Treatment and harm reduction
In Europe, treatment for dependence on cocaine and crack cocaine is generally provided in specialist outpatient treatment services. With no effective pharmacotherapy currently available, cocaine clients are provided with psychosocial treatment such as counselling and cognitive-behavioural therapies. Some countries provide guidelines for the treatment of cocaine problems (e.g. Germany, United Kingdom). Guidelines in the United Kingdom recommend, depending on the client’s needs, three to twenty treatment sessions that aim at resolving ambivalence about change, improving recognition of and controlling cocaine-use cues and urges, reducing cocaine-related harm and preventing relapse (NTA, 2006).
Pharmacotherapy is generally used in Europe to provide relief for symptoms of cocaine dependence, particularly anxiety. A qualitative study investigating current cocaine treatment practices in France found that, despite limited evidence of effectiveness, specific medications, such as methylphenidate, modafinil or topiramate, were prescribed to reduce craving or for substitution purposes (Escots and Suderie, 2009).
Public drug treatment facilities in Europe are mostly oriented towards the needs of opioid users, and socially integrated powder cocaine users may be reluctant to present for treatment due to the perceived stigma. Denmark, Ireland, Italy and Austria have therefore developed specific programmes for this population. A common feature is that treatment can be provided outside regular opening hours to accommodate work commitments and provide discretion.
Two recent studies investigated the effectiveness of psychosocial treatment provided to powder cocaine (NTA, 2010) and crack cocaine users (Marsden et al., 2009) in English treatment centres. Both compared changes in drug use before and after six months of treatment (or earlier in case of discharge). In the first study, 61 % of powder cocaine users 1 864 out of 3 075) had stopped using the drug and a further 11 % had significantly reduced their use. In the second study, 52 % of crack cocaine users (3 941 out of 7 636) were abstinent after six months of treatment. Less positively, it was found that opioid substitution treatment was not as effective with clients using heroin and crack cocaine than with those using only heroin. This finding confirms the detrimental effects of concomitant cocaine or crack cocaine use on the outcomes of substitution treatment, and underlines the need to develop new strategies to treat combined heroin and cocaine or crack-cocaine dependence.
Recent studies for the treatment of cocaine dependence
Over 50 different drugs have been evaluated for treating cocaine dependence. Not one has yet been found to be clearly effective, and neither the European Medicines Agency nor the American Food and Drug Administration have approved any drug for the treatment of cocaine dependence (Kleber et al., 2007). However, more than 100 ongoing randomised controlled trials are registered to test new substances, sometimes in association with psychological interventions.
The use of disulfiram, a substance that interferes with the metabolism of alcohol, was associated with a reduction in cocaine use among patients also suffering from alcoholism. The reduction was attributed to the diminution of alcohol-related disinhibition and impaired judgement. Recent studies have also found a direct impact of disulfiram on the metabolism of cocaine. However, given the limited quality of the evidence, it was suggested that clinicians should balance possible benefits against the potential adverse effects of disulfiram (Pani et al., 2010).
The use of a number of anticonvulsant agents was assessed in 15 studies covering 1 066 patients (Minozzi et al., 2009). The drugs were not significantly better than the placebo in keeping patients in treatment, reducing the number and type of side effects or reducing cocaine use. Antipsychotic agents were assessed in seven studies covering 293 patients (Amato et al., 2009). The studies were generally too small to confirm possible effects, but the available results do not support the use of these drugs in the treatment of cocaine dependence.
Among patients undergoing opioid substitution treatment, it was found that the use of bupropion, dextroamphetamine and modafinil are associated with higher rates of sustained cocaine abstinence than are achieved with a placebo (Castells et al., 2010).
Among non-pharmacological interventions, some psychosocial interventions provided positive results in reducing drop-out rates, reducing cocaine use and improving attendance, in particular when provided along with contingency management with vouchers (Knapp et al., 2007). Several ongoing studies are further investigating the effects of incentives-based interventions, in some cases in association with behavioural therapy and pharmacological interventions. Finally, treatment with auricular acupuncture did not provide significant results (Gates et al., 2006).
