Cocaine is extracted from the coca plant, which grows in Central and South America. The substance is processed into many forms for use as an illegal drug of abuse. Cocaine is dangerously addictive, and users of the drug experience a high—a feeling of euphoria or intense happiness, along with hypervigilance, increased sensitivity, irritability or anger, impaired judgment, and anxiety.
Forms of the drug
In its most common form, cocaine is a whitish crystalline powder that produces feelings of euphoria when ingested. In powder form, cocaine is known by such street names as coke, blow, C, flake, snow, and toot. It is most commonly inhaled or snorted. It may also be dissolved in water and injected.
Crack is a form of cocaine that can be smoked and that produces an immediate, more intense, and more short-lived high. It comes in off-white chunks or chips called rocks.
In addition to their stand-alone use, both cocaine and crack are often mixed with other substances. Cocaine may be mixed with methcathinone to create what is termed a wildcat. Cigars may be hollowed out and filled with a mixture of crack and marijuana. Either cocaine or crack used in conjunction with heroin is called a speedball. Cocaine used together with alcohol represents the most common fatal two-drug combination.
The patterns of cocaine abuse in the United States changed a lot between 1985 and 2015. They have been changing in other parts of the world as well, including South America and Western Europe. In the United States, several studies have attempted to track drug abuse in many different populations. The studies include: the Monitoring the Future Study (MTF); the National Household Survey on Drug Abuse (NHSDA); the Drug Abuse Warning Network (DAWN), which gets reports from emergency rooms and medical examiners' offices on drug-related cases and deaths; and Arrestee Drug Abuse Monitoring (ADAM), which gets information on urine samples obtained from people who have been arrested.
In the annual MTF study, cocaine use among high-school seniors declined from 13.1% in 1985 to 3.1% in 1992—the lowest it had been since 1975, when the survey was first implemented. The rate of cocaine use began to rise again and peaked at 5.5% in 1997. The NHSDA found that the levels of cocaine use declined over the same period. The decline in the rates has been thought to be due in part to education about the risks of cocaine abuse. These rates have held in studies as recent as 2016.
The incidence of new crack cocaine users also decreased. There was a minimal decline in the numbers of excessive cocaine users between the years 1985 and 1997. The Epidemiologic Catchment Area (ECA) studies done in the early 1980s combined cocaine dependence with cocaine abuse and found that one-month to six-month prevalence rates for cocaine abuse and dependence were low or could not be measured. The lifetime rate of cocaine abuse was 0.2%.
A 1997 study from the National Institute on Drug Abuse indicates that among outpatients who abuse substances, 55% abuse cocaine. Forty percent of drug-related emergency room visits involved cocaine.
Cocaine abuse affects both genders and many different populations across the United States. Males are one-and-a-half to two times more likely to abuse cocaine than females. Cocaine abuse expanded among the upper classes in the 1970s; later, the socioeconomic status of cocaine users shifted. Cocaine abuse entered lower economic classes with the advent of crack cocaine in the 1980s, which was easy to get and relatively inexpensive (current prices range from $60 to $120 per gram). These factors have led to increased violence (people who are cocaine dependent may become involved in illegal activities in order to acquire funds for their habit) and higher rates of acquired immune deficiency (AIDS) among disadvantaged populations.
A 2016 National Survey on Drug Use and Health (NSDUH) survey reported that since 2009 the rate of use had remained steady: In 2014, there were an estimated 1.5 million Americans age 12 and older who were currently (as of the previous month) using cocaine. That survey estimated that among adults 18 to 25 years of age the current rate was 1.4%.
