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Please note that the information on this page is based on the EMCDDA Annual report 2011: the state of the drugs problem in Europe. Most statistical data relate to the year 2009 (or the last year available).

 
 

Annual report 2011: the state of the drugs problem in Europe
Cocaine and crack cocaine

Published: 15 November 2011

Treatment and harm reduction

Historically, treatment for drug use problems in Europe has focused on opioid dependence. However, with growing public health concern related to cocaine and crack cocaine use, in many countries more attention has been given to responding to problems related to these drugs. Although treatment for cocaine dependence is mainly provided in specialised outpatient facilities, specific services for cocaine users are delivered in Denmark, Ireland, Italy, Austria and the United Kingdom. There is also limited provision of cocaine treatment in primary health care settings. Currently, only Germany and the United Kingdom provide guidance for the treatment of cocaine problems.

The primary treatment options for cocaine dependence are psychosocial interventions, including motivational interviewing, cognitive behavioural therapies, behavioural self-control training, relapse prevention interventions and counselling. Self-help groups, such as Cocaine Anonymous can also play a role in the recovery process for individuals with cocaine use problems. The support they provide may be combined with formal treatment.

Studies on treatment of cocaine dependence

In Germany, Koerkel and Verthein (2010) evaluated the effects of behavioural self-control training for reducing heroin and cocaine use among dependent individuals. The training was reported to have helped participants to reduce the use of both substances and to maintain drug use at self-defined levels. Two recent studies investigated the effectiveness of drug treatment programmes in England. The Drug Treatment Outcomes Research Study (Jones, A., et al., 2009) found that more than half the cocaine clients stopped using the drug within three to five months of starting treatment. After a full year in treatment, 60 % were abstinent. Similar results were reported for crack cocaine users undergoing treatment in 12 community services in London (Marsden and Stillwell, 2010).

There are numerous randomised trials underway to test new drugs for the treatment of cocaine dependence. At present, two substances show some promise. Disulfiram, a substance that interferes with the metabolism of alcohol, has proved promising in treating cocaine dependence (Pani et al., 2010), and is now being tested in conjunction with cognitive behavioural therapy in the treatment of crack cocaine addiction in a Brazilian study. Vigabatrin, an anti-epilectic drug, was tested in 103 Mexican parolees with positive results at short-term follow-up. It is now being tested in 200 patients in the USA. In the Netherlands, a new approach using rimonabant (a selective cannabinoid antagonist formerly used as an anti-obesity drug), is currently being tested. In addition, multiple pharmacotherapeutic options (topiramate, dexamphetamine and modafinil) are being compared in a randomised controlled study for crack cocaine dependence, recently registered in the Netherland (Hicks et al., 2011).

A number of other trials have produced weak or non-significant results for cocaine dependence. Modafinil, a central nervous system stimulant, was no better than the placebo in addressing cocaine use (Anderson et al., 2009). Both naltrexone (an opioid antagonist) and varenicicline (used to treat smoking addiction) were tested on patients with multiple addiction to cocaine and alcohol or tobacco, but made no difference on use compared with the placebo. Memantine (an Alzheimer's medication) was tested in combination with voucher incentives, but was not more successful than the placebo for reducing cocaine use.

Contingency management has been found to be effective regardless of ethnicity (Barry et al., 2009), and has proved to be a successful strategy when combined with relapse prevention (McKay et al., 2010). In a Spanish study, the use of vouchers as an incentive alongside community reinforcement, was found to support abstinence among cocaine dependent users (Garcia-Rodriguez et al., 2009). However, in another study, voucher incentives showed weak results in reinforcing abstinence for longer periods (Carpenedo et al., 2010).

Other interventions with promising results include employment-based abstinence reinforcement, in which clients receive job skills training for six months, followed by a year's employment, subject to random testing for cocaine use. Other methods being tested to help users reach abstinence include mindfulness training and integrative meditation. Tests being carried out in the Netherlands aim to reduce craving with transcranial magnetic stimulation, a technique which has been used to treat neurologic and psychiatric conditions.

Attempts to develop a cocaine vaccine are continuing. A randomised controlled trial conducted in the United States (Martell et al., 2009) linked a derivative of cocaine to a cholera B protein, but the results appear too weak to proceed with planned field studies in Spain and Italy. The American research group is now recruiting 300 patients to test a modified version of the vaccine and the results are expected in 2014 (Whitten, 2010). Another study is developing a vaccine using a common cold virus as a carrier to boost antibody reaction, but the model is yet to be tested with humans.

