Cocaine use in Europe: implications for service delivery : policy briefing 'Drugs in focus', issue 17.
Date: 2008-01-03
Institutions: European Monitoring Centre for Drugs and Drug Addiction
Subjects: European Monitoring Centre for Drugs and Drug Addiction, drug addiction, information, serial publication

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17Drugs in focus

Brieﬁ ng of the European Monitoring Centre for Drugs and Drug Addiction

Cocaine use in Europe: implications for service delivery

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An estimated 12 million (3.5 %) 
European adults aged 15–64 
have tried cocaine and 4.5 million 
(1.3 %) have used it in the last year. 
Overall, cocaine supply, use and 
related problems in Europe have 
risen over the last decade, and 
prices have dropped. However, this 
overall trend masks considerable 
inter-country variation. Some 
countries, such as the UK, Spain 
and Italy, have seen considerable 
increases in cocaine use while 

others, particularly in eastern Europe, 
report only very limited use. 

Cocaine use presents new 
challenges for Europe’s drug 
treatment services. Although services 
can leverage experiences gained 
in responding to other types of 
drug problems, the pharmacology 
of cocaine, the social diversity 
of users and the concurrent use 
of other psychoactive substances 
complicate the development and 
targeting of responses. And unlike 

treatment for opioid users, there are 
no proven effective substitution or 
pharmacological treatment options 
currently available for cocaine users.

This paper addresses a number of 
important issues for the delivery of 
services for cocaine users. How 
can the different groups of users be 
reached and helped? What type of 
treatment should be made available 
for dependent cocaine users? Are 
new specialised services needed, or 
should existing ones be adapted?

Deﬁ nitions

Cocaine is the hydrochloride salt produced from the leaves of the coca plant (Erythroxylon coca Lam) which is cultivated mainly 
in South America. Powder cocaine is typically snorted (insufﬂ ated) and, less frequently, injected. It produces euphoria and appetite 
suppression, and has multiple negative effects on health (see ‘Health issues’).

Crack is the smokable form of cocaine and is manufactured from cocaine hydrochloride. It is known for immediate effects and 
association with problematic patterns of use.

Key issues at a glance 

1.  Some 4.5 million European adults (1.3 %) have used cocaine 
in the last year. Last year cocaine prevalence has shown an 
overall upward trend over the last decade, although with 
variations between EU Member States, ranging from 0.1 % to 
3.0 % of the population. 

2.  Cocaine use can lead to dependence and treatment demand 
related to cocaine has increased. Psychiatric, cardiovascular 
and other health problems are also associated with cocaine 
use. Injecting cocaine carries the risk of transmission of 
blood-borne diseases such as HIV and hepatitis C. 

4.  These groups differ in drug use patterns, health and living 
conditions. Their needs range from access to information 
about cocaine-related risks to speciﬁ c treatment or harm 
reduction interventions. 

5.  Current responses to cocaine-related problems draw largely 
on existing services targeted at opioid use and drug use 
in recreational settings. These existing services may need 
adapting to meet the speciﬁ c needs of cocaine and crack 
users.

3.  Three core groups of problem cocaine users can be 

6.  Improvements could include: speciﬁ c cocaine and crack 

identiﬁ ed: socially well-integrated individuals; opioid 
users, some of whom are substitution treatment clients; and 
marginalised crack users.

strategies; training and research on the treatment of cocaine 
dependence; outreach interventions; and tailored treatment 
services for speciﬁ c groups of cocaine and crack users.

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Drugs in focus
 3rd issue 2007

1.  Growing cocaine use in 

Europe

Second only to cannabis, cocaine is 
among the most trafﬁ cked drugs in the 
world. In 2005, an estimated 752 
tonnes were seized worldwide and 
107 tonnes in Europe, with Spain 
accounting for about half of European 
seizures. Overall, the quantities seized 
and the number of seizures have 
increased in Europe since 2000, 
reaching around 70 000 cases in 
2005. Average prices of cocaine 
have fallen in most reporting countries.

