Blog Post – Stimulant Use Disorder (Cocaine)

Drug use and addiction disorders have widespread and significant health, social, and
economic implications for the global population. In 2021, the United Nations Office on Drugs
and Crime (UNODC) estimated that over 296 million people on average use drugs each year
globally, a 23% spike over the last decade (Relief Web, 2023). It is not surprising that the
number of people suffering from drug use disorders has also jumped to 39.5 million, representing
a 45% increase within the past ten years. The vast majority of drug use cases and addiction
disorders are found in America. A 2022 US National Survey on Drug Use and Health (NSDUH)
estimates that over 46.8 million Americans (16.5% of the total population) aged 12+ years
suffered from a substance use disorder within the past twelve months (American Addiction
Centers, n.d.).
Sadly, drug use/abuse/addiction is associated with multiple health, social, and economic
effects, including brain damage, heart conditions, respiratory issues, liver damage, psychological
and mental issues (suicidal ideations, depression, anxiety, and psychosis), behavioral and social
effects (legal, financial, and relationship problems), and other adverse effects, including
overdose-related deaths and withdrawal symptoms. As a PMHNP you have a huge role to play in
screening, diagnosing, monitoring, preventing, and treating substance abuse/addiction disorders.
This, however, requires an in-depth understanding of the specific drug use/addiction disorders
and pertinent information related to them. This blog post will focus on cocaine use disorder, from
diagnostic criteria to therapy to multiple other areas.

What is Cocaine Use Disorder/Cocaine Dependence and How Is It Diagnosed?
Cocaine use disorder is one of the most prevalent and deadliest stimulant use disorders in
the US and other developed countries, including Canada and most parts of Europe – emerging

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markets. It is estimated that at least 42 million Americans have tried cocaine at some point in
their life (Vankar, 2024). In 2021, 24,486 people died from cocaine-related overdoses,
representing a 54% rise from 2019 (National Institute on Drug Abuse, 2023).
Typically, cocaine use disorder, also called cocaine addiction/dependence (ICD 10 Code
F14.20) is a condition typified by a compulsive pattern/trend of cocaine use in spite of negative
implications. Cocaine dependence is classified as a substance use disorder or SUD (a chronic
relapsing condition). Cocaine is a stimulant drug used for recreational purposes, although it is
often abused. It is extracted from two Coca plant species (Erythroxylum coca and Erythroxylum
novogranatense) native to Colombia, Peru, Argentina, Bolivia, and other South American
countries. Cocaine highly addictive are makes users feel mentally alert, energetic, and euphoric.
As a stimulant, cocaine directly alters brain function with long-term effects linked to extensive
psychological and physiological issues. Today, cocaine is classified as a “Schedule II drug,”
meaning it has a high likelihood of abuse, although it can be prescribed medically by a physician
for medical reasons, particularly as an anesthetic for certain throat, ear, and eye surgeries.
Cocaine is a strong CNS stimulant that interferes with dopamine reabsorption, producing
euphoric effects, including mental clarity, reduced fatigue, and hyperstimulation. Dopamine is a
chemical in the brain linked with movement and pleasure.
Like other substance use disorders (SUDs), cocaine dependence is diagnosed based on
eleven DS-5-TR criteria, including (1) taking the drug in larger amounts and longer period that
intended, (2) desiring to stop or cut down usage but not being able, (3) spending plenty of time
using, getting, or recovering from usage, (4) experiencing urges/cravings to use it, (5) not
managing to perform normal duties/work at home, work, or school because of the substance, (6)
continuing its use even when it evidently causes relationship issues, (7) giving up crucial

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recreational, occupational, and social activities because of use, (8) using the drug over and over
even when it puts your life in danger, (9) continuing to use the drug even when a psychological
or physical problem is apparent that could have been caused or worsened by the drug, (10)
needing more of the drug to achieve the effect, what is called “tolerance,” and (11) and
developing withdrawal symptoms often relieved by consuming more of the drug (Hasin et al.,
2013).

What are the Street Names of Cocaine?

