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Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis
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Cocaine use disorder in adults: Epidemiology, pharmacology, clinical manifestations, medical consequences, and diagnosis
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Literature review current through: Nov 2017. | This topic last updated: Aug 01, 2017.

INTRODUCTION — Cocaine is a tropane ester alkaloid found in leaves of the Erythroxylum coca plant, a bush that grows in the Andes Mountain region of South America [1]. Cocaine use can lead to addiction and adverse physical effects, such as stroke and cardiac arrest.

Cocaine is classified as a Schedule II medication under the Controlled Substances Act in the United States. Cocaine hydrochloride is still legally available in the United States as a 4 or 10 percent solution for use as a local or topical anesthetic, although it has largely been replaced in clinical practice by synthetic local anesthetics [2].

The DSM-IV-TR psychiatric diagnoses cocaine abuse and cocaine dependence were replaced by one diagnosis, cocaine use disorder, in DSM-5 [3]. Although the crosswalk between DSM-IV and DSM-5 disorders is imprecise, cocaine dependence is approximately comparable to cocaine use disorder, moderate to severe subtype, while cocaine abuse is similar to the mild subtype [4].

This topic addresses the epidemiology, pharmacology, clinical effects, and diagnosis of cocaine use disorder in adults. Acute intoxication from cocaine use, specific cardiovascular and pulmonary complications related to cocaine, and treatment of stimulant use disorder are discussed separately. (See "Cocaine: Acute intoxication" and "Pulmonary complications of cocaine abuse" and "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse" and "Pharmacotherapy for stimulant use disorders in adults" and "Psychosocial interventions for stimulant use disorder in adults".)

EPIDEMIOLOGY — Cocaine is used by an estimated 18.2 million people worldwide, about 0.4 percent of the global population age 15 to 64 years [5]. Use is most prevalent in North America (5.1 million people, 1.6 percent of population older than 14 years) and Central and South America (4.4 million people, 1.5 percent) and in Western and Central Europe (3.5 million people, 1.1 percent). Current use (3.4 percent in 2013) in the United Kingdom and Spain now exceeds population rates in the United States [6], which have declined by almost one-quarter over the past 15 years [5]. Common street names used in the United States for cocaine are shown in a table (table 1).

There is less cocaine use in West and Central Africa, East and Southeast Asia, and Eastern and Southeastern Europe, with little use elsewhere in the world [5]. This pattern may be due to supply rather than demand factors, because of the difficulty in obtaining cocaine from its only source in South America and the ready availability of alternative synthetic stimulants such as amphetamines [7] or synthetic cathinones (“bath salts”).

Most cocaine use is by urban men age 15 to 35 years. About 3 percent of current users in the United States are adolescents 12 to 17 years old [8]. Cocaine use has declined almost fourfold among this age group in the past decade, while declining about one-quarter in the overall population.

Less than one-fifth (18.6 percent) of the 4.8 million United States residents estimated to use cocaine in 2015 met DSM-IV diagnostic criteria for cocaine abuse or dependence (cocaine use disorder in DSM-5) [8]. Six-hundred and fifteen thousand cocaine users received specialty treatment for their cocaine use or associated medical problems in 2015 [8].

Cocaine is the illegal drug most often associated with visits to Untied States hospital emergency departments. In 2011, it was involved in an estimated 40.3 percent of illicit drug-related emergency department visits (about 505,000 visits), versus about 36 percent (456,000 visits) for marijuana and about 20.6 percent (258,000 visits) for heroin [9]. Nearly one-quarter of emergency room visits by patients seeking medical assistance for withdrawal (“detoxification”) involved cocaine use; 6.3 percent of emergency room visits for suicide attempts involved cocaine use.

Patterns of use — Cocaine is used in a variety of patterns [10,11]. The typical "binge" involves short periods of heavy use (eg, payday or weekends) separated by longer periods of little or no use. Others may use for an extended period until their finances are exhausted or access to cocaine is interrupted. A small number of users may be self-medicating an underlying neuropsychiatric disorder, such as attention deficit hyperactivity disorder (ADHD) [12], excessive daytime sleepiness [13], Parkinsonism [14], or cluster headaches [15]. Most cocaine users living in the community do not use very frequently. More than half (58 percent) of past-year users used less than 12 times in the year; only 22 percent used at least 50 times [16].

Risk factors — While cocaine use occurs in all sociodemographic groups, it is not equally distributed among the United States population. The highest prevalence of use is among unemployed men in their 20s with no more than a high school education who live in urban areas.

