Episode 2 – What Is Addiction?
Dr. Ashish Bhatt ❘
What is addiction? Breaking down our brain’s behaviors.
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Hayley: Hi everyone, this is Hayley and you are listening to Straight Talk With The Doc, the podcast that takes a real and in-depth look at addiction, mental health, and treatment. I’m here with our medical director, addiction medicine specialist, Dr. Bhatt, as well as our content director Jeff. How have you guys been doing?
Dr. Bhatt: Doing well Hayley, how are you guys, Jeff?
Jeff: I’m doing well, it’s been going good for me.
Hayley: Good, me too. Today we’re going to be breaking down a drug that a surprising number of people use. In fact, the National Institute on Drug Abuse says that 1.5 million adults in America use this drug, and that drug is Cocaine. Cocaine is one of those drugs that is seen fairly often in media and in party settings, and because of that, some people may not consider it a hard drug, but it is. It’s very addictive and it is possible to overdose on it. So, I want to get into those societal viewpoints on Cocaine and also talk about its effects on the brain. But first, let’s start with the basics. Dr. Bhatt, what is Cocaine made from? What class of drug does it belong to?
Dr. Bhatt: Cocaine is made from the coca plant, the coca plant is a plant that we see is native to South America, and that plant historically was used when people chewed it. They chewed it, often with lemon, that would help with its absorption, and people would get a euphoria, a high, they would get stimulated, they would feel a little bit more focused or energized. And here in the United States, and all over the world, it belongs to the stimulant class of drugs. The reason it is, is because it does stimulant you, it stimulants a lot of brain activity. So, a lot of brain processing is happening at that time, a lot of activation of dopamine, a certain chemical that is implicated in the reward mechanism and the pleasure cycle in the brain, that’s going on overdrive. So, Cocaine is quite an addictive drug. It’s probably in the top three addictive drugs in the world.
Hayley: Are other drugs mixed into cocaine? If so, what are they, and do they make that more dangerous?
Dr. Bhatt: We have drugs, or products, cutters, or fillers. It depends really the purpose of it, or if somebody that’s trying to distribute it is trying to achieve. So, we are seeing on the streets Cocaine cut with Benzodiazepines and even Fentanyl, and these can intensify the high and actually cause a mixed type of high, and an unpredictable type of high because they are two different classes of substances. On the flip side we see fillers, people even mix it to just create bulk with powder, baking soda, talcum powder, laundry detergent. There’s so many different things that people mix. So, the purity of cocaine on the streets is very wide ranged. And the amount of impurities that exists within their similarities, it’s very wide.
Jeff: It’s extremely common for Cocaine to be mixed with other substances. Depending on where you are, it’s very rare to find Cocaine that isn’t mixed with who knows what else. It’s very dangerous to take drugs that you get on the street, especially illegal ones.
Hayley: And when somebody snorts Cocaine, what happens in the brain? What kind of physical effects do they feel?
Dr. Bhatt: When we speak about drug addiction in general, I think that buzz chemical, the buzz neurotransmitter that everybody hears about is dopamine, and with Cocaine it’s no different. When you inhale, or snort Cocaine, it actually triggers activation of dopamine. But not in a way that we think. Basically, Cocaine stops the re-uptake of dopamine in between nerve cells. So, dopamine being that pleasure reward chemical, it stays in between the nerve cells longer, so there’s more dopamine present. So, you have a euphoric, pleasurable feeling as a result of that increased duration of dopamine there in the space between the nerve cells. That’s what happens when Cocaine is introduced to the body.
Hayley: Is that why Cocaine is so addictive? What causes someone to keep going back and using it again and again?
Dr. Bhatt: Well when that Cocaine is introduced and the dopamine is flooded and in excess in that nerve space, in what we call the synapse, the nerves recognize that. But over time, there’s a desensitization. So, when there’s so much of something our body has this feedback mechanism, our body kind of down regulates and desensitizes itself. Over time, whatever amount of Cocaine created this certain amount of dopamine flooding, because of the desensitization we’ll need more Cocaine to produce a similar feeling. A person whose addicted is going to have to use more to achieve a similar previously attained high.
Hayley: How addictive is Cocaine compared to other stimulant drugs?
