Substance Use Guidelines - Cocaine
October 2024
Introduction
• Cocaine is a powerful stimulant derived from the leaves of coca plants native to South America. It is a schedule II drug with limited medical uses; the vast majority of cocaine used in the United States is obtained from the unregulated/illegal market.1
• Cocaine is sold in two forms, as a powder or as a solid (rock, or “crack”). Cocaine can be smoked, injected, inhaled/snorted, or absorbed through the gums or rectum (booty bumping)
• Cocaine's effects can include increased energy, euphoria, and anxiety, as well as decreased appetite and decreased need for sleep
• The effects of cocaine appear almost immediately after use and last a few minutes to an hour. Injecting or smoking cocaine produces a quicker and stronger but shorter-lasting high than snorting.
• Repeated, ongoing cocaine use can result in increased tolerance (needing more of the drug to get the same effect), dependence, and withdrawal symptoms upon decreasing or stopping use.
• In recent years, more overdose deaths in the U.S. have involved stimulants like cocaine and methamphetamine. A multi-year cohort study of people experiencing homelessness (PEH) in Boston found that among opioid-involved polysubstance (more than one substance) overdose deaths, cocaine was the most common second drug found (after opioids) 2
• Like most of the drug supply in the U.S., cocaine can be adulterated, or “cut,” with other substances, most notably fentanyl. Fentanyl overdose is a risk for those using both opioids and cocaine as well as for those who exclusively use cocaine products.
Key Terms and Definitions
• Over-amping: Refers to a broad spectrum of psychological and physical responses that can occur as a result of using a large amount of cocaine, repeated, high frequency use, or using over several days. Overamping can be unpredictable and may occur when someone is overly tired, has not eaten, or is dehydrated. Symptoms can range from physical discomfort or agitation to anxiety, paranoia, or psychosis.
• Trauma-informed care (TIC): A patient-centered approach to care that recognizes the impacts of trauma and actively works to prevent re-traumatization and promote recovery. The principles of TIC are grounded in establishing a trusting relationship and a safe physical and psychological space in which to address needs.
• Harm reduction: A philosophical approach to care that establishes individual agency and selfdetermination as central to all efforts towards well-being. Harm reduction approaches call for the non-judgmental, non-coercive provision of services and resources to people who use substances to assist them in reducing harm related to their substance use or other health behaviors. Harm reduction-based care is collaborative, provides education on available interventions, and centers the goals of the individual in care planning.
Clinical Considerations
Physical and Behavioral Health Impacts
• Desired effects of cocaine use include increased energy, elevated mood, alertness, sociability, elation or euphoria, decreased need for sleep, and decreased fatigue and appetite.
• Some more common physical complications of cocaine use include headache, bruxism (clenching or grinding teeth), cough, chest pain, tachycardia (fast heart rate), palpitations (irregular heart rate), elevated blood pressure, tremors and tics, and mild fever.
• Severe physical complications of cocaine use include damage to the heart and heart attack, gastrointestinal ulcer perforation, cerebral infarction or hemorrhage (stroke), mesenteric ischemia (decreased blood flow to the small intestine that can result in tissue damage and tissue death), kidney injuries and renal failure, and malignant hyperthermia (overheating).
• Smoking cocaine can cause respiratory complications such as cough, airway irritation and wheezing, and damage to lung tissue causing hemoptysis (coughing up blood)
• Cocaine use can cause a number of unpleasant psychological effects that can vary significantly in severity, including anxiety, irritability, panic attacks, interpersonal sensitivity, hypervigilance, paranoia, grandiosity, hallucinations, and delusions.
• Cocaine-induced psychosis is psychotic symptoms induced by cocaine use. This type of psychosis can be difficult to separate from non-substance related psychosis, such as in schizophrenia. Psychosis resulting from cocaine use is typically episodic and resolves once the drug leaves the system, though it can persist for days or longer 3
• Chronic or long-term cocaine use can be associated with cognitive impairment, including decreased verbal fluency, sensory-perceptual functions, response inhibition, and impulsivity. Cognitive impairment can last several months after abstinence.4
• Abrupt cessation of cocaine use is associated with a range of withdrawal symptoms, including depression, anxiety, fatigue, difficulty concentrating, and anhedonia (lack of interest or pleasure). Individuals can also experience increased drug cravings, increased appetite, hypersomnolence (inability to stay awake/alert), and increased vivid dreams. The initial period of withdrawal (or "crash") is more intense and progressively improves, with mild symptoms resolving in 1-2 weeks
• Sharing injection, snorting and smoking supplies can result in infectious disease transmission. Both HIV and hepatitis C (HCV) can be transmitted through shared injection supplies, and HCV has been isolated on pipes used to smoke cocaine, demonstrating that sharing equipment that comes in contact with mucus membranes in the mouth and nose is another potential source of transmission.5
Use of Cocaine and Experiences of Homelessness
• People are motivated to use drugs for many different reasons. For PEH, the use of stimulants like cocaine can sometimes be a survival strategy to remain alert in unsafe situations, for example when staying outside. People may also use cocaine as a coping strategy to address past and ongoing trauma or mental health challenges.
