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Clinical Crossroads |

A 28-Year-Old Man Addicted to Cocaine

Steven E. Hyman, MD, Discussant
JAMA. 2001;286(20):2586-2594. doi:10.1001/jama.286.20.2586.
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DR REYNOLDS: Mr R is a healthy 28-year-old man with a 4-year history of cocaine addiction. He lives in Boston with his girlfriend. He has Massachusetts free care insurance coverage and sees his primary care physician, Dr B, at Beth Israel Deaconess Medical Center.

About 4 years ago at a party, Mr R first tried cocaine intranasally. Although he did not seek out more cocaine, about 6 months later, he smoked some cocaine. He has been pursuing smoked cocaine, or crack, ever since. He began using crack several times a day, subsequently losing jobs, apartments, and relationships. He stole a car from his family and money from his friends.

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Figure. Cocaine Addiction: Neural Pathways and Molecular Mechanisms
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The neural substrates of cocaine action are shown at 3 levels: A, neural pathways on which cocaine acts; B, medium spiny neurons in the nucleus accumbens (ventral striatum) and dorsal striatum (caudate nucleus and putamen), which receive dopamine afferents from the ventral tegmental area and substantia nigra, respectively; and C and D, molecular level, including the synapse (C) between the dopamine terminal and the medium spiny neuron in which cocaine acts to increase dopamine levels, and (D) altered gene expression in the nucleus of the medium spiny neuron that is hypothesized to yield transcripts and eventually proteins that act to remodel synapses. Synaptic remodeling is thought to consolidate addiction-related behaviors.



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