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Cocaine Use Disorder

Like methamphetamine, cocaine is a powerful, highly addictive stimulant that activates the body’s central and peripheral nervous systems. This drug directly affects brain function. As noted in The Reward System of the Brain, dopamine or the reward pathway is stimulated by all types of stimuli, such as food, sex, and many drugs, including cocaine. Besides reward, this circuit also regulates emotions and motivation. Cocaine does not allow for the normal reabsorption of dopamine which then results in a buildup of dopamine contributing to the high that characterizes cocaine use.

While the methamphetamine molecule is structurally similar to amphetamine and to the neurotransmitter dopamine, it is quite different from cocaine.(1)

In contrast to cocaine, which is quickly removed from and almost completely metabolized in the body, methamphetamine has a much longer duration of action, and a larger percentage of the drug remains unchanged in the body. It remains in the brain longer, which ultimately leads to prolonged stimulant effects.(1)

Methamphetamine versus Cocaine

Methamphetamine	Cocaine
Stimulant	Stimulant and local anesthetic
Man-made	Plant derived
Smoking produces a long-lasting high	Smoking produces a brief high
50% of the drug is removed from the body in 12 hours	50% of the drug is removed from the body in 1 hour
Increases dopamine release and blocks dopamine re-uptake	Blocks dopamine re-uptake
Limited medical use for ADHD, narcolepsy and weight loss	Limited medical use as a local anesthetic in some surgical procedures

Cocaine is made from the leaves of the coca plant (Erythroxylon coca) that is native to South America. It is grown in Bolivia, Peru, and Columbia. Columbia produces about 90 percent of the cocaine powder reaching the United States. Most of the cocaine entering the United States comes through Mexico.(2)

A well-researched historical background is provided in Gootenberg’s book, Cocaine: Global Histories (3):

• It was first synthesized in 1859 in Germany.

• Initially, Sigmund Freud espoused the benefits as treatment for depression, alcoholism and morphine addiction, but later retracted those benefits.

• Cocaine’s local anesthetic effects were utilized by surgeon William Halstead.

• Freud and Halstead developed documented cocaine addictions.

• Coca-Cola^®, introduced in 1886, contained both cocaine and caffeine. By 1903, cocaine was removed from the Coca-Cola^® formulation.

Cocaine was being added to tonics, elixirs, and throat lozenges. The episodes of erratic behavior, convulsions, and death associated with cocaine led the 27^th U.S. President William Howard Taft, in 1910, to declare cocaine to be Public Enemy No.1.

The Harrison Narcotic Act of 1914 severely restricted the manufacture, distribution, and sale of cocaine in the United States. This made cocaine only available by prescription.

By the late 1960s, illicit cocaine use rebounded, and by the late 1970s, the drug had become popular among middle-and upper-middle-class Americans. Researchers, by the mid-1980s, found widespread evidence of physiological and psychological problems among cocaine users.

Cocaine is a Schedule II drug, which means that it has a high potential for misuse, but can be administered by a doctor for medical uses, such as local anesthesia for some eye, ear, and throat surgeries.

Chemical Forms of Cocaine(4):
Water-soluble hydrochloride salt (powdered)

• Cocaine is usually distributed as a white, crystalline powder.

• It can be injected (absorbed directly into the bloodstream) or snorted (inhaled through the nostrils and absorbed into the blood stream through nasal tissue).

• It may also be rubbed onto the gums (oral use).

Water-insoluble cocaine base (freebase)

• Base form is created by processing the drug with ammonia or sodium bicarbonate (baking soda) and water, then heating it to remove the hydrochloride to produce a smokable substance.

• This form is called crack. It looks like small, irregularly shaped chunks (“rocks”) of a whitish or light brown solid.

• It is called crack as a result of the crackling sound of the rock as it is heated.

• Crack can also be used by sprinkling it on marijuana or tobacco and smoking it.

• When smoked (inhalation), people inhale its vapor or smoke into the lungs. Absorption into the bloodstream is almost as rapid as by injection.

Cocaine may also be used in combination with an opiate, like heroin, a practice known as “speedballing.” The adulteration of cocaine with highly potent fentanyl is a major contributor to the rising drug overdose deaths.

Common Street Names

Blow, Coca, Coke, Crack, Flake, Snow, and Soda Cot

Short-term effects of cocaine use(4):

• Appear almost immediately after a single dose and typically disappear within a few minutes to an hour.

• Makes people feel euphoric, talkative, mentally alert, and hypersensitive to sight, sound, and touch.

• Temporarily decreases the need for food and sleep.

• Snorting cocaine produces a slow onset of the high, but may last from 15 to 30 minutes.

• Smoking cocaine is more immediate, but may last only 5 to 10 minutes.

Short-term physiological effects:

• Constricted blood vessels.

• Dilated pupils.

• Increased body temperature.

• Increased heart rate.

• Increased blood pressure.

• Large amounts of cocaine may lead to bizarre, erratic, and violent behavior.

• Severe medical complications can occur that may lead to heart attacks, neurological effects, including seizures, strokes and coma.

Many people who use cocaine also use alcohol, and this combination can be particularly dangerous. The two substances react to produce cocaethylene, which may increase the toxic effects of cocaine and alcohol on the heart.

The combination of cocaine and heroin is also very dangerous. People combine these drugs because the stimulating effects of cocaine are offset by the sedating effects of heroin. This can lead to taking a high dose of heroin without initially realizing it. Because cocaine’s effects wear off sooner, this can lead to a heroin overdose.

Long-term effects of cocaine use(4):

• With repeated exposure to cocaine, the brain starts to adapt so that the reward pathway becomes less sensitive.

