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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20

The Syndrome of Coca Paste a

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F. R. Jeri , C. Sanchez , T. Del Pozo & M. Fernandez

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Departments of Neurology and Psychiatry , University of San Marcos, Medical School , Lima , Peru Published online: 20 Jan 2012.

To cite this article: F. R. Jeri , C. Sanchez , T. Del Pozo & M. Fernandez (1992) The Syndrome of Coca Paste, Journal of Psychoactive Drugs, 24:2, 173-182, DOI: 10.1080/02791072.1992.10471637 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471637

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The Syndrome of Coca Paste'

F. R. JERI·· ; C. SANCHEZ·· : T . DEL POZO·· & M. FERNANDEZ··

recreational group where one cigarette was shared by several persons. In this paper we shall refer to the symptoms and signs presented by 158 heavy coca-paste smokers examined personally by the authors In several psychiatric services in Lima (Peru). Later we shall refer to the epidemiology, differential diagnosis and treatment of this new modality of drug dependence.

In the last few years Peruvian psychiatrists have observed the appearance of a new modality of cocaine use through smoking coca paste in cigarettes prepared with tobacco or marijuana. These two latter substances also have pharmacological effects and therefore can not be considered simply as filling material. Coca paste is a mixture containing cocaine sulfate, ecgonine, other coca alkaloids, benzoic acid, methanol and impurities (e.g ., kerosene, alkali, sulfuric acid). Therefore it is not correct to call it basic cocaine paste or cocaine paste. The pharmacological effects of this preparation are subject to many variables, such as type of paste (brute or purified) , dose, frequency of use, aggregate substances (impurities, contaminants, other psychoactive products), environment (social, recreative, individual), motivation (stimulant, antidepressive, situational) and other factors . In consequence, the effects can be diverse according to the prevailing conditions of observation or experimentation. In 1976 jeri, Sanchez and dclPozo (1976) described coca use in a group of 79 youngsters who had drug problems. Among them seven smoked coca paste. More recently Siegel (1977) mentioned four individuals who had smoked base-free cocaine and described how they used this substance, in very small amounts, in a

MATERIAL ANI> METHOI>

The clinical material of th is report is based on the examination and follow-up of 158 persons who were admitted, as in-patients, to four psychiatric services in Lima for serious problems related to heavy coca-paste smoking. The four psychiatric services were : the Alcohol and Drug Dependence service of the 2000-bed Larco Herrera Psychiatric Hospital (ward VIII) ; the San Antonio Hospital , a private ISO-bed psychiatric institution ; the San Isidro Hospital, a 125-bed private psychiatric facility; and the psychiatric department, a 30-bed sector, of the Police Hospital (Sanidad del Ministerio del Interior). Some patients were initially seen in private consultations. The observations were compiled ovcr a four-ycar pcriod (1974-1977). All patients were initially examined by one of the authors by means of clinical history , physical evaluation, mental status, laboratory studies and, In some, psychological tests. During hospitalization and outpatient visits the patients were interviewed frequently by the authors, describing the symptoms and response to treatment methods. The patients were treated by

·This is an abridged version of an article published in Spanish in the Revista de Sanidad del Ministerio del Interior Vol. 39 : 1-18, (March, 1978). ""Departments of Neurology and Psychiatry, University of San Marcos, Medical School, Lima, Peru. Journal

of Psychoactive Drugs

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COCA PASTE

t rend in Peru . Abou t 64.1 per cent o f these pat ients starte d ex pe ri m e nt ing wit h co ca paste two y ea rs before, 5.6 percent had a hist ory o f three years us e a nd o n ly 2.5 percen t had been smo king coca paste for m ore than four yea rs. The d rug was used alo ne in 15.8 per cent of o u r pat ients. In a great ma j ority o f cases (84.2 percent) it was preced ed, co m b ine d o r co n t in ued b y o t he r dru gs ( us u ally alcoh o l o r marijuana) . In the we alth y, cocai ne sno rti ng co uld b e combined w ith co ca-p aste smo ki ng. Some of o u r pat ients were poly dru g users, m ix ing or em ployi ng successively four, five , six o r even twe lve d rugs. Most of th e pat ients in th is se ries be came dependent o n coca past e afte r using it seve ra l t im es. At t he time o f t he ir referral the maj ority of su bjec ts sai d they had be en smo king co ca past e for le ss t ha n two years (6 5 .3 per ce nt ) . They preferred to smoke it every day if po ssible . In fact, 46 .8 percent of th is group smo ke d da ily until th e paste was no longer a vai lab le , th e y fclt very sic k or were ca ugh t by th e p oli ce o r rela tives. Therefo re, we m ay conclude that coca pa st e tends to be smok ed in long sessions, wh ich m ay last seve ra l days. When th e a dd ict has n o more drug s/he h as t o sto p , th ough s/he might become desperate t o o b ta in more paste. T hat is w hy some of o u r patients were forced to smoke o nly three times a week (l0 .1 percent) , tw ice a we ek (6 . 3 p erce nt), on ce a week (1 1.3 percent) o r o ccasio na lly (6 .9 percent).

ind ivid ua l o r group ps ychothe rapy , neu rolep t ics ( when necessa ry ), fami ly t he rap y, e nvi ro n me nta l ma ni pul at ion and pla y t he ra py .