General population surveys show an 
increase in cocaine use in many EU 
countries, although this may now be 
slowing down in some Member 
States with the highest prevalence 
(UK, Spain). Cocaine use is more 
common among young adults aged 
15–34 (Figure 1) and males. The 
drug is often consumed alongside 
other illicit drugs and alcohol.

2.  Health issues

Cocaine use has been shown to have 
negative effects on health, especially 
among frequent users. However, 
the extent of both the morbidity and 
mortality related directly to cocaine 
use remains difﬁ cult to estimate. 

Cocaine and crack act on the reward 
system of the brain and repeated use 
can lead to dependence. It is the 
third most commonly reported drug 
cited as the reason for entering drug 
treatment in the EU, with about 13 % 
of all treatment demands in 2005. 
However, there are considerable 
variations between countries. In Spain 
and the Netherlands, cocaine accounts 
for respectively 40 % and 35 % of all 
treatment demands while this ﬁ gure is 
0 % in Finland and 0.1 % in Lithuania. 
The number of treatment demands 
related to cocaine use has increased 
in recent years, notably among those 
entering treatment for the ﬁ rst time 
(Figure 2). In 2005, more than one in 
ﬁ ve ﬁ rst treatment demands (21.5 %) 
were cocaine-related. 

Figure 1: Last-year prevalence of cocaine use among young adults (aged 15–34) in Europe

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        Source: EMCDDA Statistical bulletin, ﬁ gure GPS-38.

Acute and chronic cocaine use, often 
in combination with other substances, 
can cause multiple disorders 
(cardiovascular, cerebrovascular, 
neurological, psychiatric, etc.). 
Cocaine injection also carries the 
risk of transmission of blood-borne 
diseases such as HIV and hepatitis 
C. Acute cocaine-related deaths from 
overdose are not frequently reported, 
but in such rare cases a massive 
exposure is mentioned. Most reported 
cocaine deaths are the consequence 
of its chronic toxicity, leading to 
cardiovascular and neurological 
complications. 

3. Different groups of users

the general population. Studies with 
cocaine users who are not in treatment 
typically report a well-educated and 
socially integrated user demographic. 
Furthermore, studies and treatment 
data allow us to distinguish three 
different proﬁ les or groups of problem 
cocaine users.

The ﬁ rst group uses powder cocaine 
alone or in combination with cannabis 
and/or alcohol. This group is mainly 
composed of males, often referred 
to treatment by the criminal justice 
system or under the pressure of 
social and family networks. They are 
relatively well-integrated socially, with 
stable living conditions and regular 
employment.

Cocaine users are spread across 
diverse social groups. For example, 
surveys in recreational nightlife settings 
show prevalence rates 5 to 20 times 
higher among clubbers than among 

The second group uses both opioids 
and cocaine. Its members are current 
or former heroin users who have 
also developed problems related 
to cocaine use. Some may be 

Figure 2: Evolution in number of ﬁ rst treatment demands with cocaine as the primary drug 
in 20 EU countries (indexed to 100 in 1999)

Index
300

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1999

2000

2001

2002

2003

2004

2005

         20 countries: BG, CZ, DK, DE, IE, EL, ES, FR, IT, HU, MT, NL, PL, PT, RO, SI, SK, FI, SE, UK included.

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undergoing substitution treatment. 
National studies focusing on cocaine 
users in treatment report that this group 
is often the largest. 

problems and are difﬁ cult to reach. 
They might seek treatment and support 
at a later stage of their dependence 
and thus be more difﬁ cult to treat. 

United States, research on their 
transferability to Europe is urgently 
required.

The third group uses crack cocaine, 
often in combination with opioids. 
Its members are frequently highly 
marginalised, and may comprise a 
high proportion of ethnic minority 
members and people who are 
homeless, unemployed or in 
precarious labour conditions. It is the 
smallest of the three groups (2.5 % 
of all European clients in treatment) 
and has only been identiﬁ ed in a few 
locations.

