Cocaine Use Disorder

Cocaine is a stimulant drug that is frequently abused. Cocaine abuse in the United States peaked in the 1970s and 1980s but remains an significant problem today. The stimulant directly affects brain function, and long-term addiction leads to extensive physiological and psychological problems.

Definition

Cocaine is a stimulant that makes users feel euphoric, energetic, and mentally alert. Highly addictive, it can cause severe mental and physical problems.

Pure cocaine was first extracted from the leaf of the Erythroxylon coca bush in the mid-19th century. In the early 1900s, people were lacing tonics and elixirs with the stimulant in hopes of treating a wide range of illnesses. Cocaine quickly became popular as an ingredient in patented medicines (such as throat lozenges and tonics) and other products (such as Coca-Cola, from which it was later removed).

Concern soon mounted due to increased instances of addiction, erratic behavior, convulsion, and death. The Pure Food and Drug Act, passed in 1906, required that dangerous ingredients such as cocaine be listed on product labels. The Harrison Act of 1914 outlawed the use of cocaine altogether in over-the-counter products and made it available only by prescription. Cocaine use dropped dramatically and remained at minimal levels for nearly half a century.

In the 1960s, illicit cocaine use rebounded, and by the late 1970s, the drug had become popular among middle- and upper-middle-class Americans. By the mid-1980s, researchers found widespread evidence of physiological and psychological problems among cocaine users, with increased emergency-room episodes and admissions for treatment.

Today, cocaine is a Schedule II drug — it has high potential for abuse but can be administered by a doctor for legitimate medical uses, such as a local anesthetic for certain eye, ear, and throat surgeries.

There are two basic forms of cocaine: powdered and freebase. The powdered form is a hydrochloride salt that dissolves in water; freebase is a compound that has not been neutralized by an acid to make hydrochloride salt. The freebase form of cocaine can be smoked, as in "crack" cocaine, processed from cocaine hydrochloride to a freebase for smoking.

The major routes of administration of cocaine are inhaling (or snorting), injecting, and smoking. There is great risk regardless of the method of use, and it is possible to overdose fatally. Compulsive cocaine use may develop even more rapidly if the substance is smoked rather than snorted. Smoking allows extremely high doses of cocaine to reach the brain very quickly and brings an intense and immediate high. The injecting drug user is at risk for acquiring or transmitting HIV infection/AIDS as well as hepatitis C if needles or other injection equipment are shared.

Health Hazards

Cocaine is a strong central nervous system stimulant that interferes with the reabsorption of dopamine, a chemical messenger associated with pleasure and movement. This resulting buildup of dopamine contributes to the high that characterizes cocaine consumption.

The duration of cocaine's immediate euphoric effects, which include a state of  hyperstimulation, reduced fatigue, and mental clarity, depends on the route of administration. The faster the cocaine is absorbed, the more intense the high. On the other hand, the faster the absorption, the shorter the duration of action. The high from snorting cocaine may last 15 to 30 minutes, while that from smoking may last 5 to 10 minutes. Increased use can reduce the period of stimulation.

Cocaine's effects appear almost immediately after a single dose and disappear within a few minutes or hours. Taken in small amounts (up to 100 milligrams), cocaine usually makes the user feel euphoric, energetic, talkative, and mentally alert, especially to the sensations of sight, sound, and touch. It can also temporarily decrease the need for food and sleep. Some users find that the drug helps them to perform simple physical and intellectual tasks more quickly, while others experience the opposite effect.

The short-term physiological effects of cocaine include constricted blood vessels, dilated pupils, and increased temperature, heart rate, and blood pressure. Large amounts of the stimulant (several hundred milligrams or more) intensify the user's high, but may also lead to bizarre, erratic, or violent behavior. These users may experience tremors, vertigo, muscle twitches, paranoia, or, with repeated doses, a toxic reaction closely resembling amphetamine poisoning. Some users of cocaine report feelings of restlessness, irritability, and anxiety. In rare instances, sudden death can occur on the first use of cocaine or sometime thereafter. Cocaine-related deaths are often a result of cardiac arrest or seizures followed by respiratory arrest.

Long-term effects of cocaine use include addiction, irritability and mood disturbances, restlessness, paranoia, and auditory hallucinations.

Binge cocaine use, in which the drug is taken repeatedly and at increasingly higher doses, leads to a state of increasing irritability, restlessness, and paranoia. It may result in a full-blown paranoid psychosis in which the individual loses touch with reality and experiences auditory hallucinations.

Medical Complications of Cocaine Use

There can be severe medical complications associated with cocaine use. Some of the most frequent complications are cardiovascular effects, including disturbances in heart rhythm and frank heart attacks; respiratory effects such as chest pain and respiratory failure; neurological effects, including strokes, seizures, and headaches; and gastrointestinal complications, including abdominal pain and nausea.

Cocaine use has been linked to many types of heart disease. Cocaine has been found to trigger chaotic heart rhythms called ventricular fibrillation; accelerate heartbeat and breathing; and increase blood pressure and body temperature. Physical symptoms may include chest pain, nausea, blurred vision, fever, muscle spasms, convulsions, coma, and death.