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ES U L TS

Gen e ral Trai ts F ro m a gro up o f 800 dr ug -p robl em pat ients we sele c te d 158 wh ose mam trou ble was e xcessive co ca- pas te smo ki ng. T he y used dr ied p ast e , o ne gra m o r less. whi c h was fragmen ted into seve ra l p ie ces a nd int ro du ced a t the lo wer e n d of a t obacco o r m ar ijuan a c igar e tte. T he n th is e n d wa s cl osed by twist ing th e pap er , lighte d a n d s m o ke d. Most users b egan sm o k ing co ca past e in bise xu al-recre ati onal grou ps . If th ey pro gres se d to heavy smoki ng usu all y th ey wou ld turn to un ise x u al gro u ps. When smo k ing becam e ver y fr equent a nd in te nsi ve th e y te nde d to sm o ke alo ne . O f cou rse we on ly o bta ine d dat a fro m pati en ts a nd rel atives. We were info rmed th a t so me o t he r in d ivid ua ls, wh o smoked fo r curiosi ty, pleasu re or fo r social reaso ns fo u nd the ex per ie nc e unsa t isf acto ry a nd d id not repeat it. Amo ng t he p ati ents we saw, 9 7 .4 per cent were m al es a nd 2 .6 pe rcen t fe m a les. As to m arit al sta t us , 74 .8 percen t were single an d 20.2 percent m arri ed. Ab ou t 80 perce n t of th ese users beg an to use d rugs befor e th ey were 20 ye a rs old . Usua lly th ey sta rte d wit h t obacc o c igar e t tcs , t he n alco ho l and / o r m ar iju an a an d lastl y coca pastc . Most o f th e pa ti en ts ca me f rom Lima or its su bur bs ( 8 6 pe rce n t) an d t he rest fro m o the r t o wn s in Per u . In rel at io n to o cc u pa tio n , 36 percent we re un emp loyed o r had unsp e cified o ccasiona l jo bs , 15 .8 per l'l' nt were la bo rers, 26 . 5 per cen t wer e o ffi ce cl erks, 20 .2 perce nt st u de n ts a nd 1.2 per cent p rofessional pe ople . We ha ve d ivid e d soc ial class in Peru accordi ng t o th e m on thl y fam ily inco me. Most of o u r p atients ca m e fr om middle ( 52 .2 p erc en t ) or low (42 .4 per cent) inco me gro u ps, whereas o n ly a very sma ll pr oport ion came fro m we al t hy ho mes ( 5 .0 pe rcen t ). A co nsid e rab le numbe r o f o ur patient s (77 .8 pe rcent ) Legan se co nda ry sc hoo l hut o nly 39. 2 per cent finis he d th eir st ud ies sa ti sfac tor ily. A lso , 12 per cent o f th ese beg an un iversit y studies b u t o nly t wo o f t he m were gra d u a te d a t the end o f writing t his re port .

Clinical Manifestations Thes e patients we re seen under sev eral c ircumsta nces. A fcw were e xam in ed in the e m e rge n c y ro oms of d iffer ent hospitals, during st ates o f acute intoxicati on, suff e ring from cr ises resulting from e xc essive or pr ol onged use o f the drug. Mo st of th em h owever were inte rviewed aft e r th e acute intoxication o r the si t ua tio na l c risis was ove r. Du ring the in itial phases o f intoxication with co ca pa ste m o st o f th e su bjects e xper ien ced co nsi de rab le eupho ria, wh ich was verbal ized as an e xperience o f inten se ple asure , happiness o r the satisfact ion o f doing so me t hi ng y earned for very mu ch. They smo ke d deeply and repeatedly - so met imes slowly , other times rapidly - e x pe rie nci ng feelings o f deperson al ization, in d iff e ren ce or accomplishment. After a few minutes of intense e njoy me nt the y devel oped anxiety and vehement wishes to co nt in ue sm o k ing, leading t o repeated , or c hain, smoki ng. When they run o u t of paste the y try t o obtain or bu y m ore in a sta te o f compulsive anx iety. The us er does not sleep, has n o appe t ite a nd his/her o nly w ish is t o con t in ue smo ki ng. Most users began sm oking, as sa id before , for

Fo rm of Use Mos t o f o ur patients beg an the use o f drugs by sm o king mariju ana , so me aft er ex pe rie nce with tobacco ciga re tt cs a n d/ o r alc o h o l (7 5 .3 per cent ) ; o t he rs sta rted o n ly with can na b is (J 0 .8 percent ). Only 13.9 per cen t sm o ke d coc a past e as th eir first dru g. This st u dy fo un d t hat co ca-pa st e sm ok ing is a recent Journal of Psychoactive Drugs

