STIMULANTS

• Historical aspects of stimulant use,
• Methods of administering stimulants,
• Physical and psychological effects triggered by stimulant use,
• Side effects caused by stimulant use,
• The effects of chronic stimulant use,
• Resulting effects of stimulant overdose,
• Results that occur from stimulant withdrawal,
• Distinctive features of stimulant use.

A stimulant increases the functioning of the central nervous system. The nervous system works in a hierarchial manner. This means stimulants arouse the central nervous system directly or indirectly by stimulating the lower parts of the central nervous system; especially the sympathetic division of the system.8 This is why stimulants are often called sympathomimetics. They mimic the effects of the sympathetic nervous system.

Stimulants are used by people to produce alertness, decrease fatigue and to prolong physical work. They elevate mood and enhance self-confidence. The effects of the drugs in the stimulant classification are similar to one another. The difference in their effects results from the individual's mental state, drug dosage, and potency. All stimulants increase blood pressure, heart rate and body temperature. The body temperature is elevated by the effect caused by increasing muscle activity and constricting the blood vessels. This results in decreased heat loss, increased heart rate and elevated blood pressure. Examples of drugs in this classification include caffeine, nicotine, amphetamines and cocaine. Psychological dependence and tolerance are risks associated with stimulant use.

Caffeine
History. Caffeine is our national non-alcoholic drink. It is present in a number of plants including coffee beans, tea leaves, and cacao beans. It is found in coffee, tea, soft drinks, candy bars, and in over-the-counter pain killers.

The coffee bean is native to Ethiopia. It appears to have been first ingested by chewing the bean. The practice of making a drink from the coffee bean began in Arabia. One of the plants earliest cultural uses was in religious observances and was often used by people to stay attentive during the long nights they spent in prayer. Tea use began in China. In some countries caffeine is also sold in tablet form as an anti-fatigue compound.

Methods of Administration. The drug is usually ingested in a beverage but it can be consumed in tablet form, as a suppository or injected.

Effects. There is a great deal of variation in the amount of caffeine that is found in over- the-counter medications. Caffeine initially produces a mild stimulation. The initial effects of caffeine occur within 15–60 minutes; a maximum effect occurring within two hours. The duration of effects can last from seven to eight hours.4 Alertness may be increased and performance of uncomplicated tasks may be improved. The consumption of 150–250 milligrams will produce arousal. In amounts ranging between 200–300 milligrams, fatigue is relieved and the amount of physical work an individual can perform is prolonged. In doses of 200 to 400 milligrams marked stimulation of the nervous system may occur.9 Caffeine can function as a performance aid in athletic endurance sports when three to five cups of coffee are taken one hour before a contest. Two to three cups of coffee a day can increase the basic metabolic rate between three and five percent. This enhanced metabolic effect lasts up to four hours. Caffeine also causes the release of fatty acids in the blood which spares the muscles from using the muscle sugar glycogen. This further improves performance in endurance events.

Chronic Use. Chronic use leads to the development of tolerance and psychological dependence. Caffeine is similar to other stimulants in that the beneficial stimulating effect is followed by a rebound effect which ranges from mild fatigue to varying levels of depression. Headache, diarrhea and fatigue are also associated with this rebound effect.

Overdose. The International Olympic Committee has stated that 600 mg (approximately four to five cups of coffee) of caffeine taken in 30 minutes produces a blood doping infraction because at this level caffeine improves performance in endurance activities. If caffeine is consumed at this level, irregular heartbeat, tinnitus (ringing in the ears), nervousness, diarrhea, restlessness, insomnia, anxiety, delirium, headache, upset stomach and peptic ulcers can result.19 Psychological effects caused by an overdose include insomnia and anxiety. Caffeine overdose is treated with antipsychotics, and medications to reduce blood pressure and heart rate. Anticonvulsant drugs may be given to combat convulsions associated with caffeine overdose.

Side Effects. Caffeine can have a powerful diuretic effect. Although therapeutic caffeine use can enhance attention span higher doses actually hampers performance of tasks that require concentration and critical analysis. Caffeine causes muscle tremors which hinders performance in activities that require fine muscle control. This includes any activity that demands delicate coordination and accurate timing such as riflery and archery. Heartburn is one of the common side effects of caffeine use and is one of the major reasons why many people stop drinking caffeine beverages.