Cocaine use is highly associated with use of other legal and illegal substances and with psychiatric disorders. Cigarette smokers and heavy alcohol drinkers are 10 and 20 times more likely, respectively, than non-users to also use cocaine [16]. Concurrent use of cocaine and alcohol produces a new compound, cocaethylene, which is pharmacologically active (see 'Metabolism' below).

Cocaine users are at high risk for developing a cocaine use disorder. Community-based interview surveys suggest that up to one in six persons who use cocaine will develop dependence by DSM-IV-TR criteria [17]. Heavier users and users who take the drug intravenously or by smoking are more likely to develop dependence than lighter users or intranasal and oral users [18-20]. The greater abuse potential of intravenous or smoked cocaine is attributed to the faster rate of drug delivery to the brain (within 10 seconds), and faster onset of psychological effects [21,22]. This faster onset is associated with a more intense pleasurable response (the so-called "rate hypothesis" of psychoactive drug action) [23]. Oral use of the coca leaf is not typically associated with significant adverse consequences [24].

The environment (including family, religious, and social factors) has the strongest influence on initial cocaine use [25]. Studies of drug use by pairs of fraternal (dizygotic) and identical (monozygotic) twins suggested a significant genetic influence on the risk of developing cocaine abuse or dependence after use has begun. Several promising candidate genes have been identified, including those for cholinergic nicotinic and cannabinoid CB1 receptors, but no specific gene has been clearly linked with cocaine addiction [26].

Co-occurring conditions — Many cocaine users use other substances either to enhance the "high" (eg, simultaneous use of opiates ["speedballing"]) or to ameliorate adverse effects of intoxication or withdrawal (eg, use of alcohol, cannabis, or benzodiazepines). Current cocaine users are twice as likely as non-users to have symptoms of depressive or anxiety disorders [27].

MECHANISM OF ACTION — Cocaine enhances monoamine neurotransmitter (dopamine, norepinephrine, and serotonin) activity in the central and peripheral nervous systems by blocking the presynaptic reuptake pumps (transporters) for these neurotransmitters [28,29]. Cocaine's positive psychological effects and abuse liability are considered to be due to its enhancement of brain dopamine activity, especially in the so-called corticomesolimbic dopamine reward circuit. Cocaine addiction has been conceptualized as a disease of the brain's dopamine reward system [30].

Cocaine is unique among stimulant drugs in having a second action of blocking voltage-gated membrane sodium ion channels. This action accounts for its local anesthetic effect, and may contribute to cardiac arrhythmias. (See "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse".)

PHARMACOLOGY — Illegal cocaine comes in two forms: base (alkaloid, as in coca leaves) and salt [31,32]. Both forms consist of the same cocaine molecule and exert the same pharmacological actions once they reach the brain or other target organ. They differ in physical properties, which allow different routes of administration.

Cocaine base ("crack," "freebase") can be smoked because it has a relatively low melting point (98ºC) and vaporizes before substantial pyrolytic destruction has occurred. Cocaine base is difficult to dissolve for injection because it is relatively insoluble in water.

Cocaine salt, in contrast, cannot be efficiently smoked because it melts at 195ºC, with substantial breakdown of the cocaine molecule before vaporization. Cocaine salt is readily injected or insufflated ("snorted") through the nose; it is highly water soluble, making it easy to dissolve for injection purposes and facilitating absorption across mucus membranes.

The average purity of seized cocaine samples in the United States is around 50 percent [33]. Common adulterants include both inert fillers that resemble cocaine in appearance (such as dextrose, lactose, mannitol, or starch) and active chemicals that may mimic the local anesthetic effect of cocaine (such as benzocaine, lidocaine, or procaine) or provide some psychoactive effect (such as ephedrine, amphetamine, caffeine, or PCP) [34]. Street cocaine also may contain contaminants from the preparation process (such as benzene, acetone, or sodium bicarbonate). An increasingly common cocaine adulterant is the veterinary anti-helminthic agent levamisole [35]. Cocaine adulterated with levamisole is associated with serious side effects, including leucopenia, agranulocytosis, and cutaneous vasculitis.

Absorption — Cocaine is readily absorbed through the mucous membranes of the nose and mouth, and from the genitourinary, gastrointestinal, and respiratory tracts. Passive absorption may occur through intact skin or by inhalation of second-hand cocaine smoke [36-38]. Such passive exposure can cause adverse effects in infants [39,40].

