Further experience with the syndromes produced by coca paste smoking

Sections

Summary
Methods
Results
Discussion

Details

Author: F. R. JERI, C.C. SANCHEZ, T. del POZO, M. FERNANDEZ, C. CARBAJAL
Pages: 1 to 11
Creation Date: 1978/01/01

Further experience with the syndromes produced by coca paste smoking

M.D., F.R.C.Psy. F. R. JERI Professor of Clinical Neurology, National University of San Marcos; Chairman, Peruvian Committee on Drug Addiction, Lima, Peru
M.D. C.C. SANCHEZ Head, Department of Psychiatry, Police Hospital
M.D. T. del POZO Assistant Physician, Department of Psychiatry, Police Hospital
M.D. M. FERNANDEZ Chief, Alcohol and Drug Dependence Service, Hospital Psiquiatrico Victor Larco Herrera
M.D. C. CARBAJAL Consultant Psychiatrist, Health Services, Ministry of the Interior

Summary

Cocaine base or white coca paste was smoked heavily by 188 patients who came to four hospitals of Lima, Peru. The length of hospitalization varied from two days to six months. All patients were admitted because coca paste smoking had become a serious problem for their health or for social adjustment. Coca paste was smoked mixed with tobacco or marihuana. The main symptoms were anxiety mingled with euphoria and a rapidly developing compulsion to continue smoking. Frequently the patients developed irritability, illusions, hallucinations. When the use of the drug was heavy and continued for many hours or several days, the patients developed successively four stages of psychological reaction: euphoria, dysphoria, hallucinosis, and acute paranoid psychosis. The main symptoms and signs of all of these phases are discussed.

In the last five years Peruvian physicians have noticed the appearence of a new way to use cocaine through smoking the coca paste or cocaine base, mixed with tobacco or marihuana. The effects of the cannabis-paste, and the tobacco-paste cigarettes are quite different and therefore are used for diverse purposes, as we shall discuss later.

The cocaine paste epidemic began in 1974 in Lima, spread rapidly to the main Peruvian cities, Piura, Trujillo, Chiclayo, Chimbote, Huarez, Ica, Arequipa, Cuzco, and has since extended to two neighbouring countries, Ecuador and Bolivia.

The coca paste, also called cocaine basic paste [ 1] or cocaine sulphate [ 2] is a white semi-solid or solid preparation which contains cocaine sulphate, other coca alkaloids, ecgonine, benzoic acid, methanol, kerosene, alkaline compounds, sulphuric acid and many impurities. We do not think therefore that it should be called cocaine base or cocaine sulphate, but have adopted the suggestion of one of our pharmacologists [ 3] , to call it coca paste.

The effects of coca paste smoking depend on many variables which include type of preparation (white or "washed" paste, brown or "brute" paste), doses, frequency of use, impurities and adulterants, milieu (social, recreational, individualistic), motivation (stimulant, pleasure seeking, antidepressive, situational) and others. Thus the effects can be quite different according to the conditions of observation or experimentation.

There were no psychiatric admissions in Peruvian urban areas related to coca leaf chewing or cocaine hydrochloride abuse prior to 1975.

In 1976 some of us [ 4] presented seven patients who had problems due to coca paste smoking among a group of 79 drug dependent youngsters. A year later Siegel [ 5] reported briefly that four of his experimental subjects had smoked cocaine base, using very small amounts (one-third gram throughout a cigarette for each person smoking). But his "base" seems different from the Peruvian one, because he said that cocaine base is an intermediate compound in the manufacture of the hydrochloride and can be obtained from street cocaine via simple chemical procedures. Our base is obtained from the treatment of coca leaves by elementary chemical procedures, using kerosene, then alkaline substances and later sulphuric acid to obtain the coca paste as described above. Ether is used next and finally hydrochloric acid to obtain cocaine hydrochloride. The Peruvian and the Bolivian paste is illegally exported to Ecuador and Colombia, where it is transformed into cocaine hydrochloride to be finally smuggled into the United States of America and Europe. We do not know if coca paste has been introduced to America, but Panamanian authorities have reported heavy transportation of coca paste by American and Peruvian citizens [ 6] . Early in 1978 [ 7] we reported the clinical syndromes observed in a group of 158 coca paste dependent persons. in this communication additional experience with 188 patients who were treated in Lima, Peru, is presented.

