Cocaine

Cocaine (benzoylmethylecgonine) is a central nervous system stimulant derived from the leaves of the coca plant. Historically, it was used by natives in the Andes region to alleviate altitude sickness and other ailments. In the latter half of the 1800s, cocaine was isolated for use as a local anesthetic and was once a popular additive in wines and soft drinks, including Coca-Cola. Cocaine typically increases energy, well-being, and self-confidence, and creates a desire to take more doses.

Traditionally, cocaine has been consumed by chewing coca leaves or in the form of tea. Today, illegally produced cocaine is usually sold in powder form, made by soaking coca leaves in gasoline or other solvents. It is normally ingested through the mucous membranes in the nose or mouth, but some users also inject it. A smokable form of cocaine, known as crack, is also available but is less common in Norway. Illegally produced cocaine often contains a variety of other active and inactive substances, some of which can be harmful to health on their own.

The international cocaine trade causes significant economic and social damage, especially in the producing and transit countries, and funds mafia and terrorist activities worldwide. Cocaine is also highly damaging to health, particularly to the cardiovascular system, and is often used in combination with alcohol and tobacco, which exacerbates its harmful effects. Cocaine-related deaths are not uncommon, and there are likely unreported cases as heart attacks or strokes can occur long after use. Cocaine is one of the most addictive substances, especially when smoked, injected, or used in conjunction with tobacco. The American National Academy of Science estimates that 17 percent of cocaine users develop a dependence on the drug.

Please see our 10 general rules for sensible drug use. You should also be mindful of the following:

1. Do not use cocaine if you or anyone in your immediate family has heart disease or high blood pressure.
   
   
2. Be very cautious with cocaine if you have liver or kidney disease, are using medications that stress the liver or kidneys, or have consumed a lot of alcohol in recent weeks.
   
   
3. Avoid injecting or smoking cocaine, as these methods are more addictive than sniffing and more likely to lead to an overdose. You can avoid damage to the nasal wall by rubbing the powder on your gums instead of sniffing it.
   
   
4. Avoid combining cocaine with opioids or GHB, as you risk an overdose when the effects of cocaine wear off. Also avoid combining cocaine with alcohol, tobacco, caffeine, or drugs such as MDMA and amphetamines, as this worsens the harmful effects and increases the risk of acute heart problems.
   
   
5. Decide in advance how much you want to use in one evening, and avoid having more available if you think you will have difficulty controlling intake. Avoid using cocaine on weekdays, as this increases the risk of addiction and heart problems.
   
   
6. Avoid sniffing cocaine off unclean surfaces or using unclean sniffing equipment, e.g., rolled-up banknotes. Avoid sharing sniffing equipment with others, as this can expose you to diseases such as hepatitis C and herpes.
   
   
7. If you choose to sniff cocaine, do not inhale the powder too deeply. The blood vessels that best absorb the substance are located at the front of the nose, and you want to avoid sinusitis and respiratory infections.
   
   
8. If you experience chest pain during or after using cocaine, you should call emergency services at 113.
   
   

We employ a five-step risk scale with values ranging from "very low" to "very high" within six categories: Acute toxicity, Long-term toxicity, Dependence, Cognitive problems, Unpleasant events, and Interactions.

These values are based on qualitative reviews of available knowledge, and should only be viewed as guidelines. They are also relative, so a score of "very low risk" does not mean the substance is risk-free. The scale assumes users are normal, healthy individuals; beware that even drugs which are well-tolerated by most people may nevertheless be harmful to some users. It also assumes normal use patterns; that is, if a given drug is only harmful when used in a certain way, yet is almost never used in that way, then the drug will be considered less harmful compared to a similar drug which is commonly used in a harmful way.


ACUTE TOXICITY

⦿⦿⦿⦾⦾ (Moderate risk)

It is difficult to determine a lethal dose for cocaine, as it seems to vary greatly depending on the individual. Generally, it is believed that a lethal dose for most adults would be over 1 gram, but some individuals have died from as little as 20-30 mg. This unpredictability may be due to cocaine's specific effects on the heart, which some may be more vulnerable to than others.