Distribution — Cocaine is rapidly taken up into most body organs, including the heart, kidney, adrenal glands, and liver [41]. Cocaine (and its hydrolytic metabolites) appears in blood, urine, hair [42], sweat [43], saliva [44], and breast milk [45,46]. It crosses the placenta to appear in meconium [47]. Analysis of these tissues and fluids is used for drug detection in workplace, legal, and treatment settings [48].

Onset of action — The onset of action for cocaine depends on the route of administration. Intravenous and inhaled (smoked) administration results in onset of action within seconds. Intranasal and gastrointestinal administration result in slower onsets of 20 to 30 minutes and up to 90 minutes, respectively.

Duration of action — The effects of intravenous or inhaled cocaine administration typically last 15 to 30 minutes; effects of intranasal and gastrointestinal administration are about one and three hours, respectively.

Metabolism — Cocaine is 95 percent metabolized by hydrolysis of its ester bonds to benzoylecgonine (by carboxyesterases in the liver) and to ecgonine methylester (by butyrylcholinesterase in the liver, plasma, brain, lung, and other tissues) [49-51]. The remaining 5 percent is N-demethylated to norcocaine by the liver cytochrome P450 microsomal enzyme system. The hydrolytic metabolites appear to be largely inactive. Norcocaine has some pharmacological actions similar to those of cocaine, and is hepatotoxic [52].

Smoked cocaine produces an additional series of pyrolysis products, the chief of which are anhydroecgonine methylester and noranhydroecgonine methylester [50,53].

Cocaine used together with alcohol leads to formation of a new compound, cocaethylene, by transesterification [50]. Cocaethylene has pharmacological actions similar to, but less potent than, those of cocaine, and has a longer half-life [54,55]. Formation of cocaethylene may contribute to more severe or longer lasting toxic effects of cocaine when it is used along with alcohol.

Elimination — Cocaine is largely eliminated in the urine [50]. Benzoylecgonine is the metabolite found in highest concentration in urine. It is this metabolite, rather than the parent drug cocaine, that is measured in urine drug tests for cocaine (see 'Screening' below).


Acute intoxication — Typical cocaine doses are 12 to 15 g orally (coca leaf), 20 to 100 mg intranasally, 10 to 50 mg intravenously, and 50 to 200 mg smoked. The intended effects include increased energy, alertness, and sociability; elation or euphoria; and decreased fatigue, need for sleep, and appetite [56-58]. The intense pleasurable feeling has been described as a "total body orgasm" [56].

There is wide variability in the acute response to cocaine and poor correlation between cocaine plasma concentrations and toxic effects [56,59]. Fatal cases of cocaine intoxication may present with 100-fold differences in plasma cocaine concentration [32].

Unintended adverse effects occur with increasing dose, duration of use, or a more efficient route of administration (eg, intravenous or smoked versus intranasal). These effects include dysphoric mood (anxiety, irritability), panic attacks, suspiciousness, paranoia, grandiosity, impaired judgment, and psychotic symptoms such as delusions and hallucinations. Up to one-quarter of non-treatment-seeking cocaine users may experience anxiety, depression, sleep disturbance, or weight loss (due to appetite suppression and changes in fat regulation) [60,61]. Concurrent behavioral effects include restlessness, agitation, tremor, dyskinesia, and repetitive or stereotyped behaviors such as picking at the skin or foraging for drugs ("punding," "hung-up activity") [62]. Associated physiological effects include tachycardia, pupil dilation, diaphoresis, and nausea, reflecting stimulation of the sympathetic nervous system.

Cocaine-associated psychotic symptoms (paranoia, delusions, hallucinations) are reported by up to 80 percent of individuals with a cocaine use disorder [63,64]. These symptoms may somewhat resemble those due to acute schizophrenia [65]. Cocaine-associated psychosis may differ from acute schizophrenic psychosis in being marked by less thought disorder and bizarre delusions and fewer negative symptoms such as alogia and inattention [64]. Hallucinations may be auditory, visual, or tactile, but the last two are much more common with cocaine use than with schizophrenia [63,66]. Tactile hallucinations are especially typical of stimulant-associated psychosis and include the sensation of something (eg, insects) crawling under the skin (“formication,” “cocaine bugs”).

The presentation and treatment of cocaine intoxication is discussed in greater detail separately (see "Cocaine: Acute intoxication").

Chronic use — Chronic cocaine use can result in either of two distinct pharmacological adaptations: sensitization (increased drug response) or tolerance (decreased drug response) [67,68]. In animal studies, sensitization results from low-dose, intermittent exposure, while tolerance results from frequent, high-dose, or long-term exposure.

