Injection of crack cocaine: a case report

A 26-year-old American man was referred to our service for methadone replacement therapy and treatment of crack/cocaine addiction. His addiction history started with use of opioids in early adolescence. As his tolerance escalated, he began injecting cocaine with morphine, also known as “speedball.” Since he started methadone replacement therapy and discontinued morphine use, he reported a substantial increase in cocaine injection, as well as crack injection, the latter motivated by lower prices and wider availability. He fulfills DSM-5 diagnosis criteria for severe dependence on both opioids and cocaine. A multidisciplinary team managed his case.

In 2013, the United Nations Office on Drugs and Crime estimated the number of injecting drug users (IDU) worldwide at 14 million.¹ The prevalence of crack cocaine injection (CCI) is unknown; however, some local studies have assessed it and observed variable frequencies. A PubMed search using the terms “injection crack AND intravenous crack” yielded 44 papers, eight of which reported actual CCI. None concerned the Brazilian context. This is, to our knowledge, the first Brazilian case report of CCI.

One paper reports an increase of CCI between 1990 and 1993 in London, from 1 to 27%.² Another study presented the results of a 1997-1999 cohort of 2,198 homeless IDUs recruited from six U.S. cities and estimated the frequency of CCI as 15% among participants.³ A later U.S. study with 989 participants reported a 9% lifetime prevalence of CCI among IDUs,⁴ and a Canadian study with 4,088 IDUs reported a 15.2% rate of CCI.⁵

CCI is accomplished by dissolving crack in vinegar or lemon juice and does not require the application of heat. The shift from cocaine use to CCI can be explained by several reasons, including changes in illicit drug markets and a desire for greater psychoactive effects. This is particularly important as some anecdotal unpublished reports state that cocaine may be present in greater amounts in crack than in its powder form.

CCI may be a marker of high-risk behaviors, and correlates with use of shooting galleries, initiation of others into drug injection, and serologic evidence of hepatitis B virus and hepatitis C virus infection.³ Furthermore, crack injectors reported higher rates of abscesses and mental illness.⁴ HIV infection is also a real risk for all IDUs. All of these factors can have an important impact on public health issues related to drug use, and must be considered in policy development.

Furthermore, this population may require broader treatment strategies. For instance, since severe mental illness may be more prevalent in crack cocaine injectors, hospitalization can be necessary for acute management of high-risk symptomatology (suicidality, aggressiveness, agitation). Moreover, health maintenance programs (i.e., management of infectious diseases), first-line social assistance (shelter, food, hygiene), and access to sustainable livelihood programs (housing, vocational training) can be vital for comprehensive treatment.

CCI deserves a more comprehensive investigation among the Brazilian drug user population, as it may be a marker of high-risk behaviors. Public health surveillance of this practice is of great importance to provide a better understanding of the behavior of users who self-administer crack cocaine via this route and to enable implementation of prevention and harm reduction policies.

References

• ¹
  United Nations Office on Drugs and Crime (UNODC). World Drug Report 2013. United Nations publication, Sales N°. E.13.XI.6 [Internet]. 2013 [cited 2014 Ago 14]. http://www.unodc.org/unodc/secured/wdr/wdr2013/World_Drug_Report_2013.pdf
  » http://www.unodc.org/unodc/secured/wdr/wdr2013/World_Drug_Report_2013.pdf
• ²
  Hunter GM, Donoghoe MC, Stimson GV. Crack use and injection on the increase among injecting drug users in London. Addiction. 1995;90:1397-400.
• ³
  Santibanez SS, Garfein RS, Swartzendruber A, Kerndt PR, Morse E, Ompad D, et al. Prevalence and correlates of crack-cocaine injection among young injection drug users in the United States, 1997-1999. Drug Alcohol Depend. 20057;77:227-33.
• ⁴
  Buchanan D, Tooze JA, Shaw S, Kinzly M, Heimer R, Singer M. Demographic, HIV risk behavior, and health status characteristics of “crack” cocaine injectors compared to other injection drug users in three New England cities. Drug Alcohol Depend. 2006;81:221-9.
• ⁵
  Roy E, Leclerc P, Morissette C, Arruda N, Blanchette C, Blouin K, et al. Prevalence and temporal trends of crack injection among injection drug users in eastern central Canada. Drug Alcohol Depend. 2013;133:275-8.

Publication Dates

• Publication in this collection
  Jan-Mar 2015

History

• Received
  28 May 2014
• Accepted
  24 July 2014