Editorial, Journal of the Irish Colleges of Physicians and Sureons, Vol 20, No.1, Jan 1991

The potential perilous effects of crack in the US have been widely reported in newspapers and on television. How serious a threat is the phenomenon for Europe?

Crack is not a new drug but a new potent delivery system. It is cocaine powder separated fro its hydrocloride salt. To smoke cocaine powder it must first be converted into a smokable form and this is known as 'freebase' or crack. This procedure is easily carried out by means of a simple chemical reaction using baking soda, water and heat.¹ When cocaine is smoked, it enters the pulmonary circulation and reaches the brain in eight to ten seconds. The 'high' associated is short-lived and lasts only two to five minutes. Thereafter, the user's mood elevation declines rapidly. The symptoms are irritability, depression and anxiety accompanied by drug craving. In addition, the user runs the risk of developing a short-lived psychosis² sometimes with characteristic formication consisting of imaginary 'bugs' under the skin with much itching, severe scratching and self-mutilation. With the danger of AIDS from intravenous drug administration crack might be considered a safer alternative. However, the association of crack with hyper-sexuality and the practice of exchanging sex for drugs is more likely to contribute to an even more rapid spread of the AIDS virus.

Neurological complications associated with the use of crack include lateral medullary syndrome, transient ischaemic attacks, vertebrobasilar insufficiency and partial motor seizures. Ventricular arrythmias, respiratory and cardiac failure have also been reported.³

In the UK customs seized 35 kilogrammes of cocaine in 1984. In 1988, this figure has increased to 282 kilogrammes, and in the first quarter of 1989, 202 kilogrammes were confiscated. In 1987, 236 kilogrammes of heroin were seized by customs. Cocaine, therefore, is now on a par with heroin. Customs seizures for crack in the UK are rising - from six in 1987, 13 in 1988 and 27 in the first half of 1989.⁴

At the National Drug Treatment Centre in Dublin, 13 patients were treated for cocaine misuse in 1986 and a similar number were treated in 1987. By 1988, 25 cocaine and two crack misusers (both from the US) were treated. One crack and 29 cocaine misusers presented for detoxification in 1989. A further indication of misuse can be found in the annual Report n Crime published by the Garda Commissioners Office.⁶ Part of this report which is tabulated below provides information on persons charged with offences relating to all drugs and cocaine between the year 1979-1988 inclusive.

Persons Charged
Year	All Drugs	Cocaine
1979	594	20
1980	991	50
1981	1256	40
1982	1593	36
1983	1872	23
1984	1369	23
1985	1270	25
1986	1163	17
1987	1196	14
1988	1333	15

It is interesting to note that the total number of persons charged peaked in 1983 and the number charged relating to cocaine was highest in 1980.

Various treatment strategies have been tried with limited success. These include carbamazepine, which in one study, was found to alleviate 'cocaine craving'⁷. Treatment options are influenced by the fact that cocaine misuse is common among opioid addicts.⁸ The greater the cocaine dependence, the less the severity of opioid withdrawal. Thus, cocaine reduces the severity of opioid withdrawal and may be one reason for the widespread cocaine misuse by opioid misusers seen in other countries.⁹ The strategy of using methadone detoxification/maintenance in the treatment of opioid addiction is not applicable to cocaine addicts as there is no obvious substitute drug available.¹⁰ Tricyclic anti-depressant drugs have been used in the belief that dopaminergic pathways and recepters which have been supersentsitised by cocaine can be corrected and 'normalised' by the actions of the tricyclic compounds.¹⁰ It is argued in controlling the depression associated with the withdrawal of cocaine.¹⁰ Group and individual psychotherapy which are effective in the treatment of other addictions may be of benefit. Such programmes, however, need to be designed to suit the specific needs of the cocaine addict. Attendances at self-help groups such as Narcotics Anonymous (NA), Cocaine Anonymous (CA) are also beneficial.

Unlike heroin misuse, which has an established market and clientele with known characteristics, cocaine users in Ireland tend to be middle class, not criminally involved, and catering only to their own needs. There does not appear to be a pattern of street seizures.¹¹ However, a feature of all drug abuse is that when the supply of drugs increases so does the demand. The increase in cocaine abuse observed at the National Drug Treatment Centre is worrying, and similarities to the patterns of heroin misuse in the seventies and early eighties which so quickly developed into an epidemic, can be discerned. It remains to be seen if the use of crack will inflame this trend.

John J. O'Connor,
National Drug Treatment Centre,
McCarthy Centre,
30/31 Pearse Street,
Dublin 2.

References

1.Washton, A.M. Cocaine Addiction - Treatment, Recovery and Relapse Prevention. W. Norton and Co.:New York, 1989, p 14.
2. Lemere, F., Smith, J.W. Hypomanic Personality Trait Cocaine Addiction. Br. J Addict 85:575.
3. Mody, C.K., Miller, B.L., McIntyre, H.B., Cobb, S.K., Goldberg, M.A. Neurologic Complications of Cocaine Abuse, Neurology, 1988; 38: 1189-1193.
4. Home Office, Statistics on the Misuse of Drugs in the UK for 1987, 1988, 1989. London, HMSO, 1988.
5. Drug Treatment Centre Board. Statistics on the Misuse of Drugs in Dublin 1986, 1987, 1988 and 1989.
6. Report on Crime (1980-1988) Commissioner, Garda Siochana to the Minister for Justice, Stationary Office, Dublin.
7. Millan, R. Evalution of Clinical Management of Cocaine Abusers, J Clin Psy 1988, 49: 27-33.
8. Kosten, F.R., Rounsaville, B.J. Kleber, M.D., A 2.5 year follow-up of Cocaine Use Among Treated Opioid Addicts. Arch Gen Psychiatry 1987; 44: 281-284.
9.Kosten, T.A., Jacobsen, L.K., Kosten T.R., Severity of Precipitated Opiate Withdrawal Predicts Drug Dependency by DSM III - Criteria American Journal. Drug A1 Dep 1989; 15: 237-250.
10. Strang, J., Edwards, G. Cocaine and Crack. Br MEd J 1989; 299: 337-338.
11. O'Hare, A. A Review of Existing Data on Cocaine in Ireland. Paper presented at the Council of Europe for the Pompidou Group. Februrary 1990.