Substance Abuse

Online Course #975 or #175 - 10 Contact Hours

Author: Peggy M. Goulding, Ph.D.
Editor: Shelda L. Shank, RN, BSN, PHN
©2009 National Center of Continuing Education, Inc.

For your convenience, this course has been divided into 3 sections:
Below is Part 1 of 3.
Table of Contents …Part 2 …Part 3 …Independent Analysis …Evaluation

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Purpose and Goals

The purpose of this course is to provide nurses and other health care providers with a comprehensive overview of the drugs of abuse that are most commonly used in the United States today. Emphasis is on short-term and long-term effects of the drugs, as well as treatment strategies and principles for prevention.

Instructional Objectives

1. Define and differentiate among drug use, drug abuse, and drug addiction.
2. Name the characteristic signs of drug abuse.
3. Recall the anatomy and neurophysiology of pleasure and its role in drug use.
4. Identify some commonly abused drugs and their characteristic short term and long term effects.
5. List the medical complications associated with various drugs of abuse.
6. Recognize the specific physiological effects of various classes of drugs of abuse.
7. Outline issues and concerns specific to the abuse of prescription medications.
8. List procedures for management of drug overdose.
9. Summarize current approaches to treatment of drug abuse and addiction.
10. Evaluate the efficacy of current strategies for prevention of drug abuse.

Introduction

Recreational drugs have been around for centuries, but drug abuse has never been so widespread. Marijuana was listed as an agent for achieving euphoria in a Chinese medical compendium traditionally dated from 2737 B.C. As far back as 2000 B.C., the Greeks used opium and the Aztecs incorporated hallucinogens into their religious rituals. Andean Indians chewed the leaves of the coca plant to decrease hunger and increase their stamina for work. Witches in the Middle Ages brewed potent concoctions, and New World merchants peddled a little opium along with their rum and slaves. Civil War soldiers were among the first addicts to prescription drugs, as their battlefield pains were dulled by laudanum.
Then along came cocaine and heroin, recommended for every malady from headaches to skin rashes. Cocaine was first extracted from coca in the 19th century, and it was hailed as a miracle drug, prescribed for everything from exhaustion to depression, and widely available in patent medicines. Heroin, first produced in 1874, was sold by traveling salesmen and through mail order catalogs; it was thought to be useful as a cure for respiratory illnesses and for relieving morphine withdrawal. Eventually, the addictive potential of these "harmless cure-alls" was recognized: they were shunned by mainstream society and their use driven underground.
The use of marijuana as an intoxicant was commonplace from the 1850s to the 1930s, and was reinforced by use among migrant workers from Mexico. The Federal government conducted a campaign in the 1930s to discourage its use. The message of a 1936 movie, "Reefer Madness," was that "smoking the killer weed was a direct road to hell, suicide, or at least insanity," and marijuana use came to be regarded as a gateway to addiction to more powerful and dangerous drugs.
Drugs remained on the fringes of society into the 1950s, when the "beat generation" bent their minds with hallucinogens and enhanced their worldly perceptions with pot. By the 1960s, youth rebellion was in full swing, while the hippies of "Hair" and the anti-heroes of "Easy Rider" romanticized the drug culture. Recreational use of drugs was the "in" thing, an activity shared by young people with a common point of view. Following this era, drug use continued to gain in social acceptance, as people thought they could experiment with a wide range of street drugs but not become addicted. Use of the old standbys was on the rise, even as more and more use of amphetamines, inhalants, and designer drugs was recorded. A second epidemic in cocaine use began in the United States in the 1970s and peaked in the mid- to late-1980s; again the drug was at first considered relatively harmless. Even middle class America began to use this chic drug in the workplace: it was seen as a quick pick-me-up, a little "perkier" than coffee. "Crack," a new and inexpensive form of freebase cocaine with magnified effects, hit the markets in the 1980s and soon was widespread in poorer neighborhoods. By the late 1990s the cocaine and crack epidemic had subsided somewhat, however, as heroin regained popularity among illicit drug users. A growing group of new middle-class heroin users emerged in the 1990s as a potent powdered heroin became available. Throughout this period, marijuana retained its role as the gateway to other drug use. After over a decade of decreasing use, marijuana smoking began an upward trend once more in the early 1990s, especially among teenagers, but by the end of the decade this upswing had leveled off well below former peaks of use.
Despite increased public outcry and an intensification of the government's war on drugs, it appears that drug abuse will remain a significant public health concern for the foreseeable future. In this course we will outline the neuroanatomy and neurophysiology of drug use, abuse, and addiction; review the most common classes of drugs of abuse; and summarize current approaches to treatment and prevention.

