Cocaine and Stimulant Use Disorder
Cocaine use is a serious psychiatric disorder with a neurobiological basis. Psychiatrist Paschalis Gkikas provides specialized assessment and treatment in Athens.
Cocaine and Stimulant Use Disorder
Cocaine Use Disorder is not a matter of willpower or moral weakness. It is a chronic, relapsing brain disease that reshapes the circuits of reward, decision-making and impulse control. Psychiatrist Paschalis Gkikas has specialized experience in the assessment and treatment of substance use disorders, with an integrated and non-stigmatizing approach.
What is Cocaine Use Disorder?
Cocaine is a central nervous system (CNS) stimulant that acts primarily by inhibiting the reuptake of dopamine, serotonin and norepinephrine. Its extremely rapid effect on the reward circuit — the mesolimbic dopamine pathway, especially when used by smoking or intravenously — creates a powerful use reflex that can appear after minimal exposures.
The disorder is characterized by:
- Inability to control the amount and frequency of use
- Continued use despite clear negative consequences
- Increasing tolerance and withdrawal symptoms
- Displacement of other activities in favor of the substance
Cocaine can be used nasally (snorting), by smoking vapors (crack), or intravenously — each route has a different speed of dependence and risk profile.
Clinical presentation and symptoms
Acute effects / intoxication
- Euphoria, sense of increased energy and confidence
- Reduced need for sleep and food
- Tachycardia, hypertension, mydriasis
- Paranoid thinking, flight of ideas, pressured speech
- Reduced perception of risk
Withdrawal stage / crash
- Intense dysphoria and depression
- Binge eating, sleepiness
- Strong craving for reuse
- Anxious restlessness, irritability
Chronic use
- Psychotic symptoms, such as paranoid ideas and visual hallucinations
- Cognitive decline affecting memory, executive functions and attention
- Depression and anhedonia outside use
- Cardiovascular complications, such as arrhythmias and myocardial infarction
- Deviated or damaged nasal septum in nasal use
- Severe impairment of social and occupational functioning
Comorbidities
Cocaine often coexists with:
- Alcohol, with increased cardiotoxicity
- Other substances, such as opioids and benzodiazepines
- Bipolar disorder, ADHD and social anxiety disorder
- PTSD and trauma history
Neurobiological basis
Cocaine inhibits dopamine (DAT), serotonin (SERT) and norepinephrine (NET) transporters, causing accumulation of these neurotransmitters in the synaptic cleft.
The nucleus accumbens (NAc), a key node of the mesolimbic circuit, is flooded with dopamine, producing euphoria far more intense than any physiological reward. With repeated use:
- The number of D2 receptors decreases through down-regulation — natural reward is no longer enough
- The prefrontal cortex (PFC) gradually loses inhibitory control over the reward circuit
- The amygdala encodes environmental stimuli as conditioned cues — this is why “triggers” can provoke craving years after discontinuation
Neurobiologically, recovery requires months of neuroplastic remodeling — which can be enhanced by appropriate interventions.
Treatment approach
Assessment
Assessment includes a full psychiatric history, detection of coexisting disorders, evaluation of cardiovascular risk and examination of the social and occupational context. There is no “average” case — every patient has a distinct profile.
Detoxification
There is no specific pharmacological antidote for acute cocaine withdrawal. Treatment is symptomatic: management of emerging depression, anxiety symptoms and sleep disturbances. Inpatient detoxification may be necessary in severe dependence or serious coexisting medical or psychiatric conditions.
Pharmacological support
No medication has yet received FDA/EMA approval specifically for cocaine dependence, but several options have a strong research basis:
- Bupropion: Dopaminergic action, useful in managing craving and coexisting depression
- Modafinil: Reduces craving and improves cognitive functions
- N-acetylcysteine (NAC): Antioxidant and glutamatergic action, an emerging option
- Naltrexone: Investigated particularly when alcohol use coexists
Pharmacogenomic analysis (PGx) allows individualized treatment design, avoiding toxicity or ineffectiveness due to genetic variants.
Psychotherapy
Cognitive Behavioral Therapy (CBT) is the gold standard — identification of triggers, development of coping skills and craving management. Motivational Interviewing strengthens the therapeutic alliance, especially in patients with ambivalent motivation.
rTMS in Cocaine Use Disorder
Repetitive transcranial magnetic stimulation (rTMS for cocaine addiction) is one of the most effective non-pharmacological interventions studied in this field. Left DLPFC targeting has been studied to strengthen executive control and reduce craving.
Research shows a significant reduction in cocaine craving severity with high-frequency rTMS (10 Hz) over the DLPFC. The method can be integrated into a comprehensive treatment protocol as an adjunctive intervention.
Every relapse is treated as clinical information, not as failure. The chronic nature of the disorder means that the therapeutic relationship is built long-term, with realistic goals and without judgment.
Frequently asked questions (FAQ)
Can someone stop cocaine alone?
In mild cases it may be possible, but the risk of relapse without support is high. Psychiatric assessment helps clarify underlying causes, such as coexisting disorders and triggers, and allows a realistic plan to be designed.
How long does treatment last?
Active treatment usually lasts 3 to 12 months. The supportive phase may be long-term. Stable abstinence is built gradually — it is not a linear process.
Is there a medication that stops cocaine craving?
There is no single medication, but combined pharmacological treatment tailored to the patient’s profile, together with psychotherapy, can show significant results. PGx analysis helps individualize treatment.
What happens if other psychiatric problems coexist?
Coexisting bipolar disorder, ADHD or depression is common. Treatment must address both disorders simultaneously — treating only one of them increases relapse risk.
