Commentary

Will a cocaine epidemic follow the opioid crisis?


 

Is another cocaine epidemic inevitable?

The late David F. Musto, MD, who was revered as both expert medical historian and physician at Yale University, New Haven, Conn., offered perhaps the most poignant observation in this regard: He argued that almost every opiate epidemic seems to transition into a psychostimulant epidemic.6 Experts have been looking at cocaine and methamphetamine as a way to try to understand the current opioid epidemic. Indeed, the Centers for Disease Control and Prevention’s most recent report on emerging trends in cocaine use shows numerous, concerning upticks in several realms germane to a possible emerging epidemic. One of the more upstream concerns is a gigantic spike in the shear production of coca leaves and cocaine thought to be occurring in Colombia (the principal source of cocaine in the United States). Current U.S. government estimates based on seizure rates from 2016 indicate that Colombia is producing about 910 metric tons of export quality cocaine. That represents a large increase from the 670-ton estimate the year before and the 325-ton estimate the year before that.

Similarly, a sharp rise in cocaine-related deaths, an approximate 52% increase, has been charted from 2015 to 2016. This finding is likely related to the growing presence of adulterants, such as fentanyl and carfentanil, found in seized cocaine samples. However, a rise in first-time cocaine users in the past year, which, according to the National Survey on Drug Use and Health, is up by about 12% (1.1 million people) in the 2015-2016 period, shows that the danger of cocaine-related deaths might not lie solely in adulteration but also increases in use. These signals might herald a grim return of cocaine to the center stage of public health, a development that would be an encore of the crack cocaine epidemic experienced throughout the 1980s and early 1990s.

Dr. Michael L. Wenzinger, a clinical fellow, PGY-4, in the department of child and adolescent psychiatry at St. Louis Children's Hospital.

Dr. Michael L. Wenzinger

All the above findings support cocaine as an agent of swift and massive change to our reward systems that might be poised to again surge across the United States at epidemic levels. Given this insight into just how extensively it rewires brains and the unfortunate truth that direct pharmacotherapy treatments remain mostly theoretical, it is evident that the best course of action is simply to keep cocaine from ever reaching the brain in the first place. Prevention does work, and these findings underline the importance of that message. Direct psychoeducation, awareness programs, and deterrence are the best defense we can offer to our patients at this time. In addition to these tried and true techniques, fascinating new models of prevention for cocaine abuse also are in development: vaccines. Synthesized by binding cocaine to inert proteins, these vaccines are designed to prevent addiction by training the immune system to bind cocaine and thus prevent it from crossing the blood brain barrier.7 Currently approved for clinical study in humans, these might offer a game-changing new method in the prevention of substance abuse.

Dr. Mark S. Gold, 7th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University, St. Louis. He is chairman of the scientific advisory boards for RiverMend Health.

Dr. Mark S. Gold

In summary, continued research has enriched us with a deeper appreciation of just how profoundly cocaine, even after a single exposure, rewires the brain. Some people might have a cavalier attitude about drugs and even use terms such as experimentation to describe teen use, but cocaine is not cannabis. Not only initial cocaine self-administration, but also withdrawal and context of use (a bathroom, a bar table, a countertop) all serve to debase the natural transcriptome balance of the brain’s reward system. Our knowledge of what exactly contributes to the path of the cocaine addiction has grown, but options for how to treat cocaine overdose and addiction remain slim. This is particularly concerning, as history and data indicate a likelihood that a cocaine epidemic might come on the heels of the opiate epidemic. Now more than ever we need to emphasize the importance of preventing cocaine use – and continue to develop new interventions.

Dr. Wenzinger is a clinical fellow, PGY-4, in the department of child and adolescent psychiatry at St. Louis Children’s Hospital. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University in St. Louis. He also serves as chairman of the scientific advisory boards for RiverMend Health.

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