Cocaine is a widely used alkaloid drug isolated from the leaves of the coca plant. Its salt form is cocaine hydrochloride, which is a white crystalline powder, and is sometimes referred to as cocaine powder to distinguish it from crack cocaine, a base form of the drug. Cocaine is used for its euphoric and stimulant effects. Cocaine powder is typically insufflated (snorted) into the nose, allowing the drug to be absorbed through mucosal membranes, or mixed with water to form an aqueous solution and injected intravenously (“mainlining”). Crack cocaine is smoked/vaporized in a specialized pipe, often consisting of a glass tube into which scouring pad-based mesh has been inserted and onto which the drug can melt before entering the vapor phase.
The psychoactive effects of cocaine result from its ability to block the reuptake of monoamine neurotransmitters. In particular, its blockade of dopamine reuptake in the mesolimbic area (often referred to as the “rewards center”) of the brain is responsible for its reinforcing and addictive effects.
Approximately 15 percent of the U.S. population age 12 or older has used cocaine at least once in their lifetime. According to the National Survey on Drug Use and Health, approximately 0.7 percent of the U.S. population over the age of 12 has used cocaine within the past month; however, this estimate largely misses the population of criminally active heavy users.
Today in the United States cocaine falls under Schedule II of the Controlled Substances Act. Cocaine falls under Schedule II rather than Schedule I because it still has limited medical use as a local anesthetic and vasoconstrictor resulting from blockade of local norepinephrine reuptake.
The coca plant (Erythroxylon coca), which naturally contains cocaine, is indigenous to the Andes region of South America, and has been used by indigenous cultures in that area for thousands of years. Coca was not only used for the benefit of increased endurance, but it was also used medicinally for other indications and within religious and social settings. Coca has been traditionally used by indigenous peoples by chewing and sucking on the leaves of the coca plant, much as with the chewing of tobacco. When used in this manner, the intensity of drug effect is more comparable to that of the typical use of caffeine or tobacco in the United States than to the intensity of effects from pure cocaine powder or crack cocaine.
Albert Niemann published the isolation of highly pure cocaine in 1860, but it was in 1884 that the world's first local anesthetic was identified when Karl Koller showed cocaine's utility as a topical anesthetic in eye surgery. Cocaine was initially well received by the medical community, and indications soon expanded to include topical anesthesia for nose and throat surgery, in addition to nausea, opiate addiction, and respiratory problems. Sigmund Freud was both a user and medical advocate for cocaine use during this time. Freud proclaimed the benefits of cocaine for opiate addiction and depression. He was also working with cocaine's local anesthetic properties, although Koller first made the medical community aware of the discovery and received professional credit.
By the end of the 1890s, physician prescriptions for cocaine strongly declined. Clinical experience revealed problems including an often easily and rapidly acquired addiction that was tenacious despite little physical withdrawal relative to opiates. Cocaine addiction also appeared to lead to more pronounced physical deterioration relative to opiate addiction. Addiction was more commonly observed in indication requiring repeated treatment, such as respiratory problems, as opposed to surgical use. Other problems included adverse reactions at high doses or when delivered by the newly developed hypodermic syringe.
These included psychological reactions such as manic episodes or delusions, and physical disturbances such as nausea. Freud also retracted his endorsement of cocaine. However, as a result of efforts from the drug manufacturers, distribution of cocaine increased through the newly emerging alternative, the direct-to-consumer medical market, in which cocaine and opiates were widely included in “patent medicines.” In addition, cocaine or coca extract was included in beverages such as CocaCola (which still uses in its manufacture coca from which cocaine has been removed), and the wine Vin Mariani. The Pure Food and Drug Act of 1906 mandated all medicine to list active ingredients on the label, which helped users to become aware of addictive ingredients such as cocaine and opiates. Cocaine was included in the Harrison Act of 1914, which banned the nonmedical use of cocaine, including its use in patent medicines and beverages.
As a highly addictive drug of abuse, cocaine use is associated with a number of harms. Chief among these may be a narrowing of the behavioral repertoire such that for those addicted, substantial time and financial resources are allocated to cocaine use, detracting from prosocial domains such as family, school, work, and community. An explicit goal of the U.S. Drug Enforcement Administration is to increase the price of black market cocaine; however, despite a 15-fold increase in cocaine-dealing incarceration since 1980, the price has fallen more than 80 percent in inflation-adjusted terms. Because the price of cocaine is high, those addicted to the drug can spend incredible amounts of money for the drug, sometimes resulting in criminal behavior such as theft and prostitution to maintain their drug use. Cocaine accounts for approximately 60 percent of the total illicit drug revenues in the United States, and cocaine dealing accounts for 60 percent of dealing-related violence and incarceration.
