Cocaine

Cocaine is a powerful short-acting stimulant that blocks the reuptake of dopamine, norepinephrine, and serotonin. Used in sexual contexts for confidence, energy, disinhibition, and perceived sexual enhancement, though it frequently causes erectile dysfunction at higher doses.

How It Works

Cocaine blocks the dopamine, norepinephrine, and serotonin transporters, preventing reuptake and causing accumulation in the synaptic cleft. It also blocks sodium channels (local anesthetic effect). The dopamine reuptake blockade produces the euphoria.

Legal Status

Schedule II in the US (medical use as local anesthetic). Class A in UK. Illegal for recreational use worldwide.

Dosage Guide (Insufflation)

Note: Street cocaine purity is wildly variable (15-80%+). Common adulterants: levamisole (causes skin necrosis and immune suppression), phenacetin, benzocaine, caffeine. Increasingly contaminated with fentanyl.

Organ System Impacts

cardiovascular — Dangerous

Cocaine is profoundly cardiotoxic. Causes coronary artery spasm, accelerates atherosclerosis, causes cardiomyopathy. Heart attacks occur even in young, healthy users. The combination with alcohol produces cocaethylene, which is more cardiotoxic than either alone.

neurological — High

Disrupts dopamine system with chronic use. Stroke risk from vasoconstriction and hypertension. Seizure risk. Chronic use: cognitive impairment, impulsivity, dopamine depletion → depression.

respiratory — Moderate

Snorting damages nasal passages, septum, and sinuses. Smoking crack causes 'crack lung' — diffuse alveolar damage, hemorrhage, bronchospasm.

hepatic — Moderate

Cocaine itself causes hepatotoxicity. Combined with alcohol, the liver produces cocaethylene — more toxic and longer-lasting than cocaine alone. Chronic use stresses liver significantly.

renal — Moderate

Vasoconstriction reduces renal blood flow. Rhabdomyolysis can cause acute kidney injury. Chronic use accelerates kidney disease.

dermatological — Moderate

Levamisole (common adulterant) causes severe vasculitis with skin necrosis — painful purplish patches, especially on ears, nose, cheeks. Vasoconstriction causes skin ischemia.

gastrointestinal — Moderate

Vasoconstriction can cause bowel ischemia. Loss of appetite and weight loss. Oral use erodes gum tissue and teeth.

musculoskeletal — Low

Jaw clenching. Muscle tension. Rhabdomyolysis possible with high doses or extreme exertion.

ocular — Low

Dilated pupils (mydriasis). Increased intraocular pressure. Blurred vision at high doses.

hematological — Moderate

Levamisole (adulterant) causes agranulocytosis — dangerous drop in white blood cells, leaving user vulnerable to infections.

Effects

Desired Effects

• Euphoria and confidence
• Increased energy and alertness
• Talkativeness and sociability
• Feelings of power and invincibility
• Reduced inhibitions
• Increased libido (at lower doses)

Negative Effects

• Erectile dysfunction (very common at moderate-high doses)
• Anxiety, paranoia, and agitation
• Jaw clenching
• Runny or bloody nose
• Compulsive redosing
• Irritability and aggressiveness
• Insomnia
• Comedown: fatigue, depression, cravings

Rare but Serious

• Cardiac arrest (cocaine is the #1 drug-related cause of ER visits for chest pain)
• Stroke
• Seizures
• Aortic dissection
• Nasal septum perforation (chronic use)
• Levamisole-induced vasculitis (skin necrosis from adulterant)
• Cocaine-induced psychosis

Drug Interactions

Detection Times

Cocaine and its metabolite benzoylecgonine are detected on all standard drug panels.

Urine

Benzoylecgonine (metabolite) detected on standard panels. Heavy use extends window. Detection window: up to 4 days.

Blood

Cocaine itself clears quickly; metabolite persists longer. Detection window: up to 2 days.

Hair

Hair follicle testing detects cocaine use over months. Detection window: up to 90 days.

Saliva

Oral fluid testing for recent use. Detection window: up to 2 days.

Harm Reduction Tips

• TEST with fentanyl strips — fentanyl contamination in cocaine is increasing and has caused many deaths

• Avoid binging — cardiovascular risk increases with each line

• Cocaine + alcohol = cocaethylene (more cardiotoxic). Keep alcohol minimal or avoid it.

• Set a limit on how much you'll use BEFORE you start — cocaine's 'more-ish' quality makes in-the-moment limits useless

• Alternate nostrils. Rinse sinuses with saline after a session to reduce nasal damage.

• Chop powder as finely as possible to reduce nasal trauma

• Don't share straws/tubes — transmission risk for Hep C and other infections

• If you get painful purple/dark patches on skin (especially ears, nose, cheeks), seek medical help — this is levamisole vasculitis

• Know that erectile dysfunction is extremely common on cocaine — don't add multiple substances trying to fix it

• If you feel chest pain at ANY point: stop using, sit down, and call 911 if it persists beyond a few minutes

• The comedown cravings are the drug talking. Ride it out. Don't re-up.

Withdrawal Symptoms

Severity: High

Crash: hours to days (exhaustion, hunger). Acute withdrawal: 1-2 weeks (cravings, depression). Protracted: months (intermittent cravings, mood instability).

Physical

• Extreme fatigue
• Increased appetite
• Psychomotor slowing
• Muscle aches
• Chills

Psychological

• Intense cravings
• Depression and suicidal ideation
• Anxiety and agitation
• Anhedonia
• Vivid unpleasant dreams
• Paranoia
• Difficulty concentrating

Emergency Information

Call 911 If:

• Chest pain — especially if it radiates to arm, jaw, or back
• Sudden severe headache (worst headache of your life)
• Seizures
• Loss of consciousness
• Difficulty breathing
• Stroke symptoms: face drooping, arm weakness, speech difficulty (FAST)
• Someone is unresponsive after mixing cocaine with opioids

What To Do

1. Stop using immediately
2. Sit down in a calm environment
3. If chest pain: chew an aspirin (325mg) if available while waiting for EMS
4. Do NOT use beta-blockers for cocaine-related chest pain (they can worsen coronary spasm)
5. If someone mixed cocaine + opioids and is unresponsive: administer naloxone if available and start CPR
6. Try to stay calm — anxiety amplifies cardiovascular stress

What To Tell EMS

The patient used cocaine. Report route, approximate amount, timing, and any other substances (especially alcohol, opioids). Key concerns: acute coronary syndrome, stroke, seizures. Note: beta-blockers are contraindicated. Benzodiazepines are first-line for agitation and cardiovascular symptoms.

Seek Help If

• Chest tightness or pressure that comes and goes
• Rapid heartbeat that doesn't settle (over 150bpm)
• Nosebleed that won't stop after 20 minutes
• Severe anxiety or panic attack
• Numbness or weakness on one side of body
• Purple or dark discoloration on skin

Normal Discomfort

• Mild jitteriness
• Runny nose
• Brief jaw clenching
• Restlessness between lines
• Mild comedown fatigue