Gabor Zacher: When cocaine is consumed after a good wine

Heroin and synthetic drugs are almost a daily topic, but there seems to be a silence around cocaine. What could be the reason?

It is worth noting that record quantities of cocaine were produced in South America last year. While huge seizures have been mentioned by the press, these cases will not fundamentally shake the cocaine market like the two-ton heroin seizure did a few years ago. That seizure greatly contributed to the appearance of more than thirty types of synthetic fentanyl, which is still taking its victims in the United States, Northern Europe, and the Baltic States. The "silence" surrounding cocaine may be the relative lack ofacute overdose cases that can be attributed to it, which isrelatively uncommon.

However, we do not have much information about the consequences from cocaine-induced heart attacks, or even the number of people who have experienced such an attack. Such an infarction is not like someone is absorbing cocaine and then gets to his heart and gets off the bed. 

When a person consumes alcohol along with cocaine, a metabolic product called cocaine ethylene is formed in the body around four to five hours afterwards. This compound has a significant vasoconstrictor effect, which can occur in the small blood vessels that supplythe heart. This results in an infarction-like disease. Today, it is not uncommon for people in their forties to be hospitalized with this problem.

In such a situation, the imperative question that the emergency cardiologist should ask is: "Have you used cocaine in the last ten to twelve hours?" I would like to emphasize that it should not be their duty to call the police, as health data is very strictly guarded information, anyway. It is merely in the patient's best interest if doctors have accurate information to make a proper diagnosis. This question is crucial because there is a difference in treatment between cocaine-induced infarctions and conventional heart attacks.

A quick response and a brief test to clarify the situation would not only protect the patient from a misdiagnosis. It would also provide good research information about the extent of the problem over time. Perhaps this lack of relevant information is part of the reason why we do not have a record of that many cocaine cases in Hungary.

Should the test use be a standard procedure?

Yes, absolutely, but unfortunately this isn’t case. We do not deal with it often enough at the emergency room or even in cardiology. However, a cocaine-induced heart attack is a phenomenon that is widely understood in the medical community, where therapeutic approaches for such situations are well known.

There's also a latency factor, isn't there?

Sure, there is. But it is important to emphasise that cocaine is basically a drug for just a subset of society. While some synthetic drugs costs 400-600 forints, depending on the quality, cocaine can cost anywhere from 16 000 - 30 000 forints. Of course few can afford it, but there are some peoplethat can, and they are willing to consume large quantities of cocaine worth up to a hundred thousand forints at a single party.

Who uses cocaine these days?

Those people who can afford it. The question is: what is the minimum level of income that allows someone to consistently indulge in cocaine? Cocaine consumption requires a massive financial base.

Is this a drug for the elite?

What do we mean by elite? A bank manager with an annual salary of three to four million forints? Or a decent, honest entrepreneur with a similar monthly income or higher? Or a doctor earning the same income but being paid illegally by patients? Or maybe a gangster? A highly paid athlete?

To what extent is cocaine present among company executives and managers?

They tend to use cocaine when trying to relax. How does their work week look like? They don't stop working at 5pm and rush home to eat stew and watch TV. On the contrary, their work requires a very constant, mindful presence and high concentration.

Business is a cruel world. One person is at the top at one moment, but can lose everything the next day. It is a very stressful lifestyle that can cause both mental and physical illnesses. 

There are not just the janitors in those illuminated office buildings in the evening, but managers still at work. They go to work in the morning earlier than the shops open and they finish in the evening when the shops are already closed. And when the weekend comes, they hit the party scene where these kinds of psychoactive substances can appear alongside the finewine. Of course, I do not mean to generalize, as many of these people jump on their bikes, either alone or with their family,to take a ride around Lake Balaton. Yet, 15 to 16 percent of managers who have only a day and a half to relax still choose to dive into the party district.

Why only a day and a half to relax?

Because on Sunday they are already "detoxifying", maybe sleeping or resting in the steam bath, as they know they must soon be sitting at the conference table on Monday morning. In a day and a half, as I mentioned, anyone who can afford it, can spend up to one hundred thousand forints to have fun. This money can, of course, cover two fine dinners with a fineFrench wine. But it can also go for drugs, like a few lines of cocaine.

Do you think that cocaine or other substance use occursduring working hours?

It happens every now and then.

I’m asking this because we see a lot of examples of this in movies and television series, not to mention those drunken employees in the workplace. How does cocaine affect the body?

Cocaine is a stimulant drug, but don’t think that every cocaine user ends up in a life-threatening condition. At certain quantities, the drug exerts a burden on the body, while at the same time invoking a euphoric state and a feeling of happiness. It is also characterized by a rapid heartbeat, high blood pressure, blurred vision and changes in hearing quality. Of course, this can also turn into a kind of psychosis or aggression, not to mention that many people use cocaine for sex.

Can a person quit using this drug?

Of course, you can. The question is whether someone is an addict or a casual user. The former will become addict for life,and in some lucky cases, a drug-free addict. The casual users don’t have severe withdrawal symptoms.

Because on Sunday they are already "detoxifying", sleeping, or resting in the steam bath, as they must sit at the conference table on Monday morning. In a day and a half, as I mentioned, anyone who can afford it, can spend up to one hundred thousand forints to have fun. This can of course cover two fine dinners and a good quality French wine, but it can also go for drugs, among others a few strips of cocaine.

Who might be an occasional consumer and who might become addicted?

No matter what the addictive psychoactive substance is, the addict consumes the substance because it is not just the way to feel euphoric, but it is necessary for his body and mind to even work at all. Abstinence from the drug creates strong symptoms of withdrawal. If he snorts, swallows or smokes the material, the world will come to his place for him. One of the best examples for this is alcohol.

There's nothing wrong having a serving of wine or beer after a good dinner. But when you go home in the evenings and finishan entire bottle of rose wine that makes you so sleepy in front of the TV, and then wake up in the morning with a little sweat, a bad stomach, a trembling hand, breath like Shrek's and then decide to have some liquor - which can be a whiskey costingthirty thousand forints - to get rid of all these problems, then we can talk about your addiction.

Do you know how many cocaine users enter the health care system?

They are fewer in proportion to other drug users. Cocaine use is less common in Hungary compared to other parts of Europe.It is more common in cities like Barcelona, London, Antwerpor Amsterdam, not to mention the United States.

What is the duty of a doctor or toxicologist in such a situation?

The first task is to stabilize any patient that enters the hospital,presumably because of an overdose.

You must save his or her life.

That's right. The primary thing is to sort out the epileptic seizures, the 42 degrees body temperature, the 300 beats per minute heart rate, or the 250/150 blood pressure. And if the patient's condition is stable and becoming psychologically accessible, you may think of other steps. The question is how cooperative will a patient be in such a situation, because patients all respond to a near-death experience in differentways.

Some people are frightened and realize that, after such a slap in the face, there is so little to separate them from death at the young age of forty. 

Unfortunately, there are also those who are not at all affected by such an event.