• It is not uncommon for people to combine sedatives like fentanyl/heroin or alcohol with stimulants like cocaine or methamphetamine to modulate the effects of both substances, or as a balancing measure.6 The use of multiple substances, all of which have the potential to contain fentanyl, increases the risk of overdose.
• Many substances, including cocaine, contain adulterants or cutting agents added to bulk up the substance or to impact the drug’s effects. Cocaine may contain fentanyl, xylazine, and/or levamisole, an anti-parasitic worm treatment given to animals that has multiple negative impacts on humans, most notably on the vascular system.7
• Living in unsheltered locations and/or not having an indoor place to go during the day puts people who use drugs at increased risk in several ways. Using in isolated outdoor locations or in tents or abandoned properties increases the risk of overdose. Using substances like cocaine that can impact the body’s ability to regulate temperature can also put people at risk of heat and cold-related illness.
• Cocaine use has a high prevalence in sex work, as stimulants are often used to enhance sexual encounters or to endure very challenging circumstances in sex work. 8
Harm Reduction Strategies
• Start low and go slow: Use cocaine in small, consecutive doses to achieve the desired effect. Inconsistent and unsafe supply impacts potency and carries the potential for dangerous adulterants, such as fentanyl. This strategy reduces the risk of overdose from unintentional ingestion of other substances, as well as overamping.
• Never use alone: Individuals who use drugs should use with at least one other person who could respond in the event of an overdose; it is also a good idea to stagger use with another person, so that one person is available to help the other if needed. For those who need to use alone and have access to a phone, services like Never Use Alone can decrease risk.
• Use test strips: Due to the prevalence of impurities in drugs, drug testing with fentanyl and xylazine test strips can be used to inform the individual of what they are consuming. A small amount of the drug can be dissolved and the test strip dipped in the liquid. Regardless of the results, “low and slow” is still advised when first consuming a drug.
• Ensure access to clean supplies: The provision of safe consumption equipment has been shown to reduce HIV and HCV transmission and offers an opportunity for engagement in care and referral to other services.9 People should be offered a variety of supplies regardless of their reported preferred consumption method as situations may arise where alternative supplies are needed. Safer cocaine use supplies include safer smoking and safer injection supplies.
• There are several ways to make cocaine use safer:
o Do not share straws or pipes: individual straws or rolled Post-it notes, and individual mouth pieces can help reduce disease transmission; rubber mouth pieces (or rubber bands) can help prevent burns.
o Use a screen when smoking cocaine in crystalline form (crack/rock) to prevent inhalation of particles. A screen provided in a safer smoking kit is best; a piece of a copper scouring pad (Chore Boy) can be used, but can break down with repeated heat exposure.
o When mixing for injection, it is ideal to use sterile water, however the cleanest water available is best (tap or bottled water are an alternative).
o If injecting cocaine from a solid crystal form, it will need to be dissolved using an acid People often use lemon juice, vinegar, vitamin C, or citric acid. The safest acidifier is medical grade vitamin C (ascorbic acid). It is best to use the smallest amount needed to dissolve crystal; if using ascorbic acid it is usually ¼ the size of the rock. The use of fruit
juices and vinegar have been associated with fungal and bacterial blood infections, and can be more irritating to veins. 10
• Provide education on over-amping: Teach people how to respond to physical and mental distress, both for oneself and for others, including a safety plan and accessible resources like where to go to decrease stimulation and how to access support people, behavioral health services, and crisis response.
• Carry naloxone: Although naloxone does not have an effect on someone who is overamping on cocaine, naloxone should be provided with education on proper administration due to the frequency with which substances are adulterated Individuals who use drugs are best equipped to intervene and reverse an overdose of someone they are using with.
• Ensure access to safer sex supplies and reproductive health care: Safer sex education and provision of materials such as condoms, dental dams, and lube should be included in all conversations It is important to speak with all clients about their reproductive health needs.
• It is important to recognize that people’s recovery goals can vary widely, from not wanting to stop using, to trying different forms of consumption, to wanting to decrease use or stop altogether. It is important to meet people where they are and co-create a plan to increase safety and decrease risk.