Cocaine-related disorders form a broad topic. According to the mental health clinician's handbook, Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), the broad category of cocaine-related disorders has been condensed into a subcategory of the substance use disorder with three levels of severity. Two or three symptoms constitute a mild level, four or five a moderate level, and more than five a severe level. The eleven symptoms of cocaine use disorder are:
- larger amounts taken or over a longer period than was intended
- A persistent desire or unsuccessful efforts to cut down or control cocaine use
- A great deal of time spent in activities necessary to obtain cocaine, use it, or recover from its effects
- Craving, or a strong desire or urge to use cocaine
- Failure to fulfill major role obligations at work, school, or home due to cocaine use
- Continued cocaine use despite having persistent or recurrent social or interpersonal problems because of cocaine use
- Important social, occupational, or recreational activities given up or reduced because of cocaine use
- Recurrent cocaine use in situations in which it is physically hazardous
- Continued cocaine use despite a persistent or recurrent physical or psychological problem because of cocaine use
- Development of tolerance
- Withdrawal symptoms that occur after stopping or reducing use
Cocaine abuse and dependence
The terms cocaine abuse and cocaine dependence are no longer used as diagnoses. However, the terms are still commonly used. For cocaine abusers, the use of the substance leads to maladaptive behavior over a 12-month period. Individuals may fail to meet responsibilities at school, work, or home. The cocaine abuse impairs their judgment, and these individuals put themselves in physical danger to use the substance. For example, individuals may use cocaine in an unsafe environment. Those who abuse cocaine may be arrested or charged with possession of the substance yet continue to use cocaine despite the personal and legal problems that may result. As a diagnosis, the term cocaine abuse has been replaced with mild substance use disorder with a distinction that the substance is cocaine.
Cocaine dependence is even more serious than cocaine abuse. Dependence is a maladaptive behavior that, over a three-month period, has caused affected individuals to experience tolerance for, and withdrawal symptoms from, cocaine. Tolerance is the need to increase the amount of cocaine intake to achieve the same desired effect. In other words, individuals who are dependent on cocaine need more cocaine to produce the same high that a lesser amount produced in the past. Dependent persons also experience cocaine withdrawal. Withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. As a diagnosis, cocaine abuse has been replaced with moderate to severe substance use disorder with a distinction that the substance is cocaine.
Cocaine-induced psychological problems
Cocaine intoxication occurs after recent cocaine use. Individuals experience a feeling of intense happiness, hypervigilance, increased sensitivity, irritability or anger, with impaired judgment, and anxiety. The intoxication impairs their ability to function at work or school or in social situations.
Withdrawal symptoms develop within hours or days after cocaine use that has been heavy and prolonged and then abruptly stopped. The symptoms include irritable mood and two or more of the following symptoms: fatigue, nightmares, difficulty sleeping or too much sleep, elevated appetite, agitation (restlessness), or slowed physical movements.
Before the acceptance of the DSM-V health-care professionals used the diagnosis of cocaine-induced delirium. Patients with this psychological problem have a disturbance of their level of consciousness or awareness, evidenced by drowsiness or an inability to concentrate or pay attention. Patients also experience a change in their cognition (ability to think) shown by a deficit in their language or their memory. For example, these patients may forget where they have placed an item, or their speech may be confusing. These symptoms have rapid onset within hours or days of using cocaine, and the symptoms fluctuate throughout the course of the day. These findings cannot be explained by dementia (state of impaired thought processes and memory that can be caused by various diseases and conditions). Furthermore, there is no evidence suggesting a physical reason that accounts for the symptoms other than cocaine intoxication.
Cocaine-induced psychosis, with delusions
Individuals with this disorder have experienced intoxication or withdrawal from cocaine within a month from the time they began to experience delusions (beliefs that they continue to maintain, despite evidence to the contrary). In order for this state to be considered as cocaine-induced psychosis, these symptoms cannot be due to another condition or substance.
Cocaine-induced psychosis, with hallucinations
This condition is the same as cocaine-induced psychotic disorder with delusions, except that affected individuals experience hallucinations instead of delusions. Hallucinations can be described as hearing and seeing things that are not real.
Cocaine-induced mood instability
Individuals with this disorder have experienced intoxication or withdrawal from cocaine within a month from the time they begin to experience depressed, elevated, or irritable mood with apathy (lack of empathy for others and lack of showing a broad range of appropriate emotions).
Individuals with this disorder have experienced intoxication or withdrawal from cocaine within a month from the time they begin to experience anxiety, panic attacks, obsessions, or compulsions. Panic attacks are discrete episodes of intense anxiety. Persons affected with panic attacks may experience accelerated heart rate, shaking or trembling, sweating, shortness of breath, or fear of going crazy or losing control, as well as other symptoms. An obsession is an unwelcome, uncontrollable, persistent idea, thought, image, or emotion that these individuals cannot help thinking even though doing so creates significant distress or anxiety. A compulsion is a repetitive, excessive, meaningless activity or mental exercise that individuals perform in an attempt to avoid distress or worry.
Cocaine-induced sexual dysfunction
Individuals with this disorder have experienced intoxication or withdrawal from cocaine within a month from the time they began to experience sexual difficulties, and these difficulties are deemed by the clinician to be due directly to the cocaine use. Substance-induced sexual difficulties can include impaired desire, impaired arousal, impaired orgasm, or sexual pain.
