Highlights & Basics
- Cocaine use disorder is a pattern of cocaine use leading to clinically significant impairment or distress. The majority of people who use cocaine do not have a use disorder. There is an increased risk of dependence with heavier use and when cocaine is smoked or injected.
- Comorbid medical and psychiatric illnesses, as well as other substance use disorders, should be assessed.
- Treatment options are limited with drug counseling as the mainstay.
- There is no evidence to support the use of antipsychotic agents for cocaine dependence. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death.
- Chronic cocaine use can lead to scarring of heart tissue and myocardial hypertrophy and other changes collectively known as myocardial remodeling. These changes constitute the substrate for the occurrence of lethal arrhythmias.
- Psychosis can be seen in chronic users as an isolated condition or as a feature of "excited delirium", an agitated confusional state associated with potentially lethal hyperthermia.
Quick Reference
History & Exam
Key Factors
presence of cocaine or other substance use disorders in family members
hypertension
tachycardia
chest pain
mydriasis
diaphoresis
tremulousness
agitation (mild to severe)
mood changes (e.g., irritability, euphoria, dysphoria)
Other Factors
anxiety (panic state: mild to severe)
drug-induced formication
previous hospitalization for detoxification
suspicious burns (e.g., crack lip, crack thumb)
nasal septum ulceration, perforation
focal neurologic abnormalities
seizure activity
loss of consciousness/altered consciousness
skin lesions (e.g., subcutaneous salmon-colored patches, infections, erosions, necrosis)
dyspnea
Diagnostics Tests
1st Tests to Order
urine toxicology ± gas chromatography/mass spectrometry testing for levamisole
ECG
chest x-ray
CT head
electroencephalogram
Other Tests to consider
CBC
CT chest
bronchoalveolar lavage
transthoracic echocardiogram
Treatment Options
acute
acute intoxication
acute management in emergency department
nonpregnant adults and adolescents: mild cocaine use disorder
nonpregnant adults and adolescents: mild cocaine use disorder
significant mental health issues or prominent psychiatric symptoms
Definition
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Crack lip: burns to the lips, caused by hot pipes, are characteristic of crack cocaine smokers
Coronary dissection: acute myocardial infarction is uncommon in crack cocaine smokers but does occur occasionally. One cause, usually forgotten, is coronary artery dissection
Hematoxylin and eosin stained lung section from a 56-year-old male chronic cocaine abuser who died of an apparent arrhythmia. He had been complaining of shortness of breath for several weeks. Note the thickened alveolar septa; medial hyperplasia is obvious in several vessels. The very dark cells scattered among the alveoli are hemosiderin-containing macrophages, a common find in pulmonary hypertension
Diagnostic Approach
Historical factors
Symptoms
Physical findings
Urine toxicology
Testing for complications
Risk Factors
History & Exam
Tests
Differential Diagnosis
Thyrotoxicosis
Differentiating Signs/Symptoms
- Weight loss may be prominent. May be suggestive findings on physical examination of the thyroid, such as tenderness to palpation, goiter, and thyroid bruit.
Differentiating Tests
- Elevated thyroxine, suppressed thyroid-stimulating hormone.
Differentiating Signs/Symptoms
- Reported history of methamphetamine use. Significant dental erosion and skin ulcerations/other skin lesions from scratching and picking may be present.
Differentiating Tests
- Urine toxicology screening positive for methamphetamine.[33]
Amphetamine abuse
Differentiating Signs/Symptoms
- Medical and psychiatric adverse effects may be longer-lived (days to weeks) than those due to cocaine (typically lasting hours to 2-3 days) due to longer half-life of amphetamines versus cocaine.
Differentiating Tests
- Urine toxicology screening positive for amphetamine.[33]
Differentiating Signs/Symptoms
- Reported history of ephedrine use. Significant weight loss may be evident. Alternatively, there may be evidence of particular attention to physique/muscle development.
Differentiating Tests
- Urine toxicology screening positive for ephedrine.[34]
Mood disorder
Differentiating Signs/Symptoms
- Can be difficult to distinguish clinically and may be comorbid. Somatic symptoms, such as insomnia, weight loss, or psychomotor agitation may be more prominent.
