Most cocaine users are episodic recreational users. However, about 25% (or more) of users meet criteria for abuse or dependence. Use among adolescents has declined recently. Availability of highly biologically active forms, such as crack cocaine, has worsened the problem of cocaine dependence. Most cocaine in the US is about 45 to 60% pure; it may contain a wide array of fillers, adulterants, and contaminants.
Most cocaine in the US is volatilized and inhaled, but it may be snorted, or injected IV. For inhalation, the powdered hydrochloride salt is converted into a more volatile form, usually by adding sodium bicarbonate, water, and heat. The resultant precipitate (crack cocaine) is volatilized by heating (it is not burned) and inhaled. Onset of effect is quick, and intensity of the high rivals that associated with IV injection. Tolerance to cocaine occurs, and withdrawal from heavy use is characterized by somnolence, difficulty concentrating, increased appetite, and depression. The tendency to continue taking the drug is strong after a period of withdrawal.
Pathophysiology
Cocaine, an alkaloid present in the leaves of the coca plant, enhances norepinephrine, dopamine, and serotonin activity in the central and peripheral nervous systems.
Enhancement of dopamine activity is the likely cause of the drug’s intended effects and thus of the reinforcement that contributes to developing abuse and dependence.
Norepinephrine activity accounts for the sympathomimetic effects: tachycardia, hypertension, mydriasis, diaphoresis, and hyperthermia.
Cocaine also blocks sodium channels, accounting for its action as a local anesthetic. Cocaine causes vasoconstriction and thus can affect almost any organ. myocardial infarction, cerebral ischemia and hemorrhage, aortic dissection, intestinal ischemia, and renal ischemia are possible sequelae.
Onset of cocaine’s effects depends on mode of use:
IV injection and smoking: Immediate onset, peak effect after about 3 to 5 minutes, and duration of about 15 to 20 minutes
Intranasal use: Onset after about 3 to 5 minutes, peak effect at 20 to 30 minutes, and duration of about 45 to 90 minutes
Oral use: Onset after about 10 minutes, peak effect at about 60 minutes, and duration of about 90 minutes
Because cocaine is such a short-acting drug, heavy users may inject it or smoke it repeatedly every 10 to 15 minutes.
Pregnancy
Cocaine use during pregnancy Cocaine Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more can affect the fetus; the rate of placental abruption Abruptio Placentae Abruptio placentae is premature separation of a normally implanted placenta from the uterus, usually after 20 weeks gestation. It can be an obstetric emergency. Manifestations may include vaginal... read more and spontaneous abortion Spontaneous Abortion Spontaneous abortion is noninduced embryonic or fetal death or passage of products of conception before 20 weeks gestation. Threatened abortion is vaginal bleeding without cervical dilation... read more is higher.
Symptoms and Signs
Acute effects
Effects of cocaine use may differ depending on mode of use. When injected or smoked, cocaine causes hyperstimulation, alertness, euphoria, a sense of increased energy, and feelings of competence and power. The excitation and high are similar to those produced by injecting amphetamines Symptoms and Signs Amphetamines are sympathomimetic drugs with central nervous system stimulant and euphoriant properties whose toxic adverse effects include delirium, hypertension, seizures, and hyperthermia... read more . These feelings are less intense and disruptive in users who snort cocaine powder.
Users who smoke the drug may develop pneumothorax Pneumothorax Pneumothorax is air in the pleural space causing partial or complete lung collapse. Pneumothorax can occur spontaneously or result from trauma or medical procedures. Diagnosis is based on clinical... read more 
or pneumomediastinum Pneumomediastinum Pneumomediastinum is air in mediastinal interstices. The main causes of pneumomediastinum are Alveolar rupture with dissection of air into the interstitium of the lung with translocation to... read more 
, causing chest pain, dyspnea, or both. Myocardial ischemia due to cocaine use may also cause chest pain (“cocaine chest pain”), but cocaine can also cause chest pain in the absence of myocardial ischemia; the mechanism is unclear. Arrhythmias and conduction abnormalities may occur. Cardiac effects may result in sudden death. Binges, often over several days, lead to an exhaustion syndrome or "washed out" syndrome, involving intense fatigue and need for sleep.
Toxicity or overdose
An overdose may cause severe anxiety, panic, agitation, aggression, sleeplessness, hallucinations, paranoid delusions, impaired judgment, tremors, seizures, and delirium. Mydriasis and diaphoresis are apparent, and heart rate and blood pressure are increased. Death may result from myocardial infarction or arrhythmias.