Cocaine-induced sleep problems
This condition is characterized by difficulty sleeping (insomnia) during intoxication or increased sleep duration when patients are in withdrawal.
Twin studies have demonstrated that there is a higher rate of cocaine abuse in identical twins as compared to fraternal twins. This indicates that genetic factors contribute to the development of cocaine abuse. This finding also indicates, however, that unique environmental factors contribute to the development of cocaine abuse as well. (If genes alone determined who would develop cocaine dependence, 100% of the identical twins with the predisposing genes would develop the disorder. However, because the results show only a relationship, or a correlation, between genetics and cocaine use among twins, these results indicate that other factors must be at work as well.) Studies have also shown that disorders such as attention deficit hyperactivity disorder (ADHD), conduct disorder, and antisocial personality disorder all have genetic components, and since patients who abuse cocaine have a high incidence of these diagnoses, they may also be genetically predisposed to abusing cocaine.
Learning and conditioning play a unique role in the perpetuation of cocaine abuse. Each inhalation and injection of cocaine causes pleasurable feelings that reinforce the drug-taking procedure. In addition, the patient's environment plays a role in cueing and reinforcing the experience in the patient's mind. The association between cocaine and environment is so strong that many people recovering from cocaine addiction report that being in an area where they used drugs brings back memories of the experience and makes them crave drugs. Specific areas of the brain are thought to be involved in cocaine craving, including the amygdala (a part of the brain that controls aggression and emotional reactivity) and the prefrontal cortex (a part of the brain that regulates anger, aggression, and the brain's assessment of fear, threats, and danger).
The following list is a summary of the acute (short-term) physical and psychological effects of cocaine on the body:
- constricted blood vessels
- elevated heart rate
- elevated blood pressure
- a feeling of intense happiness
- elevated energy level
- a state of increased alertness and sensory sensitivity
- elevated anxiety
- panic attacks
- elevated self-esteem
- diminished appetite
- spontaneous ejaculation and heightened sexual arousal
- psychosis (loss of contact with reality)
The following list is a summary of the chronic (long-term) physical and psychological effects of cocaine on the body:
- depressed mood
- physical agitation
- decreased motivation
- difficulty sleeping
- elevated anxiety
- panic attacks
When cocaine use is suspected, the health-care provider may ask the patient specifically about swallowing, injecting, or smoking the substance. Urine and blood testing will also be conducted to determine the presence of the substance. Doctors may talk to friends or relatives concerning the patient's drug use, especially for cases in which the physician suspects that the patient is not being honest about substance use. The clinician may also investigate a patient's legal history for drug arrests that may give clues to periods of substance abuse to which the patient will not admit.
Differential diagnosis is the process of distinguishing one condition from other, similar conditions. The cocaine abuse disorder is easily confused with other substance abuse disorders and various forms of mental illness.
The symptoms of cocaine intoxication, such as increased talkativeness, poor sleep, and the intense feelings of happiness, are similar to the symptoms for bipolar disorder, so the urine toxification screening test may play a key role in the diagnosis. Patients with cocaine intoxication with hallucinations and delusions can be mistaken for schizophrenic patients instead, further emphasizing the importance of the urine and blood screens. As part of establishing the diagnosis, the physician must also rule out PCP (phencyclidine) intoxication and Cushing's disease (an endocrine disorder of excessive cortisol production). Withdrawal symptoms are similar to those of patients with major depression. For this reason, the clinician may ask patients about their mood during times of abstinence from drug use to discern whether any true mood disorders are present. If cocaine use is causing depression, the depression should resolve within a couple of weeks of stopping drug use.
The breakdown products of cocaine remain in the urine. The length of time that they remain depends on the dose of cocaine, but most doses would not remain in the urine longer than a few days. Cocaine can also be found in other bodily fluids such as blood, saliva, and sweat, and in hair, and these provide better estimates as to recent cocaine use. The hair can hold evidence that a patient has been using drugs for weeks to months. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) are different kinds of imaging studies. Both kinds of scans look at the amount of blood that is flowing to the brain. When these images are taken of the brains of people who abuse cocaine, the resulting scans can reveal abnormalities in certain sections of the brain. The brains of people addicted to cocaine shrink, or atrophy.
