5%). The most common complaint was chest pain though rarely was it believed to represent ischemia. Altered mental status was common (27.4%) and ranged from psychosis to coma. Short-term pharmacologic intervention was necessary in only 24% of patients, and only 9.9% of patients were admitted. Acute mortality was less than 1%.

CONCLUSION

Most medical complications of cocaine are short-lived and appear to be related to cocaine's hyperadrenergic effects. Patients usually do not require short-term therapy or hospital admission. Acute morbidity and mortality rates from cocaine use in patients presenting to the hospital are very low, suggesting that a major focus in the treatment of cocaine-related emergencies should be referral for drug abuse detoxification and treatment.

Intravenous cocaine: psychiatric effects, biological mechanisms

Volunteer addicts were administered iv loading doses of cocaine, followed by 4-hr cocaine infusions that maintained steady-state conditions. The loading doses were followed by the "rush" and "high" subjective effects that users typically experience; cocaine infusions maintained the experience of drug "high", but not "rush". In a subsequent experiment, haloperidol pretreatment did not alter cocaine "rush" but partially attenuated cocaine "high." During cocaine infusions, we also noted suspicious and paranoid behavior, which were blindly rated by nurses. During one of the infusion conditions, the degree of suspiciousness observed was related to the amount of cocaine previously administered. Although cardiovascular responses to cocaine were marked, we found no alterations in plasma catecholamines following cocaine administrations. Baseline homovanillic acid (HVA) levels, however, were related to the degree of suspiciousness observed following cocaine dosing. The potential contributions of dopaminergic systems and physiological sensitization to the development of the psychiatric toxicity of cocaine are discussed.

Clinical toxicity of cocaine adulterants

Adulterants are found in all street samples of cocaine. They add an unappreciated dimension to the clinical toxicity of cocaine abuse. Identification of these adulterants is necessary to separate their effects from those of cocaine. The comprehensive toxic screen, which provides multiple modalities of drug analysis, will be a key diagnostic tool in the further investigation of these inherently toxic agents and their impact on syndromes of cocaine intoxication.

Bromocriptine in cocaine withdrawal--does it work?

Heavy cocaine use has been reported to lead to dopamine depletion in the brain, which in turn may be responsible for strong cocaine craving after withdrawal. Bromocriptine, a dopaminergic agonist, was used on that basis to prevent relapses in the withdrawal period. In an uncontrolled trial of 25 heavy cocaine users, measurements of pre- and post-bromocriptine serum prolactin levels-as indicators of inhibitory dopaminergic control-did not suggest dopamine depletion. Moreover, in 13 of these 25 patients, an assessment scale for craving and for other subjective discomforts indicated some improvement in only a slight majority, which is probably inseparable from placebo effect.

Chronic cocaine effects on peripheral biogenic amines: a long-term reduction in peripheral dopamine and phenylethylamine production

The short- (during 12 h after last treatment) and long- (6 weeks after last treatment) term effects of repeated administration of cocaine on the total output of norepinephrine (NE) and its metabolites (sum NE), dopamine (DA) and its metabolites (sum DA) as well as the excretion of 5-hydroxyindoleacetic acid (5-HIAA) and phenylethylamine were evaluated in rats. The concentration of NE, DA and 3,4-dihydroxyphenylacetic acid (DOPAC) in the celiac ganglion after 1, 2 and 3 weeks of repeated cocaine administration were also measured. Sum NE remained unchanged during the cocaine treatment but NE and normetanephrine excretions were significantly decreased and increased respectively. 5-HIAA excretion was significantly reduced only after 3 weeks cocaine treatment. In the celiac ganglion NE and DOPAC contents showed tendencies towards being increased and decreased respectively. DA content was not changed. The excretions of DA, DOPAC, homovanillic acid (HVA) and phenylethylamine were significantly reduced during chronic exposure to cocaine. The above short-term changes in DA and phenylethylamine persisted for periods as long as 6 weeks after 1 week repeated exposure to cocaine. It is concluded that chronic exposure to cocaine can produce preferential long term deficiencies in the production of DA and phenylethylamine in the periphery. Peripheral noradrenergic and serotonergic neuronal systems are apparently minimally affected. The close association between DA or sum DA and phenylethylamine excretion suggest these 2 amines may coexist in the same neuron.

Cocaine-related intracranial hemorrhage. Report of nine cases and review

Nine cases of intracranial hemorrhages related to cocaine usage are presented. Another 5 cases from the literature are reviewed. The relationship between severe cocaine-induced hypertension, and the development of subarachnoid or intracerebral hemorrhages is noted, and apparently is related to sudden transient increases of blood pressure related to cocaine use.

