Pregnancy Category C

Uses. The drug was first isolated from coca plants in the mid-1800s. Cocaine apparently functions as an insecticide in the plants, but the substance has had no commercial agricultural use for that purpose. Early medical applications included administration to treat addiction to alcohol and opiates, but persons addicted to those drugs did not better on cocaine. Like many stimulants, cocaine has anorectic (weight-reducing) properties that decline as usage stretches over time; but the drug's main medical use has been as a local anesthetic, particularly in ear, nose, and mouth surgery. Experimental use as an antide-pressant has been unsuccessful. Cocaine has been used to treat tonsillitis, earache, toothache, burns, skin rash, hay fever, asthma, hemorrhoids, nerve pain, nausea, and vomiting. It makes the body's immune system more active. For medical purposes cocaine has been largely superseded by drugs having less potential for abuse, but it is still called an excellent anesthetic for nose and throat surgery, has been used for gynecological surgery in modern times, and still has ophthalmological use as eye drops, although the latter employment must be cautious in order to prevent corneal damage. Due to hazards of cocaine injections, since the 1920s medical usage of cocaine has been largely limited to topical (applying it directly to a body surface).

Like other stimulants, cocaine may improve mood, self-confidence, and sociability. Taking the drug for such purposes may be recreational or for self-medication of psychological distress; for example, a strong association exists between posttraumatic stress disorder and cocaine use. Cocaine can temporarily enhance work performance whether the task be manual labor or intellectual concentration. A century ago railroad engineers, dock workers, and cotton pickers were reported to be using the drug for that purpose, and it also received experimental military use in that pre-amphetamine era. On an occasional basis cocaine can help accomplish intense intellectual effort, such as staying awake all night to finish a piece of writing, and on a regular basis, cocaine can help accomplish dull repetitive tasks requiring close mental attention. As with other stimulants, steady use can eventually worsen work ability as a person's physical reserves are exhausted and as a person becomes emotionally strung out.

For over a century the most popular ways of taking cocaine were by injection or by inhaling the drug as a snuff. The latter technique inherently produces sensations of lesser strength than injection does, but a person desiring more can simply inhale larger quantities of powder.

Drawbacks. Habitually inhaling cocaine powder can cause a runny or congested nose and nosebleeds. Too much inhalation can bring on nasal ulcers and in exceptional cases can kill tissue and pierce the cartilage in the middle of the nose. Snorting can cause headaches. Abuse can also damage muscles (including heart), kidneys, and liver. Cases of heart attack and stroke are known, as are cases of serious intestinal damage related to problems with blood flow. Preexisting asthma can be worsened. Rupture of pulmonary air sacs and lung collapse are possible, though uncommon, results from cocaine smoking. The drug may bring on a type of glaucoma.

Some undesired effects are similar to those of amphetamine abuse: peevishness, nervousness, combativeness, paranoia, insomnia, and (after a dose wears off) depression. Typical afflictions include repetitions in movement or speech. Males may engage in sexual intercourse far longer than usual. Abusers may cut themselves off from other persons and become suspicious of them. Assorted hallucinations may occur, the classic one being "coke bugs" crawling under the skin. Psychological problems produced by unwise use of cocaine are so similar to those from other stimulants that some scientists believe similar mechanisms must cause the problems. Psychosis can be induced by cocaine but, as with other stimulants, generally does not continue after the drug use stops. Smoking cocaine can produce respiratory difficulties reminiscent of tobacco smoking—difficulties that develop faster than with tobacco because lungs must deal not only with the "air pollution" but with powerful drug effects as well. Particles of crack smoke floating in the air and landing on someone's eye can damage the cornea.

The amount of drug needed to kill a person varies; depending on a person's condition a dose that provides pleasure one day can kill on another. The same goes for persons sharing a supply: What satisfies one user can cause serious trouble for another. In rat experiments females are more sensitive to cocaine than males. Immediate problems in humans may include high blood pressure, irregular heartbeat, and seizures. The drug promotes rises in pulse rate and body temperature, which can be problems if a person engages in strenuous physical activity such as wild dancing.

Abuse factors. Before the 1970s cocaine smoking was never popular because the necessary heat destroyed much of the drug's potency. In that decade, however, the practice of freebasing cocaine began. That process allowed the drug's potency to be retained when smoking it, thereby allowing a route of administration providing the same intense impact formerly available only through intravenous injection. Freebasing, however, involves volatile chemicals that can explode in a flash fire if they are mishandled. In the 1980s illicit chemists discovered a much safer way to modify cocaine into a smokable format. The resultant product was known as crack cocaine and became the most notorious illicit drug since heroin.