Dr. Bhatt: Well when we look at Cocaine and Methamphetamine for example, these are right up there. With Heroin, Meth, and Cocaine being in the top three, and nicotine too. They’re quite addictive. There are studies done of the Lancet Journal out of England about 10-11 years ago, and they ranked them. They’re in the top two or three drugs in terms of their addictive potential, so Cocaine is a very, very addictive drug.
Hayley: Do people who use Cocaine often abuse other drugs with Cocaine, or alcohol with Cocaine at the same time?
Dr. Bhatt: Yeah, because Cocaine is a stimulant, depending on what the person is trying to achieve, depending what setting they’re in, people do often use other things with that. They’re out partying, they want that high, they like that energy that they get to keep going. But sometimes they go so far, they need to come down. They sometimes will mix that with something to calm them, and they will drink in excess to bring them down, they’ll use benzos to bring them down, they often mix Cocaine with Heroin and that has been known as speed balling. Often people have smoked and laced their cannabis with crack. Many people do use Cocaine mixed with, or intermixed, with other substances at the same time, or during the same binge or run, just to offset or augment the feelings that Cocaine produce.
Hayley: Does mixing Cocaine with other drugs increase the risk of overdosing?
Dr. Bhatt: For sure. Cocaine is very risky, due to the properties that Cocaine can cause in terms of increasing your blood pressure, your heart rate, your temperature. It also is a potent vasoconstrictor. It can increase your blood pressure due to blood vessel constriction. When you mix that with other drugs, or other stimulants, it potentiates all of that. But then when you’re coming down you can mix it with substances that can cause sedative type affects. These can cause a very big dysregulation within your body. So, there’s potential for heart attack, strokes, respiratory depression, it really depends on when and how the drugs are combined. But the bottom line is, if you mix the drugs together they increase likelihood of negative outcomes from both drugs. Of course, they’re synergized.
Hayley: Are there other things that can increase the risk of an overdose?
Dr. Bhatt: I think speaking about it before, is using it with other drugs. If you are using Heroin and Cocaine together, or using it with Fentanyl, or Benzodiazepines, the risk of overdosing is huge. I think that’s one of the biggest risks, is it being combined together with other illicit substances. The irony is that when people are using Cocaine, many are doing it in a binge type fashion and on a significant run, so these likelihoods are there. Another thing that we see that’s a little bit different with cocaine compared to other things is tolerance that often can be somewhat protective. I hate to use that word, but in terms of negative effects we don’t see that distinctly with cocaine. Cocaine in terms of the ability for it to produce a stroke or a heart attack or an infarction, it can happen on the first time you’re using it, so it doesn’t have this dose or repetitive dependency, dose dependent response in that sense. And so, there’s almost no safety gaging that may occur with other substances. It’s risky. The more frequently you’re using the more chances you have just to have that first or last negative effect, so the risk is there whenever you use it.
Hayley: So, I have a two-part question, about the long-term effects on first the mind and then the body. What are the long-term effects of Cocaine?
Dr. Bhatt: After time of being exposed to this increased dopamine, and then the transient changes with the desensitization, there’s this psychological crash, there’s this depression that sinks in. And that’s often that we see in those initial signs of withdrawal and that could be quite long lasting, where people are just feeling complete apathy, demotivated, and irritability. That we see not just in the short term but that can last for a long time. We often see the opposite. Some people who are using Cocaine do have underlying mental health conditions; mania, bipolar disorder, schizophrenia, and the irony is that these mimic one another, because the underlying path of physiology in schizophrenia is increased dopamine, where people are paranoid and hallucinating. This can be mimicked by Cocaine, and there has been some correlation where people are using these drugs that somehow are either- I’m not saying that they’re masking them, but there is this correlation where people tend to have this ongoing delusional, psychotic, paranoid type picture even when we see the acute intoxication removed. We see these psychological phenomenon’s that happen both in the depressive nature and in the hypomanic or psychotic side. From a physical side, there’s a lot of destruction that can happen. Especially when we talked about again, it’s a potent vasoconstrictor, it could be blood vessel damage, in the brain, in the nose. It can cause decreased blood supply to the nose and areas of the face, which can alter the tissue in the formations of the way one looks and breathes. It can cause an infarction like a stroke, or ischemia even in your gastrointestinal tract where you basically kill off parts of your intestines. There’s so many different things that can happen. So, bottom line is there is a lot of negative physical consequences for somebody whose using Cocaine.