Severe overdose causes a syndrome of acute psychosis (eg, schizophrenic-like symptoms), hypertension, hyperthermia, rhabdomyolysis, coagulopathy, renal failure, and seizures. Patients with extreme clinical toxicity may, on a genetic basis, have decreased (atypical) serum cholinesterase, an enzyme needed for clearance of cocaine.
Patients who inhale cocaine may develop an acute pulmonary syndrome (crack lung) with fever, hemoptysis, and hypoxia, that may progress to respiratory failure.
The concurrent use of cocaine and alcohol produces a condensation product, cocaethylene, which has stimulant properties and may contribute to toxicity.
Chronic effects
Severe toxic effects occur in compulsive heavy cocaine users. Myocardial fibrosis, left ventricular hypertrophy, and cardiomyopathy Overview of Cardiomyopathies A cardiomyopathy is a primary disorder of the heart muscle. It is distinct from structural cardiac disorders such as coronary artery disease, valvular disorders, and congenital heart disorders... read more can develop. Rarely, repeated snorting causes nasal septal perforation Septal Deviation and Perforation Deviations of the nasal septum due to developmental abnormalities or trauma are common but often are asymptomatic and require no treatment. Symptomatic septal deviation causes nasal obstruction... read more 
due to local ischemia. Cognitive impairment, including impaired attention and verbal memory, occurs in some heavy users. Users who inject cocaine are subject to the typical infectious complications Infectious agents A number of drugs of abuse are given by injection to achieve a more rapid or potent effect or both. Drugs are typically injected IV but may be injected subcutaneously, IM, or even sublingually... read more .
Withdrawal
The main symptoms of cocaine use are depression, difficulty concentrating, and somnolence (cocaine washout syndrome). Appetite is increased.
Diagnosis
Clinical evaluation
Diagnosis of cocaine intoxication is usually made clinically. Drug levels are not measured. The cocaine metabolite, benzoylecgonine, is part of most routine urine drug screens Drug Testing Drug testing is done primarily to screen people systematically or randomly for evidence of use of one or more substances with potential for abuse. Testing is done in the following: Certain groups... read more .
Treatment
IV benzodiazepines
Avoidance of beta-blockers
Cooling for hyperthermia as needed
Toxicity or overdose
Treatment of mild cocaine intoxication is generally unnecessary because the drug is extremely short-acting. Benzodiazepines are the preferred initial treatment for most toxic effects, including central nervous system excitation and seizures, tachycardia, and hypertension. Lorazepam 2 to 3 mg IV every 5 minutes titrated to effect may be used. High doses and a continuous infusion may be required. Propofol infusion, with mechanical ventilation Overview of Mechanical Ventilation Mechanical ventilation can be Noninvasive, involving various types of face masks Invasive, involving endotracheal intubation Selection and use of appropriate techniques require an understanding... read more , may be used for resistant cases.
Hypertension that does not respond to benzodiazepines is treated with IV nitrates (eg, nitroprusside) or phentolamine; beta-blockers are not recommended because they allow continued alpha-adrenergic stimulation.
Hyperthermia can be life threatening and should be managed aggressively with sedation plus evaporative cooling, ice packs, and maintenance of intravascular volume and urine flow with IV normal saline solution.
Phenothiazines lower seizure threshold, and their anticholinergic effects can interfere with cooling; thus, they are not preferred for sedation.
Occasionally, severely agitated patients must be pharmacologically paralyzed and mechanically ventilated to ameliorate acidosis, rhabdomyolysis, or multisystem dysfunction.
Cocaine-related chest pain is evaluated as for any other patient with potential myocardial ischemia or aortic dissection, with chest x-ray, serial ECG, and serum cardiac markers. As discussed, beta-blockers are contraindicated, and benzodiazepines are a first-line drug. If coronary vasodilation is required after benzodiazepines are given, nitrates are used, or phentolamine 1 to 5 mg IV given slowly can be considered.
Abuse
Heavy cocaine users and people who inject the drug IV or smoke it are most likely to become dependent. Light users and people who take the drug nasally or orally are at lower risk of becoming dependent. Stopping sustained use requires considerable assistance, and the depression that may result requires close supervision and treatment.
Many outpatient therapies, including support and self-help groups and cocaine hotlines, exist. Inpatient therapy is used primarily when it is required for serious physical or mental comorbidity or when outpatient therapy has repeatedly been unsuccessful.
For treatment of infants born to cocaine-addicted mothers, see Prenatal Drug Exposure Prenatal Drug Exposure Alcohol and illicit drugs are toxic to the placenta and developing fetus and can cause congenital syndromes and withdrawal symptoms. Prescription drugs also may have adverse effects on the fetus... read more .
More Information
Findtreatment.gov: Listing of licensed US providers of treatment for substance use disorders