The factors that determine sensitization and tolerance in humans, however, are not well understood. Sensitization to the cardiovascular effects of oral cocaine, but not to its psychological effects, has been demonstrated in laboratory studies [69]. Tolerance to the psychological, cardiovascular, and neuroendocrine effects of cocaine develops after several doses [70,71]. Tolerance to cardiovascular effects may develop more quickly and completely than does tolerance to psychological effects [71,72]. This rapid tolerance presumably allows binge users to take large cumulative doses of cocaine.

Chronic cocaine use is associated with cognitive impairment affecting visuo-motor performance, attention, verbal memory, and risk-reward decision-making [73]. These impairments persist for at least several weeks of abstinence.

Cocaine use is associated with suicidal ideation and suicide attempts [74,75]. The extent to which suicide is a direct consequence of use, rather than an associated sociodemographic or psychological factor, remains unclear [76,77]. Factors associated with increased risk of suicidality among cocaine users include depression, severe cocaine withdrawal, comorbid alcohol or opioid dependence, history of childhood trauma, and family history of suicidality [78,79].

Chronic cocaine use by any route of administration is associated with increased risk of infection, especially viral hepatitis [80] and HIV [81], and of risky sexual behavior (such as unprotected sex) [82].

Chronic cocaine use does not appear to increase the risk of general anesthesia, as long as the patient has normal cardiovascular parameters at the time of surgery [83].

Withdrawal symptoms — Cessation of heavy chronic cocaine use results in a withdrawal syndrome that has prominent psychological features, but is rarely medically serious [84-86]. Symptoms include depression, anxiety, fatigue, difficulty concentrating, decreased ability to experience pleasure (anhedonia), increased cocaine craving, increased appetite, increased sleep, and increased dreaming (due to increased REM sleep). An initial period of intense symptoms (commonly termed the "crash") may occur, including psychomotor retardation and severe depression with suicidal ideation. However, most users experience milder symptoms that resolve within one to two weeks without treatment.

Physical signs of cocaine withdrawal are usually minor and rarely require treatment. These include nonspecific musculoskeletal pain, tremors, chills, and involuntary motor movement [87]. The first week of stimulant withdrawal has been associated with myocardial ischemia [88], possibly due to coronary vasospasm.


Central nervous system

Seizure – Evidence regarding an association between cocaine use and seizures is mixed:

A 2016 prospective observational study of 1134 patients hospitalized for aneurysmal subarachnoid hemorrhage found that cocaine use within 72 hours of the event was associated with seizures during the hospitalization (odds ratio 2.06, 95% CI 1.330-3.175) after controlling for age, clinical grade, presence of intracranial hemorrhage, and location of aneurysm [89].

An earlier 2013 systematic review of 22 cross-sectional studies and one case-control study found no good-quality evidence of an association between cocaine use and seizures [90].  

Case reports and case series have reported an association between cocaine use (including first-time use) and seizures in persons without a seizure history. The seizures were described as usually single, generalized tonic-clonic seizures occurring within 90 minutes of cocaine use [91-93].

Cocaine euphoria is associated with transient increases in EEG activity followed by longer-lasting increases in activity [94].

Stroke – Cerebral vasoconstriction, cerebrovascular disease, and hemorrhagic and ischemic stroke are increased in cocaine users, even in patients with no other risk factors [91-93,95,96]. A systematic review of seven case-control studies and two cross-sectional studies found a positive association between cocaine use and both hemorrhagic and ischemic stroke (adjusted odds ratios of 2 to 6 [97]).

A population-based case-control study of 1090 cocaine users and 1154 controls found an increased risk of stroke with cocaine use in the prior 24 hours (adjusted odds ratio 5.7, 95% CI 1.7-19.7, adjusted for current alcohol and tobacco use and hypertension) [98]. Etiologic mechanisms include tachycardia and increased blood pressure from sympathetic activation, vasoconstriction, vasospasm, and intravascular thrombosis due to increased platelet aggregation [99].

Brain abnormalities – MRI, SPECT, and PET imaging in chronic cocaine users demonstrate structural and functional brain abnormalities: cerebral gray matter atrophy and decreased glucose metabolism in the frontal and temporal lobes, small cerebral perfusion defects, increased creatine concentration in parietal white matter (suggesting abnormal energy metabolism), and decreased D2 dopamine receptors in the striatum [99-101]. An autopsy study using melanin immunoreactivity found cocaine users to have 16 percent fewer midbrain dopamine neurons than non-using subjects [102]. Impairment of behavioral inhibition in cocaine users has been associated with reduced activity in the anterior cingulate and prefrontal cortices [101].

