LAST UPDATE | 8 Oct 2023
THE THREE MOST dangerous ‘white powders’ in human history are probably sugar, salt and cocaine hydrochloride, the bitter white crystal that European chemists finally managed to extract – on an industrial level in the 1860s – from the leaf of the South American shrub, Erythroxylum Coca.
It’s useful to group these man-made products together because all have been harnessed for centuries for their remarkable properties and staggering economic value. Lamentably, all have driven the enslavement of vanquished peoples, toiling in salt and silver mines, sugar plantations or coca fields.
And, for years, the customers for the first two products at least, lured into lifelong habits of consumption by clever admen, concealment in cheap and tasty foodstuffs, or celebrity endorsement, have poured into our GP surgeries and hospitals, with their raised blood pressure, blocked arteries, and galloping diabesity.
As for the ‘newest’ white powder, cocaine, reports that the Irish are now among its biggest consumers in Europe suggest that we’re way beyond the historical inflection point, where cocaine joined sugar and salt as a permanent determinant of public health in Ireland (and, of course, crime).
But I’m not convinced that telling people ‘cocaine is bad’ for them will reduce its use. I’ve seen the effects of the drug for years, close up in emergency departments, in the press, and on screen and the only feature of the ‘public debate’ about cocaine in Ireland that ‘cuts through’ is the ‘hilarious’ picture of a guy snorting white surf on a beach that’s posted on social media every time a cocaine seizure occurs or someone famous gets ‘busted’.
That jaded meme replaced an equally cliched quip that ‘cocaine is God’s way of saying you’re making too much money’.
In truth, the best way to ‘educate’ people about the reality of cocaine use may well be to get them to read the obituaries of some of their favourite celebrities. In the meantime, I suggest we prepare for the coming wave of cocaine casualties. Failure to prepare means that people are ‘shocked’ when they see (or hear about or suspect) the often-surprising side effects of cocaine.
Actual preparation (i.e., genuine learning) would mean that we could at least more readily recognise the sometimes insidious but occasionally explosive consequences of cocaine consumption. And, for reasons I’ll explain, a cocaine crisis may warrant almost instant intervention, if it is not to become a calamity.
Cocaine is a fascinating stimulant. Chewing the leaf of the coca bush found on the barren slopes of the Andes is an ancient practice that seems to have enabled half-starving indigenous peoples to build temples high up in the sky: the slowly liberated cocaine suppresses the appetite, provides a ‘shot of energy’, eliminates feelings of tiredness, cold or discomfort.
Tragically, this remarkable ability to enhance ‘endurance’ was exploited by the Conquistadores, who found that the Inca people could be deliberately half-starved and still work astonishingly hard, digging out the treasure for which the Spaniards yearned.
Pharmacologically, the benefits of the coca leaf are obvious in areas where there is little food or oxygen. However, the hazards are massively multiplied when the key bioactive ingredient is isolated and turned into easily snorted, swallowed, or injected cocaine hydrochloride powder (not to mention the notorious ‘freebase’ derivative, crack, which is smoked).
The reason why we should expect a surge of cocaine-related medical presentations in the coming years in Ireland is because 303 tonnes of exceptionally pure cocaine were seized by EU states in 2021, and two tonnes were seized just last month in Irish coastal waters.
Given that only 10% of smuggled drugs are intercepted, this gives us a sense of the amount of cocaine currently being consumed in this country.
Another harbinger of the future came from the 2022 Drug Use in Higher Education Institutions (DUHEI) survey of 11,500 students in Ireland, which found that a fifth of students reported using drugs in the previous month, and cocaine had replaced ecstasy (MDMA) to become their second most popular drug.
In short, then, we can anticipate a pretty relentless stream of ‘cocaine cases’ in our GP surgeries, outpatient clinics and hospitals, as well as our garda stations and mortuaries (at least until our next economic recession, when the ready availability of cocaine will find fewer customers with the ready cash).
But, for now, I suggest that we all keep an eye out for the following common cocaine use patterns in our own ‘parish’.