Withdrawal. Withdrawal from caffeine includes effects such as headache, diarrhea, irregular heartbeats, and psychological complaints including anxiety, irritability, mood changes, sleep disturbances and fatigue. The withdrawal is not long lasting and no permanent effects have been reported.

Unique Aspects. Caffeine's ability to increase heart rate makes it useful in the treatment of heart failure. Caffeine relaxes the smooth muscles of the bronchial tubes of the lungs. This makes it valuable in the treatment of asthma—both in preventive and emergency situations. Its ability to constrict blood vessels in the brain makes it effective in the treatment of severe headaches (migraine). Caffeine has also been helpful in counteracting the effects of barbiturate overdose.

Nicotine
History. Nicotine, the active ingredient in tobacco was isolated by a French chemist by the name of Nicot and the drug was named after him. Nicotine is the principal active ingredient in tobacco. A number of varieties of exist and include bright, burley and Turkish tobaccos. Most of our cigarettes contain a mixture of these various types of tobacco. Prior to the introduction of the pipe or cigarette in Europe chewing was the preferred way to use tobacco. It was smoked in pipes and used as snuff by the Native American Indians. Pipe smoking was used for ceremonial purposes, but it was also for preventing hunger and as a medicine. The rapid acceptance of pipe smoking among the aristocrats of Europe helped spread the popularity of tobacco use.

The spread of tobacco use across Europe was strongly opposed by the church and several national governments. In the 1500–1600s the death penalty was imposed in Germany, China, and Turkey for anyone convicted of using tobacco products. Castration was the sentence for tobacco use in Russia. Public health officials discouraged tobacco use by campaigning against the use of chewing tobacco because it contributed to the spread of tuberculosis. The introduction of the cigarette provided a sanitary and inexpensive alternative to chewing tobacco and created a change in the pattern of tobacco use. Most of the early pipe and cigar smokers were men. However, women quickly adopted the tobacco habit with the introduction of cigarette smoking.

The health hazards of smoking have been widely publicized. The effect of public notices have resulted in a restriction placed on advertising and the banning of smoking in public areas including elevators, hospitals, theaters, restaurants and aircraft.

Methods of Administration. Nicotine is usually inhaled (smoking), snorted or chewed. It has also been used as a tincture like tea.



Effects. Over four thousand chemicals are found in tobacco in addition to nicotine. Some of these include acetone, carbon monoxide, ammonia, acids, insecticides, tar, and radioactive substances. The active ingredient in cigarette smoke is nicotine. The nicotine is a powerful agent that modifies behavior. Nicotine that is injected intravenously is more potent than intravenous cocaine in terms of its "reward" potential for the user. When nicotine is smoked it takes approximately seven seconds to reach the brain. Approximately 60 milligrams of nicotine can produce a lethal dose. The average cigarette delivers between 0.05 and 2.5 milligrams of nicotine to the smoker. The smoker who inhales gets approximately 90% of the nicotine in their bloodstream as compared to 20% to 50% for the person who does not inhale.

Nicotine is a highly toxic compound that has also been used as an insecticide. Nicotine is a curious drug because it causes both stimulation and depression of the nervous system. It increases respiration by stimulating the receptors in the carotid artery that monitors the brain's need for oxygen.1 Its depressant effect causes fluctuations in blood pressure. The depth of inhaling and the frequency of puffing will determine the amount of nicotine reaching the bloodstream. Tobacco smoke also contains acetaldehyde which is produced when the liver first breaks down alcohol. Acetaldehyde is more potent than alcohol and produces a sedative effect in the tobacco user.

Nicotine affects the part of the brain that directly controls swallowing, blood pressure, respiration and vomiting. Nicotine is also an activator of the sympathetic nervous system and the organs affected by the sympathetic nervous system. This effect causes the release of the neurotransmitters norepinephrine and can induce skeletal muscle tremors, increased blood flow to the heart, and elevated heart rate and blood pressure.

