# Cocaine use in Europe: the need for cross-sectoral collaboration between security, justice, health, and social systems

Marie Lhosmot-Marquet, Clotilde Champeyrache, Hélène Donnadieu, Emilie Jouanjus, Yasser Khazaal, Perrine Roux, Bénédicte Varignon, Laurent Fleury, Etienne Coyaud

► To cite this version:

Marie Lhosmot-Marquet, Clotilde Champeyrache, Hélène Donnadieu, Emilie Jouanjus, Yasser Khazaal, et al.. Cocaine use in Europe: the need for cross-sectoral collaboration between security, justice, health, and social systems. The Lancet Public Health, 2026, 11 (1), pp.e61-e68. 10.1016/S2468-2667(25)00283-X. hal-05474207

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# Cocaine use in Europe: the need for cross-sectoral collaboration between security, justice, health, and social systems

Marie Lhosmot-Marquet, Clotilde Champeyrache, Hélène Donnadieu, Emilie Jouanjus, Yasser Khazaal, Perrine Roux, Bénédicte Varignon, Laurent Fleury*, Etienne Coyaud*

Cocaine use has increased in Europe over the past decade, raising concerns regarding its associated harms. This increase is driven by the contemporary transformation of the international cocaine supply chain, which has led to increased availability, purity, and use rates. Cocaine use affects both health and society, challenging European countries' health and social care capabilities and models. Addressing these challenges requires multisectoral collaboration to understand the issues better and develop appropriate public health strategies. Integrating security, social, and health policies is thus necessary, and their coordinated actions should lead to improving health and living conditions of people who use cocaine. Given the recent evolutions of the market, there is an awareness of the need to improve security measures to combat drug trafficking in Europe, but health and social aspects have not been sufficiently considered. In this Viewpoint, we review key facts about cocaine use within the European context and propose pragmatic and prioritised measures, reconciling health, social, justice, and security aspects.

## The new landscape of cocaine in Europe

### Increased cocaine production and use

Cocaine use is at an all-time high, with an estimated 25 million people who use cocaine globally in 2023.¹ Due to a substantial expansion in coca cultivation in the Andean region—rising from 120 000 hectares in 2013, to 346 000 hectares in 2023¹—and anti-trafficking efforts targeting North American supply routes, around 2012 cocaine was partially diverted towards Europe, leading Europe to emerge as a primary market over the past decade.² In 2022, cocaine seizures were estimated at 322·5 tons in Europe and reached 419 tons in 2023 (figure 1),³ exceeding North American seizures since 2022.¹ Cocaine-related hospitalisations (half of which are associated with co-consumption of alcohol), treatment requests, and deaths linked to cocaine use have also increased in Europe.³ Cocaine was mentioned in 25% of acute drug-toxicity cases in the European Drug Emergencies Network Plus sentinel hospitals network in 2023, and implicated in 26% of drug-induced deaths across 20 European countries.⁴

### Cocaine trafficking determinants

The rise of cocaine in illicit drug markets and its global- rerouting towards Europe is made possible by the internationalisation of organised criminal networks, with new criminal actors centred around brokers and scattered across all territories affected by traffics (origin and destination countries, and transit countries such as Brazil, Ecuador, or the West African region). Vulner- abilities at ports facilitate cocaine trafficking, and occur amid extremely low customs control (2% of goods entering European ports are checked at customs), as a result of prioritising trade over security.⁵ Furthermore, although traditional dealing locations are still in use, new distribution methods emerged during the COVID-19 pandemic, such as ordering via encrypted messaging

apps for delivery to homes, meeting points, or workplaces, facilitating use among new categories of people who use drugs across social classes and locations, including rural areas.⁶,⁷