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socialization, recreation, sexual facilitation or situational relief ; others to diminish the sedative effects of alcohol. Gradually all these needs arc no longer important and the individual is only interested in smoking paste until it is finished, slhe is caught or slhe is so intoxicated that the session has to be interrupted. At the beginning of use, most youngsters started smo king in the evenings, in small groups, sharing the paste they could buy among all of them . Later, they tended to isolate themselves and smoke alone or in pairs. When the session has lasted for about half-an-hour the user begins to experience unpleasant effects: numbness in lips, tongue , checks and nose; dryness of mouth ; itching eyes; palpitation; shakiness; headache; dizziness ; generalized warmth ; profuse perspiration ; colicky pain ; and a need to empty the bowel (sec Table I). At almost the same time the majo rity of subjects (83 .5 percent) experienced marked anxiety, which was o nly partially relieved by smoking more pa ste, and visual illusions and hallucinations, which began as elementary photopsiae and later took more complex forms, such as white dots, white elouds, b rilliant lights, shadows (sometimes dark, other times whitish or col ored) which seemed momentarily to be human beings and later were clearly identified as persons (police officers, paren ts, relatives, enemies) . When the user reached this point sl he would look app rehensively from one side to another and could pass from doubt to conviction that s/he was being foll owed . Users have man y slang words for this unpleasant period of the intoxication ; so me can not be translated to English, others would mean "pale trip ," "paranoid trip," "the anxiou s one" and so o n, but all cou ld be likened to the English "bad t rip." Once the users became assured that there was no outside danger, they continued smoking. Most of them said that at the start they wanted to enjoy the paste , but later in the session they thought that they had to continue smoking to diminish the overwhelm ing anxiety . Tactile hallucinations were also very frequent but had to be asked about because the subjects did not give them so much importance as the visual illusions and ha llucinations. Experienced by most subjects during acute in t ox icat ion , t hese unpleasant ski n sensatio ns came from immediately under the skin, giving the impression of num bness, itching, worms or insects crawling on the surface . Ma ny times the patients were seen scratching, touching or picking at different areas of their bodies. Sometimes the subject experienced auditory hallucinations, as elementary sounds, noises or voices which called, threatened or insulted them . Rarely they would hear the voices order ing aggressio n or death to them or Journal of Psychoactive Drugs

T ABLE 1 M A IN S Y M P T O M S REPOR TED B Y 1 58 C OC A PAST E DEP END E N T P ERSO N S DURI NG T HE I NTOXI C AT I ON STATE

Signs & Sympto ms

Number

Percen t

Euphoria Anxiety Anorexia Inso m nia Talkative ness Hallucinations Sweati ng No thirst Paranoia Irritability Sexual indifference Uneasiness Instability Aggressive ness Dry mouth Sex ual stimulation Headache Incoherence Dizziness Jealousy Self aggres sio ns Suicide attempt

141 132 11 5 110 68 59 56 53 51 43 41 38 36 31 30 17 14 12 10 8 6 3

89 .2 83 .5 72 .7 69.6 43 .0 37 .3 35.4 33.5 32 .2 27 .2 25.9 24.0 22 .7 19 .6 18 .9 10 .7 8 .8 7.5 6.3 5.0 3.7 1.8

others. Generally the auditory hallucinations were observed in the pat ie nt s who remained in a psychotic state after the acute intoxication was over. During the advanced phases of a smoking session many other disturbances could be observed such as sleeplessness, ano rexia , talkativeness, irritability, aggressiveness, sexual indifference and sexual impote nce . The session ended when there was no more paste or when the intoxication was so severe that the subjects went ho me or others took them home or left them in a hospital. However, usually the subjects tried to dimin ish the unpleasant effects by drinki ng alcohol (pisco , vodka, rum, anisette), alone or mixed with soft d rinks. When they wanted to sleep they drank more alcohol or used a sedative (diazepam (Valium®) was very popular with some). A session generally lasted many hours, from early evening until the next day . O ccasio nally some subjects cou ld smoke for two or t hree days without stopping. Many others would smoke daily, several hours each day, if they had the paste. 175

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euphoric to a dysph oric sta te. Man y also could transfer from euphori a to hallucinosis or from d ysphoria to hallu cinosis. The latter co uld persist for several days or co uld progress to a paranoid psychosis . At th e beginning of t hes e abnormal men tal st ates the subj ects had insight as to th e unreal nature of their experien ces; lat er they bec am e involved in th e delusional interpretation and would develop paran o id actio ns .

When an individua l smoked freq uently s/ he wo uld become pale, th in , m aln ourished, shak y , unkempt , in troverted, irri ta ble, indi ffere nt, un reliabl e an d antisocia l. S/ he wo uld lie freque ntly , negle ct his/her famil y, leave his/h er jo b o r drop o ut of school. T o obtai n mo re dr ug s/ he stole, got in debt , swindled o r became a paste peddle r. Hallu cination s and par an o id interpreta tio ns are freq ue nt du ring acute intoxi cati on and are clearl y rela ted to t he amo unt of drug co nsume d. How ever , th ey had the tend ency to disappear so me hours afte r smo king was sto pped. Neve rt heless 30 of ou r pati ents were ad mitt ed because th ey prese n te d a state o f acu te hallu ci nosis, whic h had not cleared up aft er st opping drug consu mptio n. Si x ot he rs sho we d signs o f a parano id psy ch osis, also develop ed by co ca-pas te sm oking, which did not disa p pear aft er dr ug wit hdra wal (see Tabl e II). T he clinica l co ntact with th ese pati ents sho we d th at many of t he m co uld pass, in a matter of hours, from a