LONG-TERM TOXICITY

⦿⦿⦿⦿⦾ (High risk)

Cocaine causes significant constriction of blood vessels, which puts stress on all end organs in the circulatory system by inhibiting blood supply and increasing blood pressure. This effect can lead to brain hemorrhage, lung bleeding, liver failure, kidney failure, heart failure, and heart attack – either as a result of prolonged use or following an overdose. In the heart, cocaine also blocks the ion channels in the muscle cells, which causes heart rhythm disturbances and further increases the risk of a heart attack. Sniffing powdered cocaine can directly damage the nasal passages and esophagus over time as repeated constriction of the blood vessels leads to tissue death due to lack of blood supply.

Using cocaine through injection or smoking puts even more strain on the heart and circulatory system, as the levels of cocaine in the blood rise faster. This also increases the risk of serious infections from injection, and the risk of lung and respiratory problems significantly increases with smoking. The same harmful effects are not documented with traditional use of coca leaves as with the use of powdered cocaine. This may be because the levels of cocaine in the blood do not become high enough or rise quickly enough to have the same harmful effect. However, frequent use and large intake of coca leaves should still be avoided if there is a high risk of heart problems, as well as concurrent use of alcohol, tobacco, or caffeine.

Illegally produced cocaine is often mixed with other active substances, such as phenacetin. This is a pain and fever reducing agent for animals that can damage the kidneys and bladder and increases the risk of cancer and heart disease. Cocaine also often contains levamisole, a drug formerly used to treat rheumatoid arthritis but was withdrawn due to side effects. The drug is currently used as a dewormer for livestock and is likely added to cocaine because it is converted into the amphetamine-like substance aminorex in the body. Levamisole can cause agranulocytosis, a condition where the body's production of white blood cells is weakened and common infections can become life-threatening. The risk of developing agranulocytosis depends on the dose and frequency of use, and typically requires either regular use of very large amounts or nearly daily use of cocaine with levamisole over a certain period. Individuals with the HLA-B27 gene variant, which is found in about 10 percent of the population in Southern Norway and 16 percent in Northern Norway, however, are at higher risk and make up to 50 percent of those who develop agranulocytosis from using cocaine with levamisole.

DEPENDENCE

⦿⦿⦿⦿⦿ (Very high risk)

Cocaine is considered a highly addictive drug, and approximately 17 per cent of users develop dependence.[5] The risk of developing dependence nevertheless depends on the context in which the substance is used, the route of administration and individual vulnerability. Weekday users are more vulnerable than weekend users, and smoking and injecting are more addictive than ingestion via the nose or mouth. Young people and people with poor impulse control, a history of trauma or social anxiety are apparently particularly vulnerable to becoming addicted to cocaine. Women are probably also more exposed than men, as estrogen apparently enhances cocaine's addictive effects.[8] Cocaine also appears to be more addictive when used concurrently with tobacco, and tobacco use confers a higher risk of developing cocaine addiction later in life.[9] Cocaine use can change the functioning of the brain's reward center over time, and some people find that the desire for cocaine can be triggered in certain situations long after any abstinence. The withdrawal syndrome usually consists of low energy levels, difficulty concentrating and lethargy, and depression is not uncommon. These symptoms can be mild and last only a few days after more short-term use, but become more severe and can last for months after excessive long-term use. Cocaine can be tempting to use often, as it has a short duration of action and can be perceived as performance-enhancing. This means that one succumbs to the temptation to use the drug on a daily basis, and eventually uses it daily. Traditional use of natural coca is not associated with problematic addiction, but is probably also addictive to some extent.

COGNITIVE PROBLEMS

⦿⦿⦿⦾⦾ (Moderate risk)

Common mental health issues associated with cocaine use include depression, irritability, or anxiety, typically in conjunction with withdrawal or hangovers. Sporadic use of cocaine in moderate doses rarely leads to significant mental health problems, but side effects such as irritability and short-term depression are not uncommon. Excessive use of cocaine can in some individuals lead to paranoia or delusions of grandeur, as well as psychotic episodes. The risk of this occurring increases with overdose or continuous use over a long period.

UNDESIRABLE EVENTS

⦿⦿⦿⦾⦾ (Moderate risk)

Some users become aggressive while under the influence of cocaine, primarily when combining it with alcohol. This can lead to arguments, violence, or other behavior that one may later regret. Daily use of cocaine can also lead to poor decision-making due to excessive self-confidence.