Methods

The patients were examined at the wards of one mental hospital, one general hospital and two private psychiatric hospitals. The mental hospital called Victor Larco Herrera, has 2,000 beds and the coca paste dependent persons were observed in Ward Eight, which specializes in alcoholism and other drug problems. Other wards also have some patients who use alcohol and drugs to excess, but the majority of drug dependent individuals are attended to by one of us (M. F.). The general hospital called Hospital Central de la Sanidad del Ministerio del Interior, has 500 beds and a 30-bed psychiatric department. Most coca paste dependent patients were hospitalized in this service under the care of two of us (C. C. S. and T. D. P.) and under the supervision of the senior authors (F. R. J. and C. C.).

The first private psychiatric hospital is called Clinica San Isidro. It has 130 beds and the coca paste patients were under the care of three of us (F. R. J., C.C., C. C.S.). There are of course other coca paste dependent persons under the care of other psychiatrists. The second private psychiatric hospital is called Clinica San Antonio, it has 100 beds and some of the coca dependent persons were under the care of one of us (T. D.P.). All patients were seen in the in-patient sector, during a five-year period (1974-1978). They were admitted on a voluntary basis and all were examined by at least one of the authors. They were referred to the hospital by family physicians, by their relatives or by themselves. On admission they were interviewed by one of us, a physical and psychiatric examination was performed and some laboratory tests were done. However, no cocaine blood or urine tests were undertaken on admission due to lack of facilities. Psychological tests were performed on some patients, especially these admitted to the private hospitals.

The length of hospitalization varied from two days to six months but most patients remained for about twelve weeks.

During the in-patient phase all cases were examined daily and a record was kept of the evolution of the symptoms and clinical signs. The treatments used were group and individual psychotherapy, family psychotherapy, environmental modification (when feasible), work and play therapy. Some patients received neuroleptics when necessary. Some individuals were followed up on an outpatient basis, but as the relapse index was rather high, we did not attempt, at this stage, to evaluate the results of treatment. Nevertheless, the mental state was always recorded when the patients appeared for out-patient consultation.

Results

Smoking modalities

All patients were admitted because coca paste smoking had become a serious problem for their health or for their social adjustment (table 1).

TABLE 1

Significant consequences of the habit in coca dependent patients

After-effect

Number

Percentage

Deficient at work a
75 98.6
Marriage problems a
34 94.4
School failure a
89 79.4
Frequently absent from work a
60 78.9
Swindling and theft
145 77.1
Non-payment of debts
127 67.5
Job desertion a
23 30.2
Family desertion
25 13.2
Drug trafficking
15 7.9

a Percentages were calculated only on those who worked or had worked, students and married individuals. The other percentages were calculated over the total of 188 patients.

Coca paste was smoked frequently, mixed nearly always with tobacco (" taba-cazo") and sometimes with marihuana (" mixto"). Paste-tobacco cigarettes were smoked for pleasure-seeking purposes. Many patients said that they found no other drug as pleasurable as this one. At the beginning of use it was smoked in groups, later individually. Some acknowledged that paste made them solitary and selfish. "When I have paste I keep it for myself and do not want to share it with anyone", said one of these youngsters.

Paste-marihuana cigarettes instead were smoked for social purposes. This combination made the subjects garrulous and sociable, enjoying company, dancing and music, according to some. But the problems started rapidly, sometimes after a few sessions, and were always related to paste-tobacco smoking, which permitted them to smoke many cigarettes on end because, in Peru, paste and tobacco are much easier to obtain than marihuana.