Dy sphoric Reactions In th e Span ish ver sion of this pap er we ha ve prese nte d 27 representat ive case hist ories. Becau se of t he sp ace limitati ons here we will refer o nly to a fe w o f them . T he first illust rates the devel opment of m ark ed dysph oria with coca paste. Case 6: A 22 -year-old patient, wh o was married and e mploye d as an e ngine o pe ra to r, began to sm oke marijuana t h ree years ago because he felt depressed and had problems . One ye ar later he began smo king coca past e. At the beginning of ea ch sm oking session he felt good. Late r he felt un st eady ; he thought th at th e police follo wed him and th at people knew th at he wa s smoki ng coc a pa ste . He sold hou seh old items to bu y co ca paste , caus ing argu me nts with his wife. He became fed up with his difficulties and planned to resign his job . Hc th ought t hat he th en would tak e the indem nifica tio n m on ey half fo r his wife, half for him to buy pa st e. When the paste was finish ed, he would kill himself. His expens es in past e had becom e very considerable be cause he would smo ke up to 50 g in one session . Fin all y he. made a suicide atte mpt with a large qu antit y of ph en othiazin e. T his pat ient had had psy cholog ical pr oblems since child hood. At seven he began steal ing from sch o ol. He soon becam e aggressive and rebellious . When he was 14 his parents fo rced him to leave home. At 18, he joined a gang of robbers and was ja iled seven times. He was released on parole. On examination he was a thin , lucid, well oriented man, markedly depressed, though at other moments he was o bserved to be very restless. He had marked insomnia. This patient developed paranoid ideation during into xicat io n and a severe depressive react ion related to co ca-paste smoking, wh ich ended in a seri ous suic ide attempt. Case 7: Another patient who was 45-years-old, began drink ing alcohol heavily at 22 . One-and-a-half yea rs before admission, he started smoking paste (10-12 cigarettes in each session). During this stage he felt un stable and excited ; he could not sleep. If he continued smok ing he would feel better for a while . But if the exp er ience co ntinue d, again he would feel "very bad ." On o ne occasio n he co uld not sleep for " t we nty days "

TABLE 2 MAIN SIGNS OBSERVED ON ADMITTANCE OF 158 COCA PASTE DEPENDENT PATIENTS

Si!-'T1s and Symptoms Pale ne ss Low weight Personal neg lec t Freq ue n t lat era l glances Dep ressio n Ta ch y card ia My dr iasis Ilallu cin osis Hyperhydrosis Psych om o to r ex citement Scrat ch marks Hypervi gilance Ind iff eren ce Inact ivit y Nause a a nd vomi ting Tremo r Psy ch om otor agitation High bl ood pressur e In coordination My ocl onus Paranoid psychosis Ventricular arrythmias Ast h ma Muscular rigidity Co nvulsio ns Jou rnal of Psyc hoactive Drugs

Number

Percent

123 118 110 75 74

77 .8 74 .6 69.6 47.4 46 .8 45.5 40.5 37 .3 35.4 30.3 27.8 22.1 20 .2 18.9 15.8 15 .1 13.2 12.6 5.6 5.0 3.7 3.1 3.1 1.8 1.2

72

64 59 56 48 44 35 32 30 25 24 21 20 9 8 6 5 5 3 2

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Case 14 : Some patients developed audi tory hallucinations, anxiety and depression as observed in a 31-year-old worker who began to consume paste seven months before admission. Gradually he smoked more and more . Before admission, he had used paste every day and was eager for the weekend because then he co uld smoke paste without interruption for two days. One week before admission he began to hear threaten ing voices and thought that he was being followed; also he experienced sleeplessness and when he did sleep had frequent nightmares. On examination he was a thin, lucid, alert, well oriented man who talked in a low voice , was depressed and anxious. He had definite paranoid thoughts, slept poorly and woke up frequently due to terrifying dreams. He was treated with trifluoperazine and the hallucinations and paranoid ideas cleared up in ten days. Case 15 : Delusional thought disturban ces and olfactory hallucinations were seen in a 33-year-old office clerk. He began to use marijuana when he was 14 ye ars old . Two years before admission he began to sm oke co ca paste, about 10 cigarettes daily . Occasionally he would snort cocaine hydrochloride when drinking alcohol. Gradually he increased paste consumption until he used 40 g dail y, several times a week. In the two months pri or to admission , he lost weight (19 pounds) and noticed that his work performance diminished considerably due to memory loss. He also noticed bad odors and , as he smelled them everywhere, became convinced that the odors came from his body, though he bathed daily and used deodorants frequently . He also thought that people did not like him and were saying nasty things about him . This patient received parenteral and oral neuroleptics (chlorpromazine) and the hallucinations and pathological ideas cleared up in two weeks .

after a coca-pastc binge and felt anxious, fearful, restless and finally panicky. This was the reason for hospital admission. He had had two previous admissions with the same dysphoric reaction to coca-paste smoking. Case 11: The different dysphoric reactions produced by coca paste, as contrasted to alcohol effects, were seen in a 25-year-old, single, male patient. This man began drinking heavily when he was 19. He could not abstain nor could he stop drinking when he started a spree. Five months before admission he started to smoke coca paste. During the smoking session, and many hours afterward, he became impulsive and aggressive. His behavior became completely disorganized. After each coca-paste binge, he felt extenuated, low, anxious, depressed, asthenic and anorexic. Case 12 : Also contrasting effects were seen between marijuana and coca paste. A 23-year-old, asthmatic, male patient began to smoke marijuana when he was 14. This drug produced very pleasant effects but eventually precipitated asthmatic attacks so he had to stop smoking it for a year-and-a-half. A year before admission , he began to smoke paste wh ile drinking beer. During these binges, he became very restless, anxious, paranoid and agitated. He had to be taken to emergency room services several times and was treated with parenteral neuroIeptics for several days. In the last crisis he felt anx ious, had a severe headache and began to shout and cry. He was taken to his room, where he got hold of a knife and stabbed himself repeatedly in the chest. This was another serious suicide attempt due to the acute effects of coca-paste smoking. Hallucinosis The considerable tendency for coca-paste smoking to produce illusions and hallucinations in many subjects can be illustrated by very brief summaries: A 25-year-old, male, married accountant began to smoke marijuana when he was 16. In his college years he was a polydrug user, employing alcohol, amphetamines, methaqualone, LSD and cocaine hydrochloride. These drugs were snorted, drunk, swallowed or mainlined. Lately he was introduced to coca-paste smoking. He liked it so much that he said he would use it every day if he could and in fact he smoked paste for fifteen consecutive days before being admitted to a hospital. I lc said that he had discovered that coca paste was the only drug for him. This caused an urge to usc it more and more, While he smoked, he experienced auditory hallucinations: he heard his brother coughing, who was not in the room and he also heard many other noises. When he stopped smoking paste the hallucinations disappeared in about two weeks. Journal

