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Cocaine-Related Psychiatric Disorders Treatment & Management

  • Author: Christopher P Holstege, MD; Chief Editor: David Bienenfeld, MD  more...
Updated: Apr 14, 2016

Medical Care

People who abuse cocaine present with many different medical symptoms. At times, clinicians may have difficulty determining which signs and symptoms are significant and which are not. For example, cocaine-induced chest pain is usually benign. However, these patients may have an acute coronary syndrome, pneumothorax, pulmonary embolism, pulmonary edema, or aortic dissection. Before these patients are discharged home or admitted to a psychiatric ward, the clinicians involved must evaluate the patient for other nonpsychiatric medical problems.

Cocaine intoxication

Acute cocaine intoxication is usually self limited and can be managed with supportive care.

Benzodiazepines are the first-line therapy in treating patients who are intoxicated from cocaine and are extremely agitated. Typically, benzodiazepines can be titrated until the patient is calm and the pulse and blood pressure have stabilized.

Use neuroleptics with caution in acute intoxication. Acute hyperthermia syndromes associated with acute cocaine intoxication have been reported, and the use of neuroleptics with the risk of neuroleptic malignant syndrome may confuse this situation.

Specific laboratory tests can be ordered as necessary.

Cocaine-induced chest pain

Chest pain associated with cocaine use may be from musculoskeletal, cardiovascular, or pulmonary etiologies.

Obtain a chest radiograph to exclude localized infiltrates, pneumothorax, pneumomediastinum, and pulmonary edema. An ECG and serial cardiac enzyme evaluation assist in excluding acute myocardial infarction and acute coronary syndromes.

If an acute coronary syndrome is suggested, then oxygen, aspirin, benzodiazepines, and nitroglycerin can be administered. Nonselective beta-blockers are best avoided in all patients who are intoxicated with cocaine.


Cocaine-induced hypertension is treated first with benzodiazepines. Benzodiazepines decrease the cocaine-induced sympathomimetic drive from the CNS.

If this fails, phentolamine may be considered. Phentolamine is an alpha-antagonist and counteracts cocaine's vasoconstrictive effects.

Nitroprusside and nitroglycerin also may be considered.


Cocaine-induced seizures may be either generalized or partial and result from cocaine toxicity itself or from a cocaine-induced process, such as a cerebral vascular accident.

The first-line therapy is benzodiazepines, followed by barbiturates.

Consider a head CT scan for seizures associated with the use of cocaine.

No evidence exists that anticonvulsants prevent cocaine-induced seizures, and they are not recommended for this purpose.


Rhabdomyolysis may manifest in patients who are agitated and intoxicated with cocaine. This disorder must be recognized early to prevent secondary renal failure.

Obtain a creatine kinase measurement and test the urine for myoglobin. If the urinalysis reveals blood on the dipstick but no red blood cells upon microscopic examination, then myoglobinuria may be present.

Treatment of rhabdomyolysis focuses on ensuring adequate urine output and, possibly, alkalization of the urine.


Cocaine-induced dyspnea has multiple causes.

Obtain a chest radiograph to exclude pulmonary edema, focal infiltrate, pneumothorax, and pneumomediastinum

Sleep disturbance

In a study by Morgan et al, modafinil was evaluated for its ability to normalize sleep patterns in chronic cocaine users. Progressive cocaine abstinence is associated with disruptive sleep outcomes. In patients who received modafinil each morning, nocturnal sleep was promoted and daytime sleepiness decreased compared with those taking placebo.[8]



A number of consultations may be necessary when caring for a patient who abuses cocaine. Consultations to consider include medical toxicologists, regional poison control center personnel, cardiologists, neurologists, psychiatrists, substance abuse clinicians, and social services personnel, depending on the presenting signs and symptoms.




Recent work has suggested that a cocaine vaccine may induce the formation of sufficient antibodies to reduce cocaine use.

Martell et al conducted a phase IIb randomized, double-blind, placebo-controlled trial to evaluate the immunogenicity, safety, and efficacy of a cocaine vaccine in cocaine-dependent and opioid-dependent individuals. Of the 115 patients recruited, 94 (82%) completed the trial. Participants were administered 5 vaccinations with placebo or succinylnorcocaine over 12 weeks. Within the vaccine group, those with serum IgG anticocaine antibody levels ≥ 43 mcg/mL had significantly more cocaine-free urine samples than those with serum levels < 43 mcg/mL and those who received placebo. Reduction of cocaine use by 50% was significantly greater if a high IgG level was achieved (53% of participants) compared with a low IgG level (23% of participants) (P =0.048).[9]

Contributor Information and Disclosures

Christopher P Holstege, MD Professor of Emergency Medicine and Pediatrics, University of Virginia School of Medicine; Chief, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Center

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, Medical Society of Virginia, Society of Toxicology, Wilderness Medical Society, European Association of Poisons Centres and Clinical Toxicologists, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Lori Holstege, MD Assistant Clinical Professor, Department of Psychiatry, Michigan State University

Lori Holstege, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Nathan P Charlton, MD Fellow in Medical Toxicology, University of Virginia, Blue Ridge Poison Center

Nathan P Charlton, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, South Carolina Medical Association, Wilderness Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

  1. American Psychiatric Association. Substance-Related and Addictive Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 561-570.

