The recent ONS drug-related deaths data revealed that fatalities involving cocaine rose by over 30 per cent last year (DDN, November, page 4), and currently stand at nearly ten times the rate of a decade ago. It’s crucial that a concerted effort is made by the government and public health services to tackle this worrying development.
The rise in cocaine-related deaths is a result of a combination of factors. There has been an increase in the purity of cocaine, which makes it potentially more toxic and more lethal. It has also become easier and cheaper to get hold of, and more people are using it – some in larger quantities, putting themselves at greater risk.
Increasing supply
According to the European Union Drugs Agency (EUDA) cocaine purity has been on an upward trend for a number of years, and in 2022 reached a level 45 per cent higher than in 2012. In the first half of 2022, 50 per cent of the samples tested by 18 drug checking services across eight EU countries exhibited a purity ranging from 80 per cent to 100 per cent. By the first half of 2023, this equivalent share was 55 per cent.
Global cocaine production has increased year-on-year since 2014. In 2022, more than 160 tons of cocaine were confiscated in Antwerp and Rotterdam alone, and much more got into Europe undetected, evidencing the increasing demand for the drug.
Across the sector we’re seeing an increase in the number of clients presenting with cocaine and polysubstance use, with people using cocaine alongside other drugs such as alcohol, cannabis and MDMA. As a stimulant it’s often combined with something that will bring people down at the end of the night such as benzodiazepines and/or alcohol. Sometimes a drug-related death is a combination of the cocaine and other substances.
In 2020, a government review of the UK’s £10bn drugs market found a sharp rise in illegal drug use, particularly among the middle classes. The UK has the second highest rate of cocaine use in the world, with studies suggesting it’s both fuelled by – and fuelling – the country’s drinking culture.
Societal attitudes
There seems to be a shift in attitudes towards cocaine consumption, with it being seen as more socially acceptable. We’re also seeing an increase in use among women and across different ages. Cocaine and alcohol in particular are both commonly used in social settings by people who use substances casually/recreationally, and people sometimes use the two together in order to prolong nights out and allow alcohol consumption for longer periods. This is not a phenomenon unique to the UK, of course. In Bern, high rates of cocaine use have led to discussions of a pilot scheme to allow its legal sale.
While using cocaine and alcohol together is often recreational, mixing the two increases the risks, with a new toxic substance formed in the body – cocaethylene. There are known associations with cardiotoxicity from cocaethylene, something that our sector and our clinicians need to be more aware of. There are also considerations around the possible habit-forming nature of always using both substances together – according to EUDA more than 50 per cent of people with cocaine use issues also struggle with alcohol dependence.
The age profile of people who die as a result of their cocaine use is younger than for opiate-related deaths, with the most common cause of death related to cardiovascular events linked to the heart and blood vessels – such as strokes, heart attacks, and cardiac arrhythmia. Cocaine use may unmask underlying conditions – cardiovascular issues are one of the leading causes of death in the British population, and cocaine use might make those deaths happen much earlier. The latest EUDA data revealed a time lag of 13 years between first cocaine use – on average at age 22 – and first treatment for cocaine-related problems, on average at age 35.
Intervention
The lack of any substitute prescribing for cocaine can make treatment feel less attractive, but Turning Point’s recently reviewed RECLAIM psychosocial intervention aims to meet people where they’re at – in the understanding that many people using cocaine will be ambivalent about behaviour change in the context of a drug which can be powerfully reinforcing, but with equally powerful ‘comedowns’.
The intervention offers two structured individual sessions based on discussing harm reduction in the context of motivational interviewing, and exploring the person’s values and goals. The person can then choose to join a four-session rolling group programme with other people using the same or similar substances to enhance social support, and explore future mutual aid options if helpful.
This four-session rolling group is facilitated by recovery workers and peer mentors, trained and supervised in use of the intervention. It aligns with NICE guidance in its use of cognitive behavioural therapy principles, motivational interviewing and in the understanding that most people who use cocaine will experience dysphoria. It also uses elements of acceptance and commitment therapy to continue focus on core values as a motivator for continued change.
For some people, use of RECLAIM and engagement with mutual aid – such as SMART Recovery – will be enough to begin to make the desired changes. For others, particularly those with co-occurring mental health difficulties, a longer period of treatment – including groups such as recovery skills and mindfulness-based relapse prevention – would be helpful in terms of sustaining changes in conjunction with work on increasing social support and behavioural activation.
Positive change
Contingency management is the reinforcement of positive behavioural change – such as attendance at appointments or negative urine tests – through a reward such as a voucher payment. Internationally, there’s strong evidence for the effectiveness of contingency management in the treatment of cocaine use. However, it’s very rarely used.
Where it is used, it’s mainly related to physical health interventions and mostly targeted at people using opiates. Barriers to use of contingency management include funding, the administrative burden, and sustainability. Politically, it’s not uncontroversial; however, the increased rates of cocaine use and cocaine related deaths suggest that this is an approach worthy of consideration by government and the sector.
