Cocaine dependence

Cocaine is a drug made from the coca plant found in some South American countries. It stimulates your body, raising your heart rate, and can make you feel excited, confident, anxious or cause other heightened emotions.

In the UK cocaine is classified as a Class A drug under the Misuse of Drugs Act 1971. This means that possessing or selling the drug is illegal. Its importation, sale and distribution in the UK is usually controlled by organised criminal gangs.

Cocaine does have some recognised medical uses. Its chemical makeup is similar to anaesthetic medications used by surgeons and anaesthetists. It can be used as a topical anaesthetic, meaning it can be used to numb the surface of a body part. It does this by blocking nerve impulses and constricting blood vessels. It is licensed for medical use in some countries like the USA, Germany and Australia. However, it is not licensed in the UK for this purpose.

Cocaine comes in three forms:

• Powder – This is a white powder that can be snorted, rubbed onto the gums or injected.
• Crack – These are small rocks of cocaine that can be ground up and snorted, smoked or turned into a liquid and injected.
• Freebase – This is a crystallised form that can be smoked.

Cocaine is often ‘cut’ or mixed with other substances before being sold. This can be very dangerous for drug users because it increases the likelihood of overdose or even death. Research has shown that the other substances that are mixed with cocaine can make up to 80% of the drug being sold.

Cocaine can be mixed with relatively harmless powders like sugar, cornflour or creatine (a supplement). Other drugs, such as a local anaesthetic drug called benzocaine are also commonly used.

Cocaine is also sometimes mixed with more dangerous substances. For example, levamisole, an anti-parasite agent. Levamisole can weaken the body’s immune response, which increases the risk of developing infections. This is especially risky for people who inject cocaine.

A strong painkiller called fentanyl has also been found mixed with cocaine. Fentanyl is an opioid painkiller that is 50 to 100 times stronger than heroin. It can increase the risk of overdose and death, even in small amounts.

Cocaine is the second most commonly used drug in the UK after cannabis. In England and Wales in 2019, an estimated 1 million people used powder cocaine and 180,000 used crack cocaine.

Cocaine-related deaths are currently at an all-time high in the UK. Since 2012 they have increased by five times. One in seven drug-related deaths in 2018 were thought to be caused by cocaine misuse.

Production of cocaine has increased considerably over the last 10 years. This has led to a wider availability of the drug.

Powder cocaine is used by people from all backgrounds. It is most commonly used by men under 30, and roughly a third of powder cocaine users are on higher incomes. It is often used recreationally alongside alcohol and other drugs such as MDMA (ecstasy).

The majority of people who use powder cocaine are not dependent on it. However, due to the increased availability and purity of cocaine, more people are becoming dependent.

There are also increasing numbers of people using crack cocaine, which is more addictive because of the way it is taken. Crack tends to be used in ‘binges’, where someone will take a lot of it for a few days at a time. It will often be used with other drugs or alcohol. Crack cocaine use is more common in areas with high levels of poverty and social deprivation.

Cocaine works by increasing the levels of a chemical in our brain called dopamine. This happens in an area of our brain known as the ‘nucleus accumbens’, which is part of the brain’s reward system. This system is normally activated when we do something pleasurable, like eating nice food or falling in love.

When you use cocaine, these increased dopamine levels can make you feel happy and talkative, and mean you are able to stay awake longer. They can increase your sex drive and make you feel more confident in social situations.

However, cocaine can make some people more aggressive or agitated. Using cocaine might cause you to take risks you wouldn’t normally take.

These effects often happen immediately after using the drug and can last for up to an hour. How long they last will depend on how much you have taken.

How cocaine affects you will depend on how you are feeling and where you are. Because of this, cocaine can make different people act in different ways. It is never possible to predict how cocaine will make you feel.

If you have started to use cocaine frequently, and are finding it hard to stop, this is called cocaine dependence (also known as cocaine addiction). You do not need to take cocaine every day to become dependent on it. You also do not need to be dependent on cocaine to develop problems from cocaine use.

If you have any of these symptoms, you may have developed a dependency on cocaine:

• a strong desire to take cocaine regularly
• the need to take more to get the same effect
• finding it difficult to stop using cocaine
• neglecting other interests in your life
• continuing to take cocaine despite knowing it is harming you
• getting withdrawal symptoms if you stop.
  

You can find out more about withdrawal below.

Cocaine dependence can affect anyone, no matter who they are or what life experiences they have had.

However, there are some people who are more likely to become dependent on cocaine, including:

• people who have a family history of dependence on drugs or alcohol
• people who have easier access to cocaine. For example, because they can afford it or because the people around them are using it
• people who have experienced childhood trauma.

Many people who use cocaine only do so for a short time in their lives. Most people stop using cocaine without developing any problems. However, if you use cocaine and continue to do so, it can cause long-term damage to your mental and physical health.

Physical health problems

Using cocaine can cause you specific problems with your physical health, depending on how you use it. These problems include:

• Heart conditions - Using cocaine can cause the vessels that supply blood to your heart to harden. This can increase stress on your heart muscle and lead to:
  • high blood pressure
  • abnormal heart rhythms
  • heart attacks
  • heart failure
  • strokes
  • sudden death.
• Lung conditions – Smoking cocaine can increase the risk of chest infections, lung disease and cancer.
• Nose and sinus problems – Snorting cocaine can cause a blocked nose (rhinitis), a loss of your sense of smell (anosmia) and nosebleeds. It can damage and destroy the cartilage in your nose and the roof of your mouth.
• Blood diseases – Injecting cocaine, or sharing bank notes, straws or pipes (things used to take cocaine) can increase your risk of developing HIV, hepatitis, blood clots and abscesses.