Use, Abuse, and Dependence

Most experts in addiction medicine differentiate use, abuse, and dependence or addiction, and they are often seen as representing a continuum of severity in assessing a person's drug problem. Substance use is simply the ingestion of a chemically active agent such as a prescription or illicit drug, alcohol or tobacco. Substance abuse suggests a maladaptive pattern of substance use leading to significant difficulties in meeting major role obligations at home, work, or school; use in situations in which it is physically hazardous (such as driving); or continued use despite related social and interpersonal problems, or legal problems. Dependence implies a cluster of cognitive, behavioral, and physical symptoms which indicate that the individual continues to use the substance despite the presence of significant substance-related problems. The person develops a tolerance for the substance and requires progressively larger amounts to elicit the effects desired. Also, the person will experience physical and psychological signs and symptoms of withdrawal if the substance is not used. Addiction typically refers to a compulsive and maladaptive dependence on the substance, resulting in adverse psychological, physical, economic, social, and legal ramifications.

Neurobiology in Brief

The brain consists of several large regions, each responsible for specific activities vital for living. (Figure 1)

The cerebral cortex, which is divided into right and left hemispheres, encompasses about two-thirds of the brain mass and lies over and around most of the remaining structures of the brain. It is the most highly developed part of the human brain and is responsible for thinking, perceiving, and producing and understanding language. The cerebral cortex can be divided into areas with each having a specific function, such as vision, hearing, touch, movement, or smell. Other areas are critical for thinking and reasoning. Although many functions, such as touch, are found in both the right and left cerebral hemispheres, some functions are found predominantly in only one hemisphere. For example, in most people, language abilities are localized in the left hemisphere. Even so, the cortex most often acts as a unit in processing for complex tasks, and dysfunction in any one area can affect the operation of the brain as a whole.
The brainstem is the part of the brain that connects the brain and the spinal cord. It controls basic functions such as heart rate, respiration, appetite and sleep. The cerebellum, a prominent structure located above the brainstem, coordinates the brain's processes for skilled repetitive movements and for maintaining balance and posture. It has also been implicated in higher level cognitive functions that require complex motor activities.
The diencephalon, which is also located beneath the cerebral hemispheres, contains the thalamus and hypothalamus. The thalamus is involved in sensory perception and regulation of motor functions (i.e., movement). It connects areas of the cerebral cortex that are involved in sensory perception and motor control with other parts of the brain and spinal cord that also have a role in sensation and movement. The hypothalamus is a very small but important component of the diencephalon. It plays a major role in regulating hormone production, body temperature, and many other vital activities.
On top of the brainstem and buried under the cortex, there is a set of more primitive brain structures called the limbic system. The limbic system structures are involved in many of our emotions and motivations, particularly those that are related to survival, such as fear, anger, and the pleasure derived from activities like eating and sex. Two large limbic system structures called the amygdala and hippocampus are also involved in memory. One of the reasons that drugs of abuse can exert such powerful control over our behavior is that they act directly on the more primitive brainstem and limbic structures, which can override the cortex in controlling our behavior. In effect, they eliminate the most human part of our brain from its role in behavior control.
The brain is made up of billions of nerve cells, each containing three important parts: a central cell body; short fibers called dendrites that receive messages from other neurons and relay them to the cell body; and an axon, a long single fiber that transmits messages from the cell body to the dendrites of other neurons, or to body tissues such as muscles. Although most neurons contain all three parts, there is much diversity in the shapes and sizes of neurons as well as their axons and dendrites.
The transfer of a message from the axon of one nerve cell to the dendrites of another is known as neurotransmission. Although axons and dendrites are located extremely close to each other, the transmission of a message from an axon to a dendrite does not occur through direct contact. Instead, communication between nerve cells occurs mainly through the release of chemical substances into the space, or synapse, between the axon and dendrites. When neurons communicate, a message, traveling as an electrical impulse, moves down an axon and toward the synapse. There it triggers the release of molecules called neurotransmitters from the axon into the synapse. The neurotransmitters then diffuse across the synapse and bind to special receptor molecules located within the cell membranes of the dendrites of the adjacent nerve cell. This, in turn, stimulates or inhibits an electrical response in the receiving neuron's dendrites.
There are many different types of neurotransmitters, each of which has a precise role to play in the functioning of the brain. Generally, each neurotransmitter can only bind to a very specific matching receptor. Therefore, when a neurotransmitter couples to a receptor, it is like fitting a key into a lock. This coupling then starts a whole cascade of events at both the surface of the dendrite of the receiving nerve cell and inside the cell. In this manner, the message carried by the neurotransmitter is received and processed by the receiving nerve cell. Once this has occurred, the neurotransmitter is inactivated by being either broken down by an enzyme or reabsorbed back into the nerve cell that released it. The reabsorption (also known as re-uptake) requires the action of transporter molecules, which reside in the cell membranes of the axons that release the neurotransmitters. They pick up specific neurotransmitters from the synapse and carry them back across the cell membrane and into the axon. The neurotransmitters are then available for reuse.
Pleasure is a very powerful biological force for survival. Life-sustaining activities, such as eating, activate a circuit of specialized nerve cells devoted to producing and regulating pleasure. One important set of these nerve cells, which uses a chemical neurotransmitter called dopamine, sits at the very top of the brainstem in the ventral tegmental area (VTA). These dopamine-containing neurons relay messages about pleasure through their nerve fibers to nerve cells in a limbic system structure called the nucleus accumbens. Still other fibers reach to a related part of the frontal region of the cerebral cortex. So, the pleasure circuit, which is known as the mesolimbic dopamine system, spans the survival-oriented brainstem, the emotion-oriented limbic system, and the frontal cerebral cortex.
All drugs that are addicting can activate the brain's pleasure circuit. Drug addiction is a biological, pathological process that alters the way in which the pleasure center, as well as other parts of the brain, functions. Almost all drugs that change the way the brain works do so by affecting chemical neurotransmission. Some drugs, like heroin and LSD, mimic the effects of a natural neurotransmitter. Others, like PCP, block receptors and thereby prevent neuronal messages from getting through. Still others, like cocaine, interfere with the molecules that are responsible for transporting neurotransmitters back into the neurons that released them. (Figure 2)