Treatment and Supportive Services
• There are no FDA approved medications for the treatment of cocaine use disorder. The evidence based treatment modalities that have been shown to have an impact are behavioral interventions like contingency management and community reinforcement approach.11
• Contingency management (CM) has been shown to be the most effective treatment currently available for cocaine use.12 CM programs use immediate rewards to reinforce positive behavior change. Goals for decreased use are set collaboratively with patients, and rewards – either cash or other prizes – are given when a goal is met. CM can be conducted both in individual or group treatment settings and has been shown to be effective among PEH.13
• The community reinforcement approach (CRA) is also an effective treatment for people who use cocaine and want to decrease their use. CRA focuses on changing a person’s environment and social reinforcements so that non-substance use behaviors become more rewarding than substance use 14
• Cognitive behavioral therapy (CBT) is another behavioral intervention that teaches skills to recognize situations or "triggers" that provoke drug cravings. This approach also counsels on avoiding triggering situations and on using a variety of coping skills when cravings do occur. There is some literature to suggest CBT is helpful for cocaine use, however, CM and CRA are superior to CBT in clinical studies assessing treatment response 15
• Research suggests that there are several medications that can decrease cravings and help to support abstinence, though more data are needed:
o Topiramate, a medication that is usually used to treat seizures and headaches, can reduce cocaine craving and help maintain abstinence.16
o A review of studies indicated that certain medications used to treat ADHD (Attention Deficit Hyperactivity Disorder) can be helpful in treating cocaine use, especially for individuals who have been diagnosed with ADHD.17 18 19
• Screening for hepatitis C (HCV) is recommended annually for all individuals who inject drugs and repeat HCV testing is recommended for all individuals with an increased risk of HCV infection.20
• HIV should be screened at least annually in individuals at high risk, including those who inject drugs, persons with more than one sexual partner, and those who exchange sex for money or drugs.21
• Clinical space to care for patients who are overamping or experiencing unpleasant psychological side effects of cocaine is ideal. This could be a cool, non-stimulating space with a comfortable chair or cot to allow people to deescalate from stimulant intoxication. Providers and staff should be trained to incorporate behavioral de-escalation techniques and a trauma-informed approach to patients who use stimulants.
• In some settings, for example emergency departments, inpatient settings, or outpatient settings with the ability to monitor response, medications like low-dose benzodiazepines or antipsychotics may be used to address symptoms of overamping or psychological distress.
Models of Care Delivery
• It is imperative to create low-threshold, interdisciplinary models of care that employ a harm reduction approach to support people who use cocaine and are experiencing homelessness. This should include services available by appointment and walk-in and at locations and hours that meet the needs of the community. Resource specialists who can help navigate different treatment levels of care (e g., residential programs, outpatient programs, acute treatment services ("detox"), etc.).
• Street outreach or mobile programs can be very effective in engaging and offering harm reduction supplies like safer use kits, drug checking materials when able, and naloxone. The entire spectrum of harm reduction and treatment for substance use disorders, from safer use support to treatment, should be available to everyone
• Syringe access is an important harm reduction service to provide for people who use cocaine. In addition to providing new syringes, SSPs provide the opportunity to engage in conversations around safer use practices, as well as open the door for conversations about treatment, wound care, behavioral health services, and other health care or social service needs.
• It is important to remember that people may be at various stages of recovery and have different goals for different substances. Multiple models or approaches may be needed, and what model works best may change over time. It is important for providers to be able to facilitate changes in treatment plan, including referrals to other outpatient services or support with transitioning to inpatient treatment.
• Medical hospitalizations can be a challenging time for people who use drugs, and untreated or undertreated withdrawal is a major reason for self-directed discharges. HCH teams can support people who are hospitalized for medical reasons by helping them communicate the need for withdrawal management and treatment support.
Resources
• Resource on Responding to Cocaine Overamping and Overdose and Safer Smoking (CanadaCATIE)
• Safer Injection Information from National Harm Reduction Coalition
• The Curbsiders Podcast, Addiction Medicine Series, Episode #5: Amp Up Your Treatment of Stimulant Use Disorders
• Centers for Disease Control Information on Stimulants and Overdose
• Bevel Up - Harm Reduction and Safer Use Information
References
1 National Institute on Drug Abuse. 2024. Cocaine. Accessed from: https://nida.nih.gov/research-topics/cocaine
2 Fine, D. R., Dickins, K. A., Adams, L. D., De Las Nueces, D., Weinstock, K., Wright, J., … Baggett, T. P. (2022). Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018. JAMA Network Open, 5(1), e2142676. https://doi.org/10.1001/jamanetworkopen.2021.42676
3 Tang Y, Martin NL, Cotes RO. Cocaine-induced psychotic disorders: presentation, mechanism, and management. J Dual Diagn. 2014;10(2):98–105. doi: 10.1080/15504263.2014.906133.