Nicotine also stimulates the release of the neurotransmitter dopamine. This release helps the smoker associate smoking with pleasurable sensations and helps reinforces the craving for tobacco. The relaxing sensation is also reinforced through the psychological belief that smoking relaxes a person. This placebo effect produces a relaxation that many smokers say they sense when they smoke. Chronic Use. Chronic nicotine use is related to tooth discoloration, tooth decay and gum diseases, such as gingivitis. Bronchitis, emphysema, cancers of the mouth, throat, digestive system and lungs are all associated with tobacco smoking and the chewing of tobacco products.16

Nicotine helps deaden taste buds, and depresses appetite by slightly increasing blood sugar. Its use can inhibit hunger contractions in the stomach for up to an hour. These effects may explain the reason for the decrease in appetite described by many smokers. The body's metabolism may decrease as much as 10% once the smoker quits. This may account for the weight gain often associated with people who have quit smoking.2

Physically, smoking has some very direct effects on the efficiency of oxygen absorption. The carbon monoxide in tobacco smoke is more readily absorbed by the hemoglobin molecules in the red blood cells than is oxygen. The interaction of oxygen and carbon monoxide produces carboxyhemoglobin. This form of hemoglobin cannot carry oxygen. Therefore, less oxygen is circulated in the blood when you smoke. The tar found in the residue of cigarette smoke coats the lining of the air sacks in the lungs, further decreasing the amount of oxygen delivered to the body and brain. These factors combine to cause the classic smoker's shortness of breath. The tars and radioactive substances in cigarette smoke also combine to produce one-third of all cancer deaths. Chronic smoking contributes to increased chances of heart disease by inhibiting the production of a cholesterol removing enzyme and interferes with its ability to clear excess cholesterol from the artery walls and deliver it to the liver where it is metabolized into bile and eliminated from the body through the digestive tract.

Overdose. One of the results of nicotine overdose is its effect on blood pressure. Low to medium doses raises heart rate and blood pressure but increasing the amount often leads to a reduction in blood pressure. This characteristic feature of nicotine poses problems for individuals with coronary artery disease or who are using medications to control blood pressure.

Side Effects. The initial effect of nicotine on the brain causes first time smokers to feel dizziness, nausea and often causes them to vomit. Nicotine reduces blood flow to the extremities of the body and can reduce the strength of the heartbeat. It also irritates the lining of the lungs and slows down the functioning of the cilia which helps clean the lungs of foreign particles.

Passive, secondhand or sidestream smoke has received a great deal of attention recently. Breathing the air in close proximity to a person who is smoking has been documented to cause a detrimental effect on the nonsmoker.31 This smoke has higher concentrations of carbon monoxide, nicotine and ammonia than does inhaled smoke. This effect can be particularly harmful to young children whose immature liver and excretory systems cannot effectively screen out these substances.

Withdrawal. Withdrawal symptoms include irritability or anger, decreased alertness and increased aggressiveness. Insomnia, drowsiness, hunger, muscle tremors and a craving for tobacco also occur. The individual will experience a decrease in both heart rate and blood pressure after withdrawal from nicotine. The first symptoms will appear within two hours and the symptoms will intensify for up to 24 hours. The symptoms will gradually decline over a period of time ranging from 10 days to several weeks. Some people report symptoms one month after stopping smoking, and 75% of smokers who have stopped have reported cravings for up to six months.15

Unique Aspects. It is now well established that smoking has been linked to coronary artery disease, lung cancer, bronchitis, emphysema, duodenal ulcers and allergies. Smoking statistically is related to more deaths than illicit drugs, alcohol, all accidents, homicides and suicides combined. The smoking habit is acquired early in life. It appears to be a coping behavior that produces a positive self-concept, allows an individual to demonstrate autonomy, and relates to our perception of being tough, accepted by peer groups and independent. Peer influence, social conformity, a positive family attitude toward smoking, stress, and inadequate personal coping skills help students increase the likelihood of their smoking. Twenty–seven percent of high school students and 16% of junior high school students smoke seven or more cigarettes a day. It is estimated that 83% of the population will try smoking by the age of 25.27

Nicotine seems to be able to act as an antagonist to counteract the sedative effect produced by alcohol, and also potentiates caffeine effects. This reduces the amount of caffeine needed to produce a stimulating effect. Nicotine interacts with oral contraceptives. This interaction increases the possibility of strokes and embolisms in female tobacco users. Nicotine crosses the placental barrier and easily enters the fetal bloodstream. Cigarette smoking for women also increases the chances for cervical cancer, miscarriages, early menopause and osteoporosis.

