Cocaine occurs naturally in the leaves of the coca plant Erythroxylum coca, which grows predominantly in South America. Cocaine hydrochloride is a white powder that is usually snorted but can be taken orally. Crack is prepared by mixing cocaine hydrochloride with sodium bicarbonate and water and heating it. The cocaine base precipitates out and forms small "rocks" as it cools. Crack may be smoked in a pipe or heated on foil with the vapor inhaled. Both crack and cocaine may be injected.
The onset-of-action and plasma half-life varies depending on the route of use, rapidly if taken intravenously or smoked compared with when it is snorted. The duration of effects will also vary with administration route (70). Ingestion of stimulant drugs, such as cocaine or amphetamine, result in activation of the sympathetic nervous system with resulting euphoria followed by irritability, depression, insomnia, and paranoia (Table 12).
Tolerance occurs to the psychological effects but not to the effects on the heart. Deaths may occur, most commonly from cardiac dysrhythmias, myo-cardial infarction, agitated delirium, and stroke. Chronic effects include per-
Initial low dose Euphoria, insomnia, dry mouth, hyperthermia, tachycardia, hypertension, increased respiration, sweating, dilated pupils With increasing dose Irritability, impulsivity, aggressiveness, agitated delirium, _paranoia, delusions, seizures_
foration of the nasal septum and rhinorrhea, and long-term use may result in a range of psychiatric problems and vascular diseases (71).
Cocaine produces a physical and psychological dependence, the severity of which will vary depending on the method of administration, being more severe if the drug is smoked or injected than if snorted. Dependence may result in a particular strong craving for the drug, followed by a withdrawal syndrome, or "crash," with irritability, insomnia, depression, and anxiety on cessation. In conditions of police custody, the depression and inability to sleep may lead to acts of self-harm and suicide, and close supervision may be required, with consideration given to prescribing hypnotics and antidepressants.
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