Drug Addiction Part 3 Karen Revere Kian Eftekhari Will Hiesinger

Risk of Addiction Ever Used (%) Dependence (%) Risk (%) Tobacco *31.9 Cocaine Heroin Alcohol Cannabis Source: Anthony et al, 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 D 2 Binding in Cocaine Dependence One of the most interesting findings in cocaine research.... Raclopride binds D 2 receptors in the nucleus accumbens…  D 2 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 , p = 0.03) Study Week Dackis et al.. Neuropsychopharmacology 2005 Modafinil is a Dopamine enhancing drug Courtesy of Charles A. Dackis, MD