Movement disorders – Cocaine use is associated with a variety of movement disorders, including stereotyped behaviors, acute dystonic reactions, choreoathetosis and akathisia (so-called "crack dancers"), buccolingual dyskinesias ("twisted mouth" or "boca torcida"), and exacerbation of Tourette's syndrome and tardive dyskinesia [56,91,103]. Cocaine users are at increased risk of acute dystonic reactions from neuroleptic (antipsychotic) medications [104].

Cardiovascular system — Cardiopulmonary symptoms are the most frequent complaints in cocaine users who seek medical help, with chest pain being the most frequent symptom [105]. Cocaine acutely increases heart rate, blood pressure, and systemic vascular resistance by increasing adrenergic activity in the heart, and indirectly via the CNS [105,106]. The increased myocardial oxygen demand, coupled with decreased coronary blood flow from vasospasm and vasoconstriction, can cause acute myocardial infarction (AMI), even in young persons without atherosclerosis.

Cocaine use is a factor in about one-quarter of nonfatal heart attacks in persons younger than 45 years [107]. Cocaine is not necessarily associated with a more serious outcome of AMI. As an example, a prospective cohort study of 1003 adult inpatients following an AMI with S-T segment elevation (STEMI) found no difference between 58 subjects with cocaine-associated STEMI and 945 subjects with non-cocaine-associated STEMI in subsequent death (hazard ratio 1.46, 95% CI 0.49-4.37) or death or hospital readmission (hazard ratio 1.14, 95% CI 0.74-1.76) [108]. The median follow-up period was 2.7 years.

Cocaine use is not usually associated with chronic hypertension [109], but appears to enhance the progression of renal disease in patients with hypertension (see 'Kidneys' below) [110,111].

Cocaine use is associated with supraventricular and ventricular cardiac arrhythmias, S-T segment elevation (often asymptomatic), and sudden death [112-114]. Chronic use is associated with left ventricular hypertrophy and dysfunction, cardiomyopathy, myocardial fibrosis, and myocarditis [115]. (See "Clinical manifestations, diagnosis, and management of the cardiovascular complications of cocaine abuse".)

Respiratory system — The effects of cocaine on the respiratory system depend on the route of administration. Intranasal cocaine use ("snorting") may cause chronic rhinitis, perforation of the nasal septum, oropharyngeal ulcers, and osteolytic sinusitis, due to vasoconstriction and resulting ischemic necrosis [91,103]. Anosmia is rare.

Smoked (“crack”) cocaine produces acute respiratory symptoms in up to half of users, including productive cough, shortness of breath, wheezing, chest pain, and hemoptysis [116], and is a factor in up to one-third of young adult cases of acute asthma exacerbation seen in hospital emergency departments [117]. Rarer pulmonary complications of smoked cocaine use include pulmonary edema, pulmonary hemorrhage, pneumothorax, pneumomediastinum, and thermal airway injury [116,118]. These effects are due to a combination of direct damage to the alveolar-capillary membrane by cocaine or inhaled microparticles, damage to the pulmonary vascular bed from vasoconstriction, interstitial disease, and/or toxicity from adulterants such as levamisole [119].

Chronic cocaine smokers generally have normal spirometry tests, but may have increased alveolar epithelial permeability and moderately decreased pulmonary diffusion capacity, even when asymptomatic. “Crack lung” refers to an acute pulmonary syndrome, associated with smoked cocaine use, whose pathophysiology and optimum treatment remain unclear [116,118]. It is associated with fever, hypoxemia, hemoptysis, respiratory failure, and diffuse alveolar infiltrates (usually eosinophil-rich). (See "Pulmonary complications of cocaine abuse".)

Gastrointestinal system — Cocaine use by any route of administration reduces salivary secretions (xerostomia) [120] and causes bruxism [121]. Cocaine reduces gastric motility and delays gastric emptying [91]. Cocaine-induced vasoconstriction and ischemia may result in gastrointestinal ulceration, infarction, perforation, and ischemic colitis [91,103]. Cocaine-associated ulcers are distributed primarily in the greater curvature and prepyloric region of the stomach, pyloric canal, but, similar to peptic ulcers, also occur in the first portion of the duodenum.

