Chapter 5
Cocaine and crack cocaine

Cocaine supply and availability (133)

Production and trafficking

Cocaine is the most trafficked drug in the world after herbal cannabis and cannabis resin. In terms of volume seized – 578 tonnes worldwide in 2004 – trafficking continued to be predominantly in South America (44 %) and North America (34 %), followed by Western and Central Europe (15 %) (CND, 2006).

Colombia is by far the largest source of illicit coca in the world, followed by Peru and Bolivia. Global production of cocaine in 2004 is estimated to have increased to 687 tonnes, of which Colombia contributed 56 %, Peru 28 % and Bolivia 16 % (UNODC, 2005). Most of the cocaine seized in Europe comes directly from South America (mainly Colombia) or via Central America and the Caribbean. In 2004, Suriname, Brazil, Argentina, Venezuela, Ecuador, Curaçao, Jamaica, Mexico, Guyana and Panama were reported as transit countries for cocaine imported into the EU (Reitox national reports, 2005; WCO, 2005; CND, 2006; INCB, 2006a; Europol, 2006). Some also passed through Africa, increasingly through Western Africa and countries in the Gulf of Guinea (mainly Nigeria), but also East Africa (Kenya) and North-west Africa through the islands off the coast of Mauritania and Senegal (CND, 2006; INCB, 2006a). The main points of entry in the EU remain Spain, the Netherlands and Portugal, as well as Belgium, France and the United Kingdom (Reitox national reports, 2005; CND, 2006; Europol, 2006). Although Spain and the Netherlands still play an important role as distribution points for the cocaine entering the EU, the intensified controls along the Spanish north coast (Galicia) and the 100 % controls policy on flights from specific countries (134) at Schipol Airport (Amsterdam) may have played a part in the development of alternative routes, increasingly, for example, via Africa, but also via Eastern and Central Europe and secondary distribution from there to Western Europe (Reitox national reports, 2005; WCO, 2005; INCB, 2006a).

Seizures

In 2004, an estimated 60 000 seizures of 74 tonnes of cocaine were made in the EU. Most seizures of cocaine are reported in Western European countries, especially Spain, which accounts for about half the seizures and amounts recovered in the EU in the last 5 years (135). Over the period 1999–2004, the number of cocaine seizures (136) increased overall at EU level, while quantities (137) seized fluctuated within an upward trend. However, based on reporting countries, quantities appear to have declined in 2004 – perhaps in comparison with the exceptional amount recovered in Spain the year before.

Price and purity

In 2004, the average retail price of cocaine varied widely across the EU, from 41 euros per gram in Belgium to over 100 euros per gram in Cyprus, Romania and Norway (138). The average prices of cocaine, corrected for inflation (139), showed an overall downward trend over the period 1999–2004 in all reporting countries (140) except Luxembourg, where it declined until 2002 and then increased, and Norway, where prices rose sharply in 2001 and then stabilised.

Compared with heroin, the average purity of cocaine at user level is high, varying in 2004 from 24 % in Denmark to 80 % in Poland, with most countries reporting purities of 40–65 % (141). Data available for 1999–2004 indicate an overall decrease in the average purity of cocaine in most reporting countries (142), although it increased in Estonia (since 2003), France and Lithuania, and remained stable in Luxembourg and Austria.

International action against cocaine production and trafficking

Project COLA, run by Europol, aims at identifying and targeting Latin American and associated criminal groups operating towards and within the EU and engaged primarily in the trafficking of cocaine. In particular, it provides operational support to live investigations in participating Member States and enhances the strategic intelligence picture. It is complemented by the Europol Cocaine Logo System, which collates, in an annually updated catalogue, modus operandi and photographic and other information on cocaine seizures and on logos/markings on the drugs and their packaging, in order to identify matches between seizures and promote international law enforcement cooperation and information exchange (Europol, 2006).