The fetus cannot metabolize nicotine or carbon monoxide as efficiently as does the mother. This can affect the fetus's nervous system, cause spontaneous abortions, or low birth weight. Studies have shown that passive smoking can hinder lung development in children. Children born to parents who smoke are more likely to develop bronchitis and pneumonia during the first year of life than are children of nonsmokers. Nicotine is also secreted in breast milk thus has the ability to affect the nursing child.

Smokeless Tobacco

There is a false perception by many that smokeless tobacco is less dangerous than tobacco smoking and therefore is a safe alternative to smoking tobacco. The use of this form of tobacco is especially popular with adolescent males between the ages of 18 to 30 years of age. There are a variety of techniques for using smokeless tobacco. Dipping is performed by placing a pinch of powdered tobacco called snuff between the cheek and gum. Chewing consists of placing leaf tobacco called a wad or chaw on the inner cheek. A chaw is a ball of leaf or plug tobacco. The decreased saliva production that long term tobacco chewing causes can result in less protection for the teeth against infections and cavities.

Persistent use of smokeless tobacco reduces the sense of taste and smell, contributes to bad breath and tooth discoloration. The sweeteners, flavorings, and additives including sugars, and fluoride helps contribute to the staining and eroding of the tooth enamel.

Leukoplakia results from the continued contact of smokeless tobacco with the gums. Leukoplakia begins with an irritation and a reddening of the gums. As the disease progresses the gums recede, become wrinkled and form white lesions. There is a strong possibility of the development to oral cancers with continued smokeless tobacco use. The risk of cancer varies depending on the frequency, duration and the placement of the tobacco in the mouth.

Amphetamines
History. Amphetamines were introduced into American medicine in the 1930s to produce wakefulness, self-confidence and euphoria. Its use as a prescribed medication for weight control reached its peak in 1967. Its use was restricted in 1970 to the treatment of narcolepsy, hyperkinetic behavior, and for short-term weight loss. The drug was used by the militaries of The United States, England, Germany and Japan in World War II to counteract fatigue and enhance aggressiveness. Following World War II, the drug companies in Japan dumped amphetamines onto the civilian market. No prescription was required to purchase the drug at that time. The United States military used the drug for the same reason during the Korean Conflict. The most common examples of amphetamines include Benzridrine, Dexidrine and Methamphetamine.
Methods of Administration. Amphetamines can be taken as a tablet, inhaled or injected.

Effects. Amphetamines are similar to our body's own neurotransmitter noradrenalin and dopamine. Amphetamines cause norepinephrine to seep from its presynaptic storage sites and artificially places the body in a state of stress. This results in a stimulation of the adjacent neuron. Amphetamines block the re-absorption of dopamine and norepinephrine causing a continuous stimulation of the nervous system. Such successive stimulation can induce a situation called behavior stereotype in which the individual continuously performs a given task such as repeating phrases of music, a task, or repeatedly cleaning the same object.6

At low to moderate doses users report the feelings of self-confidence, increased alertness and the ability to concentrate, loss of fatigue and mood elevation. The amphetamines and cocaine also have the ability to magnify the pleasure experienced in many activities. The "rush" or euphoria activates the brain's pleasure center with effects lasting from four to 14 hours.3 Performance may be enhanced in tasks that demand physical activity or are boring and monotonous. Performance involving intellectual tasks may be worsened.13 Amphetamines and cocaine suppress appetite and delay the onset of sleep. The strong sense of well-being that amphetamines and cocaine produce increases the likelihood of psychological dependence and tolerance.

Chronic use. In many cases amphetamine's effect of suppressing appetite causes users to neglect good nutritional habits. This results in dietary deficiencies and malnutrition. The users must also contend with the effects of the lack of sleep and psychosis. The physical complications associated with long-term amphetamine use include anorexia, vomiting, heart irregularities, chest pain, diarrhea, convulsions and coma, physical weakness, and insomnia. Psychological and behavioral effects of chronic use include mental confusion, irritability, anxiety, delusions, panic states suicidal and homicidal tendencies.1 The exact effect of amphetamines on brain function is still unclear. Evidence suggests that prolonged amphetamine use can cause physical damage to the cells of the brain. An individual may use amphetamines for extended periods that can last for days to get a continuous effect. Psychosis and bizarre behavior may be very severe during this time. This run is usually followed by a rebound that causes sleep, depression and excessive eating.

