Cocaine

Cocaine is a powerful, short-acting stimulant derived from the leaves of the coca plant (Erythroxylum coca), native to South America. In its common forms it appears either as a white crystalline powder (cocaine hydrochloride), which is typically snorted or dissolved and injected, or as 'crack' — a solid, smokable freebase form. Medically, cocaine has a limited legitimate role as a local anesthetic for certain ear, nose, and throat procedures, but the overwhelming majority of use is non-medical. It is classified as a Schedule II controlled substance in the United States, reflecting both a recognized medical use and a high potential for abuse and dependence. On this site, cocaine matters for a specific reason: products sold as 'pink cocaine' or 'tusi' frequently contain little or no actual cocaine, and conversely, powders sold as cocaine are increasingly found to be adulterated with other substances, including fentanyl.

Cocaine acts primarily by blocking the reuptake of dopamine, norepinephrine, and serotonin in the brain, causing these neurotransmitters to accumulate in the synapse. The resulting surge in dopamine is thought to underlie the intense, short-lived euphoria and the strong reinforcing, habit-forming quality of the drug. Because the effect is brief — often lasting only a matter of minutes to a short period depending on the route — people frequently re-dose, which is part of what makes cocaine so prone to compulsive, binge-pattern use. Its stimulant action also constricts blood vessels, raises heart rate and blood pressure, and increases body temperature, which is the basis for much of its physical danger.

Reported short-term effects include intense euphoria, increased energy and alertness, talkativeness, heightened confidence, and reduced appetite. These desired effects are accompanied by physical changes such as a faster heart rate, raised blood pressure, dilated pupils, and increased body temperature. As the brief high fades it is commonly followed by a 'crash' marked by fatigue, low mood, irritability, and strong craving. Higher amounts and repeated use can produce anxiety, panic, paranoia, agitation, and erratic or aggressive behavior. Long-term, regular use is associated with significant harms that vary by route — for example, damage to the nasal passages from snorting, and respiratory problems from smoking crack — as well as cardiovascular strain, marked weight loss, and a high risk of psychological dependence.

Cocaine carries serious acute risks. Because it sharply raises heart rate, blood pressure, and body temperature while constricting blood vessels, it can trigger heart attack, dangerous heart rhythms, stroke, and seizures — and these events can occur even in young, healthy people and even on a first use. Overdose is a real risk and may present as chest pain, a racing or irregular heartbeat, extreme agitation, very high body temperature, seizures, or loss of consciousness; it is a medical emergency. Two combination risks deserve special emphasis. First, cocaine mixed with alcohol forms cocaethylene in the body, a compound that places additional strain on the heart and is associated with greater toxicity than either substance alone. Second — and increasingly the deadliest risk in the current drug supply — cocaine is frequently contaminated with fentanyl, a potent opioid that can cause fatal overdose in very small amounts; people who do not use opioids and have no tolerance are especially vulnerable. Regular use also carries a high risk of addiction. If someone may be overdosing, call 911; for poisoning guidance call Poison Control at 1-800-222-1222. Because of the fentanyl risk, fentanyl test strips and not using alone are widely recommended harm-reduction measures.

intense euphoria, increased energy/alertness; restlessness, irritability, anxiety in some; paranoia at high dose/prolonged use

nasal-septum erosion (snorting); respiratory syndrome (smoking); cardiac arrhythmia, ischemia, sudden cardiac arrest, stroke

smoked "crack" 7–10 sec

rush/high 2–20 min (smoked)

constricted vessels, dilated pupils, raised BP/HR; arrhythmias, seizures, strokes, death; "speedballing" w/ opioids; 78.6% of cocaine OD deaths also involved an opioid (2021)

limited — topical local anesthetic (ENT/upper respiratory); rarely used medically now

long US history; "crack" free-base emerged 1980s

DAWN ~354,512 ED visits (2023); NSDUH ~5.01M past-year (2023); NFLIS ~170,640 reports (2023); ~88% of seized cocaine traced to Colombia