Different routes of cocaine administration can produce different adverse effects. Regularly snorting cocaine, for example, can lead to the loss of the sense of smell, nosebleeds, problems swallowing, hoarseness, and an overall irritation of the nasal septum, which can result in a chronically inflamed, runny nose. Ingested cocaine can cause severe bowel gangrene, due to reduced blood flow. Persons who inject cocaine have puncture marks and "tracks," most commonly in their forearms. Intravenous cocaine users may also experience allergic reactions, either to the drug or to some additive in street cocaine, which in severe cases can result in death. Because cocaine has a tendency to decrease food intake, many chronic cocaine users lose their appetite and can experience significant weight loss and malnourishment.

Research has revealed a potentially dangerous interaction between cocaine and alcohol. Taken in combination, the two drugs are converted by the body to cocaethylene, which has a prolonged duration of action in the brain and is more toxic than either drug alone. While more research needs to be done, it is noteworthy that the mixture of cocaine and alcohol is the most common two-drug combination that results in drug-related death.

Symptoms

Short-Term Effects:

  • Fast heartbeat and breathing
  • Increases in blood pressure and body temperature
  • Erratic or violent behavior
  • Blurred vision, chest pain, nausea, fever, muscle spasms, convulsions, and death from convulsions, heart failure, or brain failure

Long-Term Effects:

  • Dependence and depression
  • Feelings of restlessness, irritability, mood swings, paranoia, sleeplessness, and weight loss
  • Emotional problems and isolation from family and friends
  • Psychosis, paranoia, depression, anxiety disorders, and delusions
  • Damage to the nose and inflamed nasal passages
  • Increased risk of hepatitis and HIV
  • Severe respiratory infections
  • Heart attacks, chest pain, respiratory failure, strokes, and abdominal pain and nausea

Warning Signs of Use:

  • Red, bloodshot eyes
  • A runny nose or frequent sniffing
  • A change in eating or sleeping patterns
  • A change in groups of friends
  • A change in behavior
  • Acting withdrawn, depressed, tired, or careless about personal appearance
  • Losing interest in school, family, or activities previously enjoyed
  • Frequently needing money

Causes

Cocaine is an "upper" (stimulant) that gives its user a false sense of power and energy. When users come down from the high, they are usually depressed, edgy, and craving more drug. No one can predict whether they will become dependent and addicted, or whether the next dose will be deadly.

Treatment

Cocaine abuse and addiction comprise a complex problem involving biological changes in the brain as well as myriad social, familial, and environmental factors. Therefore, treatment of cocaine addiction is complex. Like any good treatment plan, cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patient's drug abuse.

Pharmacological Approaches

There are no medications currently available to treat cocaine addiction specifically. Consequently, the National Institute on Drug Abuse (NIDA) is aggressively pursuing the identification and testing of new cocaine treatment medications. Several emerging compounds are being investigated to assess their safety and efficacy. Two marketed medicines, topiramate and modafanil, have shown promise. Additionally, baclofen, a GABA-B agonist, showed promise in a subgroup of cocaine addicts with heavy use patterns. Antidepressant drugs are of some benefit with regard to mood changes experienced during the early stages of cocaine abuse. Medical treatments are also being developed to deal with acute emergencies resulting from excessive cocaine abuse.

Behavioral Interventions

Many behavioral treatments have been found effective for cocaine addiction, including both residential and outpatient approaches. Behavioral therapies are often the only available effective treatment for many drug problems, including cocaine addiction, although integration of both pharmacological and behavioral treatments may ultimately prove to be the most effective approach. Disulfiram (a medication that has been used to treat alcoholism), in combination with behavioral treatment, has been successful in reducing cocaine abuse. It is important that patients receive services that match all of their treatment needs. For example, if a patient is unemployed, it may be helpful to provide vocational rehabilitation or career counseling. Similarly, if a patient has marital problems, it may be important to offer couples counseling. A behavioral therapy component that may be particularly useful for helping patients achieve initial abstinence from cocaine is contingency management. Some contingency management programs use a voucher-based system to give positive rewards for staying in treatment and remaining cocaine-free.

Cognitive-behavioral treatment is a focused approach to helping cocaine-addicted individuals abstain— and remain abstinent—from abusing cocaine and other substances. The underlying assumption is that learning processes play an important role in the development and continuation of cocaine abuse and dependence. The same learning processes can be employed to help individuals reduce drug use and successfully cope with relapse. This approach attempts to help patients recognize the situations in which they are most likely to use cocaine, avoid the situations when appropriate, and cope more effectively with a range of problems associated with drug abuse. This therapy is also compatible with a range of other treatments, including pharmacotherapy.

Therapeutic communities (TCs) or residential programs with stays of several months are also on offer for treatment for cocaine addiction. TCs focus on resocialization of the individual and can include on-site vocational rehabilitation and an array of other supportive services. 

Use Psychology Today's Treatment Guide to find the right facility.

References

  • National Institute of Drug Abuse American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Last reviewed 02/22/2019