Drug Addiction Part 3Karen Revere

Kian Eftekhari

Will Hiesinger

Risk of Addiction

Ever Used (%) Dependence (%) Risk (%)

Tobacco 75.6 24.1 *31.9

Cocaine 16.2 2.7 16.7

Heroin 1.5 0.4 23.1

Alcohol 91.5 14.1 15.4

Cannabis 46.3 4.2 9.1

Source: Anthony et al, 1994. Courtesy of Charles A. Dackis, MD

Complications of Cocaine Use

Cerebrovascular Disorders

i.e. Ischemic or Hemorrhagic strokes

-Hemorrhage occurs about twice as frequently as ischemia.

-Hemorrhagic manifestations may be intraparenchymal or subarachnoid hemorrhage.

-Hemorrhage may occur within seconds of cocaine use or may lag cocaine use by as long as 12 hours. In many cases, it occurs within a few minutes.

-Ischemic strokes are likely due to vasospasm, vasculitis, or due to the procoagulant effect of the drug.

-Most cocaine-induced strokes occur in patients younger than 50 years.

The image was obtained 79 minutes from the sudden onset of right-sided weakness and numbness. T2-weighted imaging and FLAIR show the lesion as an area of increased signal intensity with a periphery of signal loss (arrows C) and a surrounding rim of increased signal intensity, most likely due to vasogenic edema encasing the hematoma. CT obtained seven hours from symptom onset shows a left thalamic hematoma. Linfante, I, Lilnas, RH, Caplan, LR, Warach, S, Stroke 1999; 30:2263. Copyright © 1999 Lippincott Williams and Wilkins.

So, why is this bad?

Hypertensive intracerebral hemorrhage

-The 30-day mortality from ICH ranges from 35 to 52 percent and one-half of these deaths occur within the first two days.

-Only a small number of patients function independently after the event.

…because you DIE.

Neuropsychiatric complications

-Neuropsychiatric complications occur in about 40% of cocaine users.

-Psychiatric disturbances include: depression, suicidal ideation, paranoia, violent antisocial behavior, catatonia, and auditory or visual hallucinations.

-A moderate proportion of addicts develop panic attacks.

-The paranoid symptoms are more severe and develop more rapidly with continuous use of cocaine.

Seizure -Seizures occur in about 3% of cocaine users.

-The majority of seizures are single, generalized, induced by intravenous or crack cocaine

-Seizures are one of the few complications of cocaine use in which a direct relationship with dose has been shown.

-All routes of administration are associated with seizures, and seizures can be induced in some persons by small quantities of cocaine.

Cocaine use is associated with a variety of movement disorders: "crack dancers"

-Stereotyped behaviors

-Acute dystonic reactions (sustained, often painful muscular spasms, producing twisting abnormal postures)

-Choreoathetosis (brief, irregular contractions with twisting and writhing movements) and akathisia (extreme sensation of restlessness)

-Buccolingual dyskinesias ("twisted mouth" or "boca torcida")

-Exacerbation of Tourette's syndrome

Not Just the Brain

Treatment-Treatment for cocaine addiction occurs primarily in the outpatient setting, and involves psychosocial treatment.

-Rates for long-term abstinence are less than 50 percent.

-Buprenorphine may be helpful for patients who are co-addicted to opiates.

-Disulfiram, topiramate, tiagabine, and modafinil have shown some promise for cocaine abstinence.

-Peer group self-help programs (such as Cocaine Anonymous) improve outcomes.

Reduced D2 Binding in Cocaine Dependence

One of the most interesting findings in cocaine research . . . .

Raclopride binds D2 receptors in the nucleus accumbens…D2 is also seen with morbid obesity, and addiction to alcohol, heroin & methamphetamine

Courtesy of Charles A. Dackis, MD

Modafinil Promotes Cocaine Abstinence

Longitudinal GEE models showed a significant main effect for cocaine abstinence in

the modafinil group (odds ratio = 2.41, 95% CI 1.09-5.31, p = 0.03)

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Placebo Modafinil

Study Week

Dackis et al.. Neuropsychopharmacology 2005

Modafinil is a Dopamine enhancing drug

Courtesy of Charles A. Dackis, MD