The majority of people who use cocaine do not have a use disorder. There is an increased risk of dependence (moderate to severe cocaine use disorder) with heavier use and when cocaine is smoked or injected.
Comorbid medical and psychiatric illnesses, as well as other substance use disorders, should be assessed.
Treatment options are limited with drug counseling as the mainstay.
There is no evidence to support the use of antipsychotic agents for cocaine dependence. Antipsychotic agents may cause QT interval prolongation and, when used concomitantly with cocaine, may compound the risk of sudden death.
Chronic cocaine use can lead to scarring of heart tissue and myocardial hypertrophy and other changes collectively known as myocardial remodeling. These changes constitute the substrate for the occurrence of lethal arrhythmias.
Psychosis can be seen in chronic users as an isolated condition or as a feature of "excited delirium", an agitated confusional state associated with potentially lethal hyperthermia.
Cocaine is a controlled illicit, highly addictive stimulant drug that is usually either insufflated (snorted), injected, or smoked in its freebase form (crack). Cocaine use is normally occasional, with the majority of users not meeting the criteria for cocaine use disorder. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) classifies cocaine use disorder as mild, moderate, or severe defined by the number of symptoms within a 12-month period.
See also our topic on Cocaine overdose.
History and exam
Key diagnostic factors
- presence of cocaine or other substance use disorders in family members
- chest pain
- agitation (mild to severe)
- mood changes (e.g., irritability, euphoria, dysphoria)
Other diagnostic factors
- anxiety (panic state: mild to severe)
- drug-induced formication
- previous hospitalization for detoxification
- suspicious burns (e.g., crack lip, crack thumb)
- nasal septum ulceration, perforation
- focal neurologic abnormalities
- seizure activity
- loss of consciousness/altered consciousness
- skin lesions (e.g., subcutaneous salmon-colored patches, infections, erosions, necrosis)
- history of alcohol/other drug abuse
- history of mental illness
- male sex
1st investigations to order
- urine toxicology ± gas chromatography/mass spectrometry testing for levamisole
- chest x-ray
- CT head
Investigations to consider
- CT chest
- bronchoalveolar lavage
- transthoracic echocardiogram
nonpregnant adults and adolescents: mild cocaine use disorder
nonpregnant adults and adolescents: moderate to severe cocaine use disorder
continued use or relapse
Steven B. Karch, MD, FFFLM, FCSFS
Consultant Cardiac Pathologist/Toxicologist (ret.)
Office of the Chief Medical Examiner
SBK is an author of a number of references cited in this topic. SBK declares that he has no other competing interests.
Kim Wolff, MBE, PhD
Professor of Analytical, Forensic, and Addiction Science, Director, King’s Forensics
Faculty Life Science and Medicine
King’s College London
KW declares that she provides expert opinion and reports as a panel member of the Secretary of State Medical Panel for Drink and Drug Driving and as a member of the World Health Organization Expert Panel on Drug Dependence.
Timothy Albertson, MD, PhD, MPH
Division of Pulmonary and Critical Care Medicine
University of California, Davis
TA declares that he has no competing interests.
Andrew Stolbach, MD
Department of Emergency Medicine
Johns Hopkins University Hospital
AS declares that he has no competing interests.
Russel Falck, MA
Assistant Professor of Community Health and Associate Director
Center for Interventions
Treatment and Addictions Research
Wright State University Boonshoft School of Medicine
RF declares that he has no competing interests.
Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD
Consultant Psychiatrist and Honorary Senior Lecturer
Addictions, Alcohol Research
Institute of Psychiatry
King's College London
CK declares that he has no competing interests.
- Methamphetamine abuse
- Amphetamine abuse
- Clinical practice guideline for the management of substance use disorders
- Unhealthy drug use: screening
Cocaine use disorderMore Patient leaflets
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