Cocaine Addiction Turns Out to Be an Equal-Opportunity Disease

White middle-class America used to take comfort in the notion that drug addiction was primarily a disease of the ghettos, the minorities and the mentally ill with sociopathic and addictive personalities. But cocaine--with its chic, upper-class image--has proved to be an equal-opportunity drug, and it has shown drug addiction to be an equal-opportunity disease.

Challenging some of the most fundamental concepts about addiction and its treatment, cocaine has forced us to redefine the very concept of addiction by eliminating the longstanding artificial distinction between physical and psychological addiction. Although repeated use of cocaine does not produce a dramatic physical withdrawal syndrome like that of heroin, it produces biochemical changes in the brain’s “pleasure circuits” leading to a drug hunger that drives the user toward compulsive drug-taking.

These drug-induced changes in brain activity that cause drug hunger and psychiatric symptoms due to the drug’s impairment of brain function are undoubtedly “physical.” In fact, we now know that in order for any drug to produce its desirable euphoria or “high” it must penetrate certain brain cells and chemically alter their functioning. There is no such thing as a drug that can get you high without causing physical changes in your brain--thus there is no such thing as a purely psychological addiction to these drugs. Cocaine has shown us that it is better to define addiction in terms of compulsive drug-taking rather than withdrawal symptoms.

Asserting chemical control of people’s behavior, cocaine is highly seductive and insidious. In the early “honeymoon” stage, cocaine offers enhanced performance, energy, confidence and sexuality. The more intensely pleasurable these effects are for the user, the greater the potential for recurring use. With continuing usage, cocaine becomes more and more of a priority, and the user’s judgment and functioning become more and more impaired--this is the vicious, progressive cycle of addictive disease. Not every user becomes an addict, but we can’t predict who will and who won’t develop into one.

Because cocaine is a potent brain stimulant, it can overcome boredom and fatigue, and in early stages of use can augment a user’s performance by providing increased energy and confidence and stimulating mental activity. However, these desirable effects lay a trap for the user who seeks only the “good” effects from cocaine while ignoring the potential dangers. Any performance-enhancing effects are time-limited because of cocaine’s short action (often no more than 20 to 30 minutes) and to the progressive tolerance that develops with repeated use. Contrary to popular belief and to the recent intimation by a well-known basketball coach, athletes don’t use cocaine to improve their performance--they’d have to run into the locker room every half hour for another dose to keep themselves from “crashing” when the effects wear off. The drug inevitably impairs judgment and self-awareness while simultaneously stimulating grandiosity and arrogance. As a result, anyone’s performance is likely to deteriorate from using cocaine.

Another byproduct of the cocaine problem has been a reduction in some of the traditional barriers between alcohol and drug-abuse treatment. A contributing factor is the realization that very few cocaine users are involved only with cocaine. Their use of alcohol and other drugs to alleviate unpleasant side effects from cocaine or to achieve combination drug highs is common. Similarly, an increasing number of primary alcoholics are becoming involved with cocaine. Among substance abusers who apply for treatment at drug or alcohol programs, dual addiction to cocaine and alcohol is rampant. The so-called “pure” alcoholic or drug addict is rapidly become extinct. Not only are more chemical abusers combining drugs and alcohol, but alcohol is a major factor in relapse to drug use just as drugs are a major factor in relapse to alcoholism. In an increasing number of cases the two problems are inseparable. This has underscored the fundamental importance of complete abstinence from all mood-altering chemicals as the only reasonable treatment goal for recovering drug addicts and alcoholics alike.

Drug abusers can now be found in significant numbers among the ranks of professionals, business executives, military personnel, government officials and those responsible for public safety. Among the many addicts whom I have treated are airline pilots, air-traffic controllers, schoolbus drivers, surgeons, internists and supervisors in nuclear-power plants.

Because physicians, psychologists and other health professionals have typically received almost no training in the diagnosis and treatment of problems associated with drug dependency, many cocaine abusers have often been misdiagnosed and subjected to erroneous treatment. Substance abuse is our nation’s leading public-health problem, yet our health-care system has been ill prepared to recognize it, let alone deal with it.