### Diversity of people who use cocaine

The increased supply meets a demand supported by enhanced access to cocaine, higher purity, and stable or declining prices in inflationist contexts (figure 1).³ There are multiple profiles of people who use cocaine powder or crack cocaine,⁸ originating from diverse socioeconomic backgrounds. They are found in party scenes,⁹ certain professional environments,¹⁰ or among precarious populations experiencing social or economic difficulties (eg, people experiencing homelessness, migrants, or refugees).¹¹ According to the European Union Drugs Agency (EUDA), during 2024 an average of 2·3% young adults (age 15–34 years) used cocaine (figure 1).¹² Cocaine lifetime use among individuals aged 15–64 years is also heterogeneous across Europe, with a median of 2·9%.¹² The highest rates of cocaine use are found in Spain (13·3%), the UK (11%), and Denmark (9%), and remain below 1% in several eastern European countries (eg, Hungary and Romania).¹² The EUDA also reports cocaine powder as the most frequently consumed drug alongside at least one other substance.¹³ The increased use was corroborated by increasing concentrations of benzoylcgonine, a cocaine metabolite, in analyses of European cities wastewater over 10 years (figure 1).¹⁴

### Multiple legislations across Europe

European drug legislation encompasses a range of different approaches and perspectives. Most countries (eg, the UK, France, Germany, Denmark, Belgium, and Spain) criminalise both people who use drugs and traffickers. However, some countries distinguish people who use cannabis (de facto tolerance or

Lancet Public Health 2026; 11: e61-68

*Contributed equally

Collective Expertise Centre,
Public Health Institute, Inserm,
Paris, France

(M Lhosmot-Marquet PharmD,
B Varignon PhD, L Fleury PhD,
E Coyaud PhD); Security-
Defense-Intelligence Division,

Conservatoire National des Arts
et Métiers, Paris, France
(C Champeyrache PhD);

Addictions Department,
Hôpital La Colombiere,
University Hospital of
Montpellier, Inserm U1058,
Montpellier, France

(H Donnadieu PhD); Montpellier
Faculty of Medicine, University
of Montpellier, Montpellier,
France (H Donnadieu PhD);

Addictovigilance Center,
Department of Medical and
Clinical Pharmacology,
Toulouse University Hospital,
Toulouse, France

(E Jouanjus PhD); CERPOP,
UMR 1295, University of
Toulouse, Toulouse, France

(E Jouanjus PhD); Faculty of
Health, University of Toulouse,
Toulouse, France

(E Jouanjus PhD); Addiction
Medicine Department of
Psychiatry, Lausanne University
Hospital, Lausanne University,
Lausanne, Switzerland

(Y Khazaal MD); Department of
Psychiatry and Addictology,
University of Montreal,
Montreal, QC, Canada

(Y Khazaal MD); Aix Marseille
University, Inserm, IRD,
SESTTIM, Economic and Social
Sciences of Health and Medical
Information Processing,
ISSPAM, Marseille, France

(P Roux PhD); Inserm U1192,
Proteomics Inflammatory
Response Mass Spectrometry
(PRISM), Lille University, CHU
Lille, Lille, France (E Coyaud PhD)

Correspondence to:
Dr Etienne Coyaud, Collective
Expertise Centre, Public Health
Institute, Inserm, Paris 75013,
France

etienne.coyaud@inserm.fr
<figure><img src="image_2.png" /><figcaption>**Figure 1:** Evolution of the cocaine market in Europe

(A) Comparison of cocaine-type seizures in Europe between 2013 and 2023. Wholesale (B) and retail (C) price changes per country between 2013 and 2023. (D) Prevalence of cocaine use in the past 12 months in young adults. (E) Aggregated trends in cocaine residues in seven EU cities' wastewater, 2011-24 (data reproduced from the European Union Drugs Agency sewage analysis core group—Europe; see appendix for sources and data).

See Online for appendix</figcaption></figure>
decriminalisation).¹⁵ Since the early 2000s, in Europe, there have been notable turning points in the evolution of laws regarding drugs, often indicating a shift towards fewer criminalisation-oriented approaches for people who use drugs.¹⁶ For instance, Portugal has decriminalised all substance use, supported by health counselling, but this system faces limitations—it efficiently addresses opioid users' needs but struggles to frame stimulant use disorders.¹⁷ The model was developed primarily for opioid dependence, leveraging the benefits of effective substitution therapies (eg, methadone).¹⁸ However, there is a complete absence of pharmacological substitutes for cocaine, and behavioural interventions remain insufficient and underfunded.¹⁹ On the other hand, fully repressive policies targeting people who use drugs have proven ineffective,¹⁵ and both models are no longer suited to address cocaine use and trafficking realities.