Operation Purple, running since 1999, is designed to prevent the diversion of potassium permanganate (143) from licit trade for use in the illicit manufacture of cocaine, in particular in the Americas. The licit trade in potassium permanganate is large: since 1999, 30 exporting countries/territories have provided 4 380 pre-export notifications to the INCB involving over 136 560 tonnes of potassium permanganate. Since 1999, 233 shipments involving over 14 316 tonnes of the substance have been stopped or seized because of concerns over the legitimacy of the orders or the end-users, and diversions were identified. In 2004, 1.4 tonnes of potassium permanganate was seized in Europe, mainly in the Russian Federation, followed by Romania and the Ukraine (144) (INCB, 2006b).

Traffickers appear to have found ways to avoid controls and monitoring mechanisms introduced under Operation Purple. Indeed, although the illicit manufacture of cocaine is not associated with Asia, there is growing concern that traffickers may be targeting the region for diverting potassium permanganate from licit trade. There is also concern that traffickers may be diverting potassium permanganate to the Andean sub-region through the Caribbean Islands. Thus, while acknowledging some success in identifying suspicious transactions and in stopping shipments, the INCB (2006b) has urged governments to develop operating procedures to backtrack information from cocaine laboratory seizures in order to trace the chemicals back to the source, identify transit countries and investigate trade companies, so that traffickers may experience more difficulties in relocating their activities.

Prevalence and patterns of cocaine use

Based on recent national population surveys, it is estimated that about 10 million Europeans (145) have tried cocaine at least once (lifetime prevalence), representing over 3 % of all adults (146). National figures on reported use range between 0.5 % and 6 %, with Italy (4.6 %), Spain (5.9 %) and the United Kingdom (6.1 %) at the upper end of this range. It is estimated that about 3.5 million adults have used cocaine in the last year, representing 1 % of all adults. National figures in most countries range between 0.3 % and 1 %, although prevalence levels are higher in Spain (2.7 %) and the United Kingdom (2 %).

As with other illegal drugs, cocaine use is concentrated among young adults. Lifetime experience is highest among young adults aged 15–34 years, although last year use is slightly higher among 15- to 24-year-olds. Cocaine seems be predominantly a drug used by those in their 20s, but, compared with cannabis use, cocaine use is less concentrated among younger people. Lifetime experience among 15- to 34-year-olds ranges from 1 % to 10 %, with the highest levels again found in Spain (8.9 %) and the United Kingdom (10.5 %). Last year use ranges between 0.2 % and 4.8 %, with the figures for Denmark, Ireland, Italy and the Netherlands being around 2 %, and for Spain and the United Kingdom over 4 % (Figure 6). Data from school surveys show very low lifetime prevalence for the use of cocaine, ranging from 0 % in Cyprus, Finland and Sweden to 6 % in Spain, with even lower lifetime prevalence rates for use of crack cocaine, ranging from 0 % to 3 % (Hibell et al., 2004).


Figure 6 Last year prevalence of cocaine use among all adults (aged 15–64) and young adults (aged 15–34 and 15–24)

NB:

Data are from the most recent national surveys available in each country at the time of reporting. See Tables GPS-8, GPS-11 and GPS-18 in the 2006 statistical bulletin for further information.

Sources:

Reitox national reports (2005), taken from population surveys, reports or scientific articles.

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Cocaine consumption is higher among young males. For instance, among males aged 15–34 years, surveys from Denmark, Germany, Spain, Italy, the Netherlands, the United Kingdom and Norway found that lifetime experience was between 5 % and 14 %. Last year use was lower, but four countries reported figures higher than 3 %, with Spain and the United Kingdom reporting figures of about 6–7 % (147), suggesting that in these countries about 1 in 15 young males has used cocaine recently. This proportion will be substantially higher in urban areas.