4. The needs of different user 
groups

Cocaine and crack users represent 
a heterogeneous population with 
speciﬁ c needs which may require 
tailored services. Socially integrated 
powder cocaine users may need to be 
better informed about cocaine-related 
risks. They may also be reluctant to 
initiate or continue treatment among 
marginalised drug users and feel there 
is a stigma attached to users attending 
such services. 

Among dependent cocaine users 
who are also heroin users and/
or in substitution, continued cocaine 
use may, if not addressed properly, 
interfere with the treatment programme 
and subsequently jeopardise the 
overall treatment outcome. Similarly, 
co-use of alcohol and often observed 
co-morbid psychiatric and personality 
disorders in cocaine clients (e.g. 
aggression, acute psychosis and 
paranoid behaviour) constitute major 
problems for staff and clinicians. The 
co-use of multiple substances also 
substantially increases the risk of 
additional health problems and the 
risk of death among this population. 

Finally, crack cocaine often 
affects marginalised and deprived 
populations (e.g. the homeless, sex 
workers). These populations show a 
broad variety of health and social 

5. Policies and interventions

There are very few drug strategies 
which speciﬁ cally target cocaine 
and crack cocaine use and only the 
UK and Ireland have implemented 
strategies at national and/or local 
level. Most European countries 
report that cocaine users can access 
information about cocaine and the 
risks of cocaine use through various 
sources such as websites, helplines 
and interventions in the nightlife 
setting. In some cities, especially those 
with signiﬁ cant crack cocaine use, 
harm-reduction agencies also provide 
outreach interventions. 

Currently, most reported cocaine 
treatment in Europe takes place in 
outpatient settings which are primarily 
oriented to the needs of opioid users. 
However, socially integrated cocaine 
users are likely to seek help through 
other healthcare providers such 
as general practitioners or private 
clinics. There is a growing interest 
for countries with signiﬁ cant cocaine-
using populations to provide services 
tailored speciﬁ cally to cocaine users. 

A recent EMCDDA review of the 
literature on the treatment of cocaine 
dependence found that no effective 
pharmacological therapeutic agent 
is yet available but that recent 
experimental trials (e.g. Topiramate, 
cocaine vaccines) have shown 
promising ﬁ rst results. Cognitive 
behavioural interventions, such 
as cognitive behavioural therapy, 
motivational interviewing, and a 
community reinforcement approach 
sometimes combined with contingency 
management (e.g. voucher-based 
incentives), have been shown to 
be most effective in reducing and 
preventing future cocaine use. 
However, as these approaches and 
the research about their effectiveness 
come almost exclusively from the 

6.  The way forward

At policy level, strategies for cocaine- 
or crack cocaine-only services should 
be developed where the extent of 
the problem merits a concerted and 
intensive response, for example in 
some European countries and cities. 
Outside such locations, drug policies 
should address the growing diversity 
in drug use patterns and needs of 
problem drug users.

The treatment of cocaine dependence 
relies mainly on psychosocial 
interventions, with pharmacological 
agents being used as a support by 
many clinicians. However, until now, 
no effective pharmacological agent 
has emerged to manage cocaine 
abstinence and reduce craving. 
Therefore, research and training in 
psychosocial interventions should be 
given highest priority. The exchange of 
experiences and best practice among 
clinicians should be encouraged. 
Research on pharmaceutical agents 
should also be supported and the 
results made rapidly available, both 
for positive as well as negative 
outcomes. Finally, cocaine users who 
are undergoing opioid substitution 
treatment should be assessed to make 
sure that their cocaine use is not linked 
with too low a dosage of methadone 
or buprenorphine. 

Interventions to reach socially 
integrated problem cocaine users 
and marginalised crack users also 
pose a challenge. A recent Irish pilot 
project revealed that cocaine users’ 
reluctance to attend opioid-oriented 
programmes could be circumvented 
by providing special access during 
evenings, or immediately before and 
after the weekend. For crack users 
and marginalised populations of 
drug users, harm reduction outreach 
interventions, combined with service 
referral, need to be given higher 
priority. 

