Cocaine in your caseload

Australian cocaine use has increased substantially over the past decade. The National Wastewater Drug Monitoring Programme reports doubled or tripled per-capita cocaine loads in capital city catchments compared to 2016 baselines. The National Drug Strategy Household Survey shows past-year cocaine use at approximately 4.5% of adults, with significantly higher rates in the 20–35 urban demographic.

The clinical implication is straightforward: cocaine is increasingly present in general practice and AOD caseloads, and it presents differently from alcohol or cannabis in ways that require specific clinical attention.

Who is presenting

The demographic profile of cocaine users in Australia is distinct from the methamphetamine-using population that has dominated stimulant AOD presentations historically. Cocaine use is concentrated in:

Higher-income urban professional groups
Hospitality and entertainment industry workers
University students, particularly in inner-city areas
Tradespeople in higher-income brackets

Many of these people do not present primarily for substance use. They present with anxiety, sleep difficulties, low mood, or generalised fatigue , and cocaine is either not mentioned or mentioned incidentally. Systematic questioning that normalises the topic is required to identify stimulant use in this population.

The ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) is well suited to this , its multi-substance structure normalises the breadth of enquiry and avoids the implicit suggestion that you're asking specifically because you suspect cocaine use.

The clinical picture

Cocaine presentations exist on a spectrum from occasional recreational use through regular non-dependent use to psychological dependence. The majority of presentations in primary care and community AOD settings fall in the middle category: regular use (typically weekend-based) without physical dependence, but with significant psychological effects and emerging pattern entrenchment.

Key clinical features to assess:

Frequency and pattern. Weekly use produces different neurobiological effects than monthly use. Weekend use produces a systematic cycle of stimulation and comedown that affects the working week. Daily or near-daily use suggests more significant dependence and is associated with more severe psychological effects.

Comedown presentation. Cocaine comedown (peaking 12–24 hours post-use, resolving over 48–72 hours) is characterised by dysphoria, fatigue, irritability, impaired concentration, and anxiety. In clients presenting with anxiety or low mood, establishing whether symptoms correlate with a use-comedown cycle is clinically important. Clients often don't make this connection themselves.

Cardiovascular risk. Cocaine's cardiovascular effects , vasoconstriction, elevated heart rate and blood pressure, increased myocardial oxygen demand , are clinically significant even in recreational use. Chest pain, palpitations, or dyspnoea in a cocaine-using client should be assessed urgently. The risk is amplified by concurrent alcohol use (which produces cocaethylene, a metabolite with independent cardiovascular toxicity) and by pre-existing cardiac risk factors.

Polydrug use. Cocaine is rarely the only substance in use. Alcohol co-use is near-universal in recreational settings. Cannabis use for comedown management is common. Benzodiazepine or Z-drug use for sleep is increasingly seen. The full picture matters for risk assessment and intervention planning.

Psychological dependence indicators. Assess for: increasing amounts needed for desired effect, use expanding beyond intended occasions, difficulty stopping despite intention, persistent craving, continued use despite awareness of psychological costs.

Assessment tools

The ASSIST is the preferred brief screening instrument for multi-substance presentations , it covers cocaine specifically and produces a risk score (low/moderate/high) with corresponding intervention guidance. Scores of 4–26 indicate moderate risk and suggest brief intervention; scores above 27 indicate high risk and referral for further assessment.

For clients where cocaine use is the primary concern and more detailed assessment is warranted, the Severity of Dependence Scale (SDS) provides a brief (5-item) measure of psychological dependence applicable to any substance.

There is no cocaine-specific equivalent of the AUDIT with the same level of normative data and clinical embedding. The ASSIST score provides the most clinically actionable framework.

Brief intervention

The evidence base for brief intervention in cocaine use is less extensive than for alcohol, but what exists is consistent with the general brief intervention literature: motivational enhancement approaches reduce use in non-dependent users across settings.

Effective brief intervention for cocaine:

Provide personalised feedback. ASSIST scores place individual use in a risk context. For clients who have not considered their cocaine use as a health concern , common in the functional recreational user group , this population-context information is itself often motivating.

Explore ambivalence. Most people in the moderate-risk range have mixed feelings about their use. They value aspects of it , the social context, the effect itself, the ritual , and are uncomfortable with others , the cost, the comedown, the sense that the pattern is gradually changing. MI-consistent exploration of this ambivalence, without resolving it prematurely in either direction, is the most evidence-consistent approach.

Address the practical risks. Cardiovascular risk with alcohol co-use. Avoiding use in presence of cardiac symptoms. Not driving for 24 hours after significant use. These harm reduction points are appropriate in brief intervention regardless of whether the client is planning to reduce or stop.

Agree on a follow-up. Brief intervention outcomes improve significantly when there is a scheduled follow-up contact. Even a phone check-in at 4–6 weeks is associated with better outcomes than a single contact.

Between-session support

For clients who are motivated to track their use and understand their patterns, self-monitoring tools designed for non-treatment-seeking users provide a useful adjunct. The key features for this population , anonymity, multi-substance coverage, mood and sleep tracking alongside use, no recovery framing , address the specific barriers that cocaine users in this demographic face.

Structured diary data over 4–6 weeks also dramatically improves subsequent clinical conversations. A client who arrives with data on their use pattern, mood across the use-comedown cycle, and spending has a concrete foundation for a clinical conversation that memory-based self-report doesn't provide.

ayodee tracks cocaine and other stimulants alongside mood, sleep, and urge patterns. Clinician bulk codes available. Clients share reports at their discretion.