Among the general population, cocaine use seems to be occasional, occurring mainly at weekends and in recreational settings (bars and discos), where it can reach high levels. Research studies conducted among young people in dance and music settings in different countries reveals prevalence estimates for cocaine use that are much higher than those found in general populations, with lifetime prevalence ranging from 10 % to 75 % (see the selected issue on drug use in recreational settings). For instance, the British Crime Survey 2004/05 reported a prevalence estimate for the use of ‘class A’ drugs among people going to discos or nightclubs that was at least two times higher than the rate among those who did not go to these venues (Chivite-Matthews et al., 2005) (see also the selected issue on drug use in recreational settings). On average, about one-third of all European adults who have ever used cocaine have used it in the previous 12 months; for comparison, only 13 % report having used it in the previous 30 days. For instance, 2–4 % of males aged 15–24 years in Spain, Italy, the United Kingdom and Bulgaria (148) report having used cocaine in the previous 30 days. A rough estimate of current cocaine use in Europe would be about 1.5 million adults aged 15–64 years (80 % in the age range 15–34 years). This can be considered as a minimum estimate, given probable under-reporting.

Patterns of cocaine use are very different in different groups of users. In a European multi-city study, it was found that socially integrated cocaine users mainly snorted (95 %) the substance, while only a small fraction had smoked or injected it, but combined use of cannabis and alcohol was very common (Prinzleve et al., 2004). Among users in addiction treatment settings or in socially marginalised groups, injection was frequent, and crack use was usual in Hamburg, London and Paris, and to a lesser extent in Barcelona and Dublin. Crack use among the European general population seems to be low. For instance, lifetime prevalence of crack use was reported to be 0.5 % in Spain (2003) and 0.8 % in the United Kingdom (Chivite-Matthews et al., 2005). In three countries, lifetime prevalence of crack use was surveyed in club settings and found to be even lower than heroin use (Czech Republic 2 %, the United Kingdom 13 % and France 21 %). However, use of crack among marginalised groups or opioid users is a cause for concern in some cities. For example, among a targeted group of 94 female street prostitutes in Amsterdam, the prevalence estimate for lifetime use of crack cocaine was extremely high at 91 % (Korf, 2005, cited in the Dutch national report).

For comparison, according to the 2004 United States national survey on drug use and health, 14.2 % of adults (defined as 12 years or older) reported lifetime experience with cocaine, which contrasts with a European average of 3 %. Last year use was 2.4 %, compared with a European average of 1 %, although in some EU countries, e.g. Spain (2.7 %) and the United Kingdom (2 %), reported figures are in the same range as in the United States (149). The comparatively higher lifetime figures in the United States may be in part related to earlier spread of cocaine use in that country.

Among young adults (aged 16–34), US figures were 14.6 % (lifetime), 5.1 % (last year) and 1.7 % (last month), whereas the EU average figures for 15- to 34-year-olds were, respectively, about 5 % (lifetime), 2 % (last year) and 1 % (last month).

Trends in cocaine use


Figure 7 Trends in last year prevalence of cocaine use among young adults (aged 15–34)

Figure 7

NB:

(1) In Denmark, the value for 1994 corresponds to ‘hard drugs’.

Data are taken from the most recent national surveys available in each country at the time of reporting. See Table GPS-4 in the 2006 statistical bulletin for further information.

Sources:

Reitox national reports (2005), taken from population surveys, reports or scientific articles.

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For several years, there have been warnings about the possibility of increasing cocaine use in Europe, based on data from diverse sources (e.g. market indicators, treatment demands, deaths). Although the available information on cocaine trends among the population is improving as more countries carry out repeated surveys, the data are still limited. In the case of cocaine, added difficulties are the lower prevalence levels and the probable under-reporting of use.

Recent cocaine use (last year) increased markedly in the second half of the 1990s among young adults in the United Kingdom, until 2000, and in Spain, until 2001, with an apparent stabilisation in recent years. In Germany, a moderate increase was observed over the 1990s, but the figures have remained stable in recent years, at levels clearly lower than in Spain and the United Kingdom (Figure 7).

Moderate increases in last year use have been observed in Denmark (up to 2000), Italy, Hungary, the Netherlands (up to 2001) and Norway. This trend needs to be interpreted carefully as it is based on only two surveys in each country.

In the case of cocaine and other substances (e.g. ecstasy, amphetamines, hallucinogenic mushrooms), trends could be better identified by focusing the analysis on groups in which drug use is concentrated, in particular young people living in urban areas. These populations are explored in more depth in the selected issue on drug use in recreational settings. In addition, survey information should be complemented by focused studies among young people in selected groups (nightlife settings).