Differentiating Tests
- Clinical interview.
- Use of Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) criteria.[1]
- The Primary Care Evaluation of Mental Disorders (PRIME-MD) may indicate presence of symptoms suggestive of mood disorders.[35]
- The Mood Disorder Questionnaire may indicate presence of symptoms indicative of elevated mood states (hypomania and mania).[36]
- Urine toxicology screening is negative for cocaine or metabolites, unless there is concomitant cocaine use.
Psychotic/paranoid disorder
Differentiating Signs/Symptoms
- History positive for similar states unrelated to episodes of cocaine use.
Differentiating Tests
- Urine toxicology screening is negative for cocaine or metabolites, unless there is concomitant cocaine use.
Personality disorder
Differentiating Signs/Symptoms
- Patients with borderline personality disorder may experience transient paranoid ideation in response to stress; patients with schizotypal personality disorder may experience ideas of reference (but not delusions), as well as odd beliefs or magical thinking. May be a comorbid condition.
Differentiating Tests
- Clinical interview.
- Use of Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) criteria.[1]
- Urine toxicology screening is negative for cocaine or metabolites, unless there is concomitant cocaine use.
Differentiating Signs/Symptoms
- May exert the same symptoms as cocaine intoxication: e.g., excited delirium (psychotic hyperarousal, hyperthermia, cardiac arrest) or hyperadrenergic syndrome.
Differentiating Tests
- Patient history of drug use is key. Not detected by normal urine toxicology screening, so should be suspected (along with psychosis) if a patient with suggestive symptoms and signs tests negative for cocaine and methamphetamine use. Detectable using time of flight spectroscopy, only available in selected large tertiary centers. Results are available after at least 24 hours (too slow to be of clinical value). The distinction is largely academic and treatment should be given for excited delirium or hyper-adrenergic syndrome (if present) as described in this topic.
Criteria
- Using larger amounts of cocaine or over a longer period than was intended
- Persistent desire to cut down or unsuccessful efforts to control use
- Great deal of time spent obtaining, using, or recovering from use
- Craving, or a strong desire or urge to use substance
- Failure to fulfill major role obligations at work, school, or home due to recurrent cocaine use
- Continued use despite recurrent or persistent social or interpersonal problems caused or exacerbated by the effects of cocaine use
- Giving up or reducing social, occupational, or recreational activities due to cocaine use
- Recurrent cocaine use in physically hazardous situations
- Continued cocaine use despite knowledge of having a persistent or recurrent physical or psychologic problem caused or exacerbated by its use
- Tolerance (a need for markedly increased amounts; markedly diminished effect with continued use of the same amount)
- Withdrawal as manifested by cessation of cocaine or use of cocaine (or a closely related substance) to relieve or avoid withdrawal symptoms.
- In early remission: where none of the criteria for cocaine use disorder have been met for at least 3 months but for less than 12 months (with the exception of craving, or a strong desire or urge to use cocaine), but full criteria for cocaine use disorder were previously met.
- In sustained remission: where none of the criteria for cocaine use disorder have been met at any time during a period of 12 months or longer (with the exception of craving, or a strong desire or urge to use cocaine), but full criteria for cocaine use disorder were previously met.
