Recognising and Managing Cocaine Dependence in the Community

By Dr Mathew Joseph, Prof.John M Eagles

Many clinical presentations to general practitioners with depression, anxiety, panic attacks, non traumatic chest pain, insomnia, and elevated blood pressure could have an underlying episode of cocaine use. Deaths are caused by cocaine overdose with airway burns, pneumothorax, pneumo mediastinum, lung syndromes; it can also cause myocardial infarction, hyperthermia and convulsions, all in younger adults. (Devlin RJ, Henry JA (2008). It is thus essential that GP`s are able to recognise and advise about common problems emanating from cocaine misuse which do not merit specialist care. Knowing the treatment options in secondary care will also be helpful in making appropriate referrals.

Introduction to the extent of the problem

Cocaine misuse is a growing problem in the adult population of the UK. Around 4 million people use illicit drugs each year, of which Cocaine is the most commonly used illicit stimulant drug (Roe S, Mann L 2006). Cocaine is the second commonest drug of misuse after Cannabis. Around 2.4 % of the adult population in the UK is thought to be using Cocaine as a recreational drug. ( Chawala S 2007). Most General Practitioners would have encountered at least a few cocaine misusers in their weekly practice and may not have recognised it as the primary problem.

Cocaine

Cocaine is an alkaloid extracted from the leaves of Erythroxylon Coca bush which grows mainly in South America. The leaves were chewed by the natives even before the Spanish conquest to help them to tide over tiredness and mountain sickness when they went hunting. It is mainly available in two forms. Powder form of the drug is called cocaine hydrochloride and this can be snorted. Cocaine powder is heated with bicarbonate of soda and water to make it into `crack cocaine`. This is a stable form of cocaine which could either be smoked or even used intravenously with ascorbic acid or citric acid as it is insoluble in water. It is called "crack" cocaine because of the crackling noise it makes while being heated on a foil. Powder cocaine is well absorbed through mucous membranes, so high blood concentration can be achieved by sublingual, intranasal or rectal administration.

Why does it become a drug of misuse?

Cocaine does not cause much physical dependence but psychologically it can induce dependence since it gives euphoria almost immediately. Most users experience "cocaine highs" which can last for few minutes to a few hours, depending on the tolerance of the user. Easy use is facilitated by the fact that paraphernalia like needles or diluents (as for heroin) are not required. Generally people who use cocaine are able to lead semblances of normal lives, adding to its attractiveness as a recreational drug.

Mechanism of Action

Cocaine acts as powerful sympathomimetic agent which blocks presynaptic uptake of nor-epinephrine and dopamine thus producing high levels of these neurotransmitters at the post-synaptic receptor. It also inhibits muscarinic receptors and the reuptake of serotonin. Cocaine produces a dose dependent increase in blood pressure and heart rate, which are within physiological limits following usual recreational doses. (Orr and Jones 1968). The dopamine surge of the cocaine high is experienced through the nucleus accumbens, the reward centre of the brain. This also gives the user an intense pleasure with gradual wearing out of such feeling due to tolerance which can lead to the patient taking more of the drug to get the same effect. This dose escalation can cause the person to experience the ill effects of the drug, with changes from recreational to dependence use.

How to recognise a cocaine user in the GP setting

Cocaine use can be implicated in many presentations to general practice or at A & E. Following careful history taking, a cheap and immediate urine drug screen can reveal use in suspicious cases. Many doctors were found not to be asking about cocaine use among patients presenting to A&E with chest pains even in younger age group (Wood 2007). Having the possibility in mind and then asking the right questions sensitively would go a long way in diagnosing cocaine misuse, particularly in younger age groups. Box I lists symptoms with which cocaine misusers may present.

Symptoms to look for suggesting Cocaine Misuse in primary care:

Frequent visits to surgery for insomnia.
Dilated pupils (with opiates pupils might be mitotic).

