Cocaine Abuse and Cocaine Use Disorder

How cocaine affects the brain and body

Cocaine blocks the reuptake of dopamine, norepinephrine and serotonin, so these chemicals build up between nerve cells. The result is a short-lived rush of euphoria, energy and confidence, lasting 15 to 30 minutes when snorted and 5 to 10 minutes when smoked. The intense but brief high drives repeated use in binges.

At the same time, cocaine constricts blood vessels, raises heart rate and blood pressure, increases body temperature and makes the heart more irritable.

Over time, the brain's reward system adapts. More cocaine is needed for the same effect, normal pleasures feel flat, and stress and cues (people, places, money) trigger strong cravings.

Signs of cocaine use

Short-term signs

• dilated pupils
• talkativeness, high energy, restlessness, reduced need for sleep and food
• runny nose, sniffing or nosebleeds (snorting)
• burns on lips and fingers (smoking crack)
• jaw clenching
• irritability, anxiety or paranoia

Signs of a problem over time

• frequent "crashes" with exhaustion, low mood and long sleep
• unexplained spending, borrowing or stealing
• secrecy, new social circles, missing work or school
• weight loss
• loss of smell, chronic nasal problems or a hole in the nasal septum
• continuing use despite health, legal or relationship problems

Cocaine use disorder

Doctors diagnose stimulant use disorder when someone has at least 2 of 11 criteria within a year, including:

• using more or for longer than intended
• unsuccessful efforts to cut down
• spending a lot of time getting, using or recovering
• cravings
• failing at work, school or home
• giving up important activities
• using in dangerous situations
• continuing despite physical or psychological harm
• tolerance and withdrawal

Health risks

Heart and blood vessels

• heart attack, even in young adults with normal arteries, especially in the first hour after use
• dangerous heart rhythms and sudden death
• aortic dissection, a tear in the main artery
• stroke from bleeding or blocked vessels
• long-term heart muscle damage

Cocaine combined with alcohol forms cocaethylene, which is more toxic to the heart than either drug alone.

Brain and mental health

• seizures
• substance-induced psychosis with paranoia and hallucinations
• depression and suicidal thoughts during withdrawal
• problems with attention, memory and decision-making

Other harms

• nasal damage from snorting; lung damage ("crack lung") from smoking
• HIV, hepatitis C, endocarditis and skin infections from injecting
• bowel damage from reduced blood flow
• harm in pregnancy: placental abruption, preterm birth and low birth weight

Overdose and fentanyl

A cocaine overdose (cocaine toxicity) causes extreme agitation, high temperature, chest pain, seizures, stroke or cardiac arrest. Today, many overdose deaths involving cocaine also involve fentanyl, often without the user knowing. See stimulant overdose. Carrying naloxone and fentanyl test strips, never using alone, and calling 911 early save lives.

Withdrawal

Stopping after heavy use causes a "crash": exhaustion, increased sleep and appetite, depression, irritability, anxiety and intense cravings. Withdrawal is not usually physically dangerous, but depression and suicidal thoughts can be severe. Low mood and cravings may last weeks.

Treatment

There is no FDA-approved medicine for cocaine use disorder yet, but effective treatments exist:

• Contingency management: rewards such as vouchers for drug-free urine tests; one of the most effective approaches for stimulant use.
• Cognitive behavioral therapy (CBT): identifies triggers and builds coping skills.
• Community reinforcement approach and family therapy.
• Mutual support groups: Cocaine Anonymous, Narcotics Anonymous, SMART Recovery.
• Treatment of co-occurring conditions: depression, ADHD, PTSD, alcohol use.
• Residential or outpatient programs depending on severity.
• Harm reduction: naloxone, fentanyl test strips, not using alone, and safer use supplies.

Relapse is common and is part of a chronic condition, not a failure. Returning to treatment helps.

Helping someone else

• talk privately when they are sober, using concern rather than blame
• encourage a primary care visit or call to the SAMHSA helpline
• learn to recognize overdose and carry naloxone
• look after your own support, such as Nar-Anon or family therapy

Frequently asked questions

What are the signs of cocaine use?

Signs include dilated pupils, high energy and talkativeness, little need for sleep or food, sniffing or nosebleeds, followed by crashes with exhaustion and low mood. Over time, look for secrecy, money problems, weight loss, paranoia and neglecting responsibilities.

What does cocaine do to the heart?

Cocaine raises heart rate and blood pressure, narrows blood vessels and makes the heart prone to dangerous rhythms. It can cause heart attacks, strokes and aortic tears, even in young people and first-time users. Long-term use damages heart muscle.

Is there medication for cocaine addiction?

No medicine is currently FDA-approved for cocaine use disorder. Behavioral treatments, especially contingency management and cognitive behavioral therapy, are the most effective. Medicines may treat co-occurring depression or other conditions, and research on new drugs continues.

How long does cocaine withdrawal last?

The initial crash lasts hours to a few days, with exhaustion and low mood. Depression, poor sleep, irritability and strong cravings can persist for several weeks, and cravings can return months later in response to triggers.

Why is cocaine more dangerous now?

Much of the illicit drug supply is contaminated with fentanyl, a powerful opioid, which causes fatal overdoses in people who did not intend to take opioids. Using fentanyl test strips, never using alone and carrying naloxone reduce the risk.