• Circuits involved in stress become increasingly sensitive, leading to increased displeasure and negative moods when not taking the drug which are signs of withdrawal.

• These combined effects make people more likely to focus on seeking the drug instead of relationships, food, and other natural rewards.

• Tolerance develops with regular use so higher doses, more frequent use, or both are needed to produce the same level of pleasure and relief from withdrawal experienced initially.

• Tolerance to cocaine reward and sensitization to cocaine toxicity can increase the risk of overdose.

• Binging cocaine (used repeatedly and at increasingly higher doses), there is irritability, restlessness, panic attacks, paranoia, and even psychosis.

• Snorting can lead to loss of smell, nosebleeds, problems with swallowing, hoarseness, and an overall irritation of the nasal septum leading to a chronically inflamed, runny nose.

• Smoking crack cocaine damages the lungs and can worsen asthma.

• Injecting cocaine puts a person at risk for contracting diseases like HIV and hepatitis C. Allergic reactions, either to the drug itself or to the additives in cocaine, can result in death.

• Cocaine reduces blood flow in the gastrointestinal tract which may lead to tears or ulcerations. This can lead to significant weight loss and malnourishment.

• Chest pain can feel like a heart attack due to the toxic effects on the heart and cardiovascular system.

• Cocaine use is linked with increased risk of stroke, inflammation of the heart muscle, deterioration of the ability of the heart to contract, and aortic ruptures.

Effects of cocaine use during pregnancy(4,7):

• Migraines.

• Seizures.

• Premature membrane rupture and separation of the placental lining from the uterus prior to delivery (placental abruption).

• High blood pressure (hypertensive crisis).

• Spontaneous miscarriage.

• Preterm labor.

• Difficult delivery.

Babies exposed to cocaine during pregnancy:

• Prematurely delivered.

• Low birth weight.

• Smaller head circumferences.

• Shorter in length than babies not exposed to cocaine during pregnancy.

Long-term issues that may arise for these children:

• Behavior problems.

• Learning difficulties.

• Prenatal exposure to cocaine is related to aggressive behavior at age 5 years.

• Adolescents show increased risk for problems with language, memory, attention, and planning.

Treatment options for cocaine use disorder(4,7):

There are no medications approved by the U.S. Food and Drug Administration to treat cocaine use disorder.

Behavioral treatments have proven to be effective in both residential and outpatient settings, but cocaine craving(8) is a core feature of cocaine use disorder and remains a critical challenge for abstinence and relapse prevention.

Contingency Management (CM)

Programs use a voucher or prize-based system that offers patients who abstain from cocaine and other drugs with rewards.

Cognitive-behavioral therapy (CBT)

This approach helps patients develop critical skills that support long-term abstinence including the ability to recognize the situations in which they are most likely to use cocaine, avoid these situations, and cope more effectively with a range of problems associated with drug use.

Therapeutic Communities (TCs)

These are drug-free residences in which people in recovery from substance use disorders help each other to understand and change their behaviors. TCs may require a 6-to 12-month stay and can include vocational rehabilitation and other supportive services.

Conclusion

Cocaine use disorder (CUD) continues to be a severe public health problem impacting both individuals and society. It causes a plethora of medical, psychological, and social problems nationwide, including cardiovascular disease, infections, violence, and crime.(5,6)

Cocaine abusers suffer from poor health, poverty, employment difficulties, and poor interpersonal relationships. Crack cocaine users are at high risk for HIV, with high frequency crack users increasingly engaging in HIV-related sexual risk behaviors.(7)

The typical cocaine user is a young man with a higher-than-average income. Many users are professionals in positions of authority that entail a high level of responsibility.

Cocaine is commonly used as a club drug among gay and bisexual men.(7)

There is a direct association between craving and cocaine use. Because of this clinical significance, future studies in developing pharmacotherapies for cocaine use disorder must consider craving as a therapeutic outcome.(8)

References

1. NIDA. 2023, February 24. Overview. Retrieved from https://nida.nih.gov/publications/research-reports/methamphetamine/overview on 2024, August 25

2. U.S. Drug Enforcement Administration. DEA Drug Fact Sheet: Cocaine. Available at Drug Fact Sheet: Cocaine (dea.gov)

3. Gootenberg, P. (Ed.). (1999). Cocaine: Global Histories (1st ed.). Routledge. https://doi.org/10.4324/9780203026465

4. NIDA. 2024, April 4. Cocaine . Retrieved from https://nida.nih.gov/research-topics/cocaine on 2024, August 24

5. Schwartz, E. K. C., Wolkowicz, N. R., De Aquino, J. P., MacLean, R. R., & Sofuoglu, M. (2022). Cocaine Use Disorder (CUD): Current Clinical Perspectives. Substance abuse and rehabilitation, 13, 25–46. https://doi.org/10.2147/SAR.S337338

6. Kampman K. M. (2019). The treatment of cocaine use disorder. Science advances, 5(10), eaax1532. https://doi.org/10.1126/sciadv.aax1532

7. “Neurologic Effects of Cocaine” Drugs and Diseases/Neurology, Medscape. Updated Nov 12, 2019. Article available at: Neurologic Effects of Cocaine: Background, Pathophysiology, Epidemiology (medscape.com)

8. Lassi, D. L. S., Malbergier, A., Negrão, A. B., Florio, L., De Aquino, J. P., & Castaldelli-Maia, J. M. (2022). Pharmacological Treatments for Cocaine Craving: What Is the Way Forward? A Systematic Review. Brain sciences, 12(11), 1546. https://doi.org/10.3390/brainsci12111546

Cynthia Blair RN MA–August 2024