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The abuse of cocaine and other psychostimulant drugs reflects a complex interaction between the pharmacologic properties of each drug, the personality and expectations of the user, and the environmental context in which the drug is used. Polydrug abuse involving the concurrent use of several drugs with different pharmacologic effects is increasingly common. Some forms of polydrug abuse, such as the combined use of heroin and cocaine intravenously, are especially dangerous and are a major problem in hospital emergency rooms. Sometimes one drug is used to enhance the effects of another, as with the combined use of benzodiazepines and methadone, or cocaine and heroin in methadone-maintained patients.

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Chronic cocaine and psychostimulant abuse may cause a number of adverse health consequences, and preexisting disorders such as hypertension and cardiac disease may be exacerbated by drug abuse. The combined use of two or more drugs may accentuate medical complications associated with abuse of one of them. Chronic drug abuse is often associated with immune system dysfunction and increased vulnerability to infections, which in turn contributes to the risk for HIV infection. In addition, concurrent use of cocaine and opiates (the “speedball”) is frequently associated with needle sharing by IV drug users. Intravenous drug abusers continue to represent the largest single group of persons with HIV infection in several major metropolitan areas in the United States as well as in many parts of Europe and Asia.

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Cocaine is a stimulant and a local anesthetic with potent vasoconstrictor properties. The leaves of the coca plant (Erythroxylon coca) contain ∼0.5–1% cocaine. The drug produces physiologic and behavioral effects when administered orally, intranasally, intravenously, or via inhalation following pyrolysis (smoking). The reinforcing effects of cocaine appear to be related to activation of dopaminergic neurons in the mesolimbic system. Cocaine increases synaptic concentrations of the monamine neurotransmitters dopamine, norepinephrine, and serotonin by binding to transporter proteins in presynaptic neurons and blocking reuptake.

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Prevalence of Cocaine Use

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Cocaine is widely available throughout the United States, and cocaine abuse occurs in virtually all social and economic strata of society. The prevalence of cocaine abuse in the general population has been accompanied by an increase in cocaine abuse by heroin-dependent persons, including those in methadone maintenance programs. Intravenous cocaine is often used concurrently with IV heroin. This combination purportedly attenuates the postcocaine “crash” and substitutes a cocaine “high” for the heroin “high” blocked by methadone.

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Acute and Chronic Intoxication

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There has been an increase in both IV administration and inhalation of pyrolyzed cocaine via smoking. Following intranasal administration, changes in mood and sensation are perceived within 3–5 min, and peak effects occur at 10–20 min. The effects rarely last more than 1 h. Inhalation of pyrolyzed materials includes inhaling crack/cocaine or smoking coca paste, a product made by extracting cocaine preparations with flammable solvents, and cocaine free-base smoking. Freebase cocaine, including the freebase prepared with sodium ...

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