Hayley: So, like I mentioned at the beginning of this episode, that Cocaine is seen a lot in media, it’s been glamorized in some media. There’s certain movies that show Cocaine as something that wealthy, attractive people use. In your opinion, why has this drug been glamorized over other drugs?
Dr. Bhatt: Well, in the 1970’s and 80’s when a lot of American generation was partying and into discos, into clubs, and simultaneously at that time we had a lot of infiltration of narcotic trafficking from different parts of the world like South America. They got intertwined together. People with money went out and they partied together with their drugs, and unfortunately, I wish I could say that money and having fun and partying and having nice cars and things does not get glamorized, but it does, and it did with Cocaine. It was known as a party drug, and it kept you going, and it kept you energized, and it kept you with vigor, and it often sexualized you. It kind of went together with what people were going to party for. To have a good time, to dance, to drink, to maybe hook-up with other people and Cocaine gave them that energy. And when we saw in the 70’s and the 80’s especially, coming into that scene, it just kind of melted together as being associated with one another. Ironically it got associated with fun, party, glamor, and being acquitted to often having wealth.
Hayley: And then, on the flip side, another drug that has not been glamorized would be Crack Cocaine. What is the difference between Cocaine and Crack?
Dr. Bhatt: So, Cocaine in its form, it’s powdered form can’t really be smoked. It is snorted, and it’s basically absorbed through the mucosa within the nasal passaging. Or, people often take powdered Cocaine and you’ll see them rub them on their gums inside their mouth. But, due to the chemical properties of it, you can’t heat it. So, to get that ability to change the chemical formula, they basically try and chemically convert that powder into a rock. And they do that by a process where they take out certain parts of the chemicals and add certain things to it. Due to this extraction process of breaking down they develop this rock, but this rock actually can be broken and it actually can be heated. When you heat that rock to smoke it, the reason it’s called Crack is because it makes a crackling type of sound. So, that hits in a different way, it’s absorbed into your body through your lungs. And sometimes people confuse this, I think people confuse Crack Cocaine with freebasing. Freebasing is the extraction of Cocaine in its purest form, which Crack Cocaine isn’t. Crack Cocaine is not a pure form, it’s often mixed with a lot of junk and it does have Cocaine in it, and it is smoke-able, but not necessarily a purified form. Which is often, I think, miss-associated as a freebase. Freebase is often used with ether and other volatile substances, and it’s very dangerous to make freebase of Cocaine. But this Crack, it is smoked, and it provides a different form of taking it into the body. And being that our lungs are super vascular, it can hit you very quickly and produce a high even though it might not always be a very purified form of the Cocaine.
Hayley: Okay, and when comparing Crack and Cocaine, is one more addictive or dangerous than the other?
Dr. Bhatt: It depends on the purity level, it depends on how quickly it does absorb. In general, somebody whose injecting something versus somebody whose smoking something, if it’s a pure form, injecting is still the quickest, but versus snorting or smoking, smoking causes a very quick, short, and often robust high, and I think because it gives you that high and then drops you away and doesn’t last very long, sometimes it will make somebody want that, that reinforcement schedule will force somebody to use it again, or make somebody want it again. When you have quick, short bursts of a potent high, you want to quickly get it one more time, because it doesn’t last very long. So, in that way Crack, and all the short acting bursts of quick, pure energy, and feel-good feelings, they’re all very habit and addictive when we look at those qualities of them. Again, depending on how pure the form is, the route that you do it, I think we hear Crack Cocaine is very addictive just because it’s a large surface area, but maybe when compared just to traditional snorting, but they’re both quite addictive.
Hayley: So, what are some of the signs that someone is addicted to Cocaine?
Dr. Bhatt: You see this intoxication that happens and I think that would be the first giveaway, if somebody that was not previously using Cocaine now is using Cocaine. That intoxication would be somebody whose increasingly maybe talkative, energetic, happy, euphoric, staying up, tends to often possibly be hyper-sexualized, but then they can get somewhat irritable. They can maybe be easily agitated, angry. They might be paranoid, they might start to be delusional. These are people that might show signs of acute Cocaine intoxication. The flip side is that you see people who are the opposite of this, who are crashing from it, they are without any energy, they’re flat, they’re depressed, they’re irritable, they often have been suicidal. They get so, so depressed and dysphoric and they also can be very angry and agitated too. I’ve seen many of my patients who are coming off of Crack and these other stimulants, it’s hard to talk to them because they just want to be alone. They’re just so upset and agitated, that it’s often best that they have an opportunity to chill out.