Liver — Cocaine users may have mild, transient elevation in transaminases [122], but there is no direct evidence that cocaine is hepatotoxic in humans. As an example, a prospective cohort study of 573 patients coinfected with HIV and hepatitis C virus, who were followed from 2003 to 2013 and lacked significant baseline liver fibrosis, found no association between progression to significant fibrosis and lifetime cocaine use (hazard ratio 0.96, 95% CI 0.58-1.57) or prior-six-month cocaine use (hazard ratio 0.88, 95% CI 0.63-1.25), after adjustment for age, sex, duration of hepatitis C infection, and alcohol and other drug use [123].

Cocaine does cause liver damage in rodents; however, the responsible hepatotoxins are oxidative metabolites such as norcocaine, which are very minor metabolites in humans (see 'Metabolism' above). Liver abnormalities in cocaine users can almost always be accounted for by viral hepatitis from injection drug use, alcoholic liver disease, concurrent rhabdomyolysis [122], use of other hepatotoxic drugs (such as MDMA [“ecstasy”]), or other consequences of a drug-using lifestyle. Concurrent alcohol intake may sensitize hepatocytes to damage by cocaine, as well as generating the hepatotoxic metabolite cocaethylene [124].

Kidneys — Cocaine use can impair kidney function by a variety of mechanisms [125]. Cocaine-induced rhabdomyolysis is a significant cause of acute renal failure [126] (see "Drug-induced myopathies" and "Clinical features and diagnosis of heme pigment-induced acute kidney injury").

Cocaine use by hypertensive patients enhances their decline in kidney function [110] and the progression from hypertensive nephrosclerosis to end-stage renal disease [111]. While cocaine promotes atherosclerosis in renal vessels, cocaine-induced renal infarction is relatively rare [127].

Endocrine — Acute cocaine use activates the hypothalamic-pituitary-adrenal (HPA) axis, increasing levels of epinephrine, corticotropin-releasing hormone (CRH), ACTH, cortisol, and luteinizing hormone, and decreasing plasma prolactin levels [103,128,129]. Chronic cocaine users, however, usually have normal plasma levels of prolactin, testosterone, cortisol, luteinizing hormone, and thyroid hormones.

Skin — Cocaine use is associated with a variety of pseudovasculitic lesions that may mimic rheumatologic syndromes such as Wegener's granulomatosis, necrotizing vasculitis, and immunoglobulin A vasculitis (Henoch-Schönlein purpura) [130]. Use of cocaine contaminated with levamisole (an anti-helminthic now approved in the United States only for veterinary use) has been associated with cutaneous vasculitis or vasculopathy (picture 1) [131,132]. (See "Evaluation of adults with cutaneous lesions of vasculitis", section on 'Etiology' and "Evaluation of adults with cutaneous lesions of vasculitis", section on 'Evaluation for vasculitis due to levamisole-contaminated cocaine'.)

Sexual dysfunction — Although cocaine is often considered an aphrodisiac, it actually may impair sexual function, especially with chronic use, and may cause delayed or inhibited ejaculation in men [133-135].

Reproductive, fetal, and neonatal health — Cocaine may cause irregular menses in women [134,135].

Topical cocaine is classified as pregnancy category C (risk cannot be ruled out because human studies are lacking) by the US Food and Drug Administration. Maternal cocaine use has been associated with vaginal bleeding, abruptio placenta, placenta previa, premature rupture of membranes, premature birth, decreased head circumference, low birth weight, and autonomic instability [136,137]. However, it is unclear to what extent these adverse effects are due to prenatal (in utero) cocaine exposure, rather than to other factors in the cocaine-using lifestyle, such as concomitant drug use (including alcohol, nicotine, and opiates), poor nutrition, and lack of prenatal care. Rodent and monkey studies, in which these confounding factors are excluded, show few direct adverse effects of prenatal exposure to cocaine [138].

The long-term effects of prenatal exposure to cocaine are also unclear [139]. Well-controlled, prospective studies of children born to cocaine-using mothers have not confirmed most earlier concerns regarding long-term cognitive impairment and behavioral problems.

Cocaine appears in breast milk and may cause irritability, sleep disturbance, and tremors in the nursing infant [45,46].

ASSESSMENT — Initial assessment of the cocaine-abusing patient addresses the following areas [140].

