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Nida International Forum, Puerto Rico, June 2008

COCA PASTE (CCP) THE MOST RESISTANT COCAINE TO TREATMENT


Teobaldo Llosa, M.D., Coca Mdica, Torre de Consultorios Lima, Per, cocamedica@hotmail.com
Private support (Coca Mdica). Author have no conflict with organization

COCA PASTE (CCP)


The coca paste (CCP) is a smokable semi-industrial cocaine derivate obtained from the maceration of coca leaves with a variety of substances including kerosene, sulfuric acid and sodium bicarbonate. It is the stage prior to obtaining cocaine hydrochloride. Its origin is Peru in the mid-1970s, but currently uses in Bolivia, Colombia, Chile and Ecuador. It is usually smoked mixed with tobacco in commercial cigarettes. In the 1970s attracted the attention of international researchers, but then declined when the crack appeared. Their heyday was between the 1980s and mid1990s. Use declined thereafter. Contributed to this the fact that lowering the price of cocaine hydrochloride, and the fact that smoking coca paste with commercial cigarettes increases the cost, the characteristic odor is easily identified by the relatives and friends, psychopathological-social (compulsion to use, anedonia, vagrancy, delinquency, crime), and organic (lung diseases) effects, are accentuated. It is more resistant to treatment than other forms of cocaine uses. It is the only modality of addictive cocaine that was applied brain surgery (bilateral anterior cingulotomy / Llosa, 1981, Peru) with 50% success in the long term (25 years of follow-up). Llosa believes that the failures are based on that most therapists have not focused it as double addiction cocaine-nicotine. Its therapeutic regimen includes transdermal nicotine plus bupropion associated with anticonvulsants, but mainly with oral cocaine as agonist therapy (cocalizacin schedule), with satisfactory results, above the 70% long-term (> 1 year follow-up). Llosa suggested that smokers of crack with tobacco should also be viewed as a dual addiction patients and treated simultaneously with both anti-tobacco and anti-cocaine schedules.

COCA PASTE CLASSIFICATION


Proposed by Llosa (1994) (Llosa T., 1994. Chemistry and Toxicology of Coca Paste and Coca Paste Cigarettes Smoking, (T. Llosa, ed), Cocadi, Lima)
CCP-1, Standardized paste, elaborated in prestigeful laboratories, which contains 70% cocaine alkaloid with a very few endogenous and exogenous impurities (Toffoli & Avico, 1965) CCP-2, Non standardized paste, elaborated in clandestine laboratories, containing a non definite percentage of cocaine, and higher quantity of endogenous impurities which is characteristic of clandestine processes, and that is sold by wholesale (Paly et al., 1980) (ElSohly et al., 1987) CCP-3, It is the CCP-2, that contains 50% of cocaine alkaloid, that is sold to users by retail, which is adulterated with several organic and inorganic impurities. It is highly toxic, because contains vapors, bacterias and other contaminants captative from environment (Morales-Vaca, 1984). CCP-4, Paste used by addicted-patients. It is the CCP-2, or mainly CCP-3, associated to tobacco or marijuana, which smoke involve the products of the combustion of cocaine and nicotine (or marijuana). Likewise, its use contaminates the microenvironment where coca paste is smoke (Novak & Salemink, 1984)

DAILY DOSES
Llosa & Henningfield (Tobacco Control, 1993) Most addicts smoke CCP-3 mixed with tobacco, inside the commercial cigarette device (tube), that contains an average of: 152 mg of coca paste (95 mg of cocaine base) 298 mg of tobacco (4 mg of nicotine) In a typical binge the addict consume an average of 20 CCP-4, that contains: 3040 of CCP-3 (1900 mg of cocaine base) plus 5960 mg of tobacco (80 mg of nicotine)

CCP SMOKE EFFECTS


Lung diseases, malnutrition, oral and dental infections, traffic accidents, school and work abandonment, cardiac and brain infarction, convulsions, death (Jer et al, 1978)(Jer, 1984). Cocaine psychopathological and sociopathic effects are accentuated in coca paste: anhedonia, psychosis, vagrancy, irresponsibility, aggressiveness, crime, delinquency, family abandonment, narcotic street sellers (Nizama, 1979). Chemical: benzoylecgonine, cotinine, methylecgonidine (Paly et al., 1980) (Novak & Salemink, 1984) (U.S. DHHS, 1988) It is more refractory to treatment than cocaine when cocaine hydrochloride is used by sniff. Dual addiction to cocaine and nicotine. The characteristic odor is easily identified by the relatives and friends, Lung cancer. (Llosa, 1994).

TREATMENT SCHEDULES
Schedule proposed by Llosa (1981-1989-2000) It is the only modality of addictive cocaine in that was applied brain surgery (bilateral anterior cingulotomy, in 33 CCP-4 addicts, Llosa, 1981-1983, Per), with 50% success in the long term (25 years of follow-up)
Its pharmacologic therapeutic dual schedule includes transdermal nicotine (TN) plus bupropion (BU) associated with anticonvulsants (AC), but mainly with oral cocaine (OC) as agonist therapy (cocalizacin schedule), plus counseling (C) or cognitive therapy (CT). Satisfactory results, above the 70% long-term (> 1 year of follow-up)

Dual Schedules: anti-nicotine + anti/cocaine (plus C/CT) (1) TN + OC + C/CT (2) TN + BU + OC + C/CT (3) TN + BU + AC + OC + C/CT

COMMENTS: WHY THE DOUBLE TREATMENT?