Overdose. High levels of amphetamine use can result in irritability, fear, suspicion, confused behavior, and a psychosis. Psychosis is a psychotic-like state in which the individual experiences confusion, suspiciousness, delusional thinking and visual hallucinations during use.35 This drug-induced psychosis clears up within days of the last dose, but after-effects may last for weeks or months. Heavy use causes a rebound effect in which the extreme stimulation of the central nervous system is followed by a lethargic depressed state. Amphetamine-induced depression can last months. Death from overdose is occasionally reported and usually results from a brain hemorrhage.

Side effects. Insomnia, anxiety, irritability, and hostility occur during periods of initial amphetamine use. Hypomania (repetitive foot tapping) and formication (the sensation that bugs are crawling over the skin) may occur. Insomnia and malnutrition are also possible side effects. Amphetamine use is often combined with the use of depressants such as alcohol, barbiturates, heroin and hallucinogens such as LSD. These substances reduce or counteract the side effects of amphetamine use and helps the drug user sharpen the amphetamine effects.

Withdrawal. The initial withdrawal symptoms begins several hours after drug stoppage. Withdrawal symptoms include muscle weakness, fatigue, diarrhea, chest pain and irregular heart beats. Psychological effects include confusion, irritability, anxiety, delirium, paranoid hallucinations and depression. Depression peaks two to three days after the last dose, but the symptoms may last for approximately four days. The individual gradually develops hallucinations, and vague suspicions that can turn into delusions. If these delusions are prolonged the user feels agitated and confused and violent.

A rebound effect results from the depletion of norepinephrine and dopamine. This creates an anxiety and a craving for amphetamines. The fatigue and depression can last for months after stopping the use of amphetamines.29 Also, compulsive eating and extended periods of sleep may occur. The extended sleep may be the result of the body catching up for the depression of REM sleep during the period of amphetamine use. Withdrawal after extended use called amphetamine runs causes severe depression accompanied by suicidal thoughts. The feelings of fatigue and lethargy may last for long periods of time, this is thought to be due to the depletion of dopamine during the period of amphetamine use. The long term effect of dopamine depletion by amphetamines on the body is still unknown.

Unique Aspects. One of the beneficial uses of amphetamines occurs in the treatment of asthma and other breathing disorders. Amphetamines are effective in relieving asthmatic symptoms because they act as bronchial dilators and relax the bronchial muscles. Amphetamines were also prescribed as a short-term appetite suppressant for people with weight problems. It was also used as a remedy for fatigue, and to treat narcoleps who may have numerous sleeping bouts.

The prescribing of amphetamines such as Ritalin to treat hyperkinetic disorders (in which a child acts restless, impulsive, has a short attention span, and displays disruptive behavior) should also be mentioned. Its use tends to cause better control of the individual's muscle coordination and enhances the ability to concentrate and screen out surrounding distractions. Today in many countries amphetamine use is limited to treating narcolepsy and hyperkinetic disorders.

Cocaine
History. Cocaine has been used for thousands of years in Peru, Bolivia, and Columbia to combat fatigue, hunger, and to induce pleasurable sensations. The plant does have some nutritional value. Two ounces of coca leaves contains the RDA of vitamins and also has some essential minerals.

The South American Indians chew the coca leaves by rolling it into a ball and keeping it in the mouth. Modern natives mix cocaine leaves with lime and chew them.34 The interaction of chewing the leaves, mixing them with the lime and saliva releases the cocaine. This practice helps maintain the stimulant effects for an extended amount of time.

Cocaine is valuable at high altitudes where fatigue, the lack of oxygen, cold and limited availability of food contribute to the rapid onset of fatigue. It is used in religious ceremonies and as a medium for trade. Interestingly, cocaine also became a measure of time or distance. The cocatá was a measure of time; 40 minutes or a distance of two to three kilometers. This was the time or the distance a person could walk while experiencing the effects of cocaine.