Cocaine has a long history in the US, peaking in the 1960s, 70s. and 80s during Pablo
Escobar’s reign. Its devastating effects in American communities led to decade-long legislative
and jurisdictional changes, with the Drug Enforcement Administration (DEA) formed in 1973 to
specifically tackle illicit trafficking and abuse. This increased surveillance and policing led to the
smugglers, traffickers, and users coining various names to try to hide from authorities. Some of
the common slang names linked to cocaine include crack cocaine, boy-girl, candy flipping,
cocoa puffs, flamethrowers, spaceball, speedball, woo-woo, Apache, Big C, blonde, blow,
Florida snow, love affair, Mexican percocet, Scottie, white girl, and zip. Crack cocaine is also
called Black rock, dice, gravel, ice cubes, nuggets, RIP, or white tornado. These names though
vary from region to region (American Addiction Centers, 2024).

How Can an Individual Use or Abuse Cocaine?

Cocaine exists in two major forms: freebase and powdered. The ‘powdered’ cocaine is a
hydrochloride salt soluble in water. The ‘freebase’ cocaine has not been altered (neutralized) by
an acid. The ‘freebase’ cocaine can be smoked as “crack cocaine.” It is often processed from the
powdered hydrochloride salt to a freebase form for smoking. The processing usually involves
mixing the powdered cocaine with baking soda and heating the mixture to crystallize. The major

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routes of cocaine administration are smoking/inhalation, injection, and snorting. Snorting via the
nose yields a slower onset of effects, although it can lead to dependence and other health issues.
Smoking “crack cocaine” yields intense and rapid onset of euphoric symptoms. Smoking
increases the risk of respiratory issues and dependence. Cocaine for injection is prepared by
dissolving the powdered drug in water and then injecting it directly using a syringe into the
bloodstream (intravenous injection). This method yields an intense and immediate response
similar to inhalation but also comes with an elevated risk of infections, overdose, and other
complications (Psychology Today, 2021).

What Are the Symptoms Associated with Cocaine Abuse?

Cocaine use yields short-term and long-term symptoms. Short-term impacts include fast
breathing and heartbeat, elevated body temperature and pressure, violent behavior, chest pain,
blurred vision, muscle spasms, fever, nausea, heart failure, convulsions, brain failure, and death
due to convulsions. Long-term effects may include depression, dependence/addiction,
restlessness, mood swings, irritability, sleeplessness, paranoia, weight loss, emotional issues,
isolation from friends/family, psychosis, delusions, anxiety, nasal damage (including inflated
nasal passages), increased risks of STIs (HIV and hepatitis), severe respiratory infections,
strokes, respiratory failure, chest pain, heart attacks, and abdominal pain. Some of the warning
signs for cocaine identified by the National Institute of Drug Abuse include frequently needing
money, acting withdrawn/tired/depressed/careless, changes in behavior/friends/eating/sleeping
patterns, frequent sniffing or a runny nose, red/bloodshot eyes, and losing interest in family,
school, or previously enjoyed hobbies or activities (Psychology Today, 2021).
What are the Symptoms of Cocaine Withdrawal?

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Cocaine withdrawal can be uncomfortable for addicts. Unlike alcohol and opiates,
cocaine withdrawal is associated with more emotional and mental symptoms than physical
effects, although the latter also occurs to a lesser degree. Mental and emotional symptoms
include slowed thinking, restlessness, nightmares, cocaine cravings, suicidal actions or thoughts,
anxiety, depression, incapacity to feel pressure, and concentration issues. Physical symptoms
often include chills, tremors, nerve pain, and muscle aches. During detox, these withdrawal
symptoms usually improve after ten or more days, although cravings may occur from time to
time.

What are the Treatment Recommendations for Cocaine Use Disorders?
Although cocaine dependence/cocaine use disorder is a prevalent SUD in the US, there
are currently no FDA-approved drugs. However, there are multiple pharmacologic agents
currently under clinical trials, with some showing promising results. The most promising drug
classes are dopamine agonists (for example, long-acting modafinil and amphetamine) and
glutamate/GABA agonists (for example, topiramate). I will focus on amphetamines as the most
promising CUD treatment option. Lisdexamphetamine is one of the few amphetamines that have
shown positive results during recent empirical studies and clinical trials (Mariani et al., 2021).

