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new complications continues to emerge The symptoms of severe intoxication (overdose), noted above, may lead to coma and death and require emergency treatment in an intensive care unit, along the lines indicated for the management of other forms of coma Seizures often occur in this setting and are treated more effectively with benzodiazepines than with standard anticonvulsant drugs Spontaneous subarachnoid or intracerebral hemorrhage and cerebral infarction have rarely followed the intranasal use and smoking of cocaine (Levine et al) These complications are presumably the result of vasospasm induced by the sympathomimetic actions of cocaine Cocaine and amphetamines also, on occasion, produce a state of generalized vasospasm leading to multiple cortical infarctions and posterior white matter changes that are evident on imaging studies, not unlike those seen with hypertensive encephalopathy (page 728) Several cases of a pathologically veri ed vasculitis and instances of beading of cerebral vessels on the arteriogram have also been noted We have seen several instances of vasospasm but have no experience with the vasculitis; however, it would seem that these two different types of vasculopathy can result from cocaine and amphetamine use (page 733) Roth and colleagues have described 39 patients who developed acute rhabdomyolysis after cocaine use; 13 of these had acute renal failure, severe liver dysfunction, and disseminated intravascular coagulation and 6 of them died Some reports indicate that cocaine use during pregnancy may cause fetal damage, abortion, or persistent signs of toxicity in the newborn infant Anxiety, paranoia, and other manifestations of psychosis may develop within several hours of cocaine use These complications are best treated with haloperidol

During the past three decades the prevalence of marijuana use in the United States has declined by about half, but it is still the most commonly used illicit drug in the United States The effects, when taken by inhaling the smoke from cigarettes or pipe, are prompt in onset and evanescent With low doses, the symptoms are like those of mild alcohol intoxication (drowsiness, euphoria, dulling of the senses, and perceptual distortions) With increasing amounts, the effects are similar to those of LSD, mescaline, and psilocybin (see later); they may be quite disabling for many hours With even larger doses, severe depression and stupor may occur, but death is rare (for a full account, see Hollister, 1988) No damage to the nervous system has been found after chronic use Reverse tolerance to marijuana (ie, increasing sensitization) may be observed initially, but on continued use, tolerance to the euphoriant effects develops In one of the few experimental studies of chronic marijuana use, the subjects reported feeling jittery during the rst 24 h after abrupt cessation of smoking marijuana, although no objective withdrawal signs could be detected The mild antiemetic and antinauseant effects of marijuana coupled with euphoria have led to its use as an agent to ameliorate the effects of cancer chemotherapies, and this purported therapeutic effect is the mainstay of the movement for its legalization

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scribed, but auditory hallucinations are rare Cognitive functions are dif cult to assess because of inattention, drowsiness, and inability to cooperate in mental testing The somatic symptoms consist of dizziness, nausea, paresthesias, and blurring of vision Sympathomimetic effects pupillary dilation, piloerection, hyperthermia, and tachycardia are prominent, and the user may also show hyperre exia, incoordination of the limbs, and ataxia Tolerance to LSD, mescaline, and psilocybin develops rapidly, even on a once-daily dosage Furthermore, subjects tolerant to any one of these three drugs are cross-tolerant to the other two Tolerance is lost rapidly when the drugs are discontinued abruptly, but no characteristic signs of physical dependence (abstinence syndrome) ensue In this sense, addiction does not develop, although users may become dependent upon the drugs for emotional support (psychologic dependence or habituation) Although LSD has no therapeutic value and the use of marijuana is governed by the federal narcotic laws, these drugs are taken by narcotic addicts as a substitute for more potent drugs, by drugheads (ie, individuals who use any agent that alters consciousness), and by many troubled, unhappy college and high school students for social conformity or for reasons that even they cannot ascertain Their use is attended by a number of serious adverse reactions taking the form of acute panic attacks, long-lasting psychotic states resembling paranoid schizophrenia, and ashbacks (spontaneous recurrences of the original LSD experience, sometimes precipitated by smoking marijuana and accompanied by panic attacks) Serious physical injury may follow upon impairment of the user s critical faculties Whether prolonged usage leads to permanent damage to the nervous system is uncertain; there are some data to suggest that this may happen, but there is little doubt that the mental state of some psychologically predisposed individuals is permanently altered The reports claiming that LSD may cause chromosomal damage remain to be validated Numerous claims have been made that LSD and related drugs are effective in the treatment of mental disease and a wide variety of social ills and that they have the capacity to increase one s intellectual performance, creativity, and self-understanding To date there have been no acceptable studies that validate any of these claims.

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