Cocaine

What Is Cocaine?

Cocaine is a powerful central nervous system stimulant extracted from the leaves of the coca plant (Erythroxylum coca), native to South America. It is classified as a Schedule II controlled substance in the United States, meaning it has high abuse potential but limited accepted medical use as a local anesthetic.

The UNODC World Drug Report 2024 estimates that approximately 23 million people worldwide used cocaine in the past year. In the United States, the 2024 SAMHSA National Survey on Drug Use and Health found that 5.7 million Americans aged 12 or older used cocaine in the past year.

How Cocaine Works

Cocaine blocks the reuptake of three key neurotransmitters: dopamine, norepinephrine, and serotonin. By preventing these chemicals from being recycled back into nerve cells, cocaine causes them to accumulate in the synapse, producing amplified signaling.

The dopamine surge is primarily responsible for cocaine's euphoric effects and its addictive potential. Normal activities that release dopamine (eating, social interaction, exercise) produce modest increases. Cocaine can increase dopamine levels by 300-800% above baseline, fundamentally overwhelming the brain's reward circuitry.

Routes of Administration

Route	Form	Onset	Duration	Bioavailability
Intranasal (snorting)	Powder	3-5 minutes	15-30 minutes	60-80%
Smoking (crack)	Rock/freebase	8-10 seconds	5-10 minutes	60-70%
Intravenous	Dissolved powder	15-30 seconds	20-60 minutes	100%
Oral (gumming)	Powder on gums	10-30 minutes	45-90 minutes	33%

Faster routes of administration (smoking, injection) produce more intense but shorter highs, which drives more compulsive redosing patterns and accelerates the development of addiction.

Cocaine Short-Term Effects

System	Effect	Mechanism
Neurological	Euphoria, alertness, increased energy, reduced fatigue	Dopamine and norepinephrine flood
Cardiovascular	Increased heart rate, elevated blood pressure, vasoconstriction	Norepinephrine stimulation of sympathetic nervous system
Respiratory	Rapid breathing, potential chest pain	CNS stimulation
Psychological	Confidence, talkativeness, paranoia (at high doses)	Dopamine and serotonin effects
Physical	Dilated pupils, elevated body temperature, decreased appetite	Sympathetic activation
Gastrointestinal	Nausea, reduced appetite	Serotonin and norepinephrine effects

Cocaine Long-Term Effects

Cardiovascular Damage

Chronic cocaine use causes persistent cardiovascular damage that represents the leading cause of cocaine-related death outside of acute overdose:

• Atherosclerosis acceleration - cocaine damages blood vessel linings and promotes plaque buildup at rates far exceeding normal aging
• Cardiomyopathy - the heart muscle weakens and enlarges, reducing its pumping efficiency
• Aortic dissection - tears in the aorta wall, which can be rapidly fatal
• Heart attack - cocaine users have a 7x higher risk of heart attack in the hour after use, regardless of age or fitness
• Arrhythmias - irregular heartbeats that can cause sudden cardiac death

Neurological and Psychological

• Dopamine system damage - chronic use reduces the brain's natural dopamine production, leading to anhedonia (inability to feel pleasure) during abstinence
• Cognitive impairment - deficits in attention, memory, decision-making, and impulse control that can persist months after cessation
• Cocaine-induced psychosis - paranoia, hallucinations (including tactile "coke bugs"), and aggressive behavior
• Seizure threshold reduction - increased vulnerability to seizures
• Cerebrovascular events - hemorrhagic and ischemic strokes

Route-Specific Damage

• Snorting - deviated septum, chronic nosebleeds, loss of smell, nasal septum perforation
• Smoking (crack) - "crack lung" (acute respiratory distress), chronic cough, asthma exacerbation
• Injecting - HIV/hepatitis C transmission, abscesses, endocarditis (heart valve infection), collapsed veins

Cocaine Overdose Deaths and Statistics

Year	US Deaths Involving Cocaine	Source
2023	24,486	CDC WONDER
2022	27,569	CDC WONDER
2021	24,486	CDC WONDER
2020	19,447	CDC WONDER
2019	15,883	CDC WONDER

Critical context: Over 70% of cocaine overdose deaths also involve opioids, primarily fentanyl. The contamination of cocaine supply with fentanyl has dramatically increased cocaine-related fatalities since 2015. Many users who die from "cocaine overdose" were unaware their cocaine contained fentanyl.

Cocaine Overdose Signs

• Severe agitation, panic, or psychosis
• Chest pain or pressure
• Dangerously elevated body temperature (hyperthermia)
• Seizures
• Irregular or rapid heartbeat
• Difficulty breathing
• Loss of consciousness

Emergency Response

1. Call 911 immediately - cocaine overdose can cause cardiac arrest within minutes
2. If person is seizing, clear the area of objects and protect their head
3. If unconscious and breathing, place in recovery position
4. Administer naloxone if available - many cocaine overdoses involve fentanyl contamination
5. Cool the person if showing signs of hyperthermia (remove clothing, apply cool water)
6. Stay with the person until EMS arrives

Cocaine and Fentanyl: The Deadly Combination

Fentanyl contamination of the cocaine supply has become a critical public health crisis. Users who intentionally avoid opioids are dying because their cocaine contains fentanyl without their knowledge. The DEA reports that fentanyl has been found in cocaine across all major US markets.