Patient history

Use of all psychoactive substances (not just cocaine), including illegal, prescription, and over-the-counter as well as duration, quantity, frequency, route of administration, and effects for each substance used

Prior treatment, if any

Psychiatry history, including relationship of any psychiatric symptoms to substance use or withdrawal

Medical history

Social and developmental history, especially current social network

Family history

Substance use

Psychiatric history

Mental status

Insight into condition

Motivation and preferences for treatment

Cognitive function


Attention span

Memory, short- and long-term

Decision-making capacity

Presence of thought disorder, eg, delusions, hallucinations

Mood and affect

Physical examination

Vital signs

Heart, lungs, abdomen, extremities, skin

Neurological examination

Stigmata of cocaine use, eg, skins lesions from injection, perforated nasal septum from insufflation (“snorting”)

Laboratory tests

Blood or urine drug testing


Complete blood count (CBC)

Blood chemistries, including liver tests

Blood-borne and sexually transmitted diseases, eg, HIV, syphilis, hepatitis B and C

Goals of the initial psychiatric assessment are to:

Determine the severity of the addiction problem

Identify concurrent substance use (alcohol, opiates, or cannabis)

Diagnose co-occurring psychiatric or medical disorders

Identify strengths (eg, employment, supportive social network)

Identify weaknesses (criminal behavior, poor social skills)

Evaluate motivation for treatment

Discuss treatment preferences

Screening — Screening for cocaine use can be performed with brief self-report instruments or by drug testing. (See "Screening for unhealthy use of alcohol and other drugs in primary care", section on 'Unhealthy use of other drugs' and "Screening for unhealthy use of alcohol and other drugs in primary care".)

Patient self-report — Patient self-report via questions or instruments provide an economical and efficient means of cocaine screening, and are typically used in high-volume clinical settings such as a primary care practice or emergency department. Several studies suggest that self-reports of cocaine and other illegal substance use can be fairly accurate, as long as there are no adverse consequences (such as criminal charges) for acknowledging use [141].

Systematic review has identified several cocaine-use screening instruments, comprised of one to three questions, with good (though varying) sensitivity and reliability [142]. Based on simplicity of use and favorable test performance characteristics, we favor the use of the three-question Tobacco, Alcohol, Prescription Medication, and Other Substance Use screening instrument [143]:

“In the past three months, did you use cocaine, crack, or methamphetamine (crystal meth)?” If yes,  

“Did you use at least once a week or more often?” If yes,

“Has anyone expressed concern about your use?”

In a study of 2000 adult patients consecutively recruited from the waiting areas of five primary care clinics, a “yes” answer to the first question had a sensitivity of 0.68 (95% CI 0.59-0.77) and specificity of 0.99 (95% CI 0.98-0.99) for identifying problem stimulant use (based on at least one positive item on the Composite International Diagnostic Interview [CIDI]). Two “yes” answers had a sensitivity of 0.57 (95% CI 0.47-0.67) and specificity of 0.99 (95% CI 0.99-1.00) for identifying stimulant use disorder (based on at least two positive items on CIDI).

Drug testing — Drug testing detects cocaine use, but is not diagnostic of a cocaine use disorder, which implies adverse consequences from use. Conversely, a negative drug screen may only indicate lack of recent use. Cocaine and its metabolites can be measured in urine, blood, oral fluid, sweat, and hair [48,144]. The window of detection is shorter for cocaine than for its major metabolite, benzoylecgonine, and varies with the sensitivity of the assay method.

Urine testing (which measures benzoylecgonine, not cocaine), including rapid point-of-care methods, is common in clinical settings because the sample can be collected non-invasively. It has a detection window of about two to three days after cocaine use, but may be positive up to two weeks after chronic heavy use [145,146].

Blood testing has a detection window of 12 hours for cocaine and 48 hours for benzoylecgonine. It is rarely used outside the setting of acute intoxication. Actual blood cocaine concentrations have little correlation with acute symptoms of cocaine intoxication in the emergency department setting [59].

Oral fluid testing has a detection window similar to that of blood, with the advantage of non-invasive collection and better patient acceptability [44]. Sweat testing (via patches worn on the skin) has a detection window of several weeks, but is useful only for prospective evaluation (ie, monitoring future drug intake). Results may be influenced by location of the skin patch and environmental exposure to cocaine [147].

Hair testing has the longest detection window (potentially years), but valid results require careful technique, and some questions remain unresolved. Results may be influenced by hair location, racial/ethnic differences in hair composition, prior hair treatments, and environmental exposure to cocaine [148]. Cocaine continues to be incorporated into hair for a few months after last use [149].

A variety of relatively inexpensive commercial assays are available for testing of urine and oral fluid, including disposable kits that allow on-site testing with results available within minutes. Results from such screening tests should be confirmed by a standard laboratory assay, especially in legal or workplace settings.

DIAGNOSIS — The diagnosis of cocaine use disorder is made on the basis of history, obtained primarily from the patient and from collateral sources (eg, family, friends, and medical records) when available.