General characteristics

More than 96 per cent of the patients were male, of these 75 per cent were single (table 2). Most patients were in the 16-20 and 21-25-year-old age range, but some were very young (less than 15 years old) and lately we have been admitting patients who were in their forties and fifties (table 3). All educational levels were represented, but most had high school education (table 2). Some had completed university (4.2 per cent) and others had dropped out (5.8 per cent). In Peru, high school students enter university directly on leaving grammar school after undergoing a selective examination. When drugs began to be experimented with by youths in Peru, it was observed that the fashion started amongst the well-to-do people, in residential areas of Lima. [ (8)] In the present study the three main social classes were represented with a predominance however of the middle and lower economic sectors of the population (table 4). There was no surprise then that when dividing the patients by occupation there were less blue collar workers (13.2 per cent) than white collar workers (25.0 per cent) but the number was significant and indicated a new trend in drug use (table 5). It was also found that the unemployed were the most numerous (34.5 per cent) with a non-insignificant number of high school and university students (17.5 per cent).

TABLE 2

Sex, marital status and education in 188 coca paste dependent persons

Condition

Number

Percentage

Condition

Number

Percentage

Sex
   
Schooling
   
Male
181 96.2
Elementary
16 8.5
Female
7 3.8
High
   
Marital status
   
Incomplete
73 38.8
Single
142 75.5
Complete
72 38.2
Married
36 19.1
University
   
Divorced
10 5.3
Incomplete
11 5.8
     
Complete
8 4.2

TABLE 3

Ages on admission of 188 coca paste dependent persons

Age in years

Number

Percentage

11-15
9 4.7
16-20
71 37.7
21-25
72 38.2
26-30
18 9.5
31-35
12 6.3
36-40
4 2.1
41-46
1 0.5
47-50
1 0.5

TABLE 4

Social class in 188 coca paste dependent persons

Class

Number

Percentage

Low
70 37.2
Middie
104 55.3
High
14 7.4

TABLE 5

Occupation in 188 coca paste dependent persons

Occupation

Number

Percentage

Occupation

Number

Percentage

Blue collar workers
25 13.2
Unemployed
65 34.5
White collar workers
47 25.0
Professional
4 2.1
Students
33 17.5
Not specified
14 7.4

Symptomatology

Most patients were admitted because there had been a health or a social crisis related to recent coca paste smoking (tables 1, 6, 7). However, many were actually examined during an acute state of intoxication. The main symptoms reported by the patients during an acute reaction were anxiety mixed with euphoria and the rapid development of a compulsion to smoke more and more coca paste cigarettes. This effect developed so quickly and sometimes appeared even after smoking the second or third cigarette, in a person who had known the excitability produced in previous sessions. Anorexia, insomnia, and talkativeness were also very common. The patients also showed marked tendencies to develop persecutory delusions, which they described as the " paranoica" meaning an acute but transitory paranoid state. When there were no abnormal thoughts or interpretations, but anxiety and smoking compulsions predominated, the patients called these individuals " angustiados", the anxious ones. When the trip was very bad, associated with hallucinations or thought disturbances they said that the persons were " palteados" (which has no translation) or that they had " la palida", a palid trip.

Other symptoms were irritability, instability and aggressiveness. Sexual indifference on the whole was more frequent than sexual stimulation. Some noticed no thirst, dry mouth, sweating and one or two loose bowel movements at the beginning of the compulsive experience. Less frequent symptoms were headache, dizziness, itching, jealousy, self aggressions or suicide attempts.

TABLE 6

Main symptoms reported by 188 coca paste dependent persons during the intoxication state

Symptom

Number

Percentage

Symptom

Number

Percentage

Anxiety
151 80.3
Aggressiveness
38 20.2
Euphoria
150 79.7
Dry mouth
37 19.6
Compulsion
141 75.0
Sweating
34 18.0
Anorexia
121 64.3
Diarrhoea
30 15.9
Insomnia
116 61.7
Itching
24 12.7
Talkativeness
70 37.2
Sexual stimulation
18 9.5
Paranoia
66 35.1
Headache
17 9.0
Hallucinations
65 34.5
Dizziness
12 6.3
Sexual indifference
62 32.9
Jealousy
11 5.8
No thirst
61 32.4
Self aggressions
8 4,2
Irritability
51 27.1
Suicide attempt
4 2.1
Uneasiness
43 22.8
Incoherence
1 0.5
Instability
39 20.7      