A few seconds after inhaling crack smoke a user can experience a sense of well-being and joy accompanied by what has been described as a total body orgasm, followed by a few minutes of afterglow.

Tolerance is reported. Debate exists about whether a cocaine addict experiences physical withdrawal symptoms upon giving up the drug. A consensus holds that any physical consequences caused by the initial phase of abstinence can be less serious than those that develop when withdrawing from opiates and far less serious than withdrawing from alcohol or barbiturates.

Drug interactions. Cocaine masks some effects of alcohol, encouraging drinkers to ingest larger quantities of beverages. Alcohol's effects are longer lasting than cocaine, however, so a person functioning adequately under both drugs can suddenly become very drunk as the cocaine intoxication ends. If that transition happens while a person is operating dangerous machinery (such as a car), for example, the consequences may be disastrous. Cocaine's influence on the heart and liver seem increased by alcohol. Mazindol boosts the elevation that cocaine causes in pulse rate and blood pressure and makes those changes last longer. Mice experiments indicate possible fatal interaction if a cocaine-using asthmatic is treated with aminophylline (a combination of ethylenediamine and theophylline). Cocaine abusers also tend to be extra susceptible to the benzodiazepine class of depressant drugs. In animal experiments caffeine and nicotine boost cocaine effects. Naloxone, a drug used to counteract opiate actions, can boost cocaine effects in humans. For many years some medical practitioners have mixed adrenalin with topical applications of cocaine in order to make anesthetic effects last longer. The reason adrenalin interacts in that way with cocaine is unclear, and the custom is disputed. What works when applying cocaine to a body surface for anesthesia does not necessarily work in other contexts. Seeking to stretch out effects of recreational cocaine with various substances can be so unsuccessful as to require hospi-talization for unexpected interactions. In some manipulations of a rat experiment the tricyclic antidepressant amitriptyline reduced cocaine actions.

Cancer. Cocaine's potential for causing cancer is uncertain.

Pregnancy. The drug's potential for causing birth defects is uncertain. Some animal experiments produce birth defects; some do not. In the 1980s and 1990s cocaine was widely reported to have devastating impact on mental ability of infants whose mothers used the drug during pregnancy. Scientists have been unable to verify those reports. Evidence is growing that offspring tend to perform at the lower end of the normal range, but pregnant women who use cocaine also typically use hefty amounts of tobacco cigarettes and beverage alcohol while failing to get proper nutrition and prenatal care. Such confounding factors hinder scientists' ability to measure what cocaine does to a fetus, although persistent investigators are beginning to separate cocaine's influence from other factors. Even so, despite excellent theoretical reasons to suspect that cocaine damages fetal development, those suspicions have not been confirmed. Nonetheless, cocaine is not considered safe for a pregnant woman to use. Apparently cocaine enters human milk and can be passed to infants via that route. A case report tells of an infant hospitalized for cocaine overdose received from the mother's milk.

Additional scientific information may be found in:

Brain, P.F., and G.A. Coward. "A Review of the History, Actions, and Legitimate Uses of Cocaine." Journal of Substance Abuse 1 (1989): 431-51. Gay, G.R., et al. "Cocaine: History, Epidemiology, Human Pharmacology, and Treatment. A Perspective on a New Debut for an Old Girl." Clinical Toxicology 8 (1975): 149-78.

Johnson, B., et al. "Effects of Acute Intravenous Cocaine on Cardiovascular Function, Human Learning, and Performance in Cocaine Addicts." Psychiatry Research 77 (1998): 35-42.

Lester, B.M., L.L. LaGasse, and R. Bigsby. "Prenatal Cocaine Exposure and Child Development: What Do We Know and What Do We Do?" Seminars in Speech and Language 19 (1998): 123-46. Magura, S., and A. Rosenblum. "Modulating Effect of Alcohol Use on Cocaine Use."

Addictive Behaviors 25 (2000): 117-22. Middleton, R.M., and M.B. Kirkpatrick. "Clinical Use of Cocaine. A Review of the Risks and Benefits." Drug Safety: An International Journal of Medical Toxicology and Drug Experience 9 (1993): 212-17. Rawson, R., et al. "Methamphetamine and Cocaine Users: Differences in Characteristics and Treatment Retention." Journal of Psychoactive Drugs 32 (2000): 233-38. Siegal, H.A., et al. "Crack-Cocaine Users as Victims of Physical Attack." Journal of the

National Medical Association 92 (2000): 76-82. Siegel, R.K. "Cocaine and the Privileged Class: A Review of Historical and Contemporary Images." Advances in Alcohol and Substance Abuse 4 (1984): 37-49.

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