INTERACTIONS

⦿⦿⦿⦾⦾ (Moderate risk)

Cocaine should not be combined with substances or drugs that have significant MAOI activity, i.e., those that inhibit the enzyme monoamine oxidase. This primarily applies to intoxicants such as ayahuasca and changa (where the psychedelic substance DMT is combined with an MAOI substance for extended effect), drugs in the 2C-T series, and atypical antidepressants such as phenelzine and moclobemide. Such combinations can lead to serotonin syndrome, a potentially life-threatening condition where serotonin levels in the brain become too high.

One should avoid combining cocaine with other stimulants, as this increases the risk of overheating and brain damage. Combining it with central depressants can delay an overdose of the depressant until the effects of the cocaine wear off. Therefore, one should be mindful of dosing if using central depressants while under the influence of cocaine. Combining cocaine with tramadol is discouraged, as it can likely lead to seizures.

Combining cocaine with cannabis does not appear to be particularly harmful but can lead to confusion and anxiety during intoxication, and possibly psychotic reactions if one is vulnerable to this. If cocaine is used despite heart problems, this combination should be avoided as it can cause a significant increase in heart rate.

Combining cocaine with psychedelics or dissociatives is usually not problematic as long as one generally tolerates these substances well separately. However, doses should be reduced as the drug effects can be mutually reinforcing. Avoid taking psychedelics on the "comedown" from cocaine, as it can negatively impact the experience.

Before taking any drug, it is very important to make sure that the substance you have in front of you really is what you think it is, or what it is claimed to be. By far the safest and best way to do this is through a professional chemical analysis service (such as Energy Control in Spain), but if this is not possible, it is highly recommended to at least use a reagent test kit (such as those offered by DanceSafe in the UK). These are easy-to-use reagents that produce a characteristic color change when they come into contact with a particular drug, allowing users to identify the drug from a table of known color changes. Remember to store the reagents in the fridge and check the expiration date before using them, as expired tests can give misleading color changes.

Cocaine should essentially react more or less colorlessly with the Marquis, Mecke, and Liebermann rapid tests. Any distinct color reaction suggests that the substance at least contains other reactive substances in addition to cocaine, if it contains cocaine at all.

After excluding other substances with the mentioned rapid tests, one should use a Scott rapid test, which should give a light blue color when reacting with cocaine.

Note! The Scott rapid test also gives a light blue color when reacting with the substances MDPV (a central stimulant cathinone substance) and 5-MeO-MiPT (a potent psychedelic substance). These rarely appear in cocaine, but MDPV is sometimes sold as other central stimulants. Therefore, it is important not to go straight to the Scott rapid test, but use the first rapid tests to exclude these substances. 5-MeO-MiPT gives a brown color when reacting with the Marquis and Mecke rapid tests. MDPV gives a strong yellow color when reacting with the Marquis and Mecke rapid tests.

DOSAGE

Powder cocaine absorbed via the mucous membranes is usually dosed in lines containing 30-50 mg of pure active ingredient at a time, but heavy users may use higher doses. Since the potency of illegal cocaine is generally unknown and can vary greatly, one should proceed cautiously with very small doses in safe surroundings when acquiring a new batch of cocaine – and never bring untested drugs to a party.

Methods of intake such as smoking or injecting require a lower dose, and first-time users should always start with a very small dose regardless of the method of intake, and wait to see the effects for a while before possibly taking more. The overdose threshold for cocaine varies significantly from person to person, and if one is unaware of having congenital heart defects or a risk of cardiovascular disease, it is best to refrain from using cocaine.

FORM

In Norway and Europe, cocaine most commonly appears in powder form, usually as a hydrochloride salt, but sulfate variants also exist. In Denmark, the United Kingdom, parts of Southwest Europe, as well as large parts of North and South America, cocaine is also prevalent in so-called freebase form, popularly known as crack, which can be smoked for a more intense and short-lived intoxication. Crack is produced by reacting powder cocaine with sodium bicarbonate. This is a very simple process that typically occurs further down the production chain, sometimes even at the end-user level. Crack is typically not widespread in countries where there is a large availability of amphetamines, such as in Norway and Sweden, the Baltic states, and Eastern Europe. Cocaine is also available in natural coca leaves for chewing/snuffing or brewing in tea, which is legally sold in Colombia, Bolivia, Peru, Argentina, Ecuador, and Chile. The leaves contain a number of active alkaloids in addition to cocaine and provide a much weaker intoxication than cocaine in concentrated form.