Clinical signs

When seen these patients were generally very thin, unkempt, pale and looking suspiciously from one side to the other (table 7). These movements were associated, as manifested by the patients, with visual hallucinations (shadows, light or human figures) which they observed on the temporal fields of vision. They could be interpreted as retinal or temporal lobe cortex disturbances, but their origin cannot at present be definitively stated. Though considering that frequently the same person experienced tactile and auditory hallucinations, we think that these phenomena possibly correspond to spreading cerebral cortex stimulation (parieto-temporal-occipital). They were, however, very rapidly, interpreted as menacing images because of the intense paranoid tendency in these reactions. On physical examination many had dilated pupils, rapid pulse, psychomotor excitement (instability, tremors, myoclonus, marked anxiety). A good proportion had scratch marks on the skin. The scratches observed on users were related to the tactile hallucinations felt under the skin. On questioning, some admitted having visual hallucinations, coloured or dark, on the temporal fields mainly, elementary or complex (from points or stars to men or women), giving them the impression that they were being followed by persons or shadows that seemed to want to catch, attack or kill them. The micropsia and macropsia visual disturbances were also described as skin, olfactory, and auditory hallucinations. Some patients developed paranoid psychoses, which lasted up to two weeks. Others showed long lasting pathological jealousy. The somatic acute disturbances documented were tachycardia, high blood pressure, temperature increase, hyperhydrosis and bowel hypermotility (table 8). Motor manifestations, indicating an acute encephalopathy were tremors, myoclonic jerks, limbic seizures and generalized convulsions (rare). When the intoxication was not reversed it progressed to cardiac arrythmias, neurogenic hyperventilation, coma, respiratory and cardiac arrest. Three patients died in this series, two by acute intoxication and one by suicide. The pathological reports of the two who died from intoxication showed extensive lung damage and no brain lesions on section or routine staining (hematoxylin eosin).

TABLE 7

Main signs observed on admittance of 188 coca paste dependent patients

Sign

Number

Percentage

Sign

Number

Percentage

Low weight
143 76.0
Hallucinosis
38 20.2
Neglect of personal
   
Nausea, vomiting
30 15.9
appearance
130 69.1
Tremor
29 15.4
Paleness
128 68.0
Psychomotor agitation .
25 13.2
Frequent lateral glances
89 47.3
High blood pressure ..
22 11.7
Tachycardia
85 45.2
Fever
21 11.1
Mydriasis
83 44.1
Inco-ordination
15 7.9
Depression
81 43.0
Confusion
13 6.9
Hyperhydrosis
80 42.5
Myoclonus
12 6.3
Psychomotor excitement
78 41.4
Paranoid psychosis ...
9 4.7
Scratch marks
57 30.3
Ventricular arrythmias
6 3.1
Indifference
55 29.2
Asthma
6 3.1
Inactivity
54 28.7
Muscular rigidity
3 1.5
Hypervigilance
45 23.9
Convulsions
2 1.0

TABLE 8

Somatic acute disturbances observed during coca paste intoxication in 188 patients admitted to hospital

Manifestation

Cases

Percentage

Manifestation

Cases

Percentage

Tachycardia
85 45.2
Ventricular arrythmias
6 3.1
Mydriasis
83 44.1
Ectopic beats
4 2.1
Hyperhydrosis
80 42.5
Paroxysmal tachycardia
2 1.0
Bowel hypermotility
43 22.8
Generalized convulsions
2 1.0
Tremor
29 15.4
Neurogenic hyperventilation
2 1.0
High blood pressure
22 11.7
Respiratory arrest
2 1.0
Fever
21 11.4
Limbic seizures
1 0.5
Myoclonic jerks
12 6.3
Heart arrest
1 0.5

Phases of coca paste intoxication

From a review of the case material we may infer that this modality of cocaine abuse has four distinctive phases: euphoria, dysphoria, hallucinosis, and psychosis (table 9), a progress very similar to the mental changes postulated for cocaine hydrochloride [ 9] . The first phase is cocaine euphoria, characterized by intense pleasure which is accompanied by affective lability, hypervigilance, hyperactivity and hypersexuality. (The latter was not seen in all patients.)