Finally, some drugs, such as methamphetamine, act by causing neurotransmitters to be released in greater amounts than normal.
Prolonged drug use changes the brain in fundamental and long-lasting ways. These long-lasting changes are a major component of the addiction itself. It is as though there is a figurative "switch" in the brain that "flips" at some point during an individual's drug use. The point at which this "flip" occurs varies from individual to individual, but the effect of this change is the transformation of a drug abuser to a drug addict.

Marijuana

Marijuana has assumed a unique place in our culture and is looked upon benignly by some and with horror by others. Many people smoke marijuana now and then, perhaps combining it with alcohol to "mellow out," and that is the extent of their drug use. For others, however, especially teenagers, marijuana is a major gateway experience into the drug world.
Marijuana is made from the dried leaves and flowers of the Indian hemp plant, cannabis sativa. It has been cultivated worldwide and used as a drug for centuries. The potency of marijuana depends on the method of preparation, with hashish and ganja much more powerful than the unprocessed form. Although cannabinoids are usually smoked, they can also be eaten, drunk as tea or, rarely, injected intravenously. The active ingredient of marijuana, delta-9-tetrahydrocannabinol (THC), binds to and activates specific neuroreceptors, called cannabinoid receptors, located throughout the brain in areas that control memory, thought, concentration, time and depth perception, and coordinated movement. THC generally affects these functions negatively, by decreasing the activity of the neurons in each area. Marijuana has been shown to stimulate the dopamine pathway from the ventral tegmental area to the nucleus accumbens, within the pleasure center of the brain, leading to feelings of euphoria, relaxation, and heightened sensation. The THC content of marijuana is currently higher than that of the marijuana used in past decades. Many potential adverse effects that were reported from the 1960s through the 1980s may be understated when compared with the effects of current street preparations.
Peak plasma levels of THC are normally achieved within 10 minutes of smoking marijuana, and intoxication lasts approximately two to three hours. Because of its high lipid solubility, THC accumulates in fatty tissues, leading to its long half-life and related effects. For example, the disruptive effect that marijuana has on coordination may last for more than 24 hours, which is far beyond the period of subjective intoxication.
Many investigations using animals and some studies of humans suggest that reproductive abnormalities may occur with the use of marijuana. Maternal exposure to marijuana during pregnancy may reduce the size of the fetus and the birth weight. A 10-fold increase in the risk of nonlymphoblastic leukemia in children whose mothers used marijuana before or during gestation has also been reported.
Some patients with pre-existing medical conditions who use marijuana may be at particular risk. For example, although THC acutely increases the respiratory rate and the diameter of bronchial airways, chronic use of marijuana results in epithelial damage to the trachea and major bronchi, and decreased airway diameter. Marijuana smoke does not contain nicotine but does have a significantly higher tar content than cigarettes; it contains many carcinogens and, unlike most cigarettes, is smoked unfiltered.
A serious but often neglected adverse effect of marijuana is the risk of infection: chronic use of marijuana may lead to impairment of important pulmonary defenses. Also, marijuana can be contaminated with microorganisms such as aspergillus and salmonella, as well as fecal matter. The risk of infection may be of particular concern in patients who have HIV or AIDS, or other compromise of the immune system.