Harm-reduction interventions targeting problem crack and cocaine users is a new area of work in many Member States. One reason for the limited provision of interventions in this field, in particular for crack users, might be a lack of knowledge among key workers about the drug, the target group and their needs. A recent review of harm-reduction interventions for stimulant users concluded that more attention had been given to specifying cocaine-related harms than to developing interventions to reduce them (Grund et al., 2010).
Member States usually provide cocaine injectors with the same services and facilities as are provided to opioid users, including: recommendations for safer use, training for safer injecting, and needle and syringe programmes. However, cocaine injecting is associated with increased risks of equipment sharing and with frequent injection, which can lead to vein collapse and to injecting in higher-risk parts of the body (e.g. legs, hands, feet and groin). Therefore, safer use recommendations should be adapted to these specific risks and one-for-one syringe exchange policies should be avoided. Due to the potential high frequency of injecting, the supply of sterile equipment to injectors should not be restricted (van Beek et al., 2001). Clean crack pipes are also provided in some countries by low-threshold agencies (Spain, France).
Harm-reduction interventions targeting powder cocaine users in recreational settings focus mainly on raising awareness. Programmes offer advice and information to young people on the risks associated with alcohol and drug use in general, usually including material on the risks of cocaine use. Largely, apart from awareness raising, harm-reduction options for this target group, which constitutes the vast majority of cocaine users in Europe, are almost non-existent.
NTA (National Treatment Agency for Substance Misuse) (2006), Models of care for adult drug misusers: update (available online).
Escots, S. and Suderie, G. (2009), Usages problématiques de cocaïne, quelles interventions pour quelles demandes?, Tendances 68, Observatoire Français des Drogues et des Toxicomanies, Paris.
NTA (2010), Powder cocaine: how the treatment system is responding to a growing problem (available online).
Marsden, J., Eastwood, B., Bradbury, C., Dale-Perera, A., Farrell, M. et al. (2009), ‘Effectiveness of community treatments for heroin and crack cocaine addiction in England: a prospective, in-treatment cohort study’, Lancet 374, pp. 1262–70.
Kleber, H.D., Weiss, R.D., Anton, R.F. Jr., George, T.P., Greenfield, S.F. et al. (2007), American Psychiatric Association; Steering Committee on Practice Guidelines: Treatment of patients with substance use disorders, second edition, American Journal of Psychiatry 164 (4 Suppl), pp. 5–123.
Pani, P.P., Trogu, E., Vacca, R., Amato, L., Vecchi, S. and Davoli, M. (2010), ‘Disulfiram for the treatment of cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 1.
Minozzi, S., Amato, L., Davoli, M., Farrell, M., Lima Reisser A. et al. (2008), ‘Anticonvulsants for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 2.
Amato, L., Minozzi, S., Pani, P.P. and Davoli, M. (2007), ‘Antipsychotic medications for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 3.
Castells, X., Casas, M., Pérez-Mañá, C., Roncero, C., Vidal, X. and Capellà, D. (2010), ‘Efficacy of psychostimulant drugs for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 2.
Knapp, W.P., Soares, B.G., Farrel, M. and Lima, M.S. (2007), ‘Psychosocial interventions for cocaine and psychostimulant amphetamines related disorders’, Cochrane Database of Systematic Reviews Issue 3.
Gates, S., Smith, L.A. and Foxcroft, D. (2006), ‘Auricular acupuncture for cocaine dependence’, Cochrane Database of Systematic Reviews, Issue 1.
Grund, J.P., Coffin, P., Jauffret-Roustide, M. et al. (2010), ‘The fast and the furious: cocaine, amphetamines and harm reduction’, in Harm reduction: evidence, impacts and challenges, EMCDDA Monograph, Rhodes, T. and Hedrich, D. (editors), Publications Office of the European Union, Luxembourg, pp. 191–232.
Van Beek, I., Dwyer, R. and Malcolm, A. (2001), ‘Cocaine injecting: the sharp end of drug-related harm!’, Drug and Alcohol Review 20, pp. 333–42.