  2. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. SAMHSA. Available at September 2015;

  3. Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011 May 1. 115(1-2):120-30. [Medline]. [Full Text].

  4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Available at February 22, 2013;

  5. Kann L, Kinchen S, Shanklin SL, Flint KH, Kawkins J, Harris WA, et al. Youth risk behavior surveillance--United States, 2013. MMWR Surveill Summ. 2014 Jun 13. 63 Suppl 4:1-168. [Medline].

  6. Johnston, L. D., O’Malley, P. M., Miech, R. A., et al. Monitoring the Future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use. Available at 2015; Accessed: December 3, 2015.

  7. Martinez D, Carpenter KM, Liu F, et al. Imaging dopamine transmission in cocaine dependence: link between neurochemistry and response to treatment. Am J Psychiatry. 2011 Jun. 168(6):634-41. [Medline].

  8. Morgan PT, Pace-Schott E, Pittman B, Stickgold R, Malison RT. Normalizing effects of modafinil on sleep in chronic cocaine users. Am J Psychiatry. 2010 Mar. 167(3):331-40. [Medline].

  9. Martell BA, Orson FM, Poling J, Mitchell E, Rossen RD, Gardner T, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. 2009 Oct. 66(10):1116-23. [Medline].

  10. von Diemen L, Kapczinski F, Sordi AO, de Magalhães Narvaez JC, Guimarães LS, Kessler FH, et al. Increase in brain-derived neurotrophic factor expression in early crack cocaine withdrawal. Int J Neuropsychopharmacol. 2013 Sep 26. 1-8. [Medline].

  11. Ní Chróinín D, Gaine S. Crack-ing the case: a patient with persistent delirium due to body packing with cocaine. Ir Med J. 2012 Apr. 105(4):118-9. [Medline].

  12. Corominas-Roso M, Roncero C, Eiroa-Orosa FJ, Ribasés M, Barral C, Daigre C, et al. Serum Brain-Derived Neurotrophic Factor Levels and Cocaine-Induced Transient Psychotic Symptoms. Neuropsychobiology. 2013 Sep 13. 68(3):146-155. [Medline].

  13. Roncero C, Ros-Cucurull E, Daigre C, Casas M. Prevalence and risk factors of psychotic symptoms in cocaine-dependent patients. Actas Esp Psiquiatr. 2012 Jul-Aug. 40(4):187-97. [Medline].

  14. Abraham HD, Fava M. Order of onset of substance abuse and depression in a sample of depressed outpatients. Compr Psychiatry. 1999 Jan-Feb. 40(1):44-50. [Medline].

  15. Back S, Dansky BS, Coffey SF, et al. Cocaine dependence with and without post-traumatic stress disorder: a comparison of substance use, trauma history and psychiatric comorbidity. Am J Addict. 2000 Winter. 9(1):51-62. [Medline].

  16. Biggins CA, MacKay S, Clark W, Fein G. Event-related potential evidence for frontal cortex effects of chronic cocaine dependence. Biol Psychiatry. 1997 Sep 15. 42(6):472-85. [Medline].

  17. Blanchard DC, Blanchard RJ. Cocaine potentiates defensive behaviors related to fear and anxiety. Neurosci Biobehav Rev. 1999 Nov. 23(7):981-91. [Medline].

  18. Bolla KI, Rothman R, Cadet JL. Dose-related neurobehavioral effects of chronic cocaine use. J Neuropsychiatry Clin Neurosci. 1999 Summer. 11(3):361-9. [Medline].

  19. Cacciola JS, Alterman AI, O'Brien CP, McLellan AT. The Addiction Severity Index in clinical efficacy trials of medications for cocaine dependence. NIDA Res Monogr. 1997. 175:182-91. [Medline].

  20. Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry. 1999 Jun. 56(6):493-502. [Medline].

  21. Cubells JF, Feinn R, Pearson D. Rating the severity and character of transient cocaine-induced delusions and hallucinations with a new instrument, the Scale for Assessment of Positive Symptoms for Cocaine-Induced Psychosis (SAPS-CIP). Drug Alcohol Depend. 2005. May 12:[Medline].

  22. Franken IH, Kroon LY, Hendriks VM. Influence of individual differences in craving and obsessive cocaine thoughts on attentional processes in cocaine abuse patients. Addict Behav. 2000 Jan-Feb. 25(1):99-102. [Medline].

  23. Garbett R. National vocational qualifications?. NT Learn Curve. 1997 May 7. 1(3):15. [Medline].

  24. Gingrich JA, Rudnick-Levin F, Almeida C, et al. Cocaine and catatonia. Am J Psychiatry. 1998 Nov. 155(11):1629. [Medline].

  25. Goldfrank LR, Flomenbaum NE, Lewin NA. Cocaine. Goldfrank L, Flomenbaum N, Levin N, Weisman R, Hawland M, Hoffman R, eds. Goldfrank's Toxicologic Emergencies. 6th ed. Stamford, Conn: Appleton & Lange; 1998. 1071-89.

