Does occasional, uncomplicated cocaine use in an adult meet the criteria for dependence (cocaine use disorder)?

Occasional, Uncomplicated Cocaine Use Does Not Meet Criteria for Dependence

No, occasional and uncomplicated cocaine use does not constitute dependence or cocaine use disorder under current diagnostic criteria. Under DSM-5 criteria, a diagnosis of cocaine use disorder requires at least 2 of 11 specific criteria to be met within a 12-month period, and the term "dependence" as a standalone diagnosis no longer exists. 1

Understanding the DSM-5 Diagnostic Framework

The American Psychiatric Association eliminated the separate categories of "abuse" and "dependence" in DSM-5, replacing them with a single unified diagnosis called "substance use disorder" with severity grading. 1 This change was based on extensive data from over 200,000 participants showing that all criteria form a single unidimensional continuum rather than separate disorders. 2

The 11 DSM-5 Criteria for Cocaine Use Disorder

To meet diagnostic criteria, at least 2 of the following 11 criteria must be present within a 12-month period: 1

• Taking cocaine in larger amounts or over longer periods than intended
• Persistent desire or unsuccessful efforts to cut down
• Spending significant time obtaining, using, or recovering from cocaine
• Craving or strong desire to use cocaine 1
• Failure to fulfill major role obligations due to use
• Continued use despite social or interpersonal problems
• Giving up important activities because of cocaine use
• Recurrent use in physically hazardous situations
• Continued use despite knowledge of physical or psychological problems caused by cocaine
• Tolerance (needing more to achieve the same effect)
• Withdrawal symptoms when stopping

Severity Grading

If diagnostic threshold is met, severity is determined purely by criterion count: 2

• Mild: 2-3 criteria
• Moderate: 4-5 criteria
• Severe: 6 or more criteria

Why Occasional, Uncomplicated Use Doesn't Qualify

"Occasional" and "uncomplicated" use, by definition, means the person is not experiencing the problems described in the diagnostic criteria. 1 If cocaine use remains infrequent, does not interfere with life functioning, causes no social/interpersonal problems, involves no loss of control, and produces no physical or psychological harm, then fewer than 2 criteria are met and no diagnosis can be made. 1

Critical Distinction: Frequency Alone Is Not Diagnostic

The DSM-5 work group specifically considered adding consumption frequency as a criterion but rejected it because frequency alone does not determine disorder presence. 1 What matters is whether the use pattern causes the specific problems outlined in the 11 criteria. 1

Research demonstrates that cocaine users can be distinguished between those meeting abuse criteria versus dependence criteria based on cocaine-directed behavior, craving intensity, and loss of control—not simply on frequency of use. 3 In fact, studies show that most cocaine users take the drug regularly but not daily, and two-thirds report only minor signs of dependence despite frequent use. 4

Common Pitfalls to Avoid

Do not conflate any cocaine use with cocaine use disorder. The DSM-5 threshold of 2 criteria was specifically chosen to avoid over-diagnosis while still capturing cases needing intervention. 1 The concern that this threshold is "too low" was explicitly addressed by the work group, which emphasized that diagnosis requires meeting actual criteria, not simply being a substance user. 1

Do not assume physiological tolerance or withdrawal alone equals dependence. Under DSM-5, these are just 2 of 11 criteria, and both must be present along with at least one other criterion to reach the diagnostic threshold. 1, 5 For medically supervised cocaine use (e.g., as a topical anesthetic), tolerance and withdrawal represent normal physiological adaptation and should not trigger a diagnosis. 1

Do not use outdated DSM-IV terminology. The term "dependence" as a standalone diagnosis no longer exists in DSM-5. 1, 2 Using this terminology can create confusion and may inappropriately pathologize use patterns that don't meet current diagnostic standards.

Clinical Assessment Approach

When evaluating a patient with cocaine use, systematically assess each of the 11 criteria over the past 12 months: 1

1. Loss of control: Larger amounts, longer periods, unsuccessful quit attempts
2. Time spent: Significant time obtaining, using, or recovering
3. Craving: Strong desires or urges to use 1
4. Role impairment: Failure at work, school, or home
5. Social consequences: Continued use despite interpersonal problems
6. Activity reduction: Giving up important activities
7. Hazardous use: Use in dangerous situations
8. Physical/psychological harm: Continued use despite known problems
9. Tolerance: Need for increased amounts
10. Withdrawal: Characteristic withdrawal syndrome

If fewer than 2 criteria are met, no diagnosis of cocaine use disorder can be made, regardless of use frequency. 1 In such cases, the appropriate clinical response is education about risks and monitoring, not labeling the person with a disorder they don't have.