4 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
5 Fischer, B., Powis, J., Firestone Cruz, M., Rudzinski, K., & Rehm, J. (2008). Hepatitis C virus transmission among oral crack users: viral detection on crack paraphernalia. European Journal of Gastroenterology & Hepatology, 20(1), 29–32. https://doi.org/10.1097/MEG.0b013e3282f16a8c
6 Usdan, S. L., Schumacher, J. E., Milby, J. B., Wallace, D., McNamara, C., & Michael, M. (2001). Crack cocaine, alcohol, and other drug use patterns among homeless persons with other mental disorders. The American Journal of Drug and Alcohol Abuse, 27(1), 107–120. https://doi.org/10.1081/ADA-100103121
7 Marquez, J., Aguirre, L., Muñoz, C., Echeverri, A., Restrepo, M., & Pinto, L. F. (2017). Cocaine-Levamisole-Induced Vasculitis/Vasculopathy Syndrome. Current Rheumatology Reports, 19(6), 36. https://doi.org/10.1007/s11926-0170653-9
8 Lathan, E. C., Hong, J. H., Heads, A. M., Borgogna, N. C., & Schmitz, J. M. (2021). Prevalence and Correlates of Sex Selling and Sex Purchasing among Adults Seeking Treatment for Cocaine Use Disorder. Substance Use & Misuse, 56(14), 2229–2241. https://doi.org/10.1080/10826084.2021.1981391
9 Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., Van Velzen, E., … Hutchinson, S. J. (2014). Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. International Journal of Epidemiology, 43(1), 235–248. https://doi.org/10.1093/ije/dyt243
10 Bisbe, J., Miro, J. M., Latorre, X., Moreno, A., Mallolas, J., Gatell, J. M., … Soriano, E. (1992). Disseminated candidiasis in addicts who use brown heroin: report of 83 cases and review. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 15(6), 910–923. https://doi.org/10.1093/clind/15.6.910
11 Bentzley, B. S., Han, S. S., Neuner, S., Humphreys, K., Kampman, K. M., & Halpern, C. H. (2021). Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis. JAMA Network Open, 4(5), e218049. https://doi.org/10.1001/jamanetworkopen.2021.8049
12 De Crescenzo, F., Ciabattini, M., D’Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., … Cipriani, A. (2018). Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS Medicine, 15(12), e1002715. https://doi.org/10.1371/journal.pmed.1002715
13 Schumacher, J. E., Milby, J. B., Wallace, D., Meehan, D.-C., Kertesz, S., Vuchinich, R., … Usdan, S. (2007). Metaanalysis of day treatment and contingency-management dismantling research: Birmingham Homeless Cocaine Studies (1990-2006). Journal of Consulting and Clinical Psychology, 75(5), 823–828. https://doi.org/10.1037/0022006X.75.5.823
14 De Crescenzo, F., Ciabattini, M., D’Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., … Cipriani, A. (2018). Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS Medicine, 15(12), e1002715. https://doi.org/10.1371/journal.pmed.1002715
15 De Crescenzo, F., Ciabattini, M., D’Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., … Cipriani, A. (2018).
Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS Medicine, 15(12), e1002715. https://doi.org/10.1371/journal.pmed.1002715
16 Singh, M., Keer, D., Klimas, J., Wood, E., & Werb, D. (2016). Topiramate for cocaine dependence: a systematic review and meta-analysis of randomized controlled trials. Addiction (Abingdon, England), 111(8), 1337–1346. https://doi.org/10.1111/add.13328
17 Tardelli, V. S., Bisaga, A., Arcadepani, F. B., Gerra, G., Levin, F. R., & Fidalgo, T. M. (2020). Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis. Psychopharmacology, 237(8), 2233–2255. https://doi.org/10.1007/s00213-020-05563-3
18 Tardelli, V. S., Bisaga, A., Arcadepani, F. B., Gerra, G., Levin, F. R., & Fidalgo, T. M. (2020). Prescription psychostimulants for the treatment of stimulant use disorder: a systematic review and meta-analysis. Psychopharmacology, 237(8), 2233–2255. https://doi.org/10.1007/s00213-020-05563-3
19 Levin, F. R., Choi, C. J., Pavlicova, M., Mariani, J. J., Mahony, A., Brooks, D. J., … Grabowski, J. (2018). How treatment improvement in ADHD and cocaine dependence are related to one another: A secondary analysis. Drug and Alcohol Dependence, 188, 135–140. https://doi.org/10.1016/j.drugalcdep.2018.03.043
20 Wenger, H. C., Cifu, A. S., & Kim, A. Y. (2021). Screening for Hepatitis C Virus. JAMA - Journal of the American Medical Association, 326(4), 348–349. https://doi.org/10.1001/jama.2020.27041
21 Saag, M. S. (2021). HIV Infection Screening, Diagnosis, and Treatment. New England Journal of Medicine, 384(22), 2131–2143. https://doi.org/10.1056/NEJMcp1915826