## A wide range of consequences of cocaine use

### Health effects

The majority of drug use is episodic.²⁰ Cocaine powder is typically used intranasally in nightlife settings alongside alcohol.²¹ Acute harm can occur among occasional users, including at first use, and might result in serious health consequences or even death due to vascular spasticity.²² Concomitant alcohol ingestion increases these risks.²³ Crack cocaine use, representing only one in ten or fewer cocaine users in Europe,² is more strongly associated with dependence, polydrug use, and social marginalisation, often in conjunction with heroin use.

When cocaine use becomes problematic, such as when it is associated with health, social, or psychological issues, individuals typically wait an average of 13 years from their first use before seeking help.³ This long delay makes the recent rise in cocaine use across Europe particularly concerning. There were 70 000 patients in 2023 treated for cocaine use across Europe (including the EU, Norway, Türkiye, and the UK), half being first-time entrants.³ Here, treatment refers to medical, psychological, or social interventions aimed at addressing cocaine use disorders, and first-time entrants denotes individuals accessing such services for the first time during the reporting year. Specific patterns of use of cocaine powder and crack cocaine are associated with well documented clinically significant damages, described as cocaine use disorder, and which potentially lead to death, with an overall mortality six-fold higher than in non-users.²⁴ These health conditions include liver disease (cause-specific mortality rate per 100 person-years 0·06, 95% CI 0·01–0·55), digestive disease (0·14, 0·03–0·73), cardiovascular disease (0·13, 0·07–0·24), cancer (0·11, 0·05–0·25), AIDS-related disease (0·28, 0·12–0·63), and respiratory disease (0·09, 0·04–0·17).²⁴ Although fatal outcomes remain rare, the striking increase of 535% of cocaine-related deaths in high-income countries (from 0·14 per 100 000 people in 1990 to 0·89 per 100 000 people in 2023) illustrates the evolution of cocaine consumption.²⁵

## Social and societal damages

Beyond the somatic effect of cocaine, some individuals with cocaine use disorder, and particularly those who use crack cocaine, see their pre-existing marginalised position aggravated by cocaine use,²⁶ which can lead to unemployment, unstable housing situations, legal problems, and fractured relationships. Women make up approximately a quarter of individuals with serious drug problems and around a fifth of all entrants to drug treatment programmes in Europe.²⁷ The proportion of female individuals who use drugs is associated with vulnerability factors, including the telescopic effect (women meet criteria for substance use disorder after fewer years of drug use than men)²⁸ and the lack of dedicated reception at treatment and safe consumption facilities that could prevent them from mixing with the male consumer population, a situation that is perceived as high-risk for their safety.²⁹ Women who use cocaine manifest certain symptoms more frequently than men (eg, anxiety, anorexia, bulimia, or post-traumatic stress disorder), and often only seek care when psychiatric symptoms and social issues are more severe than similar symptoms in men, which highlights the need for a global approach specific to women.³⁰

Cocaine use consequences extend beyond people who use cocaine, including children, who are vulnerable collateral victims and face a higher prevalence of developmental disorders³¹ or substance use disorders than children not exposed to cocaine in utero;³² the legal sectors in direct contact with the cocaine value chain or their actors (eg, transporters of cocaine through forced collaboration, corruption, or without their knowledge, and social, health, security, and judicial spheres), through threats and corruption; and society as a whole, through money laundering, other criminal activities, and violence. The effect on society, particularly the violence that reaches the legal sphere or society more widely, is the focus of most politicians' speeches and actions, relegating the health and social aspects of cocaine use to the background.

## A window of opportunity to deploy integrated responses

Halting cocaine use in the near future is unrealistic; however, a comprehensive response integrating prevention of cocaine use, harm reduction, health care, law enforcement, the justice system, and social support is crucial.³³ In this Viewpoint, we propose four gradual actions that aim to conjugate security, health, and social efforts to mitigate the harm associated with cocaine without increasing the societal and financial burdens (figure 2). Some of these measures could also assist in preparing the response to the increasing use of synthetic stimulants in Europe. These recommendations are specifically tailored for people who use cocaine with cocaine use disorder, with a focus on those who are at high risk of severe health outcomes, part of a marginalised population, dependent on using cocaine, or who inject or
<figure><img src="image_3.png" /><figcaption>**Figure 2: Reorganising public policies**</figcaption></figure>