There’s a lot we can offer for people using cocaine, including relevant, targeted information which is adapted for different age groups so the decisions people make are based on having the full facts. Cocaine isn’t typically associated with drug-related deaths in the popular imagination, and younger people are also less likely to be aware of their mortality.
Reducing harms
We need to support people to start considering their options with regards to how they can use less cocaine, or use it more safely. Experts have called for a public health campaign to alert people to the risks of the drug, but there is evidence to suggest that ‘scare tactics’ simply don’t work in changing behaviour.
In one area where Turning Point currently operates, the local police proposed a campaign that linked cocaine use to significant criminal activity, such as domestic abuse, child trafficking or gangs. We supported the police to realign this messaging to focus on reducing harms and increasing understanding of possible health impacts. As providers, it’s important that we work with our system partners on the evidence base for behaviour change.
Public health campaigns must start from a point of compassion. We’ve learnt from work we have done around promoting naloxone and safer injecting equipment that the most effective approaches are developed in conjunction with people who use drugs.
The 30 per cent increase in cocaine deaths is alarming in itself, but a further consideration for the sector is the change in the opiate market and the possibility that this could also happen within the cocaine supply. This would expedite the rising deaths, and further highlight the need for the sector to respond.
Natalie Travis is national head of service at Turning Point
I NEEDED COKE TO FUNCTION
Danny sniffed his first line of cocaine at 13 – the start of a problematic relationship with it, until he sought help.
Danny has been abstinent from drugs for 11 months. He has just completed the peer mentor programme at Turning Point, and volunteers at The Hepatitis C Trust and at his local church. The 45-year-old said the last year has been ‘the best time of my life’.
It’s been a remarkable turnaround for Danny who spent 27 years using and selling cocaine. ‘I sniffed my first line of cocaine at 13 and I smoked my first pipe of crack at 17,’ he says. ‘I tried heroin a few times in prison, but I got nothing off it, so I weren’t chasing it. I was addicted to Valium. My whole life’s just been drugs. I didn’t have a clean day from the age of nine up until I was 44 – every day I done something.’
Danny explained that his drug use was a way to deal with the trauma of being sexually abused as a child. ‘I found drugs, and that just covered all my problems,’ he says. Describing himself as a ‘functioning crackhead’, Danny gives an interesting insight into an issue that’s faced by many cocaine users who often believe they’re not dependent on the drug. He’s worked all his life, first as a plasterer and then as a forklift driver. ‘It sounds stupid, but I thought I didn’t have a problem because I could get up and go to work after a couple of hours sleep and sniff cocaine all day at work and then get home and smoke crack all night – I thought I could do that for the rest of my life.’
Danny reveals that the birth of his grandson, who his daughter named after him, and then
her telling him that she felt he wouldn’t make it past 2023 was one of the reasons he sought help. ‘I couldn’t stop for my kids, which is very selfish, but I weren’t ready. It sounds horrible but you can’t stop for anyone but yourself. People can try and get you to stop, and you won’t stop.’
Danny reached out for help at Turning Point services in Suffolk where he spent a year receiving support to come off cocaine. ‘I’ve come out just a hundred times better than I ever have been throughout my whole life,’ he says. ‘I’ve never been this positive. I’ve got my family back. And I’m just looking forward to helping as many people as I can at Turning Point.’
JUST A REGULAR NIGHT OUT
Coke’s become as socially acceptable as alcohol in my respectable community, says Joanna.
When I was at uni I used to find coke very seedy and wouldn’t touch it. Plenty of others did it, off mirrors, but I didn’t join in. I couldn’t do it.
A few years later I was in a pub in London and one of my friends offered me some. I was pissed at the time and I can’t really remember how it felt. But I did it again and it started to become very moorish, especially when drinking. In fact I only ever did it when I was drinking, and it still goes hand in hand with drinking for me. I think if I started doing it when I’m not drinking it’d be time to have a word with myself.
I tend to set parameters with my husband and friends before we start, including a cut-off time for bed so we don’t stay up all night. I used to feel bad staying up late and found it hard to function the next day through lack of sleep. Despite our best intentions it doesn’t always happen and we can stay up too late – but sleep has become more important as we’ve got older. The thing is, I feel worse after a night of just alcohol, and the coke stops you getting so drunk.
I don’t do very much coke compared to other friends and can make it last all night. If someone offers me more, I take what I need and give the rest back. It gives me a feeling of wellbeing and confidence. Other people might say it makes me chat shit! But it makes me feel good.
Everyone’s on it. I know so many people that do it and it’s become very normalised – ‘oh yeah, it’s just coke’. It’s become much more socially acceptable. And it’s very easy to get hold of – it usually turns up in less than ten minutes.