Cocaine and central monoaminergic neurotransmission: a review of electrophysiological studies and comparison to amphetamine and antidepressants

Psychomotor stimulants (e.g. cocaine and amphetamine) and many antidepressants are believed to elicit their psychotropic actions by interacting primarily with central monoaminergic neurons. The acute central neuronal effects of amphetamine and antidepressants have been extensively investigated in rats utilizing extracellular single unit electrophysiological and microiontophoretic techniques in vivo. In recent years the chronic effects of these compounds on the above neuronal systems have also been reported. Such investigations have proliferated because of the realization that the mechanisms underlying the psychotomimetic effects (e.g. amphetamine and cocaine) and mood elevation (i.e. antidepressants) observed with the administration of these drugs are more accurately reflected in chronic studies. For many years it has been assumed that cocaine and amphetamine produce very similar if not identical psychotropic effects through their actions on central monoaminergic neurotransmission. In terms of effects on single monoaminergic neurons, this assumption had gone by untested until two years ago, when the first report of the electrophysiological effects of cocaine on central monoaminergic (locus ceruleus) neurons appeared in the literature (61). This review discusses recent electrophysiological studies with cocaine at the level of single identified monoaminergic neurons and compares such data with that previously reported for amphetamine and antidepressants. In addition to identifying some of the similarities and differences between these compounds, this review also highlights some of the gaps in our knowledge regarding the effects of these drugs on central monoaminergic neurotransmission.

Intracranial hemorrhage and cocaine use

Cocaine use has increased rapidly over the past few years. This has led to an increase in the number and variety of cocaine-related conditions for which medical attention is sought. Among these have been several cases of intracranial hemorrhage. Four cases reported in the literature and 6 from our own institution are presented here. They represent different diagnoses including hemorrhage from aneurysms and arteriovenous malformations, hemorrhage into a tumor, and spontaneous hemorrhage with no underlying lesion with and without preexisting hypertension. Analysis of these cases suggests that the hypertension induced by cocaine secondary to sympathetic stimulation may be the common factor. Cocaine may also cause arterial spasm. Although the pathophysiology has not been entirely resolved, the clinical significance of this association is clear. Intracranial hemorrhage should be considered in the differential diagnosis whenever a patient presents with an acute alteration in neurologic examination associated with cocaine use.

Single-dose bromocriptine reverses cocaine craving

Thirteen hospitalized cocaine addicts complaining of cocaine craving were given a single dose of bromocriptine, a dopamine agonist, in a randomized, double-blind, placebo-controlled study design. Compared to placebo, bromocriptine caused a significant reduction in craving ratings. These data suggest that bromocriptine may be effective as a new, nonaddictive pharmacological treatment for cocaine addicts and support the notion that functional dopamine depletion occurs with chronic cocaine use. Open trials indicate that low-dose bromocriptine may be useful in cocaine detoxification.

Cocaine and the heart

There is increasing evidence that cocaine can have serious adverse effects on the heart. Angina, myocardial infarction, coronary artery spasm, arrhythmia, and sudden death have been reported in association with its use. There have been only two reports of actual myocardial pathology. In an attempt to clarify the pathophysiology of cocaine-associated cardiotoxicity and to search for pathologic changes that might be useful forensically, we reviewed random microscopic sections of hearts from 30 cases of cocaine-associated death seen by the San Francisco Medical Examiner. The age of the patients at death ranged from 25 to 74 years (mean 33.9 years). Pathologic findings included the presence of mild atherosclerotic coronary artery disease without evidence of thrombosis in three cases, associated with mild interstitial fibrosis in one case as well as mild focal myocardial fibrosis without coronary disease in four other cases. The most notable abnormality was the presence of myocardial contraction bands in 28 (93 per cent) cases. In comparison to 20 control cases of death secondary to sedative-hypnotic overdose, the hearts from the cases of cocaine-associated contained significantly more myocardial contraction bands (P less than .001; two-sided). The diffuseness of the contraction bands correlated directly with the level of cocaine found in the urine and blood at autopsy during routine screening. The presence and number of contraction bands in these cases was independent of other drugs found in the urine and blood, the number of sections of myocardium examined, and a history of attempted resuscitation. Contraction bands may act to supply the anatomic substrate for the arrhythmias associated with cocaine use. They may also provide a morphologic marker that can be sought in suspected cases of lethal cocaine overdose. Their presence may also suggest a cause of death in cases of sudden and unexpected death in which autopsy reveals no other pathology, and a drug screen is positive for cocaine.