of Psychoactive

Drugs

Psychoses As has been documented in previous descriptions, the tendency to relate pseudoperceptions with paranoid thinking is very marked with coca-paste intoxication . It is therefore not easy to trace the border between hallucinosis and psychosis. In a strict sense, most of our patients hallucinated during a heavy coca-paste smoking session : they presented an acute toxic psychot ic reaction. Therefore, we consider psychotic rcact ions to have severe and prolonged hallucinations and par ... noid delusions . The paranoid pattern is so common with our paste consumers that acute intoxication with persecutory ideation is called by them "la paranoica" that is to say the paranoid reaction. When there is a predominance of dysphoric symptoms, the users are called "angustiados," the anxious ones. 177

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A fe w psy ch oti c reaction s lasted more than two week s a nd so me t im es with a ud ito ry h allu cin ati on s d ist u rbed th e pati ents co nsi de rab ly , as happen s with ma ny ac u te primar y psy ch oses. This co u ld be seen for ex ample in a 24 ·y ea r·ol d worker who beg an to smo ke mar iju an a when he was 17 . Two ye a rs later he sm ok ed m ixed co t'a'p ast e mar iju an a a nd later coc a paste-t obac co (·iga rettes. lie was t re ated in th e ho spit al a nd rema ine d d ru g f ree fo r t hrce month s. Then he relapsed a nd co nsu med seven gra ms of coca past e th ree I imes a week . Afte r a month he be cam e very a nxio us , felt perse cuted a nd he ard insu lting vo ices. Later the vo ices o rd ere d h im t o k ill. T his alarme d him so mu ch th at he ask ed to be ad m itt ed to t he h ospital o nce more . When see n , he was lu cid , exc ite d , disori en ted in ti me , h ad insight abo ut th e o rigin of his sy m p to ms but continued to pe rceiv e a u d ito ry ha ll uc inat io ns an d hi s th ought pr ocesses were accele ra t e d and inco here n t. He therefore had t ypi cal signs of an ac u te ex ogen ou s ps ych osis. He recovered in a few da ys aft e r ad m in ist rat io n of ncuro lcpt ics. After th e psych ot ic signs disapp ea red, his b ehavior was determined to be de fini tel y psych op athi c. In some patient s, je alo us delusions bec ome a se rio us p rob lem , indu cing the pat ie nt s to verbal aggre ssion, ph y sical attac ks a nd even fire arm assau lts . We can refer t o Case 18 wh o was o ve rly jealous o f h is lo ver and t ho ug ht th at he sa w her with other men in man y p laces, u n t il fina lly he di sch a rged four pistol sho ts again st the do o r of a f rie n d b ecause he was co nv inc ed that th e m an was having a n affa ir with his wom an. Another 3 I -yca r-o ld man (C ase 19) , wh o had been smo k ing co ca paste fre q ue nt ly for seve ra l week s beg an t o not icc th at pe ople in groups t alked ab out h im , o t he rs were fo llo w ing him a nd his wife w as m ak ing adva nces t o other men . The n he would acc us e his wife an d ill treat he r even if she pr otest ed inno cen ce. On questioning, he said he had no t iced a cha ngc in h imself, he wa s not like this, he was convinced that he was fo llowed and that there was so meo ne m akin g sig ns t o his wife . l ie becam e fu riou s and began to be at her. He saw persons t ha t were aft er him , he he ard ste ps, he saw the sh ad ow o f someone o bserv ing him ; other times he visu alized strange form s a n d when he ca me nc a r there was n o t h ing there. At ot he r t imes he he ard people t alking loudly abo u t h im o r hi s wife, he hurriedl y we nt out an d there was no one. He th en came in a nd immedi ately he ard the same voices aga in . lie was admitted t o the hospital and treated with phenothia zi ne, resulting in calm ing. T he ha lluci nations wer e not noticed any m ore , but he was st ill pa thol og ieall y je alou s o ne m o nth a fte r be ing hosp it alizc d. So me patien t s become so aggressive a nd agitat ed Journal of Psychoa ctive Drugs