For many years, it has been known that THC acts on cannabinoid receptors in the brain. It was hypothesized that since the normal brain has these receptors, there must also be a substance produced by the brain itself that acts on these receptors. Finally, in 1992, after years of research, scientists discovered a substance produced by the brain that activates the THC receptors and has many of the same physiological effects as THC. The scientists named the substance anandamide, from a Sanskrit word meaning bliss. The discovery of anandamide opened whole new avenues of research. It now appears that anandamide and dopamine act in opposite ways to control movements in an area of the brain called the dorsal striatum. Dopamine stimulates movements by acting in this area, and anandamide normally inhibits the action of dopamine.
The discovery of anandamide may lead to a greater understanding of certain health problems and ultimately to more effective treatments. It may be particularly useful in treating diseases related to imbalances of dopamine in the brain, including Parkinson's disease. When made synthetically and given orally, THC can be used to treat nausea associated with chemotherapy and stimulate appetite in AIDS wasting syndrome. It may also be useful for other conditions, including glaucoma. Now that the brain's own THC-like substance has been identified, researchers may soon be able to uncover the mechanisms underlying the therapeutic effects of THC, leading to the development of more effective and safer treatments for a variety of conditions.

Physcial Adverse Effects of Marijuana

Dry mouth
Nausea
Headache
Nystagmus
Tremor
Decreased coordination
Increased heart rate
Altered pulmonary status
Altered body temperature
Reduced muscle strength
Decreased cerebral blood flow
Increased food consumption

Treatment
Identifying patients with a marijuana-related disorder can be difficult, because abuse and associated problems commonly develop slowly. Often, patients do not recognize that they have a problem; if they do, they are perhaps more likely to continue their drug use while intensifying their efforts to hide it from family, physicians and other authority figures. Although marijuana abuse in adolescents and young adults is of particular concern, it should not be overlooked in other patient groups. For example, persons with certain psychiatric disorders (such as bipolar disorder and post-traumatic stress disorder), those who are under severe emotional distress, and those who have chronic pain might be at increased risk. Ultimately, patients who need treatment will be identified through direct disclosure of marijuana-related problems by the patient, a positive urine drug screen, or identification by legal, school or employment authorities.
Researchers at the U.S. National Institute on Drug Abuse (NIDA) have recently discovered a way to block the effects of THC on the cannabinoid receptors, thus minimizing the high experienced by marijuana users. The compound, called SR141716, chemically blocks the receptors and thus eliminates the intoxication associated with smoking marijuana. Subjects given the highest dose of SR141716 (90 mg) reported a 43% reduction in how "high" they felt compared with the control group. The treatment group also had a 59% smaller increase in heart rate, one of the primary physical effects of marijuana. Lead researcher Dr. Marilyn Huestis of NIDA said the findings help point the way toward possible treatment for people addicted to marijuana. "It's certainly an issue that is still a little controversial," she said. "But there's been some beautiful work showing that marijuana is addictive, and that a number of people who utilize the drug on a chronic basis have developed dependence and have a very difficult time stopping taking the drug." By blocking the brain's cannabinoid receptors, SR141716 may also prove useful in treating obesity and diseases such as schizophrenia, and improving memory.