Screening
Healthcare setting
Work setting
Pregnancy
Treatment Approach
Acute cocaine intoxication
General considerations
Mild cocaine use disorder
Moderate to severe cocaine use disorder
- Contingency management uses operant behavioral techniques. Examples include voucher-based reinforcement therapy (VBRT), rewarding the achievement of agreed therapeutic goals. Several small randomized controlled trials have shown that the addition of VBRT to standard treatment increases abstinence in people with cocaine use disorder, including people with comorbid opioid use disorder.[50] [51]
- CBT for cocaine use disorder involves recognition of triggers and teaching of coping skills to avoid drug use. Clinical trials in patients with cocaine dependence comparing CBT with control groups (meditation and relaxation training) or other psychosocial interventions have shown mixed results, although there is some evidence that the coping skills taught with CBT may be effective even once treatment has finished.[50] [60] [61]
- Computerized CBT delivered in a clinical setting has been shown to be as effective as traditional CBT in a diverse group of patients with substance use disorders. Computerized CBT was also associated with lower dropout rates.[63]
- Motivational interviewing is a directive, patient-centered counseling approach that aims to help people change problem behaviors. Clinical trials have only found motivational interviewing to be effective compared with no treatment, but not compared with control interventions such as relaxation training.[50] [64]
Treatment-resistant cocaine use disorder
Pregnancy
Treatment Options
acute intoxication
acute management in emergency department
Comments
- Specific symptom management (e.g., hypertension, tachycardia, chest pain, focal neurologic finding, seizure, significant anxiety/mood/psychotic symptoms), which generally follows the management provided in the absence of cocaine use. For details on the management of acute cocaine intoxication and for information on body-packer syndrome see our topic on Cocaine overdose.
nonpregnant adults and adolescents: mild cocaine use disorder
drug counseling
Comments
- Abrupt stimulant withdrawal typically does not produce dangerous medical consequences, and although dysphoria and other psychiatric symptoms may be significant in the initial period of drug abstinence, pharmacologic treatment is not usually required. Treatment for cocaine use disorder is the same regardless of whether the drug is snorted or smoked, and patients usually benefit from referral to a drug counselor/drug treatment service.[49]
- In general, first-line treatment is with individual or group drug counseling, or a combination of these approaches.[55]
significant mental health issues or prominent psychiatric symptoms
mental health referral
Comments
- Additional referral to mental health services may be a consideration in those with a past history of significant mental health issues or those with a current prominent display of psychiatric symptomatology.
nonpregnant adults and adolescents: moderate to severe cocaine use disorder
intensive outpatient therapy
Comments
- Abrupt stimulant withdrawal typically does not produce dangerous medical consequences, although dysphoria and other psychiatric symptoms may be significant in the initial period of drug abstinence. Selected patients with severe psychiatric symptoms and/or very adverse psychosocial situations (homeless, residing with active substance users) may benefit from a period of highly structured treatment. Intensive outpatient therapy has been shown to be as effective as inpatient or residential programs.[49] [57] [58]
- Individual and group counseling are often combined with couples/family therapy, with typically more than 9 hours of therapy per week over several weeks. However, there is some evidence that lower intensity treatment (for example 6 hours a week) may be just as effective in patients with cocaine dependence.[59]
significant mental health issues or prominent psychiatric symptoms
mental health referral
Comments
- Additional referral to mental health services may be a consideration in those with a past history of significant mental health issues or those with a current prominent display of psychiatric symptomatology.
pregnant
specialist withdrawal management ± inpatient care
Comments
- Where possible, management should be provided by services specializing in substance use in pregnancy. In addition to psychosocial interventions, it is important that appropriate social support is given, including assistance with accommodation, life-skills and vocational training, legal advice, home-visiting, and outreach.[42]
- Because of the risk of harms of ongoing cocaine use to both the mother and fetus, there is a lower threshold for inpatient withdrawal management, which may include nonteratogenic medications for the short-term management of psychologically distressing symptoms.[42]
sustained remission
continuing care
Comments
- Continuing care with drug counseling or intensive outpatient therapy, rather than care limited to periods of acute exacerbation, is likely to help reduce recurrent use, especially for people with family or social issues.[54]
- People with mild cocaine use disorder may not require continuing care.
