Cocaine Use Disorder

Cocaine is a potent central nervous system stimulant derived from the leaves of the coca plant (Erythroxylum coca). It is commonly used as an illicit recreational drug and may be administered through intranasal insufflation (snorting), smoking (freebase or crack cocaine), or intravenous injection.

Cocaine produces rapid stimulation of the brain’s reward pathways by inhibiting reuptake of dopamine, norepinephrine, and serotonin. Acute effects include intense euphoria, increased energy, heightened alertness, sexual arousal, reduced fatigue, and decreased appetite. Toxic or high doses may result in severe cardiovascular, neurological, and psychiatric complications including hypertensive crisis, hyperthermia, psychosis, seizures, myocardial infarction, and sudden death.

Risk Factors

Factors associated with cocaine use and dependence include:

• Previous substance or alcohol use disorder

• Psychiatric illness (depression, anxiety disorders, ADHD)

• Peer pressure and social environment exposure

• Poverty, unemployment, or occupational stress

• History of trauma or adverse childhood experiences

• Easy drug availability

• Young adult age group (15–35 years)

• High-risk nightlife or entertainment environments

Signs and Symptoms

Psychological Symptoms

• Euphoria and increased confidence

• Agitation or irritability

• Anxiety or panic attacks

• Paranoia or hallucinations

• Aggressive or violent behaviour

• Impaired judgment

• Depression during withdrawal

• Suicidal ideation

Physical Symptoms

• Tachycardia

• Hypertension

• Dilated pupils (mydriasis)

• Sweating

• Tremors

• Chest pain

• Reduced appetite and weight loss

• Hyperthermia

Severe Toxicity

• Seizures

• Stroke

• Cardiac arrhythmias

• Myocardial infarction

• Respiratory failure

• Sudden cardiac death

Diagnostic Criteria

Diagnosis is clinical and based on criteria for Substance Use Disorder (DSM-5 principles), including:

Presence of ≥2 of the following within 12 months:

• Persistent desire or unsuccessful attempts to stop use

• Increased quantity or duration of use

• Craving for cocaine

• Failure to fulfill social or occupational obligations

• Continued use despite physical or psychological harm

• Tolerance development

• Withdrawal symptoms

• Significant time spent obtaining or recovering from drug use

Severity classification:

• Mild: 2–3 criteria

• Moderate: 4–5 criteria

• Severe: ≥6 criteria

Investigations

Investigations aim to confirm exposure and detect complications.

Laboratory Tests

• Urine toxicology screening (benzoylecgonine metabolite)

• Full blood count

• Electrolytes and renal function

• Liver function tests

• Creatine kinase (suspected rhabdomyolysis)

• Cardiac enzymes (troponin)

Cardiovascular Assessment

• Electrocardiogram (ECG)

• Chest X-ray (if respiratory symptoms)

• Echocardiography when indicated

Neurological Assessment

• CT brain scan (stroke, seizure, altered consciousness)

Management

General Principles

• Ensure airway, breathing, and circulation stabilization

• Manage agitation early to prevent complications

• Identify co-ingestion of other substances

• Screen for psychiatric emergencies and suicide risk

Most uncomplicated cases do not require hospital admission, but careful mental health assessment is essential.

Non-Pharmacological Management

• Supportive counselling

• Brief motivational intervention

• Cognitive Behavioural Therapy (CBT)

• Substance use rehabilitation programs

• Psychoeducation on relapse risk

• Family and social support involvement

• Suicide risk assessment during withdrawal phase

Pharmacological Management

Detoxification

There is no approved substitute medication for cocaine detoxification.

Treatment is symptomatic.

Management of Anxiety, Irritability, and Insomnia

• Diazepam 5–10 mg orally every 8 hours for 5–7 days

Acute Agitation or Toxicity

• Benzodiazepines are first-line therapy

• IV fluids for dehydration

• Cooling measures for hyperthermia

• Antihypertensives if severe hypertension persists

Beta-blockers alone are generally avoided in acute cocaine toxicity due to risk of unopposed alpha-adrenergic stimulation.

Complications

• Cocaine-induced psychosis

• Major depressive disorder

• Cardiomyopathy

• Myocardial infarction

• Stroke

• Nasal septum perforation (chronic snorting)

• Infective endocarditis (injecting users)

• HIV and viral hepatitis transmission

Prevention

• Public education on substance abuse risks

• Early mental health screening

• School and community drug awareness programs

• Harm-reduction counselling

• Treatment of underlying psychiatric disorders

• Rehabilitation and relapse-prevention programs

Prognosis

Recovery depends on duration of use, psychiatric comorbidity, and access to rehabilitation services. Relapse rates are high without structured psychosocial treatment; long-term behavioral therapy significantly improves outcomes.

Patient Education

• Cocaine use can cause sudden heart attack or stroke even in young individuals

• Psychological withdrawal commonly causes depression and suicidal thoughts

• Early treatment improves recovery success

• Avoid triggers such as alcohol or drug-using environments

• Seek medical help immediately for chest pain, seizures, or severe agitation