Course and Natural History - Cocaine Use Disorders

Course and Natural History

Cocaine produces a sense of intensified pleasure in most activi-ties and a heightened sense of alertness and well-being. Anxi-ety and social inhibition are decreased. Energy, self-esteem and self-perception of ability are increased. There is enhancement of emotion and sexual feeling. Pleasurable experiences, although heightened, are not distorted and hallucinations are usually ab-sent. The person engaging in low-dose cocaine use often receives positive feedback from others responding to the user’s increased energy and enthusiasm. This, in combination with the euphoria experienced by the user, can be reinforcing, and cocaine use is perceived as free of any adverse consequences. The duration of cocaine’s euphoric effects depends on the route of administra-tion. Cocaine and alcohol are often consumed together. In addi-tion to the synergistic effects of cocaine and alcohol in humans, an active metabolite, cocaethylene, with cocaine-like pharmaco-logical properties is formed and users of both drugs simultane-ously report enhanced euphoria.

Cocaine users quickly learn that higher doses are asso-ciated with intensified and prolonged euphoria, resulting in in-creasing use of the drug and progression to cocaine dependence. The abuser is focused on the cocaine-induced euphoria and be-gins compulsively to pursue this effect. These behaviors becomepivotal in the lives of cocaine abusers who continue drug abuse despite the presence of increasing personal and social conse-quences. Uncontrolled use of cocaine often begins with either increased access and resultant escalating dosages and frequency of administration or a change from intranasal use to a route of administration with more rapid onset of effects (i.e., intravenous or smoked). Such binges produce extreme euphoria and vivid memories. These memories are later contrasted with current dys-phoria to produce intense craving, which perpetuates the binge use pattern Addicts report that during binge use, thoughts are focused exclusively on the cocaine-induced effects. Normal daily needs, including sleep and nourishment, are neglected. Respon-sibilities to family and employer and social obligations are given up. This continues until the supply of cocaine is exhausted.

Binges are often separated by several days of abstinence; cocaine-dependent individuals average one to three binges per week. This is in contrast to use patterns for opiate and alcohol de-pendence which often produce physiological dependence necessi-tating daily consumption to prevent withdrawal symptoms. This differentiation is crucial to an understanding of the syndrome of cocaine dependence. Newly abstinent cocaine abusers may ex-perience a triphasic abstinence pattern, although this varies by individual, that includes a period of acute abstinence, sometimes referred to as the “crash”, lasting several hours to several days consisting of dysphoria, fatigue, insomnia or hypersomnia, in-creased appetite, and either psychomotor agitation or retardation, subsequent to the more intensive “crash” phase. A more chronic withdrawal period sometimes occurs characterized by minor de-pressive symptoms and cocaine craving lasting 2 to 10 weeks. This may then be followed by an extinction phase characterized by intermittent drug craving that becomes increasingly manage-able with continued abstinence.

Like other drug and alcohol use disorders, cocaine use disorders are chronic relapsing illnesses that present substantial challenges in the treatment process. Cocaine abusers are at high risk for relapse, particularly in the first few months of treatment related to acute craving often in the context of ongoing psychoso-cial stressors that result from or have been exacerbated by cocaine abuse. Newly abstinent cocaine abusers often lack adequate cop-ing skills necessary to avoid cocaine use, which take time to ac-quire in the treatment process. Although the ability to cope with cocaine craving improves with continued abstinence, relapse to cocaine abuse or other drug and alcohol abuse will continue to be a risk for those with a history of a cocaine use disorder who re-lapse to cocaine abuse. Repeated treatments may be required for those with cocaine use disorders. Treatment modalities include inpatient hospitalization for medical or psychiatric complications of cocaine abuse, partial hospital programs, self-help groups, psychotherapy (usually group or family therapy for patients with primary cocaine use disorders), or some combination of these treatments according to the clinical presentation of the patient