  26. Harris D, Batki SL. Stimulant psychosis: symptom profile and acute clinical course. Am J Addict. 2000 Winter. 9(1):28-37. [Medline].

  27. Havassy BE, Arns PG. Relationship of cocaine and other substance dependence to well-being of high-risk psychiatric patients. Psychiatr Serv. 1998 Jul. 49(7):935-40. [Medline].

  28. Herning RI, King DE, Better WE, Cadet JL. Neurovascular deficits in cocaine abusers. Neuropsychopharmacology. 1999 Jul. 21(1):110-8. [Medline].

  29. Hollander JE, Todd KH, Green G, et al. Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med. 1995 Dec. 26(6):671-6. [Medline].

  30. Hyman SE. A 28-year-old man addicted to cocaine. JAMA. 2001 Nov 28. 286(20):2586-94. [Medline].

  31. Jones RT. Pharmacokinetics of cocaine: considerations when assessing cocaine use by urinalysis. NIDA Res Monogr. 1997. 175:221-34. [Medline].

  32. Kampman, K. New Medications for the Treatment of Cocaine Dependence. Psychiatry. December 2005. 2:44-48. [Full Text].

  33. Karlsgodt KH, Lukas SE, Elman I. Psychosocial stress and the duration of cocaine use in non-treatment seeking individuals with cocaine dependence. Am J Drug Alcohol Abuse. 2003 Aug. 29(3):539-51. [Medline].

  34. Levin FR, Evans SM, Coomaraswammy S, et al. Flupenthixol treatment for cocaine abusers with schizophrenia: a pilot study. Am J Drug Alcohol Abuse. 1998 Aug. 24(3):343-60. [Medline].

  35. Levin FR, Evans SM, Kleber HD. Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment. Drug Alcohol Depend. 1998 Sep 1. 52(1):15-25. [Medline].

  36. Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult attention- deficit/hyperactivity disorder: a pilot study. J Clin Psychiatry. 1998 Jun. 59(6):300-5. [Medline].

  37. Lima MS, Reisser AA, Soares BG, Farrell M. Antidepressants for cocaine dependence. Cochrane Database Syst Rev. 2003. CD002950. [Medline].

  38. Mann A. Relationships Matter: Impact of Parental, Peer Factors on Teen, Young Adult Substance Abuse. National Institute on Drug Abuse. Available at Accessed: 5/22/2008.

  39. McCance-Katz EF, Kosten TR, Jatlow P. Concurrent use of cocaine and alcohol is more potent and potentially more toxic than use of either alone--a multiple-dose study. Biol Psychiatry. 1998 Aug 15. 44(4):250-9. [Medline].

  40. McDowell DM, Levin FR, Seracini AM, Nunes EV. Venlafaxine treatment of cocaine abusers with depressive disorders. Am J Drug Alcohol Abuse. 2000 Feb. 26(1):25-31. [Medline].

  41. McKay JR, Alterman AI, Cacciola JS, et al. Prognostic significance of antisocial personality disorder in cocaine- dependent patients entering continuing care. J Nerv Ment Dis. 2000 May. 188(5):287-96. [Medline].

  42. McMahon RC, Malow R, Loewinger L. Substance abuse history predicts depression and relapse status among cocaine abusers. Am J Addict. 1999 Winter. 8(1):1-8. [Medline].

  43. Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull. 2000. 26(1):179-92. [Medline].

  44. Pettinati H. New Pharmacotherapies for Treating the Neurobiology of Alcohol and Drug Addiction. Psychiatry. May 2006. 3:14-16. [Full Text].

  45. Rivara FP, Mueller BA, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. 1997 Aug 20. 278(7):569-75. [Medline].

  46. Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. Am J Psychiatry. 1999 Jun. 156(6):849-56. [Medline].

  47. Schubiner H, Tzelepis A, Milberger S, et al. Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers. J Clin Psychiatry. 2000 Apr. 61(4):244-51. [Medline].

  48. Serper MR, Chou JC, Allen MH, et al. Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophr Bull. 1999. 25(2):387-94. [Medline].

  49. Serper MR, Copersino ML, Richarme D, et al. Neurocognitive functioning in recently abstinent, cocaine-abusing schizophrenic patients. J Subst Abuse. 2000. 11(2):205-13. [Medline].

  50. Siqueland L, Horn A, Moras K, et al. Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample. Am J Addict. 1999 Spring. 8(2):165-9. [Medline].

  51. Soares BG, Lima MS, Reisser AA, Farrell M. Dopamine agonists for cocaine dependence. Cochrane Database Syst Rev. 2003. CD003352. [Medline].

  52. Sofuoglu M, Dudish-Poulsen S, Brown SB, Hatsukami DK. Association of cocaine withdrawal symptoms with more severe dependence and enhanced subjective response to cocaine. Drug Alcohol Depend. 2003 Apr 1. 69(3):273-82. [Medline].

  53. Work Group on Substance Use Disorders. Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd edition. Am J Psychiatry Suppl. April 2007. 164:72-75.

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