Neuropsychological testing is an important tool for examining the effects of toxic substances on brain function. Some physicians may use neuropsychological assessments to reveal patients' cognitive and physical impairment after cocaine use. Neuropsychological testing assesses brain functioning through structured and systematic behavioral observation. Neuropsychological tests are designed to examine a variety of cognitive abilities, including speed of information processing, attention, memory, and language. An example of a task that a physician might ask the patient to complete as part of a neuropsychological examination is to name as many words beginning with a particular letter as the patient can in one minute. Patients who abuse cocaine often have difficulty completing tasks, such as this one, that require concentration and memory.
Psychological and social interventions
Not all patients who abuse cocaine need to resort to long-term treatment. Treatment length varies with the degree that individuals are dependent on the substance. If patients have other psychiatric conditions, such as major depression or schizophrenia, or has significant medical complications of cocaine abuse, then they are more likely to require higher-intensity treatment. Residential programs or therapeutic communities may be helpful, particularly in more severe cases. Patients typically spend six to 12 months in such programs, which may also include vocational training and other features. The availability of such treatment, as well as medical insurance's ability to cover treatment, are all issues that affect patient access to treatment.
A wide range of behavioral interventions have been successfully used to treat cocaine addiction. The approach used must be tailored to the specific needs of individual patients, however.
Contingency management rewards drug abstinence (confirmed by urine testing) with points or vouchers that patients can exchange for such benefits as an evening out or membership in a gym. Cognitive-behavioral therapy helps users learn to recognize and avoid situations most likely to lead to cocaine use and to develop healthier ways to cope with stressful situations.
Supportive therapy helps patients to modify their behavior, preventing relapse by taking actions such as staying away from drug-using friends and from neighborhoods or situations where cocaine is abundant.
Self-help groups such as Narcotics Anonymous (NA) or Cocaine Anonymous (CA) are helpful for many recovering substance abusers. CA is a 12-step program for cocaine abusers, modeled after Alcoholics Anonymous (AA). Support groups and group therapy led by a therapist can be helpful because other addicts share coping and relapse-prevention strategies. The group's support can help patients face devastating changes and life issues. Some experts recommend that patients be cocaine-free for at least two weeks before participating in a group, but other experts argue that a two-week waiting period is unnecessary and counterproductive. Group counseling sessions led by drug counselors who are in recovery themselves are useful for some people overcoming their addictions. These group counseling sessions differ from group therapy in that the people in a counseling group are constantly changing.
The National Institute of Drug Abuse conducted a study comparing different forms of psychotherapy: patients who had both group drug counseling and individual drug counseling had improved outcomes. Patients who had cognitive-behavioral therapy stayed in treatment longer.
Over 20 medications have been tested, but none has been found to reduce the intensity of withdrawal. Dopamine agonists such as amantadine and bromocriptine and tricyclic antidepressants such as desipramine have failed in studies to help treat symptoms of cocaine withdrawal or intoxication.
Alternative techniques, such as acupuncture, EEG biofeedback, and visualization, may be useful in treating addiction when combined with conventional treatment approaches.
Not all cocaine abusers become dependent on the drug. However, even someone who only uses occasionally can experience the harmful effects (interpersonal relationship conflicts and work or school difficulties) of using cocaine, and even occasional use is enough to cause addiction. In the course of the battle with cocaine abuse, individuals may vary the forms of the drug that they use. Individuals may use the inhaled form at one time and the injected form at another, for example.
Many studies of short-term outpatient treatment over a six-month to two-year period indicate that people addicted to cocaine have a better chance of recovering than people who are addicted to heroin. A study of veterans who participated in an inpatient or day hospital treatment program that lasted 28 days revealed that about 60% of people who were abstinent at four months were able to maintain their abstinence at seven months.
Having a good support network greatly improves the prognosis for recovery from cocaine abuse and dependence.
Efforts to prevent cocaine abuse, like any substance abuse, begin with prevention programs that are based in schools or in the workplace, heath-care clinics, criminal justice systems, and public housing. Programs such as Students Taught Awareness (STAR) are cost-effective and have reduced the rates of substance abuse in the schools. These school-based programs also foster parental involvement and education about substance abuse issues. The juvenile justice system also implements drug-prevention programs. Even many workplaces provide drug screening and treatment and counseling for those who test positive. Employers may also provide workshops on substance abuse prevention. The U.S. Department of Housing and Urban Development (HUD) also sponsors drug-prevention programs.