Cocaine and amphetamine psychoses
We would like to thank Dr. X. Y., a consultant psychiatrist specialising in acute addiction issues and based in Central London, for his contributions to this article which is intended for the benefit of the public at large.
Dr. X. Y. Is not responsible for any of the assertions contained in this article, and that is one reason why we have decided to preserve his anonymity.
The PALADINS do accept narcotic addiction, overdose and withdrawal cases, but typically only when the underlying narcotic issue is associated with war, civil conflict or another trauma-inducing experience intimately associated with one of our core practice areas. We are not a general psychiatry referral service, and we ask those contemplating contacting us to respect that.
Most recreational narcotics do not catalyse psychosis; the two mentioned in the title of this article do. It is most difficult, although essential, to distinguish between them in order to assess the different dangers and to secure an accurate diagnosis.
The problem is not mitigated by the fact that many forms of cut (diluted) cocaine have extremely similar appearances to amphetamine sulphate or other compounds traditionally called 'Speed', 'Whizz' or 'Crystal Meth'. Both are white crystalline powders. It is impossible to tell by sight whether the white powder in the photograph accompanying this article is cocaine, amphetamine or something else (for example, ketamine). But there are some differences.
Amphetamine is a synthetic substance that can be produced domestically (i.e. in somebody's kitchen) using commonly available chemicals. Cocaine is a natural substance produced by distilling the active ingredients of the coca leaf, a factory-based process that takes place principally in South America.
Pure cocaine (which is rare) usually has had paraffin as its solvent. Amphetamine sulphate by contrast is typically carried in an industrial solvent such as methanol or acetone. 'Straight off the boat', amphetamine in solvent is a white slime whereas cocaine in solvent is a hard block.
Cocaine, unless finely cut, is more likely to contain hard 'boulders' that can only be cut with a hard object such as a credit card; whereas amphetamine is always sufficiently powdery to squeeze between the fingers.
Both substances are traditionally dried out from their solvents before being supplied to their ultimate consumers - but not always.
Nevertheless the residual solvent smell may give away the difference.
Both are principally consumed per nasum.
Never neglect the possibility that something sold as cocaine may be cut with amphetamine (the latter being far cheaper than the former on a per weight basis). From the perspective of the user, this ought to be obvious straight away provided they know what symptoms they are looking for. Cocaine has a distinctive immediate anaesthetic effect; its elation effects start within a couple of minutes. By contrast amphetamine sulphate has no anaesthetic effects and takes at the least several minutes to induce its principal effects, namely euphoria and improved cognitive control. (Cocaine does not provide either of these effects; indeed it decreases cognitive control and makes the consumer talk nonsense or even unable to talk at all - or only high pitched nonsense).
Amphetamine produces several hours of restricted appetite. By contrast cocaine restricts appetite only for about 20 minutes.
Recreational amphetamine doses produce psychosis fairly promptly - one of the reasons for its highly addictive, dangerous properties. As amphetamine euphoria begins to subside, some 1 to 1.5 hours after consumption, the user begins to experience symptoms of high anxiety and paranoia.
By contrast as the shorter term symptoms of cocaine rapidly fade (within perhaps 30 minutes of consumption), the user reverts to a desire to have more cocaine.
Hence acute cocaine-induced psychosis is associated with endless discussions of cocaine, and how to take or procure more of it. This author has cared for a person with such a condition and it is most obvious because the conversation is relentlessly boring: how to obtain more cocaine.
Acute amphetamine-induced psychosis is indicated by the user considering every situation unusually dangerous and the patient engaged in perpetual anxiety about trivia.
We are informed that amphetamines mitigate the effects of schizophrenia whereas cocaine aggravates them. We are aware of no study that corroborates this finding and we would recommend this as a future subject of research.
However one of the principal reasons why scientific research is so scant in this field is by reason of the illegality of drug use and the associated obloquy. This surely has to change if we are to advance an advice-based approach to combatting the negative social and health effects of narcotic use.
Amphetamine sulphate keeps a person awake for far longer than cocaine. You can stay awake for days; that effect alone may cause sleep-deprived psychosis.
Amphetamine sulphate is physically addictive in the medium to long term, causing acute physical withdrawal symptoms such as shaking. It also unnaturally dries out the skin. It seems to cause long-term bodily harm in terms of weight loss, pock-marked skin and digestive organ damage.
Cocaine is potentially much more immediately lethal than amphetamine sulphate. A patient with a suspected cocaine overdose should be referred for immediate specialist medical attention, because cocaine overdose can cause rapid cardiac arrest. By contrast a patient with suspected amphetamine overdose (easier to diagnose because they will speak coherently if somewhat intensely) should be placed in a dark comforting place around people they know and then one should just wait for the psychosis to alleviate.
Both narcotics, used recreationally, are dangerous in different ways, as this short article has sought to explain. Nevertheless the initial emergency treatment for both is similar: a course of strong benzodiazepines, gradually tapered. In the case of amphetamine addiction, a short (maximum one week) supplemental course of atypical anti-psychotics may also be indicated.
Use of atypical anti-psychotics is less likely for cocaine psychosis by reason of the non-physically addictive nature of the narcotic. But it is always worth bearing in mind as an option, given the possibility of admixture of the two narcotics unbeknownst to the user or to anyone else.
Bear in mind that both narcotics may aggravate potentially undiagnosed psychiatric conditions of various kinds, in particular so-called Bipolar-II Disorder (also known as Generalised Anxiety Disorder) the causes of which may be extended periods of unusual stress. Successfully treating the underlying disorder will typically lead to remission of the narcotic-induced disorder.
Nevertheless, the fact remains that many users of recreational narcotics are 'self-medicating' by reason of some underlying trauma; and the only effective way to treat conditions related to narcotic consumption may be effectively to treat the underlying trauma. Once that is achieved, the narcotic addiction may take care of itself.
The cities with the highest amphetamine use in the world are Adelaide and Seattle; whereas those with the highest cocaine use in the world are London, Bristol, Amsterdam, Antwerp, Zurich, Geneva and St Gallen, according to a study of wastewater.
If you believe you are suffering from cocaine or amphetamine psychosis, you should seek immediate treatment either at a drugs rehabilitation centre or with a psychiatrist specialising in substance abuse and addiction. You are not a bad person and there is nothing to be ashamed of. You are just sick, and all humans get sick from time to time. Sometimes people get sick from massive underlying trauma, stress or anxiety. Just get yourself treated by a specialist. A typical General Practitioner will not do. Nor will a typical psychiatrist. Psychiatrists specialising in these sorts of issue are extremely rare, and that is because there is so little data to research the issues involved as the substances are illegal and hence the data cannot be collected.
Hence you need a high quality specialist in substance addiction. If you cannot find one or face the task of looking, ask friends or family to help you find one. Avoid people who will be too judgmental as this will not help you. Some people can seek help within family; others cannot. The approach you adopt is up to you.
If you know someone who you suspect to have one or both of the psychoses described in this article, and you want to help them, act cautiously. Do not lecture or berate them. They may have an underlying non-disclosed trauma or anxiety that you do not know about. Some traumas are hidden by people for decades, and their causes may be very complex.
Encourage them to read this article. Emphasise that this is not something to be ashamed of; people just get sick. Do not take precipitous actions such as informing a family member or employer, or you may just make the situation worse. The patient may feel very strongly that certain groups of people, such as family and staff members, not be informed. You need to persuade the person to see a psychiatrist, or go to a clinic, in either case specialising in substance addiction. But you cannot force them. Work on them gently. The psychiatry of the human mind is hugely complex, very delicate and not always well understood.