that t hey have to be admitted by force to the hospital. This happened for example to a 2 5-year -old man, a uni versit y st u de n t wh o smo ked coca paste for two days without interruptio n, consuming 40 ciga rett es. He becam e violently excited a n d had t o be ho sp italized wi th the help of the police. A nothe r pat ie nt (C ase 23) be came so ex cit ed after coca-paste smoking that he had to walk continuously from one sector of the city to anothe r, t alking, dr inki ng a nd smoking in th e street. He also fcl t perse cuted a n d thought that he would be det ained at a ny moment . A 19- year-o ld b o y (C ase 24) became so dependent o n paste th at he had t o begin sm oking at 10 in the morning, every day of the week . A fter two months, he fel t th at he was being foll owed all the time, heard voices that called him by his name and o rde red him to come to a halt . All veh icles seemed to him police patrol cars. Eve n tua lly he became so affe ct ed by th ese experiences t hat he thought the on ly way o u t was to co m m it suicide . lie co uld not sleep at night unless h e drank a con sid er ab le quantity of alcoh ol. He was admitted t o th e hospital and treated wit h phenothiazi ne . After 33 da ys, the psychoti c symptoms had vanished, but he rem embered what he fe lt and became a nxious when thinking ab o ut his past mental disorder. When coca paste is used freq uently in heavy quantities, t he psyc hotic reactions may b e severe, as with a 2 5-year-o ld press writer (Case 2 5) wh o had been smoking paste for four mo nths , seve ra l tim es a week. li e be came vio lently excited and aggressive and w as ad m itte d to the hospital against his will. lie was ext remely a ngry and attacked t he hosp it al perso nnel on man y oc casio ns. D uring th e first week he wa s confused , disoriented, incoherent and his behavior was aberrant. He improved ra pidly a nd was discharged after a month. Two months later he was readmitted , after a resumpt ion of co ca -pas te usc and deve lo pmen t of a new psy chotic-paranoid reaction . As he felt desperate be cause he t hought he was bei ng followed everywhere by ma ny peo ple , he stabbed h im sel f t h ro ugh the ab do m e n wit h a ki tchen knife and a n operation was performed in a general hospital. He was ve ry ill for seve ral weeks afte r the suicide attempt. During those day s the psychotic sym ptoms pe rsisted . He thought t h at he was a prisoner in th e hosp it al ; he be lie ved he ha d supernatu ra l po we rs ; he said t hat he cou ld t alk to a Peruvian poet, who was in Pari s (this poet had died ma ny years ago); and he saw extraterrestria l bei ngs in his room w ho made him do things agai nst h is will. T he psy c hoti c sym pto ms cleared up afte r a m o nth with t he aid of phenothiazi ne compounds. In concl usion, we can say t hat psychotic reactio ns 178

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alveo li. In relation to th e main c ha ract e rist ics pr ese n ted by th is group o f coca-paste consumers we ca n only add that they are mostly male you ngs te rs bel onging to lo we r and m iddle classes, mainl y un empl uyed , office cler ks o r students. Eighty-six percent were born in Lima and Callao . The y began the use of drugs between the ages o f 11 and 20 yea rs, but the usc of coca paste o nly st art ed four yea rs ago (1974), generall y associated with oth er drugs, espe cially alcoh ol. On ce they begin cu ca-p aste smo ki ng, they usually stop consuming other drugs , with the exception of alcohol. This preference fur pa ste is du e t o the intense effects obtained . In sp ite of the impurities it has, white or purified pa st e ma y contain up t o 85 percent cocaine sulfat e and ruugh paste up t u 60 percent. These mixtures produ ce strong effects a nd c rea te a qui ck psychic depend ence, much stronger than the o ne o bse rve d in co ca-leaf che we rs (Gutierrez-N or iega 1947 ) o r in co caine inh alati on (Wilso n 1968 ; Hy ck 1977) . Most patients in th e gr uup were introduced to coc a-pas te sm oking by frie n ds u r relat ives fo r so cia lrecr eati on purpose s a nd a fe w fo r sit ua tio na l-resol ut io n purp oses. T he effe ct s produ ced by paste arc cha ra ct er ized by a rapid development of e up horia acco m pa nied a lm ost simu lta neously by anxiet y a nd th e co m p ulsive need to go o n sm uk ing. These effect s a re intense and , as with intranasal and intraven ous cocaine administration, they pass rapidly (Chopra & Ch opra 1958 ; Ed dy et al. 1965 ; Bejerot 1969; Byck 1977). Therefore the u ser needs to repe at th e dose in orde r to continue feeling ple asure , excit ation, euphoria a nd ot he r se nsat io ns. Paste reacti on is so intense that most users, after a few minutes, experience disagreeable sensat ions (anxiety, compu lsions, insomnia, sexual impotency, disquiet, instability, aggressive ness, headaches and diz ziness). Some patients, from the very first puffs, experience perceptu al di sturbances (visual hallu cin ations) . Many requ ire co n t in uo us usc for several hours to devel op a pi cture of par an oid hallucinos is, which the y term " p altea dos" a nd co m prises visu al, t actile a nd a ud it ory hallu cin at ion s with delusive ideas of pcr sc cut ion, aggression u r jeal ou sy . Few of th ese patients were seen during ac ut e into xic at ion as the majorit y came for co ns u lt at io n a fter the se rio us effects had disappeared, even th ough 30 had , o n admi ssio n, hallucinatory d isturban ces a nd ps ych o m otor excitement or agi ta t io n . However, some sympt omat ic man ifest at ions su ch as facetiousness, hallucin osis, pa ranoia, irr it ability , depressi on , aggressive ness and insomnia persisted in man y o f them . The physical appearance of these patients was characteristic. These youngsters were pale , slim and urnkernpt with a tendency to glance from side-to-side .

and hallucinosis were observed fr equ entl y in o u r group o f heavy coca-paste smokers. T hese rea ctions are dose related and may clear up with drug withdrawal. If the ind ivid ual has been abusing co ca pa ste for man y weeks, sl he may present a more pr ol onged and dangerous parano id psychosis. However, these reactions also remit after a few weeks and the recovery is defin itely accelerated by neuroleptics of th e phenothiazine o r butyrophenone groups.