Treatment demand data (150)

After opioids and cannabis, cocaine is the drug most commonly reported as the reason for entering treatment and accounts for about 8% of all treatment demands across the EU in 2004 (151). It should be noted that Spain, a country usually reporting high treatment demands for cocaine has not yet provided data. This overall figure reflects a wide variation between countries: in most countries treatment demands related to cocaine use are quite low, but in the Netherlands (37%) and historically Spain (26% in 2002) the proportion of all clients who ask for treatment for cocaine use is far higher. In the most recent data available, a group of countries report percentages of cocaine clients among all treatment clients between 5 % and 10 % (Denmark, Germany, France, Ireland, Italy, Cyprus, Malta, the United Kingdom and Turkey), whereas in the remaining countries the proportions are very low (152). In several countries, compared to all clients, there are higher percentages of new clients demanding treatment for primary cocaine use (153) and overall around 12 % of all new treatment demands are reported as cocaine related. Cocaine is also reported as a secondary drug by around 12 % of new clients (154).

The increasing trends among clients seeking treatment for cocaine use reported in previous years is continuing; from 1999 to 2004, an analysis that interpolates for unreported data suggests that the proportion of new clients demanding treatment for cocaine use grew from around 10 % to 20 % during this period (based on 17 EU countries and Bulgaria and Romania) (155).

Overall, most cocaine treatment demands in Europe are not related to crack cocaine: around 80 % of new outpatient cocaine clients are reported to be using cocaine hydrochloride (cocaine powder), with less than 20 % using crack cocaine. However, crack cocaine users may pose particular challenges for treatment services as they tend to have a more marginalised social profile than users of cocaine powder. A European study on cocaine use (powder and crack cocaine) found an association between crack use social and mental health problems; however, the study also reported that crack cocaine use itself is not sufficient to explain the social or mental health problems (Haasen et al., 2005). A recent study of 585 cocaine and crack clients in Scotland found that the crack users are more likely to have a longer history of problematic drug use and more involvement in criminal activities (Neale and Robertson, 2004, cited in the United Kingdom national report).

Looking at the profile of cocaine clients in outpatient settings, it appears that new clients using cocaine as their primary drug are usually older than other drug consumers: 70 % are in the 20–34 years age group with a smaller group (13 %) aged between 35 and 39 years (156).

Cocaine is often used in combination with another illicit or licit subsidiary drug, often cannabis (31.6 %), opioids (28.6 %) or alcohol (17.4 %) (157). Local studies of drug injectors suggest that, in some areas, the combination of heroin and cocaine within an injection may be becoming more popular (sometimes referred to by drug injectors as ‘speedballing’). The combination of opioids and cocaine is currently more apparent in the treatment data. Among clients reporting primary use of opioids, 31 % in Italy, 42 % in the Netherlands and 44 % in United Kingdom report a secondary cocaine use. Among primary cocaine users, 28 % in Italy and 38 % in United Kingdom report secondary use of opioids.

Treatment of cocaine dependence

There is not enough evidence to support pharmacological treatment for cocaine or other psychostimulant dependence. However, in their comprehensive review of the use of pharmacotherapies for psychostimulant users, Shearer and Gowing (2004) conclude that substitution therapy, which is successful in the case of opioid and nicotine dependence and has the potential for attracting and retaining users in treatment, has not yet been adequately tested in stimulant users. A literature review on the responses to and effectiveness of cocaine treatment, including responses to mental health disorders among crack cocaine users, has been published recently by the EMCDDA (158).

In some countries, including the United States and the United Kingdom, there is currently substantial investment in building up immunotherapy treatment options by developing antibodies that can intercept cocaine in the bloodstream before it reaches the central nervous system (see box on immunotherapy for cocaine addicts).