The leaves were transported to Europe but never became popular because the long voyage reduced the cocaine content to a point that it was worthless. Wide use outside South America occurred in the late 1850s when cocaine was isolated from the coca plant, thus making it easy to store and transport. It was a popular anesthetic at that time. The invention of the hypodermic needle further increased its use. Sigmund Freud experimented with cocaine to treat depression and to ease the withdrawal from opiate addiction. Sir Arthur Conan Doyle had his character, Sherlock Holmes, use a seven percent solution of cocaine and morphine.17 During the 1800s it was used in the United States in patent medicines to help cure hay fever, whooping cough, asthma and bronchitis.

Cocaine was made into an concentrated extract in the 19th century. It was sold as a medicinal drug which would free the body of fatigue, lift the spirits, and cause a sense of well-being. In the 1890s it was used in the United States as a local anesthetic for eye surgery and as a nerve tonic. Dr. J.C. Pemberton created Coca-Cola™ from the extract of cocaine and the cola bean. Decocainized leaves are still used as a flavoring agent in the beverage today.

Cocaine was the first medically used local anesthetic. In the 1960s cocaine became the alternative for amphetamine use because government regulations resulted in a limiting the availability of amphetamines. Cocaine's use peaked in the 1980s. Present use has leveled off or declined compared to 1970s levels. Less than one percent of the cocaine is used for medical use with the remaining 99% being used recreationally.22

Methods of Administration. The drug can be chewed, snorted, inhaled or injected.

Effects. Cocaine is a powerful short-acting central nervous system stimulant that produces both stimulation similar to amphetamines or adrenalin and an anesthetic effect.36 Cocaine is a very potent reinforcer. This means cocaine has an overwhelming influence on the brain's pleasure center which leaves the user feeling competent, energetic and self-confident. The perception of increased energy is brought about by altering the perception of fatigue by stimulating the central nervous system thereby masking the fatigue.26 Tolerance develops within hours or days to cocaine. This rapid development of tolerance allows the user to move from the average dose of 300 milligrams to increased amounts in the same day (up to 30 grams or more).

Cocaine releases the neurotransmitter dopamine and norepinephrine and prevents their re-uptake thus depleting these neurotransmitters and causing depression and a craving for the drug.28 This effect results in pleasurable sensations and stimulates the nervous system. The brain's reward system reacts by requiring less stimulation. Animals with unlimited access to cocaine are most likely to select the drug in place of sex, food, or water and often use it to the point of death. It is an excellent anesthetic and constrictor of mucous vessels of the ears, nose, and throat. If taken when the user is in a relaxed state, and in small to moderate doses fatigue is almost totally eliminated for the period of time the person is under the influence of the drug and motor coordination is improved. Users also experience a strong sense of self- confidence. It functions as a sexual stimulant by delaying male and female orgasms and culminates in orgasms that are said to be extraordinary. However, long-term use has shown to decrease the ability to have an orgasm without cocaine and can lead to impotence in both men and women.21

The effects on the neurotransmitters produces a rapid high and sense of wellbeing which is followed by a prolonged low when the drug is metabolized. This rebound effect leaves the individual craving the drug; anxious, tired, mentally dull, tense and depressed.24 Over a period of time the drug is often taken to maintain a feeling of being normal. This is due to the dopamine depletion. The rapid tolerance that develops in one to two hours to the euphoric effects of the drug is called tachyphylaxis. This rapid development of tolerance motivates the user to increase the dosage to maintain the euphoric effects and may be one of the mechanisms that lead to cocaine binging.5

Cocaine is used in four forms. Coca paste is formed when sulfuric acid, kerosene, and methanol are mixed with the coca leaves. These chemicals convert cocaine to cocaine sulfate and it is collected as a paste. At this point it can be ingested or smoked. Cocaine is also converted to cocaine hydrochloride and sold as cocaine powder. The most common way that cocaine powder is used in the United States is by inhaling or snorting the drug.

More intense effects can be obtained by converting the cocaine to freebase. Solvents such as ether are used to create freebase cocaine. The freebase is heated changing the water-soluble base into a water insoluble base that is often over 90% pure. It floats to the top and is drained off with an eyedropper. It is then dried and crushed into a powder for smoking or it can be injected.

Cocaine hydrochloride can be mixed with bicarbonate soda (baking soda) and water, heated and then mixed with cold water. This hardens it into solid pieces called crack.18 It is also formed into three-inch sticks called teeth, french fries, or can be pressed into pills.