Physiologically, cocaine can stress the cardiovascular and neurovascular systems and can lead to stroke and heart attack. Other potential toxicity includes seizures, oxygen deprivation of the heart, and heart arrhythmias. Chronic use can lead to a range of psychiatric conditions such as toxic paranoid psychosis and mood disorders. Evidence suggests that long-term cocaine use may result in neurobiological damage involving the frontal cortex and mesolimbic system in the brain, which may lead to impulsive behavior. The smoking of crack cocaine is associated with lung damage.
Cocaine use is associated with an increased risk of contracting human immunodeficiency virus (HIV). Part of this risk stems from the sharing of injection equipment for intravenous use of cocaine. However, HIV risk from cocaine (and methamphetamine) use also commonly results from increased rates of sexually risky behaviors, and this increase in sexually risky behavior is greater among cocaine users than it is among users of other addictive drugs such as heroin. Some sexually risky behaviors are associated with the acute effects of the drug, including increased sexual arousal, more vigorous sex (allowing for increased abrasions on genitals during sex), and increased rates of particularly risky sexual acts such as unprotected anal sex and sex with prostitutes.
Cocaine dependence has been one of the most difficult drug dependencies to treat. Despite decades of funding and research, no effective medication has been approved for the treatment of cocaine dependence. New research, however, suggests that, as with the use of methadone in the treatment of heroin dependence, substitution (agonist) therapy using an oral, long-acting stimulant such as amphetamine may hold promise. Among psychosocial treatments, the most effective treatment of cocaine dependence has been contingency management, in which cocaine-free urine is rewarded with goods or services more consistent with a prosocial lifestyle. Although highly effective relative to other interventionsin clinical trials, there has been limited success in translating this use of “motivational enhancements” in actual community clinical practice.
Illicit cocaine entering the United States and Europe largely comes from South America, with Colombia, Peru, and Bolivia playing prominent roles. Significant harms to the people and nations of South America have resulted from the production of cocaine for black market sale and consumption in the United States and Europe. The incredible money made in this black market has given cocaine cartels in these financially poor nations tremendous power. Both political corruption and rampant violence have resulted from efforts by these cartels to maintain and expand their control of the cocaine markets. In addition, efforts to eradicate coca production in South America, driven by efforts by the United States to curb cocaine supply, have contributed to harms to the people of South America. Aerial spraying of glyphosate (the chemical in the pesticide Roundup) has been reported to damage subsistence crops in addition to coca plants, as well as causing medical and environmental damage. There has been resistance to efforts to eradicate coca growing in South America. As a salient example, in March 2009, Bolivian President Evo Morales, a former coca grower himself, brought coca leaves to the United Nations (UN) headquarters in New York City for a UN summit on drugs. During his speech, President Morales ate a coca leaf and said, “We're for the coca leaf but against cocaine.… The coca leaf should no longer be vilified and criminalized.”
Race played a prominent role in the functional illegalization of cocaine in 1914. A common theme discussed in the media and in Congress was that of the so-called “drug crazed Negro,” portrayed as an unstoppable rapist of Caucasian women. Although there was no evidence for increased cocaine-related problems among African Americans relative to Caucasians, the tactic was successful in raising fears about cocaine in the predominant racist culture. Today race continues to interact with cocaine and the law. The increased penalties for crack cocaine relative to powder cocaine have resulted in a highly disproportional incarceration of African Americans. Since the early 1980s crack cocaine use has been relatively predominant in inner-city, primarily African American communities, while powder cocaine use has been relatively more predominant in Caucasian suburban and rural areas. In 1986 Congress passed the Anti-Drug Abuse Act, which imposed mandatory minimum sentences for cocaine that set the weight threshold for mandatory imprisonment for crack cocaine at 100 times lower than that required for powder cocaine. Although the rapid onset of crack cocaine increases its addictive potential relative to nasally administered powder cocaine, this distinction is not true for crack cocaine and intravenously administered powder cocaine, which have similar onsets of action. In addition, intravenous powder cocaine use is associated with risk for HIV and hepatitis C infection via injection equipment sharing, a property not associated with crack use. Therefore, the distinction between the two forms of the drugs is not so clear in terms of public health.
Bolivia, Cocaine Cartels, Colombia, Crack, Drug Trafficking and Political Movements, Drugs and Money Laundering, Drugs-Crime Connection, Freebase, Harrison Act of 1914, International Drug Policies: Eradication of Narcotic Crops, International Drug Policies: Interdiction and Law Enforcement, Peru, Pure Food and Drug Act.
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