Mental health problems

Using cocaine for a long time can have a negative effect on your mental health. It can contribute to you developing mental health problems such as:

• depression
• anxiety disorders
• psychosis – this is where your thoughts and emotions are so disturbed that you lose touch with reality.

If you already have a mental illness, using cocaine could make this worse.

Using cocaine can also cause you to act in ways you wouldn’t usually, such as making you act aggressively or violently. This can have a negative effect on your relationships and your social life.

If you are using cocaine frequently, this can also have a negative effect on your finances or your job.

Mixing cocaine and alcohol

If you use cocaine and alcohol at the same time, your body creates a very toxic product called cocaethylene. This can damage your immune system, and mean that your risk of seizures and death is much higher than when using cocaine or alcohol on their own.

Withdrawal happens when your body has become used to cocaine and you stop using it. You can’t die from cocaine withdrawal, but you might experience unpleasant symptoms, including:

Mental symptoms

• tiredness
• poor concentration
• irritability
• feelings of depression or anxiety
• paranoia or psychosis – seeing, hearing or feeling things that aren’t real
• suicidal thoughts.
  

Physical symptoms

• restlessness
• a reduced sex drive
• insomnia or nightmares
• taking part in risky behaviour
• harming yourself or others.

For some people who want to stop using cocaine, support from friends and family or learning about cocaine-related harm can be enough. For people who are finding it hard to stop using cocaine, there are treatments available.

Addictions services

If you want to get help for cocaine use, depending on the area you live in, you can refer yourself to addiction services, or your GP can refer you. You will have an assessment where a specialist will find out more about you and your life. This will help them to decide if you need to go onto a treatment plan and how the plan could fit your needs.

Treatments for cocaine dependence can involve:

• Talking therapies – Motivational enhancement therapy, cognitive behavioural therapy (CBT) or couples therapy can help you to understand your thoughts and behaviours around cocaine use. Some of these are not available to people who are still using cocaine.
• Support groups – You might find mutual support groups useful. For example, twelve-step programmes such as Cocaine Anonymous or Narcotics Anonymous. In regular meetings, recovered drug users provide advice and guidance, and members share their experiences.
  

Most treatment for cocaine dependence is available in the community. However, you may need to go to hospital if you have physical or mental health complications, or multiple addictions.

Medication

Unfortunately, no medications have been found to have strong evidence for helping with cocaine dependence or withdrawal.

Doctors may prescribe other medication to help reduce the withdrawal effects of coming off cocaine. For example, sleeping tablets for insomnia. However, this will be on an individual basis.

Current research has shown some small potential benefits from three types of drugs. All three treatments still need more research before we can be sure they are helpful.

• Disulfiram – This medication is commonly used to help people with alcohol dependence.
• Psychostimulants – These are drugs that affect the body in the same way as cocaine. They might help someone to continue not using cocaine.
• N-acetyl cysteine – There is some evidence to show that this may help reduce cravings and help someone to continue not using cocaine once they have stopped.
  

Other medications have been studied, including:

• antidepressants
• anticonvulsants
• antipsychotics
• dopamine agonists
• baclofen

However, these have not been shown to help treat cocaine dependence.

A cocaine vaccine to block the effects of cocaine is being researched.

It is important to educate yourself and understand the effects cocaine can have on you. Here are some websites you can trust to give factual information, advice and support:

Information about drug use

• Talk to Frank – This website provides facts, support and advice on drugs and alcohol.
• Drug Science – An independent scientific body on drugs in the UK. It provides clear, evidence-based information on drugs.
• Crew, cocaine information - Crew is a Scottish harm-reduction charity. It provides information and support to help people make positive choices about their drug use and sexual health.

Support available

• NHS, cocaine addiction: get help – Find out what support is available for you from the NHS for cocaine dependence.
• Cocaine Anonymous – A twelve-step programme that aims to help people to stop using cocaine.
• Narcotics Anonymous – A twelve-step programme that aims to help people to stop using drugs.
• SMART recovery - An online, science-based programme that helps people recover from addictions.

Needle exchanges

At needle exchanges it is possible to exchange used needles for clean needles. This reduces the risk of:

• blood-borne viruses
• injection-site abscesses
• injury to others from discarded needles.
  

Needle exchange services can also offer clean foil. This can reduce damage to the lungs from smoking crack cocaine.

Needle exchange services are available across the UK. In some areas they are in community pharmacies, and in other areas they are provided by drug outreach services. Use these links to search for services in your area:

• England
• Northern Ireland
• Scotland
• Wales

You can also speak to your GP or local addictions service to find out more.

Sources of further help by region

• England
• Northern Ireland
• Scotland
• Wales

• NHS, advice for families of drug users – This page includes lots of useful organisations that can help to support you.
• Families Anonymous – This organisation provides mutual support to families and friends of people with drug problems.
• Adfam – This charity tackles the effects of alcohol, drug use or gambling on family and friends in England and Wales.
• Scottish Families Affected by Alcohol & Drugs (SFAD) – This charity supports anyone concerned about someone else’s alcohol or drug use in Scotland.
• Drugfam – This charity supports people affected by or bereaved from another person’s harmful use of alcohol, drugs, substances or gambling.
• SMART Recovery, support group for friends and family – This charity provides a national network of mutual-aid meetings and online training programmes. This includes meetings for family and friends of someone with an addiction.
• Release – A national centre providing advice and information to the public and professionals on drug use laws.

This information was produced by the Royal College of Psychiatrists’ Public Engagement Editorial Board (PEEB). It reflects the best available evidence at the time of writing.

Expert authors: Dr Donna Mullen and Dr Cedar Andress

Special thanks to the Regional Service User Network, who reviewed this resource.

Full references available on request.