Cocaine: Health and Harm Reduction

Made from the leaves of the Coca plant (Erythroxylon coca) grown in the Andean region of South America, the purified hydrochloride salt cocaine had history in the US as a medical analgesic before becoming a Schedule II restricted substance under the Controlled Substances Act. Cocaine has a bitter, numbing taste in its white powder form. It is most often "snorted", a colloquial term for insufflated, and it can also be taken orally and injected. There is another form of cocaine known as freebase cocaine or "crack" cocaine, created from the powder form for the purposes of being able to smoke it more efficiently.

Statistically, the rate of substance use disorders among people who have taken cocaine is low. A 2006 epidemiological study showed that about 80 percent of people who use cocaine are not chemically dependent two years later. However, the remaining 20 percent are at risk for developing one and may benefit from treatment. All people who use cocaine should be aware of how to mitigate risks such as adulteration, and be aware of the criminal penalties.

Why Do People Use Cocaine and How Does it Work?

Cocaine is a stimulant of the central nervous system. People use it because it can produce a euphoric feeling, increase confidence in social situations, and reduce physical fatigue. Cocaine has also been used medically as a local anaesthetic and as an appetite suppression. A 2016 article in Emergency Medicine International describes traditional use of the coca plant for altitude sickness by the Aymara, an indigenous tribe of the Andes.

Cocaine has a relatively short half-life of 0.7 to 1.5 hours. The subjective effects, or the "high", can be felt in under one minute if smoked, under two minutes if injected, around 30 minutes if taken orally, and 15 to 60 minutes if snorted.

The comedown occurs relatively soon after, typically between one and three hours after taking the cocaine, and quick onset of withdrawal effects can encourage a pattern of use called "binge and withdrawal". This pattern of excessive use for a period, followed by exhaustion and much more limited use, followed by a higher rate of consumption, has been observed in animal and clinical studies to increase the risk of dependence.

Side Effects and Overdose Risk

Some people experience dry mouth, post-nasal drip, numbness and irritation of the nose and throat when taking cocaine. Low mood and irritability are common withdrawal effects. Especially at higher doses, there is a risk of insomnia, anxiety, paranoia, agitation, anger, extreme aggression, emotional instability, and an urge to do more cocaine. Cocaine is a stimulant and can increase both heart rate and blood pressure and can be dangerous for people at risk for cardiovascular disease. Symptoms of overstimulation, otherwise known as tachycardia, include shaking, clenching, hyperthermia, muscle spasms, and seizures, detailed in this review from 2007. The intense vasoconstrictive effects of cocaine on vascular smooth muscle can accelerate the build-up of fats, cholesterol, and other substances on artery walls, which can lead to heart attacks and arrhythmias.


The estimated minimum lethal dose of cocaine is 1.2 g. People with a high tolerance for cocaine as a result of regular use may consume cocaine at higher doses than that to try to achieve effects they were previously able to achieve at lower doses, putting them at risk for overdose. Most people do not have access to pure cocaine and cannot know for sure the potency of what they are working with. As a result, they would benefit from starting with the lowest effective dose whenever they purchase a new batch. Taking in a high quality of an adulterant such as the opioid fentanyl can lead to respiratory depression, which someone expecting a stimulant experience may not be prepared to handle. Because people cannot be sure what they are getting, it is a good idea for people who use all drugs, not just opioids, to carry naloxone, which can reverse opioid overdoses, and to let a trusted friend know they are going to be using.

Harm Reduction

Reducing Overstimulation

The psychological and physical contexts in which a drug is used play a huge role in the quality of the experience. If someone is feeling a high degree of anxiety while on cocaine, reducing the stimulation in their environment (turn the lights lower, turn off any loud music, etc.) and giving them ways to better adjust to that environment (e.g. giving them an eye-mask or earplugs), can help them relax. Approaching someone who has taken a lot of cocaine and may be self-harming requires a calm, empathic presence in order to not exacerbate their symptoms. Physical effects of overstimulation such as muscle spasming may be mitigated through supplementation with magnesium.

Safer "Snorting" Practices

People who choose insufflation as their route of administration are at greater risk for damaging the tissues of the nasal passageway.

Some ways to reduce the likelihood of problems ranging from minor irritation to a deviated septum include:

  • Alternating nostrils
  • Using a straw (remember not to share with others unless you all have been tested for Hep C as this potentially fatal disease can be passed along through mucous membranes)
  • Diluting the cocaine with water and ensure the powder is as fine as possible
  • Taking breaks

Drug Testing and Drug Checking Services

Cocaine purchased in underground markets may be as little as 10 percent pure, with up to 90 percent of the substance being made up of other things that are mixed in. The substances used to "cut" cocaine are chosen because they look, taste, or feel like cocaine, such as pseudoephedrine, levamisole, benzocaine, or caffeine. According to a 2019 multi-site study published in Drug and Alcohol Dependence, drug checking services, using reagent tests or spectrometry, are looked upon favorably by many community stakeholders, and can help indicate the presence of harmful adulterants, saving lives. As long as cocaine possession remains a felony offense, many of these harm reduction services are operating in a legal grey area and are restricted from making their services more available.

Consent

Some people use cocaine for increased pleasurability of erotic sensations, however it is important to realize that someone cannot give consent for sex while on a mind-altering substance. Especially if you have not negotiated that with the person in advance, you are at greater risk of a sexual assault and are better off waiting until you are sober.

Treating Cocaine Use Disorder

Many people make the mistake of focusing on the drug rather than the person taking it when talking about addiction. According to a 2006 epidemiological review in Neuropsychopharmacology, as low as four percent of people who try cocaine develop a substance use disorder within 2 years of initial use, with a further 16 percent entering an early “prodromal” stage of addiction. Use patterns involving intermittent binging and withdrawal lead to a greater dependence, therefore the best way to stop using cocaine if experiencing problematic use is to gradually lower the dose, an approach called "tapering", while working to manage withdrawal symptoms.

Often times, excessive cocaine use is a coping mechanism for dealing with other challenges in a person's life. These challenges will still be there once you stop using cocaine, and without your coping mechanism, you will be less prepared to deal with them. As a result, it is very important that if you are trying to stop using cocaine that you also pursue accompanying mental health treatment, such as CBT, and identify and rely on a supportive community.

Politics of Cocaine Prohibition

Cocaine use was for decades the subject of a public panic, which led to the instituting of harsh criminal penalties for possession and sale. Beginning in 1986, mandatory minimum sentences for drug trafficking were introduced by the Anti-Drug Abuse Act. This act treated powder cocaine and crack cocaine very differently, with 100 times the amount of powder cocaine as crack being necessary to trigger mandatory minimum sentencing, even though the substances are pharmacologically identical. According to a 2017 article in the Journal of Empirical Legal Studies, 80 percent of people convicted for crack cocaine identify as Black, compared to the less than 33 percent convicted for powder cocaine. The Fair Sentencing Act of 2010 was passed to decrease this sentencing gap. While reforms have been made, there is still an overwhelming racial disparity in the American prison population, with white people more likely to be directed into treatment programs.

According to a 2017 article in Medical Principles and Practice, the high degree of social violence in Central America and rise in undocumented immigration to the US may be partially related to trafficking of drugs such as cocaine, and associated cartel violence. In response, both Mexico and the US have increased security at their borders, however, Mexico experienced only a small reduction in trauma deaths as a result of this policy change. The war on drugs as a strategy lead to a ballooning effect, in which increased control of illicit drug activity in one area forced activity to more vulnerable areas where there is then an increase in crime and violence. A public health approach rather than a criminal justice approach may help mitigate this crisis. 

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