Box 13: Immunotherapy for cocaine addicts

In contrast to heroin addiction, which can be treated with agonists such as methadone or antagonists such as naltrexone, there are currently no medical treatments available for cocaine addiction. The reason for this would appear to be the mechanism of action through which cocaine exerts its effects on the brain neurotransmitters dopamine and serotonin. Whereas heroin binds to brain opioid receptors, such as the mu receptors, and therefore mimics the action of the brain’s own endorphins, cocaine inhibits the reabsorption of dopamine (and indeed serotonin) from the neuronal synapse once it has had its effect, leading to a build-up of the transmitter, thus prolonging and strengthening its effect.

This does not necessarily mean that it is not possible to develop a medical treatment for cocaine addiction, only that it may be more difficult to do so and may involve different concepts from those used in the development of treatments for heroin dependence.

One exciting strand of research is the use of immunotherapy, i.e. the development of a vaccine that would effectively ‘neutralise’ the action of cocaine by preventing the drug from reaching the brain. The basic concept has undergone limited testing. A vaccine developed in the United Kingdom was tested in a small number of cocaine addicts, 18 in total, over a period of 14 weeks. It was found that three-quarters of the vaccinated cohort of cocaine addicts were able to remain drug free for a period of 3 months with no untoward side-effects. In addition, after 6 months, both those who relapsed and those who did not stated that the feelings of euphoria were not as potent as prior to vaccination. As a result of these findings, the vaccine, known as drug–protein conjugate TA-CD, is undergoing phase 2 clinical trials. An alternative immunotherapeutic approach involves the development of monoclonal antibodies to cocaine, but this has only been tested preclinically.

The potential benefit of the cocaine vaccine TA-CD has raised ethical concerns about the use of vaccine: who would receive it, who would make the decision and on what criteria, etc.


Combining several specific psychosocial treatment interventions is currently considered the most promising treatment option for cocaine and other psychostimulant users. The combination of the community reinforcement approach (CRA) with contingency management has been shown to reduce cocaine use in the short term (Higgins et al., 2003; Roozen et al., 2004).

CRA is an intensive treatment method that involves family, friends and other members of the client’s social network throughout the treatment and consists in training the clients to make social contacts, to improve their self-image, and to find work and rewarding leisure activities in order to establish a different lifestyle (Roozen et al., 2004). In combination with contingency management – a method that aims to influence clients’ behaviour by offering meaningful incentives, e.g. presents, vouchers or privileges for cocaine-free urine samples – positive effects on drug use and psychosocial functioning have been achieved during the treatment phase and post-treatment follow-up in cocaine-dependent outpatients, although effects on cocaine use appeared to be limited to the treatment period (Higgins et al., 2003).

New approaches to the highly problematic groups of cocaine- and crack-using heroin users focus on harm reduction as primary treatment goal and apply behavioural therapies, in particular contingency management approaches, in combination with methadone maintenance programmes or heroin-assisted treatment (Schottenfeld et al., 2005; van den Brink, 2005; Poling et al., 2006).

Harm reduction approaches

In Europe, the development of harm reduction approaches that target cocaine use has been limited. This might now be beginning to change as increased awareness of both the extent of cocaine use and the problems associated with it stimulates interest in developing responses to address the needs of cocaine users. The value of prevention and harm reduction approaches to reducing the risks associated with cocaine use remains largely unexplored, but a number of areas may have potential for the development of this kind of approach. For example, it is possible that cocaine users may benefit from interventions that address issues such as the increased toxicity of cocaine and alcohol combinations, the potential association of cocaine use with cardiovascular problems or behavioural links that may put the users at increased risk of HIV infection or becoming the victim of an accident or violent crime. As cocaine use can escalate quickly, brief interventions that can alert users to the fact that they may be beginning to experience negative consequences due to their use of the drug may also be worth exploring.

As a result of the serious health and social problems associated with crack cocaine use, there is more experience of developing services for this group, although activities are limited to those relatively few cities in Europe that have experienced a significant crack cocaine problem. In a number of cities crack cocaine users have been targeted by outreach schemes that attempt to engage with what is often viewed as a difficult group to work with. Although overall the evidence base remains relatively weak, some studies have suggested that benefits can accrue. For example, one study of an innovative outreach treatment programme in Rotterdam (Henskens, 2004, cited in the Dutch national report) identified factors that were observed to be important for treating this group of clients, who are often difficult to engage in conventional drug services.