Cocaine

Cocaine, a powerfully addictive stimulant, is one of the oldest known drugs. The pure chemical, cocaine hydrochloride, has been an abused substance for more than 100 years; and coca leaves, the source of cocaine, have been ingested for thousands of years. Cocaine was labeled the drug of the 1980s and '90s, because of its extensive popularity and use during this period. In 1997, an estimated 1.5 million Americans age 12 and older were chronic cocaine users. Although this is a significant reduction from the 1985 estimate of 5.7 million users, cocaine abuse and addiction remain a substantial public health problem today.
There are basically two chemical forms of cocaine: the hydrochloride salt and the "freebase." The hydrochloride salt, or powdered form of cocaine, dissolves in water and, when abused, can be taken intravenously or inhaled. Freebase refers to a compound that has not been neutralized by an acid to make the hydrochloride salt. The freebase form of cocaine is smokeable.
Cocaine is generally sold on the street as a fine, white, crystalline powder, known as "coke," "C," "snow," "flake," or "blow." Street dealers generally dilute it with such inert substances as cornstarch, talcum powder, or sugar, or with such active drugs as procaine (a chemically-related local anesthetic) or with such other stimulants as amphetamines.
Crack (or rock) is the street name given to the freebase form of cocaine that has been processed from the powdered cocaine hydrochloride form to small clumps of smokable substance. Crack cocaine is processed with ammonia or baking soda and water, and heated to remove the hydrochloride. The term "crack" refers to the crackling sound heard when the mixture is smoked. Because crack is smoked, the user experiences a high in less than 10 seconds. This rather immediate euphoric effect is one of the reasons that crack has become enormously popular; another reason is that crack is inexpensive both to produce and to buy.
The principal routes of cocaine administration are oral, intranasal, intravenous, and inhalation. The slang terms for these routes are, respectively, "chewing," "snorting," "mainlining," "injecting," and "smoking" (including freebase and crack cocaine). Snorting is the process of inhaling cocaine powder through the nostrils, where it is absorbed into the bloodstream through the nasal tissues. Injecting releases the drug directly into the bloodstream, and heightens the intensity of its effects. Smoking involves the inhalation of cocaine vapor or smoke into the lungs, where absorption into the bloodstream is as rapid as by injection. The drug can also be rubbed onto mucous tissues. Some users combine cocaine powder or crack with heroin in a "speedball."
Cocaine use ranges from occasional use to repeated or compulsive use, with a variety of patterns between these extremes. There is no safe way to use cocaine. Any route of administration can lead to absorption of toxic amounts of cocaine, leading to acute cardiovascular or cerebrovascular emergencies that could result in sudden death. Repeated cocaine use by any route of administration can produce addiction and other adverse health consequences.
Cocaine acts on the pleasure circuit within the brain to prevent reabsorption of the neurotransmitter dopamine after its release from nerve cells. Normally, the neurons that are part of the pleasure circuit release dopamine, which then crosses the synapse to stimulate another neuron in the pleasure circuit. Once this has been accomplished, the dopamine is picked up by a transporter molecule and carried back into the original neuron. However, because cocaine binds to the dopamine transporter molecule, it prevents the reabsorption of dopamine. This causes a buildup of dopamine in the synapse, which results in strong feelings of pleasure and even euphoria. The excess dopamine that accumulates in the synapse causes the neurons that have dopamine receptors to decrease the number of receptors they make. This is called down regulation. When cocaine is no longer taken and dopamine levels return to their normal (i.e., lower) concentration, the smaller number of dopamine receptors that are available for the neurotransmitter to bind to is insufficient to fully activate nerve cells. This results in a drug "craving," which compels the addict to get the level of dopamine back up by taking cocaine. Cocaine also binds to the transporters for other neurotransmitters, including serotonin and norepinephrine, and blocks their re-uptake. Scientists are still unsure of the effects of cocaine's interaction with these other neurotransmitters.
Cocaine has also been found to specifically affect the prefrontal cortex and amygdala, which are involved in aspects of memory and emotional learning. Researchers believe that a neural network involving these brain regions reacts to environmental cues and activates drug-related memories, and this in turn triggers biochemical changes that result in cocaine craving.
Cocaine's effects appear almost immediately after a single dose, and disappear within a few minutes to hours. If taken in small amounts (100 mg or less), cocaine typically makes the user feel euphoric, sociable, and mentally alert, especially to the sensations of sight, sound, and touch. It can also temporarily decrease the need for food and sleep. Some users say that the drug helps them to perform certain physical and intellectual tasks more quickly, while others experience the opposite effect.
