Cocaine Toxicity (Cocaine Overdose)

What to do in a cocaine overdose

1. Call 911 or your local emergency number. Many US states have Good Samaritan laws that protect people who call for help during an overdose.
2. Check breathing. If breathing is slow, shallow or absent, or lips are blue, give naloxone (Narcan) if available. Fentanyl contamination is common, and naloxone is safe even if no opioid is involved.
3. Start CPR if the person is not breathing normally.
4. During a seizure, move hard objects away, cushion the head and do not put anything in the mouth. Afterward, roll them onto their side.
5. If they are overheated, move them to a cool place, remove extra clothing, and cool them with water and fanning.
6. Stay calm and keep surroundings quiet. Do not restrain an agitated person unless needed for safety.
7. Stay with them until help arrives.

How cocaine harms the body

Cocaine blocks the reuptake of dopamine, norepinephrine and serotonin, flooding the brain and body with these chemicals. This causes:

• heart overload: faster heart rate, higher blood pressure and greater oxygen demand
• narrowing of blood vessels: including the coronary arteries, reducing blood flow to the heart and brain
• blood clotting: platelets become stickier
• heart rhythm disturbances: cocaine also blocks sodium channels in the heart, similar to some poisonings
• overheating: increased muscle activity and impaired heat regulation

Combining cocaine with alcohol produces cocaethylene, a compound that is more toxic to the heart than either alone.

Signs and symptoms

Early or moderate toxicity

• racing heart and palpitations
• high blood pressure
• sweating, dilated pupils
• agitation, anxiety, paranoia
• tremor, muscle twitching
• nausea

Severe toxicity

• chest pain: from heart attack, coronary spasm, aortic dissection or a collapsed lung
• irregular heartbeat and cardiac arrest
• stroke: bleeding or blocked blood flow in the brain
• seizures
• hyperthermia: body temperature above 40 °C (104 °F)
• severe agitation and delirium, sometimes called excited delirium
• rhabdomyolysis: muscle breakdown causing dark urine and kidney damage
• bowel ischemia: severe belly pain from reduced blood flow to the gut

Signs of a fentanyl-contaminated overdose

• very slow or stopped breathing
• pinpoint pupils
• blue or gray lips and fingertips
• unresponsiveness or gurgling sounds

Cocaine and chest pain

Chest pain is the most common reason people seek emergency care after cocaine. Cocaine raises the risk of heart attack many times over in the hour after use, even in people with normal arteries. Never ignore chest pain after cocaine, even if you are young and fit. In the ER, doctors check an ECG and troponin blood tests, and look for aortic dissection and other causes.

Hospital treatment

• Benzodiazepines (such as lorazepam or diazepam) are the main treatment: they calm agitation, lower heart rate and blood pressure, and prevent seizures.
• Cooling for high body temperature: ice packs, cool mist and fans, and in severe cases intensive care cooling.
• Intravenous fluids for dehydration and to protect the kidneys from muscle breakdown.
• Aspirin and nitroglycerin for cocaine-related chest pain, with heart artery procedures if a heart attack is confirmed.
• Sodium bicarbonate for certain dangerous heart rhythm changes.
• Blood pressure control with medicines that dilate blood vessels.
• Brain scans for stroke symptoms.
• Naloxone and breathing support if opioids are involved.

Long-term risks of cocaine use

• heart disease, heart failure and arrhythmias
• stroke
• damage to the nose and palate from snorting
• lung damage from smoking crack
• anxiety, paranoia and psychosis
• dependence and substance use disorder
• infections such as HIV and hepatitis C with injecting

Getting help

Cocaine use disorder is treatable. Cognitive behavioral therapy, contingency management (rewards for drug-free tests) and support groups are the most effective treatments. There is no approved medicine specifically for cocaine use disorder yet, but doctors can treat co-existing conditions. Harm reduction measures include never using alone, carrying naloxone, and using fentanyl test strips where legal.

Frequently asked questions

What are the signs of a cocaine overdose?

Signs include chest pain, a racing or irregular heartbeat, very high body temperature, extreme agitation or paranoia, confusion, seizures and collapse. Slow or stopped breathing and pinpoint pupils suggest the cocaine was mixed with fentanyl. Call 911 immediately.

Can you have a heart attack from cocaine the first time?

Yes. Cocaine can trigger a heart attack, dangerous heart rhythms or stroke in first-time users and in young people with healthy hearts. The risk is highest in the first hour after use. Any chest pain after cocaine needs emergency evaluation.

Should I give naloxone for a cocaine overdose?

Yes, if the person's breathing is slow, shallow or has stopped, or they are unresponsive. Much cocaine is contaminated with fentanyl, an opioid. Naloxone reverses opioid effects and is harmless if no opioid is present. Call 911 as well.

How long does cocaine toxicity last?

The effects of snorted cocaine peak within about 30 minutes and wear off within 1 to 2 hours, and smoked cocaine acts even faster. However, complications such as heart attack, stroke and muscle breakdown can develop or persist for hours to days, and need hospital care.