Harm reduction

The use of cocaine and crack cocaine represents a relatively new focus for harm-reduction interventions, and requires a rethinking of traditional strategies. Member States usually provide cocaine injectors with the same services and facilities as opioid users. However, cocaine injecting is associated with specific risks. In particular, it involves a potentially higher frequency of injecting, chaotic injecting behaviour and increased sexual risk behaviours. Safer-use recommendations need to be tailored to the needs of this group. Due to the potential high frequency of injecting, the supply of sterile equipment to injectors should not be restricted, but rather based on local assessment of cocaine use patterns and the social situation of injectors (Des Jarlais et al., 2009).

Provision of specific harm-reduction programmes for crack cocaine smokers in Europe is limited. Although controversial, such interventions may have the potential to reduce self-reported injecting behaviour and sharing of drug pipes (Leonard et al., 2007), although their overall effectiveness in reducing transmission of blood-borne viruses requires further study. Some drug consumption facilities in three countries (Germany, Spain, Netherlands) provide facilities for inhalation of drugs, including cocaine. Hygienic inhalation devices including clean crack pipes or 'crack kits' (glass stem with mouth piece, metal screen, lip balm and hand wipes) are reported to be sporadically provided to drug users who are smoking crack cocaine by some low-threshold facilities in Belgium, Germany, Spain, France, Luxembourg and the Netherlands. Foil is also made available to heroin or cocaine smokers at some low-threshold facilities in seven EU Member States.

Bibliographic references

Anderson, A.L., Reid, M.S., Li, S.H., Holmes, T., Shemanski, L. et al. (2009), 'Modafinil for the treatment of cocaine dependence', Drug and Alcohol Dependence 104(1-2), pp. 133-9.

Barry, D., Sullivan, B. and Petry, N.M. (2009), 'Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients', Psychology of Addictive Behaviors 23(1), pp. 168-74.

Carpenedo, C.M., Kirby, K.C., Dugosh, K.L., Rosenwasser, B.J. and Thompson, D.L. (2010), 'Extended voucher-based reinforcement therapy for long-term drug abstinence', American Journal of Health Behavior 34(6), pp. 776-87.

Des Jarlais, D., McKnight, C., Goldblatt, C. and Purchase, D. (2009), 'Doing harm reduction better: syringe exchange in the United States', Addiction 104(9), pp. 1 441-6.

Garcia-Rodriguez, O., Secades-Villa, R., Higgins, S.T., Fernandez-Hermida, J.R., Carballo, J.L. et al. (2009), 'Effects of voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: a randomized controlled trial', Experimental and Clinical Psychopharmacology 17(3), pp. 131-8.

Hicks, M., De, B., Rosenberg, J., Davidson, J., Moreno, A. et al. (2011), 'Cocaine analog coupled to disrupted adenovirus: a vaccine strategy to evoke high-titer immunity against addictive drugs', Molecular Therapy 19, pp. 612-9.

Jones, A., Donmall, M., Millar, T., Moody, A., Weston, S., Anderson, T., Gittins, M., Abeywardana, V. and D'Souza, J. (2009), The Drug Treatment Outcomes Research Study (DTORS): Final outcomes report, Home Office, London.

Koerkel, J. and Verthein, U. (2010), 'Kontrollierter Konsum von Opiaten und Kokain', Suchttherapie 11 (1), pp. 31-4.

Leonard, L., De Rubeis, E., Pelude, L., et al. (2008), 'I inject less as I have easier access to pipes: injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resources are distributed', International Journal of Drug Policy 19, pp. 255-64.

Marsden, J. and Stillwell, G. (2010),  Effective community treatment for drug misusers: outcome monitoring at Blenheim CDP, Blenheim CDP, The London Drug Agency.

Martell, B.A., Orson, F.M., Poling, J., Mitchell, E., Rossen, R.D. et al. (2009), 'Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial', Archives of General Psychiatry 66(10), pp. 1 116-23.

McKay, J.R., Lynch, K.G., Coviello, D., Morrison, R., Cary, M.S. et al. (2010), 'Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement', Journal of Consulting and Clinical Psychology 78(1), pp. 111-20.

Pani, P.P., Vacca, R., Trogu, E., Amato, L. and Davoli, M. (2010), 'Pharmacological treatment for depression during opioid agonist treatment for opioid dependence', Cochrane Database of Systematic Reviews, Issue 9, p. CD008373.

Whitten, L. (2010), 'A clinical trial encourages continued development of strategy based on immune system response', NIDA Notes 23(3).

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Page last updated: Friday, 28 October 2011