What are the Mechanisms of Action for the Medication?

Lisdexamphetamine (brand name: Vyvanse) is an amphetamine, a “long-acting dopamine
agonist.” As a dextroamphetamine prodrug, lisdexamphetamine works by blocking the reuptake
of dopamine and norepinephrine into the presynaptic neurons. It also elevates catecholamine
levels in the extracellular space. It has a high affinity for inhibiting the noradrenaline transporter
or NET, the dopamine transporter or DAT, and the vesicular monoamine transporter 2 or

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VMAT2. It has a weaker affinity for monoamine oxidase (MAO) and serotonin transporter
(SERT) (Drugs.com, n.d.).

What are the Medication’s Side Effects?

Serious side effects of lisdexamfetamine include heart issues (feeling like passing out,
fluttering in the chest, pounding heartbeats, breathing difficulty, and chest pain), psychosis
symptoms (paranoia, hostility, aggression, behavior problems, and hallucinations), and
circulatory issues (cold feeling, pain, numbness, blue/red/pale skin in the toes or fingers, and
unexplained wounds). Common side effects include insomnia, weight loss, loss of appetite, dry
mouth, fast heart rate, dizziness, irritability, constipation, diarrhea, stomach pain, vomiting, and
nausea (Drugs.com, n.d.).

How Should It Be Taken?

Lisdaxamphentamine (Vyvanse) exists in tablets (10mg, 20mg, and 40mg) and capsular
forms (30mg and 60 mg). It should be taken orally. The initial dose for adults (18+ years) and
children (6-17 years) is usually 30mg once daily taken in the morning. The maintenance dose is
30-70 mg daily; the dosages can be increased to 10-20 mg at weekly intervals as needed. The
maximum dose should not exceed 70 mg (Drugs.com, n.d.).

Baseline/Ongoing Tests and Assessments When Taking the Medication
Before prescribing lisdaxamfantamine (at baseline) test/screen for medication abuse risk
(check the patient’s drug use history) and cardiac disease risk. It is also critical to monitor the
two parameters once the patient starts using the drug.

What are the Nonpharmacologic Intervention Recommendations?
Nonpharmacologic approaches may include counseling, cognitive behavioral therapy
(CBT), harm reduction methods, art therapy, dialectical behavioral therapy, support groups,

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relapse prevention education, aftercare planning, alternate or 12-step programs, and lifestyle
modifications (exercise and healthy diets).

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References

American Addiction Centers. (2024). Slang and nicknames for cocaine.
https://americanaddictioncenters.org/blog/cocaine-slang-names
American Addiction Centers. (n.d.). Alcohol and drug abuse statistics.
https://americanaddictioncenters.org/addiction-statistics
Drugs.com. (n.d.). Lisdexamfetamine. https://www.drugs.com/mtm/lisdexamfetamine.html
Hasin, D. S., et al. (2013). DSM-5 criteria for substance use disorders: Recommendations and
rationale. American Journal of Psychiatry, 17098), 834-851. doi:
10.1176/appi.ajp.2013.12060782
Mariani, J. J., et al. (2021). Open-label pilot study of lisdexamfetamine for cocaine use disorder.
American Journal of Drug and Alcohol Abuse, 47(3), 401-409. doi:
10.1080/00952990.2021.1885677
National Institute on Drug Abuse. (2023). Drug overdose death rates.
https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
Psychology Today. (2021). Cocaine use disorder.
https://www.psychologytoday.com/us/conditions/cocaine-use-disorder
Relief Web. (2023). UNODC World Drug Report 2023 [EN/AR/RU/ZH].
https://reliefweb.int/report/world/unodc-world-drug-report-2023-enarruzh
Vankar, P. (2024, Mar. 8). Number of Americans who used cocaine in their lifetime 2009-2022.
Statista. https://www.statista.com/statistics/611637/cocaine-use-during-lifetime-in-the-
us/