Current and anticipated relationships among stakeholders connected to people who use cocaine. The transition from the current situation to the expected benefits necessitates the proposed action from the legal sectors illustrated in the diagram. Key cocaine-related issues are noted alongside the primary sector, with proposed leverage points linked by corresponding symbols: blue circle=law enforcement; green triangle=social care system; green cross=health-care system; and purple square=justice system. Health and social care demand substantial financial investments, potentially funded by expanded asset seizures from traffickers. Redirecting focus (law enforcement and the justice system) from people who use cocaine to brokers and wholesalers would improve efficiency in both fund collection and reducing cocaine availability. The multiple symbols associated with the same actions represent the essential cooperation among all stakeholders to provide adequate and effective support to people who use cocaine and the general population. The list of expected benefits is colour-coded according to the corresponding sector or population. SCFs=safe consumption facilities.

consume crack cocaine. Their overarching goal is to break the harmful cycle of health and social issues that this group encounters and to mitigate the broader societal effects.

## Changing the perception of people who use cocaine, from stigma to support

The initial focus should be on changing the public perception of people who use cocaine. Stigmatisation is a barrier that deters people who use cocaine from seeking care,³⁴,³⁵ particularly for crack cocaine users,²⁶ and this change is a prerequisite for an effective harm reduction policy. Such policies should integrate non-judgement, outreach, unconditional welcome, and community health support principles.³⁶ Training in these principles should primarily target first-line professionals (ie, law enforcement, social workers, and health-care workers) with programmes updated to reflect the current realities of cocaine use. For example, in Copenhagen, the police

have prioritised people who use drugs' access to social and health-care services over strict law enforcement.³⁷ A zone of non-enforcement has been defined near a drug consumption room, shaping the drug scene into an object of public order maintenance rather than law enforcement, of regulation rather than exclusion.³⁷ Although this programme did not eliminate issues of stigma, it has effectively reduced the most pronounced neighbourhood conflicts, thereby improving public perception. It is highly probable that the programme would gain additional benefits from the simultaneous implementation of the other measures proposed in this Viewpoint.

## Develop or extend social support

Develop integrated facilities combining health care, housing (such as the Housing First initiative)³⁸ and social support

A subset of people who use drugs, particularly those who use cocaine powder and crack cocaine, experience
homelessness, have substantial adverse effects from
drug use, and have minimal access to social and health-
care services due to structural, social, and individual
factors.³⁹ Additional efforts are therefore required to
address the specific needs of these populations, such
as modifying existing rules, policies, and health-care
systems through careful planning; implementing
diverse treatment programmes and supportive policies
to enhance treatment conditions; and supporting
interventions aimed at addressing stigma.

Provide women-dedicated services

Safe consumption facilities (SCFs) could serve as key platforms to implement prevention and care services dedicated to assisting women. Based on testimonies, the under-representation of women among people who use cocaine seeking help is likely due to gender-related stigma, histories of trauma and sexual assault, clinical specificities, or lack of dedicated services able to mitigate risks related to mixed-gender settings.⁴⁰ Reserving facilities or organising women-dedicated time slots and workshops in SCFs is important. The pervasive presence of men in such spaces can deter women seeking refuge and respite. Women-specific approaches could also be extended through outreach actions.

Support contingency management interventions

In the health sector, there is no approved pharmacological treatment for cocaine use disorder, and addiction services remain chronically understaffed to meet demand. The social sector also faces substantial workforce shortages, exacerbated by low wages, difficult working conditions, and insufficient infrastructure to address current and anticipated needs.³⁹ Additional means are needed to scale up social and health-care services, which could be funded by judicial actions proposed in this Viewpoint.

The absence of proven effective pharmacological
treatment for cocaine addiction requires implementing
other approaches.⁴¹ Non-pharmacological approaches,
such as psychosocial interventions, including cognitive
and behavioural therapies⁴² and motivational interviews,
and new approaches, such as contingency manage-
ment⁴³ and the involvement of peer users, have proven
effective and should be deployed. Contingency manage-
ment aims to facilitate the acquisition of new behaviours
or modify existing ones through the application of external
reinforcers administered contingently—ie, immediately
following the desired change or action.⁴⁴ Monetary
incentives or gift vouchers might serve as reinforcers.