mutual help group
Comments
- Patients should be advised to seek support groups such as Narcotics Anonymous or Cocaine Anonymous.Narcotics Anonymous Cocaine Anonymous
continued use or relapse
contingency management
Comments
- Contingency management uses operant behavioral techniques. Examples include voucher-based reinforcement therapy (VBRT), rewarding the achievement of agreed therapeutic goals. Several small randomized controlled trials have shown that the addition of VBRT to standard treatment increases abstinence in people with cocaine use disorder, including people with comorbid opioid use disorder.[50] [51]
mutual help group
Comments
- Patients should be advised to seek support groups such as Narcotics Anonymous or Cocaine Anonymous.Narcotics Anonymous Cocaine Anonymous
cognitive behavioral therapy or motivational interviewing
Comments
- Cognitive behavioral therapy (CBT) for cocaine use disorder involves recognition of triggers and teaching of coping skills to avoid drug use. Clinical trials in patients with cocaine dependence comparing CBT with control groups (meditation and relaxation training) or other psychosocial interventions have shown mixed results, although there is some evidence that the coping skills taught with CBT may be effective even once treatment has finished.[50] [60] [61]
- Computerized CBT delivered in a clinical setting has been shown to be as effective as traditional CBT in a diverse group of patients with substance use disorders. Computerized CBT was also associated with lower dropout rates.[63]
- Motivational interviewing is a directive, patient-centered counseling approach that aims to help people change problem behaviors. Clinical trials have only found motivational interviewing to be effective compared with no treatment, but not compared with control interventions such as relaxation training.[50] [64]
mutual help group
Comments
- Patients should be advised to seek support groups such as Narcotics Anonymous or Cocaine Anonymous.Narcotics Anonymous Cocaine Anonymous
treatment resistant
addiction specialist referral
Comments
- If after up to 12 weeks of the most intensive psychosocial treatment a patient continues to relapse, then consider referring them to an expert in addiction for possible adjunctive medication; however, evidence for this is very limited and there is no established guidance.[48]
Emerging Tx
Cocaine vaccine
Agonist-like medications
Modafinil
Disulfiram
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
United Nations Office on Drugs and Crime. World drug report 2021. Drug market trends: cocaine amphetamine-type stimulants. Jun 2021 [internet publication].[Full Text]
Degenhardt L, Wolfe D, Hall W, et al. Strategies to reduce drug-related harm: responding to the evidence base. Lancet. 2019 Oct 26;394(10208):1490-3.[Abstract]
Chan B, Kondo K, Freeman M, et al. Pharmacotherapy for cocaine use disorder-a systematic review and meta-analysis. J Gen Intern Med. 2019 Dec;34(12):2858-73.[Abstract][Full Text]
Minozzi S, Saulle R, De Crescenzo F, et al. Psychosocial interventions for psychostimulant misuse. Cochrane Database Syst Rev. 2016 Sep 29;(9):CD011866.[Abstract][Full Text]
McCarty D, Braude L, Lyman DR, et al. Substance abuse intensive outpatient programs: assessing the evidence. Psychiatr Serv. 2014 Jun 1;65(6):718-26.[Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
A best practices guide for post trauma mental health and substance misuse screening and intervention for trauma centers.Published by
American College of Surgeons
Published
2022
Summary
Guidance on screening for unhealthy drug use in adolescents and adults.Published by
US Preventive Services Task Force
Published
2020
Summary
Guidelines including recommendations on screening and diagnosis of substance use disorders in pregnancy.Published by
World Health Organization
Published
2014
Summary
Guidelines on assessing and managing comorbid severe mental illness and substance misuse in people ages 14 years and older.Published by
National Institute for Health and Care Excellence
Published
2011
Treatment
Summary
Guidelines including recommendations and clinical algorithms for the management of substance use disorders.Published by
US Department of Veterans Affairs; Department of Defense
Published
2021
Summary
Includes recommendations on treatment, education, and workforce, and public health interventions for substance use disorders.Published by
American College of Physicians
Published
2017
Summary
Guidance on targeted interventions to prevent misuse of drugs, including illegal drugs, "legal highs", and prescription-only medicines.Published by
National Institute for Health and Care Excellence
Published
2017
Summary
Guidelines including recommendations on screening and diagnosis of substance use disorders in pregnancy.Published by
World Health Organization
Published
2014
Summary
Guidelines on assessing and managing comorbid severe mental illness and substance misuse in people ages 14 years and older.Published by
National Institute for Health and Care Excellence
Published
2011
Summary
Guidelines on psychosocial interventions for adults and young people over 16 years who have a problem with or are dependent on opioids, stimulants, or cannabis.Published by
National Institute for Health and Care Excellence
Published
2007