Delight, unbounded: After the initial anxiety that first-time users experience when they snort cocaine powder up their nostril, there often follows – within just five minutes or so – a sense of being hugely energised, a surge in self-esteem and confidence, and a gradual onset of extreme pleasure or euphoria. A rictus grin, loud and rapid speech, and (“What’s he on?!”) restlessness may be obvious to those at the same dinner party or nightclub table. The effect of one snorted ‘line’ may last for up to 30 minutes.
Distress, seriously: The first unpleasant sensation that cocaine users experience is often a growing sense of paranoia (“Why is that guy over there staring at me?”), often amplified by the rapid heart rate they feel through their chest wall.
Paranoia can turn to panic, especially if the user develops symptoms that suggest one of the many conditions that cocaine can cause, like chest pain, breathlessness, sweating, headache and a weird feeling that their skin is crawling with insects. And they will often have good reason to be distressed, because cocaine is a major cause of unexpected blood pressure crises, heart attacks, lung collapse, convulsions and stroke, even in the ‘novice’.
Dependence, galloping: Cocaine is notoriously addictive (especially the much less common ‘freebase’ smoked form, ‘crack’), so up to 20% of repeat-users are said to develop a physical and mental dependence on the drug and a compulsive pattern of use.
In short, dependence or addiction means that horrible withdrawal symptoms occur when the individual stops using the drug. These range from mood swings and irritability, intense cravings for the drug, nightmares and feelings of absolute exhaustion (the ‘crash’) to vomiting, convulsions and irresistible thoughts of suicide.
Damage, everywhere: Repeated use of cocaine causes damage to small blood vessels, which in turn ‘asphyxiates’ the body’s tissues, including the nose cartilage, the heart muscle and coronary vessels, the lungs, the brain blood vessels, and other organs like the liver and kidneys. Injecting or smoking accelerates all such damage and also involves abscesses and communicable diseases.
The collapsed nose seen on some celebrities is the most grotesque, but it is the unseen damage to organs that poses the greatest risk in the long term.
And the damage can be unexpected: even though erectile dysfunction is a classic complication of too much cocaine, sexually transmitted disease is also a common consequence for the highly energised risk-taking cocaine consumer. Notwithstanding all that, the greatest harm is usually done to the user’s close relationships, which can be destroyed by lying, cheating, expenditure of huge amounts of shared income, and domestic or random violence.
Delirium, frightening: One of the most frightening complications of cocaine use is the way in which the chatty, witty and bubbly user can morph over a few minutes into a ‘raving lunatic’, sweating, shouting incoherently, and confusedly brushing aside all efforts to quieten or restrain them by their companions, security staff and paramedics. ‘Cocaine agitation delirium’ is the name of this condition which can unpredictably affect any user after taking a tiny or a large amount of the drug. It is a dreaded presentation in any ambulance or emergency department, because of the shocking strength of the addled victim, the fact that it often occurs abruptly (at a party or in a police cell), it’s very difficult to treat and about 10% of victims will die.
Death, shocking: There were over 130 deaths from cocaine in Ireland in 2020, a worrying three-fold increase in three years. It’s also possible that that number could be a slight underestimate, as toxicology is not always undertaken postmortem. Often too, the insidious damage to a heart, brain or blood vessel means that the sudden unexpected death of a cocaine user doesn’t require them to have taken any of the drug to trigger the sudden fatal haemorrhage, convulsion or cardiac arrest (although in most cases adding alcohol or nicotine to the cocaine will have greatly increased the risk of sudden death). And, medically, many such deaths occur between three and 30 minutes after the first ‘sign’ that the person is seriously ill, with delirium, chest pain, breathlessness, headache and convulsion.
I don’t expect all this gloomy medical analysis to make a jot of difference to the users of our most fashionable white powder. But it just might mean that someone around a person having an adverse reaction to the drug will realise that they need to call an ambulance. Now.
Dr Chris Luke is an author, columnist and former consultant in emergency medicine.
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