Cocaine is bought in portions of grams called quarters and eighths. Cocaine is usually sold on the streets in one gram packages. The purity of cocaine sold on the street ranges from five to 95% and the rest is comprised of fillers. The average street dose ranges from 20 to 50 milligrams; 1200 milligrams produces a lethal effect.

Chronic Use. Long term use of cocaine can result in hoarseness, bronchitis, a breakdown of cartilage in the nose, inflamed tonsils, weight loss, malnutrition, insomnia, digestive disorders, paranoia, and hallucinations.14 Formication similar to that experienced by amphetamine use causes a stimulation of the body's nerve endings. The individual feels as if coke bugs are crawling over them. Most deaths result from brain hemorrhage, blocking the heart's electrical system, and lung failure. Prolonged use creates a hypersensitive effect in which the individual overreacts to what was a tolerated dose. Snorting can cause addiction in three to four years. Smoking can cause addiction in six to 10 weeks. Vitamin B complex and Vitamin C depletion can also result from long term use. Commonly-experienced psychological effects include impaired thinking, short temper, panic attacks and paranoia .20 The injection of cocaine also increases the risk of blood infections, hepatitis B, skin abscesses, scarring at the site of infection, and acquiring HIV infection.

The effects on the fetus and newborn should also be clarified. Miscarriages, stillbirths, and premature labor during delivery are common among cocaine using mothers.7 If separation of the placenta from the uterine wall occurs the life of the mother and the fetus are endangered. Malformed kidneys and genitals have also been reported in the newborns due to the use of cocaine. After birth, the newborn is often unresponsive and irritable due to the depressing effect of cocaine withdrawal. Cocaine also interferes with the infant's breathing and can result in sudden infant death syndrome. Pregnant women and women considering pregnancy should avoid the drug because of its potential harm to the developing fetus and because of the unknown contaminants present in cocaine.

Cocaine is commonly used in combination with alcohol, marijuana, barbiturates, tranquilizers, heroin and hallucinogens. These substances help control the craving for cocaine and the rebound effect that is causing the depression after the drug is metabolized by the body.

Overdose. Cocaine's stimulating effect constricts blood vessels and increases muscle activity. Small doses slows the heart, moderate dose increase heart rate and blood pressure and high doses causes a toxic effect on the heart muscle that can induce cardiac arrest.12 Cocaine increases muscular activity that produces heat, has a direct affect on the brain's heat regulating center and causes the peripheral nervous system to constrict; resulting in fever. Paranoia, confusion, stroke, heart palpitations, slow or halted heart rate, and heart attacks are all possible from cocaine use. Muscles tremors and convulsions occur due to the depression of brain centers and may induce death as the result of lack of oxygen to the heart muscle, respiratory paralysis and heart failure. Approximately 15% of cocaine users experience seizures and still 95% of them continue to use cocaine following these episodes.25

Cocaine psychosis is a state in which the cocaine user feels anxious, appears to have superhuman power, and is paranoid to the point that they believe their lives are in danger or someone is going to steal their drug. Outbursts of anger, rage, seizures, and depression follows.23 The individual may come out of the psychosis within two to three hours but they will feel depressed for two to three days. The depression may induce suicide. People often hear and see things that don't exist within hours if the cocaine is discontinued. The dopamine depletion may be why hallucinogens and paranoid episodes occur and norepinephrine and serotonin depletion are implicated in why depression occurs after cocaine use.

An overdose that produces cocaine poisoning is composed of three distinct stages. The initial stimulation phase causes irritability, tremors, chest pain, cardiac arrhythmias, palpations, sweating and fever. The second phase involves depression of heart rate and blood pressure, labored respiration and mental confusion. The third phase involves system failure characterized by shock, a lack of oxygen, decreased body temperature, respiratory failure, cardiac failure and death. In extremely high doses the first phase my not be as noticeable as the depression and system failure phases.

The consequences of overdosing often requires stomach pumping to prevent toxic effects and the use of antagonist drugs to cancel the effects of cocaine on heart rate and blood pressure. The body is cooled to treat the fever. Antipsychotic drugs, muscle relaxants and anticonvulsant drugs may be given to reduce the number and severity of the convulsions.