Fentanyl test strips can detect fentanyl contamination in cocaine but require proper technique. Dissolving a small amount of cocaine in water and testing before use can identify contaminated batches. However, fentanyl is not always evenly distributed throughout a batch, meaning one portion may test negative while another contains lethal amounts.

Signs of Cocaine Addiction (DSM-5 Stimulant Use Disorder)

Severity	Criteria Met (of 11)	Clinical Implications
Mild	2-3	Early intervention; outpatient assessment recommended
Moderate	4-5	Structured treatment; intensive outpatient or PHP
Severe	6+	Residential treatment strongly recommended

Key diagnostic indicators include:

• Using more cocaine or for longer than intended
• Persistent desire or unsuccessful efforts to cut down
• Spending excessive time obtaining, using, or recovering from cocaine
• Cravings or strong urges to use
• Failure to fulfill major obligations (work, school, family)
• Continued use despite social or interpersonal problems
• Tolerance - needing more to achieve the same effect

Cocaine Withdrawal Timeline

Phase	Timeframe	Symptoms
Crash	Hours to 3 days	Extreme fatigue, increased appetite, depression, irritability, hypersomnia (sleeping 12-20 hours), intense cravings
Withdrawal	1-10 weeks	Anhedonia (inability to feel pleasure), anxiety, irritability, difficulty concentrating, disturbed sleep, intermittent cravings
Extinction	Months to years	Episodic cravings triggered by environmental cues, gradually decreasing in frequency and intensity

Unlike opioid withdrawal, cocaine withdrawal is not typically medically dangerous. However, the profound depression and anhedonia during the withdrawal phase create significant relapse risk and may require psychiatric monitoring.

Cocaine Treatment Options

Medication Research (No FDA-Approved Medications)

Unlike opioid or alcohol addiction, there are currently no FDA-approved medications specifically for cocaine use disorder. Research is ongoing for several candidates:

• Topiramate - anticonvulsant showing promise in reducing cocaine use
• Disulfiram - approved for alcohol use disorder; some evidence for cocaine reduction
• Modafinil - wakefulness agent being studied for cocaine dependence
• Cocaine vaccine - in clinical trials; stimulates antibodies that bind cocaine before it reaches the brain
• N-acetylcysteine (NAC) - antioxidant showing promise in restoring glutamate balance

Behavioral Therapies (Primary Treatment)

• Cognitive Behavioral Therapy (CBT) - identifies and changes thought patterns and behaviors associated with cocaine use. Teaches coping skills for triggers and cravings
• Contingency Management (CM) - provides tangible incentives (vouchers, prizes) for verified cocaine-free urine tests. Has the strongest evidence base for cocaine addiction
• Community Reinforcement Approach (CRA) - restructures social, recreational, and occupational activities to make cocaine-free lifestyle more rewarding than use
• Matrix Model - structured 16-week program combining CBT, family education, individual counseling, 12-step support, and drug testing
• 12-Step Facilitation - engagement with Cocaine Anonymous (CA) or Narcotics Anonymous (NA)

Levels of Care (ASAM Criteria)

Level	Setting	Duration	Indication
3.5	Residential Treatment	28-90 days	Severe use disorder; unstable environment
2.5	Partial Hospitalization (PHP)	2-4 weeks	Moderate severity; stable housing
2.1	Intensive Outpatient (IOP)	8-16 weeks	Mild-moderate severity; motivated
1.0	Outpatient	Ongoing	Maintenance; step-down from higher levels

Cocaine Legal Status

Cocaine is a Schedule II controlled substance under the US Controlled Substances Act. This means it has high abuse potential but has accepted medical use as a local anesthetic (topical application in certain ear, nose, and throat procedures).

Federal penalties for cocaine trafficking:

• 500g+ powder cocaine: 5-40 years (first offense); 10 years to life (second offense)
• 5kg+ powder cocaine: 10 years to life (first offense); 20 years to life (second offense)
• 28g+ crack cocaine: 5-40 years (first offense)
• 280g+ crack cocaine: 10 years to life (first offense)

The Fair Sentencing Act of 2010 reduced the sentencing disparity between crack and powder cocaine from 100:1 to 18:1. The First Step Act of 2018 made this change retroactive.

Cocaine Emergency Resources

Resource	Contact
Emergency Services	911
SAMHSA National Helpline	1-800-662-4357 (free, 24/7)
988 Suicide and Crisis Lifeline	Call or text 988
Poison Control	1-800-222-1222
Cocaine Anonymous	ca.org

Cocaine Sources

• NIDA - Cocaine DrugFacts
• CDC WONDER - Drug Overdose Deaths
• UNODC World Drug Report 2024
• DEA - Cocaine Fact Sheet
• SAMHSA - Treatment for Stimulant Use Disorders
• Wikipedia - Cocaine

---

This guide is for educational purposes only and does not constitute medical or legal advice. Always consult a qualified healthcare professional. If you are experiencing an overdose emergency, call 911 immediately. Call 988 (Crisis Lifeline) or 1-800-662-4357 (SAMHSA) for help.

Published by United Rehabs | unitedrehabs.com