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Chapter: Essentials of Psychiatry: Substance Abuse: Cocaine Use Disorders

Substance Abuse: Cocaine Use Disorders

Cocaine, a central nervous system stimulant produced by the coca plant, is consumed in several preparations.

Substance Abuse: Cocaine Use Disorders




Cocaine, a central nervous system stimulant produced by the coca plant, is consumed in several preparations. Cocaine hy-drochloride powder is usually snorted through the nostrils, or it may be mixed in water and injected intravenously. Cocaine hy-drochloride powder is also commonly heated (“cooked up”) with ammonia or baking soda and water to remove the hydrochloride, thus forming a gel-like substance that can be smoked (“freebas-ing”). “Crack” cocaine is a precooked form of cocaine alkaloid that is sold on the street as small “rocks”. Abundant supplies and falling prices for cocaine (the equivalent of 1 gram of cocaine can be purchased for as little as $25 to $50 and a vial of crack [two or three small “rocks”] can be had for about $10) have contrib-uted greatly to the prevalence of cocaine abuse and dependence as well as other related cocaine use disorders.


Cocaine intoxication produces a state of intense euphoria that is a powerful reinforcer and can lead to the development of cocaine use disorders in many individuals, although only 10 to 16% of those who try the drug go on to develop these disorders (Van Etten and Anthony, 1999). Some experience the stimulant effects of cocaine as anxiogenic; others discontinue use because of lack of easy drug availability, fear of loss of control over use, or apprehension regarding possible legal consequences of cocaine abuse. The route of administration is strongly correlated with the development of cocaine use disorders, in that the intravenous and smoked routes of administration allow rapid transport of the drug to the brain, producing intense effects that are short-lived. Rapid tolerance to euphoria occurs and plasma concentrations are not correlated with peak euphoria, producing a need for frequent dosing to regain euphoric effects (binge use) that can place the cocaine abuser at risk for medical and psychiatric complications of cocaine abuse.


Cocaine abuse is characterized by a maladaptive pattern of substance use demonstrated by recurrent and significant adverse consequences related to repeated drug use. Such consequences include family discord, legal and employment problems and inter-personal problems. The person diagnosed with cocaine abuse may have significant periods during which no cocaine-related problems are experienced, but the initiation of cocaine abuse usually her-alds the onset of psychosocial difficulties. Cocaine dependence is characterized by a more pervasive pattern of frequent cocaine use and a chronic cycle of psychosocial problems. In addition, medi-cal and psychiatric adverse events associated with cocaine use can result in serious morbidity and, in some cases, mortality


While the question of whether cocaine is physiologically addictive is not completely clear, the psychological addiction alone is powerful and can completely dominate the life of the cocaine abuser. Binge use of cocaine may be followed by what has been described as a mild withdrawal syndrome character-ized by dysphoria and anhedonia. Cocaine withdrawal may re-semble a depressive disorder, in some cases requiring emergent psychiatric treatment. Some combination of these consequences of cocaine abuse are usually responsible for the identification and diagnosis of individuals with cocaine use disorders and referral to substance abuse treatment.




The National Household Survey on Drug Abuse (NHSDA) re-ported that in 2000, 1.2 million Americans were current cocaine users representing 0.5% of the population over the age of 12 (SAMHSA, 2001a). Since 1975, the monitoring the future (MTF) study has annually examined the extent of drug abuse among 8th to 12th graders. Use of cocaine decreased significantly among 12th graders, from 6.2% in 1999 to 5.0% in 2000; crack cocaine use in the year 2000 decreased from 2.7 to 2.2% for 12th graders. While cocaine use has shown a downward trend, several statis-tics indicate that cocaine abuse is still a serious threat to the pub-lic. For example, cocaine-related emergency department visits constituted 29% of all drug related visits in 2000, more than for any other illicit substance (SAMHSA, 2001b ).

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