Compulsive patterns of crack and cocaine use may be associated with an increase in sexual health risk-taking, and some low-threshold programmes specifically target crack-using sex workers to transmit safer sex and drug use messages and to distribute condoms and lubricants (see selected issue on gender).

A more controversial approach has been adopted in some cities in Europe, where the concept of safe consumption rooms, usually targeting drug injection, has been extended to drug inhalation. Rooms for supervised inhalation have been opened in several Dutch, German and Swiss cities (EMCDDA, 2004c). Although the supervision of consumption hygiene is a main objective of such services, there is some evidence that they could also act as a conduit to other care options; for example, monitoring of one service in Frankfurt, Germany, reported that, during a 6-month evaluation period in 2004, more than 1 400 consumptions were supervised, while 332 contact talks, 40 counselling sessions and 99 referrals to other drugs services were documented.


(133) See 'Interpreting seizures and other market data'.

(134) All flights from the Netherlands Antilles, Aruba, Suriname, Peru, Venezuela and Ecuador are 100 % controlled; in 2004, 3 466 drug couriers were arrested as a result of such controls and 620 as a result of regular controls (Dutch national report).

(135) This should be checked against missing 2004 data when available. Data on both number of cocaine seizures and quantities of cocaine seized in 2004 were not available for Ireland and the United Kingdom; data on number of cocaine seizures were not available for the Netherlands in 2004. For estimating purposes, 2004 missing data were replaced by 2003 data. Data on quantities seized in 2004 provided by the Netherlands were only estimates, which could not be included in the analysis of trends to 2004.

(136) See Table SZR-9 in the 2006 statistical bulletin.

(137) See Table SZR-10 in the 2006 statistical bulletin.

(138) See Table PPP-3 in the 2006 statistical bulletin.

(139) Taking 1999 as the base year for the value of money in all countries.

(140) Over the period 1999–2004, data on cocaine prices were available for at least three consecutive years in Belgium, Czech Republic, Germany, Spain, France, Ireland, Cyprus, Latvia, Lithuania, Luxembourg, Poland, Portugal, Slovenia, Sweden, the United Kingdom, Bulgaria, Turkey and Norway.

(141) See Table PPP-7 in the 2006 statistical bulletin.

(142) Over the period 1999–2004, data on cocaine purity were available for at least three consecutive years in Belgium, Czech Republic, Denmark, Germany, Estonia, Spain, France, Ireland, Italy, Latvia, Lithuania, Luxembourg, Hungary, Netherlands, Austria, Portugal, Slovakia, United Kingdom and Norway.

(143) Precursor used in the manufacture of cocaine and scheduled under Table I of the 1988 Convention.

(144) These data do not include quantities involved in stopped shipments.

(145) Based on a weighted average of national figures; more details in footnote (53).

(146) For detailed figures for each country, see the table in 'General population surveys of drug use' in the 2006 statistical bulletin.

(147) See Figure GPS-9 in the 2006 statistical bulletin.

(148) 2001 survey. In the 2003 survey, gender breakdown was not reported by10-year age groups.

(149)  Source: SAMHSA, Office of Applied Studies, 2004 National Survey on Drug Use and Health (http://oas.samhsa.gov/nsduh.htm#nsduhinfo). Note that the age range for ‘all adults’ in the US survey (12 years and over) is wider than the age standard range for European surveys (15–64). The figures for the 16–34 years group in the United States have been recomputed by the EMCDDA.

(150) See footnote (70).

(151) See Figure TDI-2 in the 2006 statistical bulletin.

(152) See Table TDI-5 in the 2006 statistical bulletin; for Spain data refer to the 2002 reporting year.

(153) See Table TDI-4 in the 2006 statistical bulletin.

(154) See Table TDI-23 in the 2006 statistical bulletin.

(155) See Figure TDI-1 in the 2006 statistical bulletin.

(156) See Table TDI-10 in the 2006 statistical bulletin.

(157) See Table TDI-24 in the 2006 statistical bulletin.

(158http://www.emcdda.europa.eu/?nnodeid=400