Psychological symptoms/signs –
Increase in anxiety and irritability more marked during withdrawal period
Paranoid ideas to extreme paranoia.
Tactile hallucinations
Depression
Social isolation and withdrawal
Risk taking
Worsening of pre-existing psychiatric conditions like schizophrenia, bipolar affective disorders and ADHD
Personality changes
Dishevelled looks
Loss of interest in appearance.
Sudden changes in personality/ moods Box 1 (cont.)
Exaggerated self confidence at times

Physical symptoms
Loss of weight
Raised blood pressure
Impotence in men
Low birth weight and birth defects when taken during pregnancy

 

 

Medical complications of abuse


Cardiovascular system

Deep vein thrombosis
Heart rhythm-VF
Myocardial infarction Respiratory System

COPD, asthma
Pulmonary embolism
Chest pain
Respiratory failure

Neurological system

Strokes
Seizures and headaches
Hypertension encephalopathy
GI Complications

Abdominal pain – acute abdomen
Nausea
Bowel gangrene

 

Treatment

Pharmacological approaches

No specific treatments have been found as yet which block the effects of cocaine in the brain. Other medications are used symptomatically to alleviate any symptoms caused such as psychosis or depression. There are some drug treatments which show promise, but have little evidence base for use, and these will be mentioned below.

The treatment aims for stimulant use like cocaine usually comprise the management of withdrawal and maintenance of abstinence (Van den brink and Van Ree 2003)

One treatment that may be of some value is the much publicised cocaine vaccine which needs to be taken as an injection every six months. This reduces the effect of cocaine on the nucleus acumbens in the brain's reward centre. Cocaine is a small molecule and usually no immunological response is elicited, but in the vaccine cocaine is attached to a large protein molecule which is used to stimulate the body’s immune response to produce antibodies that recognise the drug. This stops cocaine from being able to get across the blood brain barrier to produce the high following cocaine intake. It is still in its experimental stages.

Psychological treatments

In addition to pharmacological approaches to cocaine dependence, psychological therapies (including Cognitive Behavioural Therapy (CBT), Psycho-education and intensive case working) are being currently being used across the UK.

Knapp et al reviewed behavioural and psychosocial interventions and found that treatment outcomes favoured approaches with some form of contingency management. This both reduced drop outs and lowered cocaine use. (Knapp 2007).

Recent NICE guidelines have reiterated that contingency measures like voucher schemes have been found to be the most useful of the behavioural modification techniques.

The following principles underlie the effective delivery of contingency management (Petry 2006).
• Robust, routine testing for drug misuse should be carried out.
• Targets should be agreed in collaboration with the service user.
• Incentives should be provided in a timely and consistent manner.
• The relationship between the treatment goal and the incentive schedule should be understood by the service user
• Incentives should be perceived by the service user to be reinforcing and to support a healthy/drug-free lifestyle.

Typical contingency measures to manage cocaine dependence comprise methods like giving out vouchers which the person can redeem at a local store for food and grocery items but not alcohol or tobacco. Other voucher schemes help people to attend local gym/ health clubs free of charge. In all schemes the person is rewarded for his behaviour with a positive rein forcer. All of these studies to date have been conducted in the U.S.A.

Other relevant treatments include recovery in a therapeutic community of which the biggest is the one in San Patrignanao in Italy. Although the evidence base for therapeutic community treatment is generally weak, this community claims to have shown that extraordinary treatments can work better than some standardised treatments for which there is a wider body of evidence.

Motivational interviewing (MI)

MI by general practitioners to engender cognitive dissonance in the patient can have a big impact when a patient visits the surgery. This technique is now widely used in other aspects of medical care to promote change in the patient. In MI the main principles used are that of like any other talk therapy where the patient is encouraged to think about the consequences of his actions by reflecting on his own behaviour. It is done not by challenging the behaviour but helping the patient to challenge his own behaviour. The five principles used are

1) Express empathy with the patient
2) Avoid argument or confrontation
3) Support self reliance of the patient
4) Roll along with resistance
5) Identify discrepancy in behaviour, make the patient aware of it, and thus facilitate behavioural changes.