The second phase, which sometimes follows after a few hours of smoking, is a dysphoric state manifested by considerable anxiety and smoking compulsion. Other affective changes can be observed in some persons as sadness, melancholy, apathy, or aggressiveness. From this state to the last one there is always sexual indifference. The third phase is the cocaine hallucinosis, which can also develop after smoking several grams of coca paste and is marked by visual, tactile, auditory, and olfactory hallucinations. The patient is generally very excited and has transitory delusional interpretations. The hallucinosis is evanescent, it may last for two or three days and then fade gradually, if the individual has discontinued to smoke or receives parenteral neuroleptics.

The fourth phase is the cocaine psychosis. It may appear after days or weeks of frequent or continued paste smoking. It is characterized by a marked agitation with hypervigilance and defined paranoid delusions of persecution, damage, death or spouse unfaithfulness. Generally it is accompanied by auditory and olfactory hallucinations. Gustatory, visual and tactile false perceptions are sometimes reported. In our experience this clinical syndrome is different from the hallucinosis because it is more defined, prolonged and complex. It may follow the hallucinatory state. Cocaine psychosis may last several weeks although some of our colleagues have seen patients who remained psychotic for several months [ 10] . Usually they respond to neuroleptics.

TABLE 9

Evolution of the four phases of intoxication by coca paste smoking

1. Cocaine euphoria
3. Cocaine hallucinosis
Excited pleasure
Visual hallucinations
Affective lability
Tactile hallucinations
Hypervigilance
Auditory hallucinations
Hyperactivity
Olfactory hallucinations
Anorexia
Delusional interpretations
Insomnia
Psychomotor excitement
Hypersexuality
Fugue tendencies
 
Aggressiveness
 
Sexual indifference
2. Cocaine dysphoria
4. Cocaine psychosis
Considerable anxiety
Hypervigilance
Smoking compulsion
Paranoid delusions
Sadness
Persecution
Melancholy
Damage
Apathy
Death
Aggressiveness
Unfaithfulness
Anorexia
Auditory and olfactory hallucinations
Insomnia
Insomnia
Sexual indifference
Aggressiveness
 
Suicide attempts
 
Homicide attempts

Coca paste smoking and other drugs

As previously reported [ 7] most coca paste smokers began by using other drugs. The majority started smoking tobacco cigarettes, then they passed to marihuana cigarettes, and finally to coca paste-tobacco cigarettes. Once they tried paste they preferred this substance over all others, whenever they could obtain it. When they had no paste, they might consider another drug (rarely cocaine hydrochloride, more frequently amphetamines, cannabis or alcohol). In the last two years we have examined some patients who were primarily introduced to paste and continued to use it without resorting to other drugs. As to the coca paste ritual, most patients smoked it alone or in small groups, using only coca paste-tobacco cigarettes, during the whole session. When they felt that the dyspboric effects were too strong they tried to diminish the unpleasant reactions with alcohol, drinking and smoking for several hours. Others used alcohol to terminate the session, so that they might go home and sleep (in order not to remain excited, hallucinated, paranoid or sleepless). Frequently, however, they were sent to hospital because alcohol was not an effective antidote.