Diagnoses of cocaine abuse and cocaine dependence in DSM-IV-TR were replaced by the single diagnosis, cocaine use disorder, in DSM-5 [3]. DSM-5 diagnostic criteria for cocaine use disorder are described below.

DSM-5 criteria — A problematic pattern of cocaine use leading to clinically significant impairment or distress, as manifested by two or more of the following within a 12-month period:

Cocaine is often taken in larger amounts or over a longer period than was intended

There is a persistent desire or unsuccessful efforts to cut down or control cocaine use

A great deal of time is spent in activities necessary to obtain cocaine, use cocaine, or recover from its effects

Craving, or a strong desire or urge to use cocaine

Recurrent cocaine use resulting in a failure to fulfill major role obligations at work, school, or home

Continued cocaine use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of cocaine

Important social, occupational, or recreational activities are given up or reduced because of cocaine use

Recurrent cocaine use in situations in which it is physically hazardous

Continued cocaine use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by cocaine



Specifiers for the diagnosis include:

In early remission – After full criteria for cocaine use disorder were previously met, none of the criteria for cocaine use disorder have been met (with the exception of craving) for at least three months but less than 12 months

In sustained remission – After full criteria for cocaine use disorder were previously met, none of the criteria for cocaine use disorder have been met (with the exception of craving) during a period of 12 months or longer

In a controlled environment – If the individual is in an environment where access to cocaine is restricted

The severity of cocaine use disorder at the time of diagnosis can be specified as a subtype based on the number of symptoms present:

Mild: Two to three symptoms

Moderate: Four to five symptoms

Severe: Six or more symptoms

Most clinical trials of treatments for cocaine use were conducted in samples limited to patients with cocaine dependence (DSM-IV-TR or earlier criteria). Applying trial results to patients diagnosed with DSM-5 cocaine use disorder is imprecise; the most closely comparable patients are those with cocaine use disorder, moderate to severe subtype [4]. Cocaine abuse is similar to the mild subtype of cocaine use disorder. (See "Pharmacotherapy for stimulant use disorders in adults" and "Psychosocial interventions for stimulant use disorder in adults".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stimulant use disorder and withdrawal".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topic (see "Patient education: Cocaine use disorder (The Basics)")


Cocaine use is most prevalent in North and South America, and increasingly in Western Europe, especially among urban men aged 15 to 35 years. It is the illegal drug most often associated with emergency department visits in the United States. (See 'Introduction' above.)

Up to one in six persons who use cocaine will develop dependence (DSM-IV-TR criteria) or moderate to severe cocaine use disorder (DSM-5 criteria); abuse liability is greater with intravenous and smoked cocaine, compared to intranasal and oral use. Cocaine base has a low melting point and can be smoked; cocaine salt is water soluble and can be injected or absorbed across mucous membranes. (See 'Risk factors' above and 'Pharmacology' above.)

Cocaine is largely metabolized to inactive hydrolytic products in the liver and plasma. Use of alcohol with cocaine produces a new metabolite, cocaethylene, which has actions similar to cocaine but a longer half-life. Concurrent alcohol use with cocaine may cause more severe and longer lasting toxic effects. (See 'Metabolism' above.)

Drug testing detects the metabolite benzoylecgonine, which is usually detectable two to four days after the last cocaine use, although this can be up to 14 days after heavy, prolonged use. (See 'Elimination' above.)

Cocaine use increases energy and alertness, can produce euphoria, and decreases appetite and need for sleep. Adverse effects may include anxiety, irritability, paranoia, delusions, and hallucinations. These may be accompanied by tachycardia, diaphoresis, nausea, and pupil dilatation. There is poor correlation between cocaine plasma concentrations and toxicity. (See 'Acute intoxication' above.)

Withdrawal symptoms from chronic cocaine use are predominantly psychological: depression, anxiety, anhedonia, cocaine craving, and increased sleep. Most symptoms are self limited and resolve within one to two weeks. (See 'Withdrawal symptoms' above.)

Effects of cocaine on specific organ systems are (see 'Effects on specific organ systems' above):

CNS: seizures, stroke, movement disorders

Cardiovascular: myocardial infarction, arrhythmia, cardiomyopathy, myocarditis

Respiratory: rhinitis and septal perforation (with intranasal use) cough, wheeze, chest pain (with smoked use)

GI: xerostomia, gastric ulcers, ischemic colitis

Diagnoses of cocaine abuse and cocaine dependence in DSM-IV-TR were replaced by the single diagnosis, cocaine use disorder, in DSM-5. (See 'Diagnosis' above.)

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