Hayley: So, you mentioned the agitation, but are there other withdrawal symptoms when someone stops using Cocaine?
Dr. Bhatt: Yeah. People, besides the depression, and the agitation, and the irritability, people can have changes in their appetite, people can have changes as a result of their weight. People have changes in the way that they’re skin- their healing processes, a lot of these people have used intravenously, and might have contracted some sort of bacterial type of infection. We see a lot of apathetic, weakened individuals, as a result of somebody who is coming off of that. But we do see that irritable, withdrawn, depressed, sullen individual as they come off and they have to often be monitored not just physically but psychologically due to the Cocaine withdrawal.
Hayley: Okay, and that was actually my next question, should somebody have a medically supervised detox from Cocaine, or is it a drug that you can come off of by yourself?
Dr. Bhatt: Well, I think from a street-scientific perspective, we don’t look at Cocaine from a medical perspective as being a life-threatening withdrawal, but definitely someone should be there looking at that human being to see if their depression turns into something else. It might not be that often, but when despair and desperation sets in, if somebody is feeling very bad- if somebody has a co-occurring major depressive disorder, and coming off of Cocaine, it might be a good idea that these people seek treatment in a supervised setting when they are coming off, because they might be having profound dysphoria and depression. Both from the depression that they’re suffering from, and the coming off of the drug itself.
Hayley: When should someone seek out treatment for Cocaine addiction?
Dr. Bhatt: I don’t know if I could say that using Cocaine in any way, shape, or form is okay. So, I would say as a physician, you shouldn’t use Cocaine, you should seek out help and you should try and stop. But obviously if somebody’s Cocaine use has reached the point of an addiction, or a troubling level in their life, they should seek out help. If they see it that they are seeing those consequences we talked about, where they’re having disruption in their personal life, family life, work life, social life, or their mood is consistently unhappy, angry, irritable, paranoid, loss of weight, or they’re suffering from these physical conditions- potential stroke, bowel issues, GI issues, there’s so many different things that can happen in terms of the physical aspects. These people definitely need treatment, but it should hopefully occur before all these things take place. There’s a time where people are using before all these significant medical, psychological, and social situations have occurred. So, obviously is someone is using Cocaine, and they notice that they feel they need to cut down, or they’re feeling bothered by somebody calling them out on their substance use, or they’re feeling guilty about it, or they’re feeling that they need it or have been pursuing this drug, they crave this drug, they need help for this, and they need to seek out treatment for this. You don’t always have to wait for all those signs we just mentioned, even if you feel psychologically or emotionally this is something that you have to stop, then you need to seek treatment for it.
Hayley: Dr. Bhatt, is there anything we didn’t talk about today that you think is important for people to know?
Dr. Bhatt: With the Opioid epidemic, that has been going on over the last many, many years I think sometimes Cocaine has taken a backseat. But, I think I read somewhere not too long ago, that just in 2020, we had thousands of deaths related to Cocaine and Methamphetamine overdoses. So, it hasn’t gone away. The amount of people using Cocaine and using it now in addictive manner, it’s still a robust problem. Just shifting drugs doesn’t make it better. The need for treatment is there and if you’re using or if you’re just experimenting, the likelihood with a drug like Cocaine becoming a full-blown addiction is very high. Just due to the nature of it’s addictive properties, and it’s important that you seek out that help. If you’re a loved one listening to this you seek out that help for that loved one as soon as possible. Really recognize and looking back at what we just spoke about and some of these symptoms and behaviors and not chalking it up to something else. Especially because sometimes people assume that if they were addicted to one drug that they might not have crossed over into anything else. But unfortunately, with many addictions, people do use poly-substances. Cocaine’s a very scary, scary drug.
Hayley: Well, thank you Dr. Bhatt, and if you want to learn more about Cocaine, other drugs, or a ton of other topics on addiction and treatment, you can go to addictioncenter.com. Addiction Center also has more podcasts episodes as well as a space where you can write in your questions to Dr. Bhatt. Thank you to everyone who has listened, and we hope to have you next time for another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.