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COMMENT

This study, done during the last four years, co n firms the dissemination o f the use of coca paste among the y oung people of Lima. It o ccurred as an epidemic wh ose cases were ea sily identified , spreading fr om o ne person to another, among pe ers, rel atives a nd eve n sp ou ses. Man y o f these individ ua ls have used ot he r drugs, but o nce they start smoking co ca paste, the y aba ndo n th e o t hers (either partially o r t otall y) becaus e in Peru , the y find the latter not very expe nsive , easy to get a nd easy t o ca rry , with a potent and fas t ac t io n a n d, ac co rd ing to wh at they beli eve , lack ing in dan ge rou s sid e effec ts. No real ep ide mio logica l stu d ies o n drug ab use have been done in this country. A survey conducted nine yea rs ago among un iver sit y st ude nts revealed th at 18.8 percent had used drugs a nd o ne percent were su spect of dep endency (de Leon 1969). Clinical in vestigations (J e ri, Carbajal & Sanchez 1971 ; Jeri, Sanchez & delPozo 1976) sh ow progressive increase o f the use o f drugs am ong y oungsters seen in general a nd psychia tr ic hospit als . Coca-paste dependency is now the main cause of admission to the se ctions of addiction of the psychiatric hospitals in Lima. We are undoubtedly experiencing a new epidemic of drug dependence which was originated by the market fluctuations between the produce , its access, use an d the repressive m easures used recently . The increase of coca pa ste or coca ine exports to the u.S . and Europe, due t o its gre at demand (Connell 1969 ; Eiswirt h, Smith & Wesson 1972; Crowley 1973 ; Ga y et al. 1973 ; Wo ods & Down s 197 3 ; Ashl e y 1975 ), produ ces an illici t increase of product ion in Peru a nd Bol ivia. When co nt ro l measures inte ns ify , locall y an d inte rnationally, exportation be comes d ifficul t , cau sing the product to remain in the country. Traffickers then try to sell lo cally and young peddlers a rc the o n es in ch arge of introducing new trends - such as making cigar ettes and mixing the coca paste with marijuana, tob acco and oth er herbs. Thus a new fashion o f us age has been developed. The person inhales a number of toxic substances (cocaine, ecgonine, methanol, ben zoic acid , nicotine , etc .), all of which have systemic and neurological effects , by means of rapid absorption fr om the pulmonary Journal of Psychoactive Drugs

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signs of intoxication aboard an airplane and was quickly taken to the nearest hospital. The autopsy of both showed a great quantity of small plastic bags containing cocaine in the digestive system . Some were broken and the contents had been absorbed into the bloodstream. The use of coca paste may have grave consequences to its consumers. Most of them were detected as coca -paste smokers by parents, wives or employers, because they dedicated themselves to robbery, swindling and became indebted in order to buy the drug. They became unreliable at their jobs, were frequently absent or neglected their duties and some even smoked paste during work hours. School and university students often abandoned their studies or failed in their courses. Many users stayed away fr om home until dawn or did not return for days, staying away until they ran out of money or paste. Others returned in a state of acute intoxication or depression, begging their relatives for medical help. Unfortunately. many relapse and have to be hospitalized several times. When the individual has a family, in almost 90 percent of the cases , serious problems arise due to the antisocial, aggressive. delinquent or psychotic behavior of the user. Therefore it can be said that this form of cocaine addiction produces harmful effects, individually and socially, equal to those caused by intravenous cocaine hydrochloride (Chopra & Chopra 1958; Bejerot 1969; Crowley 1973; Finkle & McCloskey 1977). Consequently we are facing a new epidemic which should be thoroughly controlled and investigated by all available resources in the country . As to differential diagnosis. coca-paste users often employ other drugs, sometimes to diminish the toxic effects and at other times to be able to sleep after an intense session. These combinations of drugs make it difficult to establish a typical clinical picture. However, coca-paste intoxication has similar characteristics to sympatheticomimetic drugs, and is notably different from the clinical syndromes produced by alcohol (Gutierrez-Noriega 1947 ; Chopra & Chopra 1958; Connell 1969) or by narcotics (Bowley 1965; Connell 1969; Chapel 1973). The frequent evolution seen with coca-paste intoxication is a quick progress from euphoria to dysphoria and then to psychosis or hallucinosis. This rapid change is seldom observed with alcohol, except in pathological intoxication, and is not seen with narcotics. Treatment has consisted, as mentioned before, in hospitalization of the patient. Isolation and interruption of coca-paste use has not produced intense or prolonged withdrawal symptoms. It is possible that the marked anxiety observed in many coca-paste smokers corresponds to the almost immediate development of a dependence pattern which is only relieved with the