Social consequences

The social consequences of coca paste smoking in the group studied were very serious indeed. These individuals became so dependent on the drug that they had practically no other interest in life. They became completely deficient at work, had serious marital problems and the students failed courses or dropped out of school. When they held a job they were frequently absent from work because they felt ill or were searching for the drug. They needed money to pay for coca paste, which is not very expensive when bought in one gram packages, but becomes prohibitive when a man consumes 40 or 60 grams a day. The cost of paste is now about 200 soles (= $US 1) per gram. The average daily salary of the Peruvian blue collar worker is $US 1.50; an average middle class employee earns about $US 100 a month. As money becomes scarce they resort to swindling, theft, non-payment of debts, or become drug pushers.

It is hard to believe to what extremes of social degradation these men may fall, especially those who were brilliant students, efficient professionals, or successful business men.

Our results are quite comparable to those found in another group of patients studied by physicians of Hospital Hermilio Valdizan, and as one of them said in the discussion, coca paste smoking resembles a malignant disease and is characterized by the production of a change in personality very similar to the psychopathic antisocial disorders.

Discussion

This further study confirms that coca paste smoking is increasing in Peru and now has extended to Ecuador and Bolivia. Paste was almost unknown six years ago, now it is the main drug reported by patients who are admitted to psychiatric hospitals or drug treatment centres in Lima. There is no zone of this city where youngsters do not get together to smoke coca paste and where the pushers do not sell the drug in their own homes or in the street. They even come to the school entrances to do their business.

Coca paste smoking has displaced other drugs in Peru and its dissemination may be attributed to stiffening of the drug law enforcement activities inside the country or at its borders, but probably the main reason is the considerable profits which can be obtained from a plant that is abundant on the oriental mountain sides of Peru, by simple chemical procedures, which can be carried out in the backyard of any home or even in vehicles.

This study of patients showed the majority to be males; most were students and unemployed young men of the low or middle socio-economic levels. Although the characteristics are similar to those of cocaine compound users reported by others [ 12] [ 13] [ 14] we are aware that the cases described here are a biased sample. They were former cocaine users who were experiencing problems sufficiently serious to require their hospitalization. There are of course many other persons who smoke paste occasionally or irregularly, and in those the effects are different. There is therefore an urgent need to study, by epidemiological methods, the real incidence of coca paste smoking in our main cities. This study is in progress as a general population survey, undertaken in collaboration with WHO/UN and will attempt to determine the extent of coca paste smoking as well as whether there are heavy coca paste users in the community who do not experience the symptoms seen in the hospitalized cases.

The preference for coca paste in the last few years is due to the intense pleasurable and stimulant effects experienced. In spite of impurities and aggregates, coca paste may contain 60 to 80 per cent cocaine sulphate [ 3] . This is probably the reason why this compound produces a most intense psychological dependence, much more marked than in coca leaf chewing [ 14] or sniffling cocaine hydrochloride [ 15] [ 16] . The psychological effects of coca paste smoking are very intense, develop rapidly and may range from euphoria to dysphoria, hallucinosis and psychosis sometimes in a single session, when smoking lasts many hours or several days on end.

Hallucinations are varied, beginning with visual disturbances and followed by false tactile, auditory and olfactory perceptions, similar to cocaine hydro-chloride effects [ 17] . These psychopathological changes are probably due to rapid accumulation of cocaine on the occipital [ 18] , parietal [ 19] , temporal [ 20] , or limbic cortical neurons.

Also, as it happens with cocaine hydrochloride [ 21] , coca paste smoking may, in some instances, depress brain stem functions, progressing to death due to medullary paralysis. We have also observed, according to a recent hypothesis [ 22] , that coca paste smoking has psychotic potential more marked than inhalation of cocaine hydrochloride and quite comparable to the effects produced by intravenous injection.

We must also emphasize the serious social consequence of coca paste smoking, which frequently produced deterioration in work and school, as well as family and marital disruption.

There are many areas of investigation that must be pursued in the near future, such as the exact chemical composition of street paste; blood levels of cocaine and other alkaloids during smoking; psychometric testing during the intoxication; neuropathology of brain deaths; treatment methods for acute intoxication; motivation of coca paste excessive users and the socio-economic conditions which predispose to the alarming increase of coca paste trafficking in Peru, Bolivia, Ecuador and Colombia.

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