Stimulants: health and social responses

Overview

Key issues

Overall, cocaine is the most commonly used stimulant in Europe, although in some countries MDMA, amphetamine or methamphetamine may have higher levels of prevalence.

Many harms arising from stimulant use are associated with intensive, high-dose or long-term consumption. Route of administration is an important mediating factor, with both stimulant injecting and the smoking of crack cocaine or methamphetamine particularly linked to more problematic patterns of use. However, acute problems can affect even those who experiment with stimulants or use them occasionally.

Stimulants may be used functionally, for example, to stay awake when driving, working long hours or socialising in nightlife settings. This means that some of the responses appropriate to stimulant use are setting-specific or overlap with more generic public health measures. The settings in which stimulants are used and the fact that they are sometimes used in a sexual context also mean that drug-related responses may overlap with responses to sexual health issues, particularly in certain groups.

Evidence and responses

• When people who use stimulants seek help at emergency departments for problems related to intoxication or high-dose use, referral to treatment programmes or harm reduction services can be offered.
• Psychosocial interventions, especially contingency management, can improve treatment outcomes for problematic stimulant use. There are currently no pharmacological treatments showing evidence of effectiveness in treating people engaged in problematic stimulant use.
• People who inject stimulants need regular access to needle and syringe programmes. During a binge they may inject more often than those who use opioids.
• Drug-checking services may reduce harms by providing information and advice to people who use stimulants, for example, highlighting potentially hazardous contaminants or tablets containing dangerously high doses of drugs.
• Other harm reduction services may need to be adapted to cater for people who smoke stimulant drugs, and outreach programmes may be necessary to deliver harm reduction interventions to people who use stimulants and who would not otherwise access services.

European picture

• Cocaine is the main stimulant drug for which people seek treatment in the European Union, with the majority of these cases in Spain and Italy. Typically, around 55 000 people enter treatment for problems related to cocaine annually, and among these the number entering for the first time in their life has been increasing in recent years, after a period of decline. A small proportion of those entering treatment for cocaine problems cite crack cocaine as their primary problem drug, mainly in Belgium, Spain and France.
• Typically, around 20 000 people enter treatment annually for problems associated with the use of amphetamines. Of these, more than a third enter for methamphetamine-related problems, mostly in Czechia, Germany and Slovakia. Around half of those in treatment for amphetamines use are first-time clients.
• In a few countries, drug consumption rooms also cater for people who smoke crack cocaine. These programmes may provide crack cocaine kits, including pipes and filters, to encourage safer smoking practices.
• Very few people enter specialised drug treatment for MDMA-related problems; harm reduction responses in drop-in services and in festival and nightlife settings are more relevant to this group.

Key issues: patterns of stimulant use and related harms

Key questions that need to be addressed when identifying and defining a problem include who is affected, what types of substances and patterns of use are involved, and where the problem is occurring. Responses should be tailored to the particular drug problems being experienced, and these may differ between countries and over time. The wide array of factors that have to be considered at this stage in the process are discussed in the Action framework for developing and implementing health and social responses to drug problems.

Cocaine is the most commonly used illicit stimulant in Europe, and in recent years use appears to have been increasing. Among cocaine consumers, a broad distinction can be made between those who snort powder cocaine (cocaine hydrochloride), and may be relatively more socially integrated, and more marginalised groups, where patterns of use are more likely to feature injecting, the smoking of crack cocaine (cocaine base) or the co-use of opioids.

Amphetamine and methamphetamine, two closely related stimulants, are both consumed in Europe, although amphetamine is more commonly used than methamphetamine. Methamphetamine use has historically been restricted to Czechia and, more recently, Slovakia, although increased use has also been noted in a number of other countries. With some data sources it is not possible to distinguish between these two substances, so the generic term amphetamines is used to cover both. The two drugs can be taken orally or nasally, while injection is a common route of administration among marginalised groups in some countries and methamphetamine can be smoked, although this appears to be rare in Europe.

In many countries, use of the stimulant MDMA (historically marketed as ‘ecstasy’) has stabilised in recent years; however, this has been accompanied by higher than average content levels of MDMA in both tablet and powder forms of the drug. In particular, the high doses of MDMA found in some tablets have been linked with harms to health and deaths.

European countries vary in the stimulants most often used. For example, in France in a survey of the general population, cocaine was the illicit stimulant most frequently used in the past year, closely followed by MDMA. In Finland, by contrast, similar proportions of the population reported using amphetamine and MDMA in the past year, while cocaine use is uncommon.