They had shin y and mydriatic eyes or red conjunctivae, hallu cin osis , shakiness, ale rt ness, rapid pulse, restlessness , co nfusio n and suspiciousness. We were impressed with the fast transition from euphoric to dysphoric or psychotic patterns , a phenomenon which is frequently o bser ve d during a session of paste smoking that lasts for man y hours or da ys . II is evident that co ca paste contains a considerable qu antit y of co caine which produces rapid toxic effects. Therefore the Post hyp othesis (Post 1975) is confirmed in the sense that there arc three clinical syndromes ca use d by co caine: euphoria, dy sphoria and psychosis . Man y authors (Freud 1884 ; Chopra & Chopra 1958; Bejerot 1969; Ashley 1975 ; Byck 1977) have noticed the rapid progression from one syndrome to the other, especially when cocaine is used intravenously. Coca che wing always produ ces a euphoric picture and, in chr on ic users , a dysphor ic state (Gutierrez-Noriega 1947; Blejer-Prieto 1965; Negrete & Murphy 1967; Buck et al. 1968 ; Hann a 1974). Coca-paste smoking produces a qui ck tr an sition from a normal state to a psy chotic reaction, whi ch, o f co urse, is subject to the variety of types of coc a paste , do ses employed, frequency of use , environment and so on. The individual 's genetic and constitutional factors are also important, as is his/her pr evious psychic state and the combination of drugs s/he may prepare . Some authors (Go rdo n 1908 ; Owers 1912 ; Chopra & Chopra 1947; Siegel 1977) differentiate cocaine hallucinosis a nd co caine psy chosis, relying on the brevity o f the hallucinat ions and the rare occurrence of delusi ons in the former, and in the persistence and systemati zation of pseudoperceptive experiences and thought disturbances in the latter . Most of the cases seen by us correspond to hallucinosis because they remit in a few hours or days after stopping excessive use of the drug. Acute intoxication, like chronic intoxication, may cau se death in humans or an imals, according to the doses employed (Scheppcgrcll 1898 ; Ludwing & Pyle 1969 ; By ck 1977; Finkle & McCloskey 1977). We have also observed acute re actions in many patients which include rapid pulse, mydriasis, high blood pressure, myoclonus, trembling, generali zed convulsions and loss of consciousness. In Peru, we know of two traffickers (not included in thi s group) who, in order to smuggle the drug, ate a great number of small plastic bags containing cocaine hydrochloride . Some of these small bags burst and produced intoxication, dyspnea, rapid pulse, high blood pressure, ventricular arrythmia, generalized convulsions, coma and finall y death due to heart arrest. One of these de alers d ied in a detenti on center, and the other showed Journal of Psychoactive Drugs

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Edmundson, W.F. ; Davie s, J .E.; Acker , J .U . & Myer, B. 19 72. Patterns of drug abuse ep idemiology in prisoners. Ind ustrial Medicine and Surgery Vol. 41(1) : 15-19. Eiswirth, N.A .; Smith, U.E . & Wesson , D.R . 1972 . Current perspectives on co caine use in America . j ourn al of Psychedeli c Drugs Vol. 5 : 153-157 . Finkle , B.S. & McCloskey, K. 1977. Co caine: The Foren sic Toxicology of Cocaine . NIDA Research Monograph, No . 13 . Freud, S. 1884. On co ca . Centralblatt fur die gesammt e Tb erap ie (Wien). Vol. 2 : 289-314. Ga y, G . ; Sheppard, c.. Inaba, D. & Newmeyer. J . 1973 . Co cain e in pe rspective : "Gift from the Sun God " to " t he rich ma n 's drug." Drug Forum Vol. 2 : 409 -430. Gordon, A . 1908. Insanities caused by acute and chron ic intoxication with opium and co ca ine . A study of 171 cases. Suggestions, legi slations and other measures. The questions of responsibil ity . journal of th e American Medical A ssociation Vol. 51(2 ): 97-101, Gutierrez-Noriega, C. 1947 . Alteraciones mentales producidas por la coca. R euista de Ne u ro -Psiq u iat ria Vol. 10 : 145-176 . Gut ierrez-Noriega, C. & Von Hagen, V .W. 1950. The strange case of the co ca leaf. T he Scientific Momhly Vol. 70(2 ): 81 -89. Gutierrez-Noriega, C . & Zapata-Ortiz , V . La intel igen cia y la personalidad e n los habituados a la co ca . R eu is t a de Ne u ro-Psiq uit ria Vol. 13 : 22 -60. lianna, J .M. 1974. Coca leaf us e m southern Peru : Some biological asp ects. American A n tb ro polo g ist Vo l. 76 : 281·296. lIawks, R. 1977 . Coc aine. TbeMat erial in Cocaine : 1977 . NIUA Re search Monograph, No. 13. Hindmarch, I. 1973 . The patterns of drug abuse in sc hool child ren . Bulletin on Narco ti cs Vol. 24( 3) : 23 -24 . Horowitz, J .L. & Sed iacek , W.E. 1973 . University st ud e nt att itudes and behavior toward drugs. j ournal of Co llege S t u dent Personnel Vol. 14(3): 236-237. Isbell, H. & White, W.M. 1953. Clin ical charact eristi cs of addict ions. American f ournal of Medic ine Vol. 14(5 ) : 558-565. Jeri , F .R . 1972. Drogas peligrosas y adolescen cia . Program a pa ra investigacion med ica, prevencion, asist e nc ia y reh abilitacion de la farmaco dependencia en el Peru. Reuista S a n id ad del Ministerio del Interior Vol. 33 : 309-320. Jeri , F .R. ; Ca rab ajal, C. & San che z, e.e. 1971. Efe cro s nocivos de farma cos simpatico -rnimeto cos en un grupo de ado lcs centes. A nale s del Programa A cade m ico de Medi cina . Uniu ersadad Nacional Mayor de San MarcfH de I.ima Vol. 54 : 75 -103 . Jeri, F.R. ; Sanchez, c. e. & delPozo, T. 1976. Co nsu mo de drogas peligrosas por miembros y farniliares de la fuerza armada y fuerza policial peruana. I