Reports of CCP users in treatment suggest that is easier for many to give up cocaine than smoking conventional cigarettes. In fact, many people who smoked tobacco before becoming users of CCP abandoned the CCP but not the tobacco. When patients relapsed in CCP, they usually relapsed first tobacco smoking. Another form of smoke cocaine, crack, is also commonly smoked mixed with tobacco. It also appears that the dual treatment approach is superior to simple treating the cocaine addiction with many users achieving long term abstinence (>1 year of follow) for both drugs. Our experience suggests that the double pharmacotherapy appeared to give better results (p<0.05) in the control of relapses, compared with the simple schedule. Of course, behavioral guidance is offered for managing both addictions.

We recommend that all cocaine treatment centers attempt to treat tobacco and smokable cocaine-nicotine dependence simultaneously and urge that investigators with funding for clinical trials further investigate such combination therapy. The combination treatment is acceptable, appears safe, may produce better outcome for controlling cocaine addiction, and there is good adherence to treatment.
Of course, many cocaine and tobacco users ultimately die of tobacco use, so tobacco treatment is important in its own right.

CONCLUSSIONS

The dependence on the CCP was the first addictive cocaine smoked modality.
CCP is smoked mixed with tobacco (mainly) or marijuana. Addiction to CCP and crack laced tobacco meets the criteria for double addiction: cocaine-nicotine (and double addiction cocaine-THC when CCP is smoked with marijuana).

CCP smoking, mixed with tobacco, is an strong addiction in the Andean countries which is practised by thousands of users, especially of low economic and social levels.
Despite the behavioral and organic consequences that involves the CCP smoked with tobacco (or marijuana), since the crack appeared, research on CCP have stop in the USA. Smokers of coca paste (and crack when is smoked with tobacco), should be viewed as a dual addiction patients and treated simultaneously with both anti-tobacco and anti-cocaine schedules. Of the addictions to cocaine modalities (CCP, cocaine hydrochloride, crack), CCP is the most refractory to treatment. We believes that the failures of treatments are based on that most therapists have not focused it as double addiction cocaine-nicotine or cocaine-THC Dual scheme shows better results (longest abstinence) than with the simple scheme.

REFERENCES
Toffoli F, Avico U. 1965. Coca Paste: Residues and industrial extraction of cocaine ecgonine and anhydroecgonine, Bull Narcotics, 17:27-36 Jer R, Sanchez C., Del Pozo T. 1978. The Syndrome of Coca Paste, J. Psychodelic Drugs, 10: 361-370 Nizama M. 1979. Sndrome de la pasta bsica de cocana, Rev de Neuropsiquiatra, XLII, 2, Lima Paly D, Van Dyke C, Jatlow P, Jer R, Byck R. 1980. Cocaine: Plasma levels after cocaine paste smoking. In F. R. Jeri (Ed.), Cocaine 1980. Lima: Pacific Press. Siegel R.K, 1982. Cocaine smoking, Journal of Psychoactive Drugs, Vol XIV, pp 271-359 Llosa T, 1983. Follow-up study of 28 Coca Paste addicts treated by Open Cingulotomy. 7th World Congress of Psychiatry, Vienna Jeri R, 1984. Coca-paste smoking in some Latin American countries: a severe and unabaten for of addiction. Bulletin of Narcotics, Vol XXXVI, No. 2, April Morales-Vaca M. 1984. A Laboratory Approach to the Control of Cocaine in Bolivia. Bulletin on Narcotics, Vol XXXVI, No 2, April-June Novak M. & Salemink CA. 1984. A model experiment in the study of cocaine base study. Isolation of methyl 4-(3-pyridyl)-butyrate from cocaine pyrolysate. Bull of Narcotics, Vol XXXVI, No. 2, April-June Llosa T. 1985, Mdicos contra Pacientes, (T.llosa, Ed), Eddili, Lima ElSohly M.A. 1987. Coca Paste Analysis. University of Mississipi, School of Pharmacy. Cited in: Murrelle et al., Consequences of smoking a potent cocaine product: A clinical profile of 424 basuca abusers presenting for treatment in Medellin, Columbia, PHO/WHO,1991 U.S. Departament of Health and Human Services. 1988. The Health Consequences of Smoking. Nicotine Addiction: a report of the Surgeon General, Rockiville, MD. ElSohly M.A, Brenneisen, R, & Jones, A. B. 1991. Coca paste: Chemical analysis and smoking experiments. Journal of Forensic Sciences, 36, 93103. Llosa T. & Henningfield J. 1993. Analysis of Coca Paste cigarettes. Tobacco Control, An International Journal, Vol 2, No 4, Winter Llosa T. 1994. Chemistry and Toxicology of Coca Paste and Coca Paste Cigarettes Smoking, (T. Llosa, ed), Cocadi, Lima Llosa T. 1994. The Standard Low Doses of Oral Cocaine Used for Treatment of Cocaine Dependence. Substance Abuse, 15 (4): 215-220, Plenum, Amersa Llosa T. 1997. Long Term Results of Psychosurgery in Cocaine-Smoking Dependence, 59th CPDD/NIDA meeting, Nashville. Henningfield J.E, Fant R.V, Buchhalter A.R, and Stitzer M.L. 2005. Pharmacotherapy of nicotine dependence. CA: A Cancer Journal for Clinicians, 55: 281-299 Llosa T. 2007, Handbook of Oral Cocaine in Addictions, (T.Llosa, ed). Coca Mdica, Lima Llosa T. 2009. Smoking Coca Paste and Crack-Tobacco Must Be Treated as Double Addiction, Substance Abuse, 30:81, Routledge Llosa T. 2012, Mdicos contra Pacientes (T.Llosa, Ed), Plaza y Valds, Mxico D.F. (en prensa).