Most of the harms related to the use of stimulants are associated with intensive, high-dose or long-term consumption. The route of administration is also an important mediating factor, with both stimulant injecting and the smoking of crack cocaine or methamphetamine particularly associated with more problematic patterns of use. High-dose and long-term stimulant use may cause serious cardiovascular problems, such as strokes, cardiomyopathy and myocardial infarctions, and in some European countries the prevention of deaths linked to the use of stimulants is an important policy objective. Although uncommon in Europe, the use of crystal methamphetamine is associated with a range of problems including aggressiveness, insomnia, skin inflammations and rashes, weight loss and, in rare cases, death.

Acute problems can also affect people who use stimulants experimentally, but are likely to be less common when the stimulant use is infrequent and low-dose. However, stimulant drugs obtained from the illicit drug market can be of very variable purity or potency and contain a range of contaminants. This can result in harms to health that are both acute, such as overdoses associated with exceptionally high-dose MDMA tablets, and longer-term, such as damage caused by regular exposure to contaminants like levamisole, which is frequently found in cocaine samples and can be associated with impairment of the immune system. Although uncommon, some people who use stimulants engage in high-dose use over extended periods, sometimes lasting several days. Stimulant ‘binges’ can result in a range of acute harms including psychosis, aggression and paranoia, and may also be associated with the development of dependence and other longer-term health and social problems.

Problematic stimulant use can also be associated with risks to sexual health. Some men who have sex with men engage in ‘chemsex’, which often involves injecting methamphetamine and other substances to enhance sexual pleasure. Chemsex parties, while apparently uncommon, have been reported in a number of major European cities. They have become a concern in several European countries because of the potential spread of HIV and other sexually transmitted infections. Some studies have also reported high rates of sex for money or sex for drugs exchanges by women with crack cocaine problems. This illustrates a potentially more general issue relating to stimulant and other substance use among women and men engaged in sex work and the need to develop responses that can address both substance use and sexual health risk behaviours.

Stimulants may be used in combination with alcohol and other illicit drugs. Some of these combinations, for example, cocaine and alcohol, can result in increased health risks. People who use stimulants may also use other drugs to manage the negative after-effects of use and to help induce sleep. These drugs include alcohol, cannabis and benzodiazepines. For some with more problematic patterns of use, opioids may be consumed for this purpose. This polysubstance use can expose people who use stimulants to additional risks. For this reason, responses in this area will often need to consider interactions between the use of stimulants and other drugs (see Polydrug use: health and social responses).

Evidence and responses to stimulant-related problems

Choosing the appropriate responses that are likely to be effective in dealing with a particular drug-related problem requires a clear understanding of the primary objectives for the intervention or combination of interventions. Ideally, interventions should be supported by the strongest available evidence; however, when evidence is very limited or unavailable, expert consensus may be the best option until more conclusive data is obtained. The Action framework for developing and implementing health and social responses to drug problems discusses in more detail what to bear in mind when selecting the most appropriate response options.

Stimulant use often occurs in recreational settings such as nightlife venues or music festivals.

People experiencing acute problems as a result of stimulant use may seek help from emergency medical services. The interventions offered will be dependent on the symptoms reported, but often a brief medical or psychological intervention may be sufficient. It is important, however, that emergency services are aware that it may be necessary to provide referral to appropriate treatment, harm reduction or sexual health services. The potential of stimulants to cause or aggravate cardiovascular problems also means that those responding to cardiovascular emergencies may need to consider the role drug use may have played in the event.

Harm reduction

People who inject stimulants are likely to need greater access to needle and syringe provision because they may inject more frequently than people who use opioids (see also Drug-related infectious diseases: health and social responses).

Responses for this group often include some form of outreach and the provision of sterile injection equipment, condoms, information on safer injecting and basic hygiene, vein and wound care, and antibacterial creams and ointments. These would appear to be appropriate responses, but a strong evidence base does not yet exist in this area. There is also a lack of robust data showing a measurable reduction in injecting or sexual risk behaviours resulting from these approaches. Given that stimulant-related problems appear to be growing, this is an area in need of further research and service development.

Many drug consumption rooms allow the use of stimulants. DCRS’ staff monitor service users for symptoms of stimulant toxicity and are trained to manage those who experience stimulant overdose. In the event that a service user experiences stimulant toxicity or acute mental distress, staff contact emergency help. While drug consumption rooms are notoriously difficult to evaluate, current evidence suggests they play a role in reducing injecting risk behaviours. 

To address the needs of people smoking crack cocaine, often alongside the use of opioids, harm reduction services may need to adapt their services to support safer smoking practices. This may involve the provision of kits including for example pipes and filters. Interventions intended to help reduce the risks associated with methamphetamine use may also include the provision of smoking equipment or safer-smoking kits through needle and syringe programmes. A novel intervention, established in Czechia by low-threshold services, for people who use methamphetamine is the distribution of empty gelatine capsules, which is intended to encourage oral consumption and reduce the injection-related risks of HIV and HCV infection. This intervention needs to be evaluated in order to explore its practicality and whether it has an impact on behaviour.

