Cocaine dependence: "Side effects" and syndrome formation within 1-12 months after first cocaine use

Drug Alcohol Depend. 2020 Jan 1;206:107717. doi: 10.1016/j.drugalcdep.2019.107717. Epub 2019 Nov 4.


Background: This project offers new epidemiological estimates for DSM-IV cocaine dependence among sub-groups of newly incident cocaine users in the United States (US), including estimated attack rates for 21 dependence-related cocaine side effect problems and experiences occurring <12 months after onset.

Method: In 2002-2016, US National Surveys on Drug Use and Health (NSDUH) sampled, recruited, and assessed cocaine experiences of non-institutionalized civilians. Unweighted estimates for year-pairs (2002-3,…,2015-16) are from 3488 cocaine powder-only initiates and 275 powder-then-crack initiates (all evaluated <12 months after onset). Analysis-weighted attack rate estimates are incidence proportions with 95% confidence intervals (CI), summarized via meta-analysis.

Results: Evaluated <12 months after onset, meta-analysis summaries show 5% of powder-only initiates developed cocaine dependence (95% CI = 4%, 6%) versus 22% of powder-then-crack initiates (95% CI = 17%, 29%). For several cocaine side effect problems and experiences (e.g., 'loss of control' indicators) there is a statistically robust crack-associated excess risk.

Conclusions: Three interpretations of observed crack-associated excess risk are especially cogent and deserving of continued inquiry: (1) Powder-then-crack initiates start with heightened dependence risk susceptibilities (i.e., pre-dating onset); (2) Powder-using initiates become cocaine dependent and then start using crack; (3) The cocaine delivery variant of 'crack-smoking' is more toxic than powder insufflation. For powder-then-crack initiates, the cocaine dependence risk (22%) is modestly lower but statistically undifferentiable from a recently estimated risk of heroin dependence <12 months after heroin onset (30%). Clinicians can use these side effect estimates in an evidence-based diagnostic workup when patients disclose new onsets of cocaine use.

Keywords: Cocaine dependence; Cocaine powder; Crack-cocaine; Incidence; NSDUH; National Survey on Drug Use and Health; Random effects meta-analysis.

Publication types

  • Meta-Analysis
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Cocaine / adverse effects*
  • Cocaine-Related Disorders / epidemiology*
  • Female
  • Health Surveys
  • Heroin / adverse effects*
  • Heroin Dependence / epidemiology*
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Powders
  • Syndrome
  • Time Factors
  • United States / epidemiology


  • Powders
  • Heroin
  • Cocaine