This has been widely used in other branches of medicine and was promoted by Miller and Rollnick (2002) as useful in addictions. Rubak et al (2006) showed that GPs, after a course in motivational interviewing, seemed to change their professional behaviour in daily practice compared with the control group. GPs evaluated motivational interviewing to be more effective than ‘traditional advice giving’ and did not find it to be any more time consuming.

Social interventions

Similar to Alcoholics Anonymous (A.A.) self help groups like Cocaine Anonymous (C.A) can be useful. These use 12 step programmes, and are available in an online version as well, which can be useful to patients who dislike group settings. Assisting carers of cocaine users is often important and ADFAM is a UK based charity which helps to train volunteers to support family members, both directly and through publication of leaflets. Family anonymous (FA) is a 12 step based offshoot of alcoholic anonymous (AA) which also has branches in the UK

GPs are likely to meet carers or family members who are stressed due to their family member's cocaine use, and they will often be greatly helped by empathetic listening. They can be provided with information about self help groups or agencies (as above) and their own mental health needs should be considered. In a prospective cohort study primary care relationship with primary care physician was found to quality of the physician–patient relationship, were associated with positive addiction outcomes (Kim T 2006).

Conclusion

Input by GPs could make a significant impact in both early diagnosis and treatment of cocaine misuse. The GP could also make a difference on the cost of future treatments needed for patients in their practice due to cocaine misuse. Use of motivational interviewing techniques, with or without referral to a trained counsellor, can help to induce change in patients' behaviour and thus to avoid the more serious complications associated with protracted cocaine misuse.

REFERENCES

Chawla S, Pichon T L (2007) World Drug Report 2007, United Nations. New York: United Nations Publication. ISBN 978-92-1-148222-5.

Devlin RJ Henry JA (2008) Clinical review: Major consequences of illicit drug consumption. Critical Care 2008; 12(1):202. Epub 2008 Jan 8.

Kim T W etc., Samet J H, Cheng D M, Winter M R, Safran D G, and Saitz R (2006) Primary Care Quality and Addiction Severity: A Prospective Cohort Study Health Services Research Volume 42 Issue 2, Pages 755 - 772

Knapp WP, Soares BG, Farrel M, Lima MS (2007) Psychosocial interventions for cocaine and psycho stimulant amphetamines related disorders. Cochrane data base 2007.

Miller, W.R. and Rollnick, S. Motivational Interviewing: Preparing People to Change. NY: Guilford Press, 2002

Orr D, Jones I.(1968) Anaesthesia for laryngoscopy: a comparison of the cardiovascular effects of cocaine and lignocaine. Anaesthesia 1968; 23:194–202

Petry, N. M. (2006) Contingency management treatments. British Journal of Psychiatry, 189, 97-98

Roe S, Mann L (2006) Drug misuse Declared: Findings from the 2005/06 British Crime survey England and Wales. Home Office Statistical bulletin 2006.

Rubak S, Sandbæk A, Lauritzen T, Borch-Johnsen K and Christensen B (2006) An education and training course in motivational interviewing influence: GPs’ professional behaviour – Addition Denmark. British Journal of General Practice 2006; 56: 429–436.

Van Den Brink and Van Ree (2003) Pharmacological treatments for heroin and cocaine addiction. Neuropsychopharmacol.2003 Dec; 13(6):476-87

Wood DM, Hill D,Gunasekera A, Greene SL, Jones AL, Dargan PL (2007) Is cocaine use recognised as a risk factor for acute coronary syndrome by doctors in the UK? Post Grad. Med. 2007 May; 83(979):325-8

Further Reading

1) NICE guidelines Drug misuse: psychosocial interventions’ (NICE clinical guideline 51)

2) Drug misuse: opioid detoxification’ (NICE clinical guideline 52).

3) Models of care, NTA publications 2002

 

First Published September 2008

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