Given the link between stimulant use and risky sexual behaviour, initiatives have been developed specifically for people who use stimulants including methamphetamine and cocaine in the context of chemsex. These include multidisciplinary services providing drug and sexual health services as well as efforts to improve the linkage between services (see Spotlight on… Addressing sexual health issues associated with drug use).

Drug-checking services also play a role in responding to stimulant-related harms in some EU countries, specifically providing information about the risks associated with high-purity or adulterated stimulants.

Treatment

People who seek treatment for stimulant use problems primarily use either cocaine or amphetamine. People who use MDMA rarely seek treatment. People entering treatment for problems related to cocaine can be divided, in very simple terms, according to their pattern of use, into:

• people who use powder cocaine, that is, they take cocaine intranasally (insufflation or snorting) on its own or in combination with cannabis and/or alcohol or other drugs;
• people who use crack cocaine, often in combination with other drugs including heroin;
• people who engage in polydrug use, that is, they may have problems with their use of cocaine and other drugs such as heroin. Injecting may be more common in this group.

To some extent these groups require different approaches. For example, people seeking treatment who primarily use powder cocaine may be more socially integrated than those who smoke crack cocaine or inject stimulants. This means they may be more likely to have stable housing and a regular income. People seeking treatment for problems associated with the use of amphetamines are also heterogeneous in terms of their social conditions and modes of use. This heterogeneity among people with stimulant problems may have important implications for both the responses needed and reducing barriers to treatment access. Those in employment, for example, may benefit from services offered outside of normal working hours.

Psychosocial interventions can be effective for people who use cocaine. While including a range of different measures, these interventions can be regarded as structured therapeutic processes that address both the psychological and social aspects of a client’s behaviour, and which vary in terms of their duration and intensity. Three general types of psychosocial intervention have been used to treat people who use drugs: contingency management, cognitive behavioural therapy and motivational interviewing.

In contingency management, treatment clients’ behaviours are rewarded (or, less often, punished) in line with treatment objectives and adherence to, or failure to adhere to, programme rules and regulations or their treatment plan. For example, clients can be rewarded with vouchers that can be exchanged for retail items. Cognitive behavioural therapy interventions promote the development of alternative coping skills and focus on changing behaviours and cognitions related to substance use through training that emphasises self-control, social and coping skills and relapse prevention. Motivational interviewing seeks to harness an individual’s motivation to engage with the treatment process.

There is moderate evidence that contingency management (alone or together with community reinforcement or cognitive behavioural therapy) increases abstinence and retention in treatment. More generally, there are currently no effective pharmacological treatments for treating people with problematic stimulant use. Treatment approaches or interventions that have been shown to be useful are described in the evidence overview box below.

Overview of the evidence on … treatment for problematic stimulant use

Statement	Evidence
	Effect	Quality
Psychosocial and behavioural interventions, especially contingency management (alone or together with community reinforcement or cognitive behavioural therapy), can improve treatment outcomes	Beneficial	Moderate
Drug consumption rooms may play a role in reducing injecting risk behaviours.	Beneficial	Low
Overall, there is insufficient evidence to support the use of pharmacological interventions to improve treatment outcomes in people who use stimulants. Very recent evidence has shown that prescription stimulants may be associated with a small reduction in cocaine use but not amphetamines. However, further studies are needed.	Unclear	Low

Evidence effect key:
Beneficial: Evidence of benefit in the intended direction. Unclear: It is not clear whether the intervention produces the intended benefit. Potential harm: Evidence of potential harm, or evidence that the intervention has the opposite effect to that intended (e.g. increasing rather than decreasing drug use).

Evidence quality key:
High: We can have a high level of confidence in the evidence available. Moderate: We have reasonable confidence in the evidence available. Low: We have limited confidence in the evidence available. Very low: The evidence available is currently insufficient and therefore considerable uncertainty exists as to whether the intervention will produce the intended outcome.

European picture: availability of stimulant-related interventions

In Europe, the available data suggest that cocaine treatment often takes place in outpatient settings. A caveat here is that stimulant treatment provided within a general practice setting or in private clinics may not be covered by current reporting systems. Some people seeking treatment for stimulant use may be reluctant to use these services because they may not see them as meeting their needs and do not identify with the opioid clients who may predominate at some services. Modifying service delivery models to be more in line with client needs may make them more attractive. Some countries have developed targeted programmes and interventions for people who use cocaine. Extending opening hours, specifically for working individuals with powder cocaine problems, as seen in Austria, is one such measure. In Belgium, a specialised programme has been developed using a combination of a community reinforcement approach and contingency management that specifically targets people with cocaine problems. Overall, however, targeted programmes for people who use cocaine remain limited in Europe.