The duration of cocaine's immediate effects depends upon the route of administration. The faster the absorption, the more intense the high, and the shorter the duration of action. The high from snorting, for example, is relatively slow in onset, and may last 15 to 30 minutes, while that from smoking may last only 5 to 10 minutes.
Short-term physiological effects of cocaine include constricted blood vessels; dilated pupils; and increased temperature, heart rate, and blood pressure. Large amounts (several hundred milligrams or more) intensify the user's high, but may also lead to bizarre, erratic, and violent behavior. These users may experience tremors, vertigo, muscle twitches, paranoia, or, with repeated doses, a toxic reaction closely resembling amphetamine poisoning. Some users of cocaine report feelings of restlessness, irritability, and anxiety. In rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter, perhaps the result of cardiac arrest or seizures followed by respiratory arrest.
Long-term use may lead to tolerance, and many addicts report that they eventually are unable to achieve as much pleasure as they did from their first experience. Some users will repeatedly increase their doses in an attempt to intensify and prolong the euphoric effects. While tolerance can occur, users can also become more sensitive to the drug's anesthetic and convulsant effects, without increasing the dose taken; this may explain some of the deaths that occur after apparently low doses of cocaine. Binge use of cocaine, during which the drug is taken repeatedly and at increasingly high doses, leads to a state of increasing irritability, restlessness, and paranoia. This may result in a full-blown paranoid psychosis, in which the individual loses touch with reality and experiences auditory hallucinations.
Cocaine use has been associated with severe medical complications, including cardiovascular effects such as disturbances in heart rhythm and heart attacks; increased blood pressure and body temperature; chest pain and respiratory failure; neurological effects, including seizure, headaches, strokes, and coma; and gastrointestinal complications, including abdominal pain and nausea. Because cocaine has a tendency to decrease food intake, many chronic cocaine users can experience significant weight loss and malnourishment. Research has also revealed a potentially dangerous interaction between cocaine and alcohol. Taken in combination, the two drugs are converted by the body to cocaethylene. Cocaethylene has a longer duration of action in the brain and is more toxic than either drug alone. While more research needs to be done, it is noteworthy that the mixture of cocaine and alcohol is the most common two-drug combination that results in drug-related death.
Different routes of cocaine administration can produce different adverse effects. Regularly snorting cocaine, for example, can lead to loss of sense of smell, nosebleeds, problems with swallowing, hoarseness, and an overall irritation of the nasal septum, which can in turn lead to a chronically inflamed, runny nose. Ingested cocaine can cause severe bowel gangrene, due to reduced blood flow.
Persons who inject cocaine have puncture marks and "tracks," most commonly in their forearms. Intravenous cocaine users may experience an allergic reaction to the drug or to some additive, resulting, in the most severe cases, in death. Cocaine abusers, especially those who inject, are at increased risk for contracting such infectious diseases as HIV/AIDS and hepatitis. Research has also shown that drug use can interfere with judgment about risk-taking behaviors, and can potentially lead to reduced precautions about having sex, the sharing of needles and injection paraphernalia, and the trading of sex for drugs, by both men and women.
The full extent of the effects of prenatal drug exposure on a child is not completely known, but many scientific studies have documented that babies born to mothers who abuse cocaine during pregnancy are often prematurely delivered, have low birth weights and smaller head circumferences, and are often shorter in length. In fact, "crack babies," or babies born to mothers who used cocaine while pregnant, were written off by many a decade ago as a lost generation. They were predicted to suffer from severe, irreversible brain damage, resulting in reduced intelligence and social skills. It was later found that this was a gross exaggeration. Most crack-exposed babies appear to recover fairly well. However, the fact that most of these children appear normal should not be over-interpreted as a positive sign. Using more sophisticated technologies, scientists are now finding that exposure to cocaine during fetal development may lead to subtle but significant deficits later, especially with behaviors that are crucial to success in the classroom, such as blocking out distractions and concentrating for long periods of time.

Treatment
The majority of individuals seeking treatment for cocaine addiction smoke crack, and are likely to be poly-drug users as well. The widespread abuse of cocaine has stimulated extensive efforts to develop treatment programs for this type of drug abuse. Cocaine abuse and addiction is a complex problem involving apparently permanent biological changes in the brain as well as a myriad of social, familial, and environmental factors. Therefore, treatment of cocaine addiction is complex, and must address a variety of problems. Like any good treatment plan, cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patient's drug abuse.

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