Side Effects. Over a period of time the brain becomes sensitive to cocaine to the point that the amount of cocaine needed to produce a seizure is lowered. Fillers such as lactose, sucrose, quinine, inositol (B complex vitamin), mannitol and stimulants such as amphetamines, and anesthetics cause many of the side effects associated with cocaine use (including nasal irritation, running nose, increased blood pressure, nervousness, stomach cramps and diarrhea).30 The muscles controlling breathing are also detrimentally affected. This results in irregular breathing patterns. As tolerance develops it causes impotence in males and frigidity in females. The use of cocaine can result in a 50 beat increase in heart rate. Psychological side effects include acting suspicious, paranoid, being preoccupied with their own thinking processes, psychosis in which they are out of touch with reality or are hallucinating and hyperactive.

Withdrawal. The withdrawal symptoms begins within 24 hours of the last dosage and can persist for seven to 10 days. Cocaine withdrawal similar to acute alcohol hangover includes nausea, vomiting, body chills and insomnia. Blood pressure, heart rate, respiration and body temperature remain stable but muscle tremors, headaches, agitation and craving for the drug, fatigue or lassitude, unquenchable hunger and altered sleep patterns are commonly experienced in cocaine withdrawal. Psychological feelings of withdrawal include paranoia, depression, fatigue, and a craving for the drug. This craving for the drug may be due to the depletion of the neurotransmitter dopamine that occurred during the period of drug use. The long term effects of dopamine depletion is still unknown.

Unique Aspects. The initial physical effects of cocaine causes constriction of blood flow to the heart and interferes with the electrical signals that control the heart's rhythm. This can cause an irregular heartbeat or total heart stoppage.

It is used as a local anesthetic in eye, nose, ear and throat surgery. It is also used as a local anesthetic when examining digestive and respiratory tracts with probing instruments. Cocaine's anesthetic effect is due to its ability to block the nerve transmission along the axon of neurons. When it is used as an oral anesthetic, its effect is felt within one minute and these effects last up to two hours.

Cocaine is also used in England and Canada to relieve the severe pain caused by terminal cancer. It is a main ingredient in what is called Brompton's Cocktail. It is a mixture of cocaine, morphine, and gin placed in a syrup solution. It seems to work by enhancing pain relief, clearing the senses, and by preventing deep sedation of the patient caused by chemotherapy.

Cocaine addiction differs from other addictions in several ways. These include the rapid tolerance developed and the fact that the sight or smell of the drug triggers cravings. This latter characteristic is thought to relate to the fact that cocaine may affect the part of the brain where sight, smell, taste and thought reside.


SUMMARY

Stimulants include caffeine, nicotine, amphetamines and cocaine. These substances function in similar ways to the body's own adrenalin. All stimulants increase the functioning of the central nervous system and stimulate the action of the sympathetic nervous system. In small therapeutic doses these substances can have positive effects. They can enhance the performance of tasks that involve physical activities that are boring and monotonous. However, tasks that require sustained intellectual concentration, are worsened.

Caffeine relaxes the smooth muscle of the lungs. This makes it useful in the treatment of asthma. Its ability to constrict blood vessels in the brain makes it effective in the treatment of migraine headaches.

Nicotine increases heart rate and since it is taken in combination with other chemicals (such as carbon monoxide) and tars when we smoke, it has few beneficial effects. Smoking suppresses appetite and produces a positive sense of wellbeing. Nicotine crosses the placental barrier and affects the fetal nervous system, causing low birth rates and increases the chances of spontaneous abortions. Smokeless tobacco is not a safe alternative to tobacco smoking. Its detrimental effects range from tooth discoloration to Leukoplakia and oral cancers.

Amphetamines have been used since the 1800s to produce alertness, self- confidence, and to reduce fatigue. They have been used successfully in the treatment of hyperkinetic children and narcolepsy and for short term weight loss.

Cocaine is a stimulant-like substance that produces extreme stimulation and local anesthesia. It does contain some nutritional value and has been used by the South American Indians for centuries to relieve fatigue at high altitudes. Cocaine can be used in various forms: as a coca paste, cocaine hydrochloride, freebase, and as crack. Cocaine is used effectively in operations involving the ears, nose and throat. It is also used as a local anesthetic when examining the digestive tract with probing instruments. Long term use of cocaine can result in weight loss, malnutrition, insomnia, digestive disorders, paranoia, and hallucinations.


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