Currently, only a handful of countries (including Spain and Italy) account for the majority of reported treatment entries related to cocaine use in the European Union each year, typically around 56 000 cases. The majority (around three-quarters) of people who enter specialised treatment citing cocaine as their main problem drug use powder cocaine. Currently, relatively high rates of crack‐related treatment demand are found in Belgium, Spain and France. In some countries, cocaine is reported by many of those receiving treatment for opioid problems as a drug that is used in combination with heroin or other opioids. It is likely that cocaine treatment also takes place in settings that are not necessarily well covered by existing surveillance systems and therefore the data reported here are likely to underestimate the true picture.

Typically, around 20 000 clients entering specialised drug treatment in Europe reported amphetamines as their primary drug. Around half were first-time clients. People who report a primary amphetamine problem typically accounted for 15 % or more of first-time treatment entrants in Bulgaria, Germany, Finland, Latvia and Poland. Treatment entrants with primary methamphetamine problems are concentrated in Czechia, and to a lesser extent in Germany and Slovakia. These countries together account for most of the methamphetamine clients entering specialised treatment in Europe in a year. Overall, the number of first-time treatment entrants reporting amphetamine or methamphetamine as their primary drug has been relatively stable since 2015. Similarly, the proportion of this group reporting injecting amphetamines has remained relatively stable, in contrast to the decrease in injecting that has been observed for other drug classes.

Outside a few specific countries, the use of methamphetamine is low, and this makes commenting on responses at the European level difficult. Current service responses in Europe, although limited, do include mental health provision, low-threshold services, drug treatment, and youth and sexual health services. In Czechia, where injection is the most common route of administration for methamphetamine, outpatient services providing psychosocial interventions and residential treatment programmes using a therapeutic community model have been at the centre of the response. People who inject methamphetamine are also a primary target group for harm reduction programmes.

Implications for policy and practice

Basics

• Problems associated with stimulant use vary depending on patterns of use, the groups who are using and the setting in which the drugs are used. Responses therefore need to be tailored to the local patterns of use and problems experienced.
• Core responses for stimulant problems currently include psychosocial treatment, primarily contingency management, and a range of harm reduction initiatives, particularly for people who inject stimulants.

Opportunities

• Improving links between sexual health and drug treatment services could improve the efficiency and effectiveness of both.

Gaps

• Harm reduction interventions for people who use stimulants need development and evaluation.
• Research into effective treatment models, including the possibility of developing pharmacological treatments for stimulant dependence remains a priority.

Data and graphics

In this section, we presents some key statistics on stimulants use among young people (15-34), as well as stimulants treatment in the EU-27, Norway and Turkey. For more detailed statistics on prevalance, patterns of use and treatment, as well as methodological information, please refer to the Data section of our website. To view an interactive version of the infographics below, as well as to access source data, click on the infographic.

 

 

 

 

Further resources

EMCDDA

• Best Practice Portal.
• EMCDDA resources on cocaine.
• Statistical bulletin.
• European drug report: trends and developments 2021.
• Recent changes in Europe’s cocaine market: Results from an EMCDDA trendspotter study, EMCDDA Rapid communication, 2018
• Joining up sexual health and drug services to better meet clients’ needs, Owen Bowden-Jones, Background paper, 2017.
• Treatment for cocaine dependence: reviewing current evidence, Perspectives on drugs, 2015.
• Emergency health consequences of cocaine use in Europe, Perspectives on drugs, 2014.
• Emergency health consequences of cocaine use in Europe. A review of the monitoring of drug-related acute emergencies in 30 European countries, Technical report, 2014.
• Health and social responses for methamphetamine users in Europe, Perspectives on drugs, 2014.
• Exploring methamphetamine trends in Europe, EMCDDA Paper, 2014.

About this miniguide

This miniguide provides an overview of what to consider when planning or delivering health and social responses to stimulant-related problems, and reviews the available interventions and their effectiveness. It also considers implications for policy and practice. This miniguide is one of a larger set, which together comprise Health and Social Responses to Drug Problems: A European guide.

Recommended citation: European Monitoring Centre for Drugs and Drug Addiction (2021), Stimulants: health and social responses, https://www.emcdda.europa.eu/publications/mini-guides/stimulants-health….

Identifiers

HTML: TD-03-21-332-EN-Q
ISBN: 978-92-9497-669-7
DOI: 10.2810/502967