ROUTE OF ADMINISTRATION

The most common route of administration for cocaine intake is absorption via the mucous membranes in the nose or mouth, either by sniffing powdered cocaine or by rubbing/placing it on the gums. It is also possible to place cocaine under the tongue, but this can lead to numbness of the tongue, which is very uncomfortable and may cause speech difficulties. In countries where the smokable variant of cocaine (crack) is prevalent, cocaine is often smoked as well. Some users inject cocaine by dissolving powdered cocaine in water. This provides a very intense and very short-lived intoxication with a high risk of overdose and addiction, as well as a high risk of blood clots and infections due to impurities and fillers in the powder. If one chooses to inject cocaine, it is always necessary to thoroughly filter the solution until no particles are visible. Traditional use of coca leaves involves either intake through the mucous membranes in the mouth by chewing/snuffing the leaves or through the stomach by drinking tea.

MECHANISM OF ACTION

Cocaine produces its intoxicating effects by inhibiting the brain's reuptake of the neurotransmitter dopamine, as well as to some extent norepinephrine, and to a lesser extent serotonin. This leads to elevated levels of these neurotransmitters in the brain and results in a stimulant effect. Some research suggests that cocaine also stimulates increased release of dopamine in the brain, not unlike amphetamine. Additionally, some cocaine contains the medication tetramisole, which breaks down into the amphetamine-like substance phenmetrazine in the body.

DURATION

Since the high from cocaine is short-lived, with the main effects from snorting lasting approximately 30 to 45 minutes and a total duration of 45 to 90 minutes, it is common to dose cocaine repeatedly. Combining it with alcohol extends the duration of the high due to the formation of the intoxicating substance cocaethylene in the body, which lasts up to 2-3 hours. Methods of intake with very rapid effects, such as smoking or injecting, produce a more intense high with a significantly shorter duration, from 5 to 15 minutes. Methods of intake with slow effects, such as tea or chewing coca leaves, produce a milder high that typically lasts 2-3 hours.

SUBJECTIVE EFFECTS

Cocaine typically induces a feeling of alertness, well-being, and self-confidence, and can make users talkative and outgoing in social settings. While low doses may have a calming effect on some, higher doses provide a high level of energy that can result in restlessness, motor agitation, and impatience with others. Some people become argumentative or aggressive under the influence of cocaine, which can be exacerbated when combined with alcohol, as it impairs impulse control. Users who combine alcohol and cocaine may appear more sober than they are, since cocaine counters some of the dulling effects of alcohol, but not all. This can lead to a dangerously high blood alcohol content while still being conscious and retaining motor skills, but with little control over one's actions.

While cocaine typically has a euphoric effect shortly after intake, it is common to experience a feeling of disappointment as the high begins to fade, which easily leads to taking more cocaine. This feeling ("the comedown") is more pronounced at high doses and tends to get progressively worse – towards depression or anxiety – the more often one redoses. Some users experience very frequent redosing of cocaine in pursuit of the sensation they got from the first dose, without quite being able to recreate it. This frustration can make it easy to use too much cocaine, and the repeated activation of the brain's reward center increases the risk of addiction.

SIDE-EFFECTS

Cocaine has several side effects both from acute use and from long-term use. Acutely, cocaine use can lead to dilated pupils, reduced appetite, increased body temperature, and jaw stiffness. Over time, cocaine use has a number of harmful health effects. (Read more about this above under risk profile). In addition to being harmful to the cardiovascular system and most of the body's organs, the vasoconstrictive effect of cocaine directly damages the mucous membranes in the mouth, nasal passages, and trachea/throat, and with excessive use, can lead to tissue death in the mucous membranes due to poor blood supply. Smoking cocaine (crack) is also directly harmful to the lungs, in addition to the cardiovascular effects of cocaine indirectly damaging the lungs. Excessive use of cocaine containing levamisole can cause an inflammatory condition in the skin's capillaries called vasculitis, which typically results in purple rashes on the face, stomach, legs/arms, and buttocks, and in the worst case, can lead to tissue death due to poor blood supply.

Cocaine is considered an illicit drug in Norway. This means it is illegal to use, possess, manufacture, import, export, procure, store, send, or give away without a special license for medical or scientific use.

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2. Goldstein et al., Cocaine: history, social implications, and toxicity—a review.

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5. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health.

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7. Buxton et al., Genetic determinants of cocaine-associated agranulocytosis. BMC Research Notes 8, 2015.

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