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Drugs in focus is a series of policy brieﬁ ngs published by the European Monitoring Centre for Drugs and Drug Addiction 
(EMCDDA), Lisbon. The brieﬁ ngs are published three times a year in the 23 ofﬁ cial languages of the European Union plus 
Norwegian and Turkish. Original language: English. Any item may be reproduced provided the source is acknowledged. 

For free subscriptions, please specify your requirements via e-mail info@emcdda.europa.eu

Rua da Cruz de Santa Apolónia, 23-25, P-1149-045 Lisbon 
Tel. (351) 218 11 30 00 (cid:129) Fax (351) 218 13 17 11 
info@emcdda.europa.eu (cid:129) http://www.emcdda.europa.eu

Conclusions and policy considerations 

1.  Speciﬁ c strategies targeting cocaine or crack cocaine use should 
be developed in areas where the extent of the problem, such 
as in some European countries and cities, requires a concerted 
response. Elsewhere, drug policies should address the growing 
diversity in drug use patterns and needs of problem drug users.

2.  Prevention and harm reduction approaches related to cocaine 
use need to be developed, in particular information on risks 
(cardiovascular, psychiatric, elevated toxicity of some forms of 
polydrug use). Both occasional and regular cocaine users should 
be targeted. 

3.  Interventions to reach and help socially integrated problem 

cocaine users can be developed by adapting existing services or, 
in some cases, providing dedicated treatment services.

4.  Crack users, and other marginalised populations of drug users, 
should have access to harm reduction outreach interventions 
including service referral.

5.  In all treatment settings, training in psychosocial interventions 

should have high priority as this kind of intervention has shown 
the best results. Exchanging knowledge and best practice among 
clinicians and other drug workers should be encouraged.

6.  Research on psychosocial interventions and on new 

pharmaceutical agents to treat cocaine-dependent clients should 
be promoted. There is also an urgent need to better understand 
polydrug use involving cocaine, its multiple variants and 
consequences.   

Key sources

Decorte, T. (2000), The taming of cocaine: cocaine use in European and American cities, VUB University Press, Brussels.

EMCDDA (2007), Treatment of problem cocaine use — a review of the literature, European Monitoring Centre for Drugs and Drug 
Addiction, Lisbon.

EMCDDA (2007), Annual report 2007: selected issue on Cocaine, European Monitoring Centre for Drugs and Drug Addiction, 
Lisbon.

Horgan, J. (2007), An overview of cocaine use in Ireland, National Advisory Committee on Drugs and National Drugs Strategy 
Team, Dublin.

Kraus, L. et al. (2004), Epidemiologie, Prävention und Therapie von Kokainkonsum und Kokainbezogene Störungen: Eine 
Literaturübersicht, IFT-Berichte Bd.144, Munich.

Pascual, F., Torres, M. and Calafat, A. (2001), Monografía Cocaína, Adicciones vol. 13, suplemento 2, Plan Nacional Sobre 
Drogas, Madrid. 

Prinzleve, M. et al. (2004), ‘Cocaine use in Europe — A multi-centre study: patterns of use in different groups’, European Addiction 
Research, No 10, 2004, pp.147–155. 

Weaver, T. et al. (2007), National evaluation of crack cocaine treatment and outcome study (NECTOS): a multi-centre evaluation of 
dedicated crack treatment services, National Treatment Agency for Substance Misuse, NHS, London.

Web information

EMCDDA drug proﬁ les — cocaine and crack: 
http://www.emcdda.europa.eu/index.cfm?nnodeid=25482 

National Institute on Drug Abuse, Infofacts on cocaine: 
http://www.nida.nih.gov/Infofacts/cocaine.html

OFFICIAL PUBLISHER: Ofﬁ ce for Ofﬁ cial Publications of the European Communities
© European Monitoring Centre for Drugs and Drug Addiction, 2007
DIRECTOR: Wolfgang Götz
EDITOR: Peter Thomas
AUTHOR: Frank Zobel, Roland Simon
GRAPHIC CONCEPTION: Dutton Merriﬁ eld Ltd, United Kingdom
Printed in Belgium

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