SCFs: an instrumental platform for multiple harm reduction actions

Promote social acceptability of SCFs

The core aim of harm reduction programmes should be
the development of SCFs. In 2023, there were 151 SCFs

operating across 16 countries in Europe. These harm
reduction facilities effectively decrease overdose-related
morbidity and mortality and helps to mitigate injection-
related risks.⁴⁵ The necessity of SCFs is further
underscored by the low to moderate availability of needle
and syringe exchange programmes across Europe,
with the level of access depending on the country.⁴⁶
Additionally, SCFs should be adaptable to evolving usage
patterns and offer inhalation facilities, which could
reduce the risks of burns, oral injuries, and inhalation of
toxic substances from improvised devices. Importantly,
residents of the neighbourhoods chosen for these
facilities should be informed of the anticipated benefits
once the location is finalised and before approval.
Moreover, since people who use cocaine often move
within confined areas near substance acquisition
locations, mobile SCFs could be an efficient means to
provide care to hard-to-reach people who use cocaine.⁴⁷
To ensure the safety of both the neighbourhood and
social and health-care workers, police forces should be
linked with SCFs, with a non-enforcement philosophy.

Take advantage of SCFs to implement drug checking

Expanding drug checking could be a rational approach for harm reduction,⁴⁸ informing people who use cocaine on the purity of their cocaine and avoiding risks associated with harmful adulterants such as levamisole (vasculitis and agranulocytosis) and phenacetin (renal disease).⁴⁹,⁵⁰ Drug checking can be done through harm reduction programmes in SCFs and deployed in mobile units in clubs or festivals.⁴⁸ Beyond the increase in cocaine use itself, Europe is experiencing a substantial rise in synthetic opioids.⁵¹ Implementing drug checking measures could also help stimulant users to avoid the accidental ingestion of substances such as nitazenes, making such measures of critical importance. Simultaneously, such initiatives should serve to disseminate information about the key risks associated with the concurrent use of cocaine and alcohol.

Consider implementing cocaine-assisted treatment for severe
cocaine use disorder

Finally, the SCFs could host cocaine safe supply services as a last resort medical treatment for individuals who have not responded well to harm reduction measures. There is a need for such legal and safe supply of stimulants of known quality, integrated within a health-care framework, to directly tackle the risk posed by an increasingly contaminated stimulant supply.⁵² Concerns about stimulant adulteration with fentanyl are pronounced in North America,⁵² whereas in Europe, variability in street cocaine composition—including adulteration with other substances, such as levamisole, synthetic stimulants, or opioids—remains a concern, although currently to a lesser degree. Cocaine-assisted treatment might offer an alternative to the risks associated with adulteration, similar to
heroin-assisted treatments available in several European countries.⁵³ The target population for heroin-assisted treatment includes those with chronic, treatment-refractory heroin dependence, persistent illicit use despite conventional treatment, and high vulnerability.⁵⁴ This treatment has benefits over methadone maintenance in retention of patients, risk reduction, improved health outcomes, and reduced crime levels.⁵³ Crimes by people who use crack cocaine often occur during craving phases, when they are seeking cocaine or money.⁵³ Building on heroin-assisted treatment evidence, supervised stimulant supply could improve health and social outcomes among vulnerable cocaine use disorder groups.⁵⁶ Due to cocaine's short half-life and the cardiovascular risks associated with the drug,⁵⁷ pilot implementation requires a rigorous clinical framework. Distribution methods need refinement, whether in safe consumption facilities or medical consultations. In the absence of cocaine substitution therapy, cocaine safe supply, fuelled by redirected custom seizures, could reduce harm to people who use cocaine under the EU legal frameworks' compassionate use principles. Social acceptance through communication campaigns and systematic evaluation is essential for broader implementation.⁵⁸

## Fund health and social care needs through the seizure of trafficker assets

The final recommendation consists of providing financial means for supporting educational and harm reduction

measures. These initiatives deserve strong political will and enhanced international cooperation to seize assets hidden in other countries. Noticeably reducing cocaine supply and availability, and efficient seizure of trafficker assets, and therefore the funding of harm reduction programmes, relies on the implementation of existing available measures, such as joint investigation teams and European investigation orders. Effective cooperation in investigations requires practical measures rather than formalities, such as granting Eurojust binding authority to issue instructions on interpreting technical investigations and European investigation orders.⁵⁹ Additionally, harmonising procedures (eg, admissibility of evidence)⁵⁹ in financial investigations and investing in law enforcement capabilities—particularly specialised training to track financial flows—are essential for successful asset confiscation and overall cooperation effectiveness.⁶⁰ More efficient and extensive seizure of criminal assets would support the necessary investments in implementing or scaling up the proposed harm reduction initiatives.

## Conclusion

The evolving European cocaine market has exposed key limitations across multiple sectors. Economic priorities favour the free movement of goods, often at the expense of effective customs control. Law enforcement efforts remain disproportionately focused on people who use drugs and low-level dealers—individuals who are easily replaced—and lack the time, resources, and international mechanisms necessary for coordinated investigations targeting high-level actors. Judicial systems primarily operate at the national level, with minimal cross-border cooperation and no harmonisation of legal standards such as evidence admissibility or shared jurisdiction, weakening the ability to secure convictions or asset seizures against major traffickers.

Given these systemic constraints, existing judicial, security, social, and health-care structures are insufficient to meet the complex challenges posed by cocaine use and trafficking. A coordinated, continent-wide strategy is urgently needed—one that is grounded in public health and prioritises the health of people who use cocaine, particularly those with cocaine use disorder and marginalised individuals who use crack cocaine. Such strategy would greatly benefit from dialogue among all relevant stakeholders and the meaningful involvement of people with lived experience.

This Viewpoint outlines a multicomponent action plan, including harm reduction training for law enforcement and health professionals, implementation of supervised consumption facilities to reduce overdose and injection and inhalation-related harms, gender-responsive services to address disparities in care access, drug checking to prevent accidental harm, and, where appropriate, provision of a regulated cocaine supply. Although many of these measures could be implemented with existing

## Search strategy and selection criteria

Literature and data searches were done in PubMed, Scopus, and Web of Science databases from Jan 1, 2014, to Sept 1, 2025, mining with the search terms "cocaine" or "crack cocaine" or "cocaine smoking" or "cocaine-related disorders". Our literature search qualitatively collected over 2400 articles (eg, institutional reports and peer-reviewed articles). Due to the large number of results, reviews, meta-analysis, and annual report of institutions such as the UN Office on Drugs and Crime and the European Union Drugs Agency were prioritised for specific subjects (epidemiology and harm reduction strategy and policy), and specific keywords to refine the searches were added when necessary (eg, "tendency" OR "epidemiolog*" OR "frequenc*" OR "incidence" OR "trend*" OR "statistic*" OR "estimat*" OR "rate" OR "occurence" OR "risk assessment"). Articles published in peer-reviewed journals were generally preferred, but, where necessary, grey literature was browsed across internet sites dedicated to drug addiction (The French Monitoring Centre for Drugs and Addiction, European Union Drugs Agency, drogaddiction, Groupement Romand d'Études des Addictions, Federation of European Toxicologists and European Societies of Toxicology, European harm reduction network, etc).
personnel and resources, meaningful progress will require substantial reorganisation, adequate funding, and above all, sustained political will, public support, and strengthened international cooperation. A rebalanced approach would also alleviate pressure on law enforcement and judicial systems, enabling a shift towards long-term, high-impact investigations.

### Contributors

ML-M and EC wrote the original manuscript; all authors contributed to the paper. All authors reviewed the manuscript, approved the final manuscript content, and agreed to submit for publication.

### Declaration of interests

We declare no competing interests.

### Acknowledgments

We are members of the French National Institute for Health and Medical Research (Inserm) Collective Expertise group on cocaine. The Collective Expertise (Public Health division of Inserm) was commissioned by the French Health Ministry and by the Interministerial Mission for Combating Drugs and Addictive Behaviours to conduct an evaluation of cocaine-related public health issues, which has informed this Viewpoint. We thank all the members of the Collective Expertise Reports Centre of Inserm. The opinions expressed in this Viewpoint are those of the authors and do not necessarily represent the position of the Inserm, or their institutions. During the preparation of this work the authors used the improve fluency tool from Paperpal to improve the fluency of some sections. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

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