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No reason for pessimism over treating cocaine use problems

Much of this hot topic is devoted to challenging beliefs that cocaine and especially its smokable form crack are uniquely addictive and their adherents, uniquely hard to treat. That belief no doubt has multiple roots which stretch back to lurid concerns that the drug would undermine the World War I war effort. However, Britain’s modern-day resurgence of concern over cocaine can be traced back to April 1989, when US Drug Enforcement Administration (DEA) investigator Robert Stutman addressed Britain’s chief police officers.

‘Three hits and you’re addicted’

Credited with bringing crack to national attention in the USA and “single-handedly changing the policy of the United States DEA”, this powerful speaker set about waking up the UK to the imminent threat. His story of epidemic crack-related violence in New York ignited rumbling worries that cocaine and crack could turn downtown Toxteth, Handsworth and Deptford into US-style drug ghettos. Most startling was his revelation that “A study that will be released in the next two to three weeks will probably say that of all of those people who tried crack three or more times, 75 per cent will become physically addicted at the end of the third time ... We now know that crack is the single most addicting drug available in the United States of America today and certainly the most addicting drug available in Europe. Heroin is not even in the same ballpark.” On this much else hinged: a drug this addictive causes users to commit violent crimes to get it and promises massive profits to the dealers, disrupting whole communities. The next month Stutman’s statement appeared as a headline in the Sun (25 May 1989): “Three Hits Can Get You Hooked” was their version of these “terrifying statistics”. Before that, the as yet unseen study cited by Stutman had become a “survey” which “showed” these disturbing facts (Times, 19 May 1989). Later the “survey” was attributed to an impeccable source – the Home Office itself (Grimsby Evening Telegraph, 2 August 1989).

Senior British police officers “attempted to trace the studies and figures quoted by Stutman and found they don’t exist” (Independent, 27 July 1989). Still, the House of Commons Home Affairs Committee released an emergency interim report on crack with these same discredited ‘facts’ highlighted in bold. The following year a BBC Radio File on Four investigation (10 April 1990) nailed down the credentials of Stutman’s address. It was, they concluded, “littered with misinformation”. The claim that 73% of child-battering deaths in New York in 1988 were perpetrated by crack-using parents was based on just two such deaths, one of which also involved chronic alcoholism, and Stutman was still unable to produce the ‘three hits and you’re addicted’ study.

Slow burn spread not volcanic epidemic

It was not that crack never became a problem in the UK – it did, and in certain localities a big one, but Britain’s crack and cocaine problems never rivalled the US experience, partly because the supposed hooking power of the drug, if it emerged at all, emerged from a constellation of circumstances, not deterministically from merely trying it a few times. Instead of a volcanically destructive epidemic, crack and cocaine crept up to become an established featured of the UK treatment caseload. Instead of being hard to stop using, cocaine and crack turned out to be hard to continue to use at excessive levels; heroin, rather than being out of the ball park, seems in the UK context a drug much harder to leave behind.

Patients starting treatment for drug problems, UK, 2003/04 to 2013; shows that the number of cocaine treatment starters has fallen from about 20,200 in 2008/09 to about 13,100 in 2013 and now accounts for about 1 in 8 of treatment starts

As the primary drug in relation to which an adult patient started treatment (either for the first time or returning after treatment in previous years), across the UK since 2010 cocaine powder or crack have accounted for about 1 in 8 of treatment starters, down from a peak of about 1 in 7 in 2008/09. Falling overall treatment starts mean that the numbers of cocaine treatment starters has also been falling steeply, down from about 20,200 in 2008/09 to about 13,100 in 2013, a drop of over a third chart. However, as a secondary drug used by patients primarily addicted to heroin, crack in particular is much more common, in 2013 being noted for 38% of patients starting treatment.

For England, these figures for treatment starters can be supplemented by figures for all patients in treatment for drug problems at some time during a year, whether treatment starters or continuing in treatment from the previous year. Of all 193,198 patients during 2013/14, cocaine powder was the primary problem for 5% and crack for 2%, though in association with opiates like heroin, crack was used by 32% of patients.

At 3%, 2008/09 was also the peak in the proportion of the 16–59-year-olds in England and Wales who when surveyed said they had used cocaine powder in the past year. That figure fell to 1.9% in 2012/13 before rising slightly to 2.4% in 2013/14.

Most patients stop using

For heroin there are effective pharmacological treatments like methadone to more safely and legally meet the patient’s need for opiate-type drugs, and naltrexone to block the effects of opiates and promote abstinence. For cocaine, decades of searching have failed to find a recognised drug-based treatment, and no specific psychosocial therapy has been constructed which can fill the therapeutic gap. Instead services have turned to less conventional methods such as acupuncture, yet studies show that too fails to help.

England treatment starters sampled in 2006 and 2007: % of baseline users of that drug not using at follow-up. Of the heroin users who could be followed up (many patients were not), three to five months after starting treatment 44% had stopped using, and about a year after starting treatment, 49%. Corresponding figures for stopping crack use were higher at 53% and 61% respectively, and for cocaine powder, 75% and 68%

Serial disappointment in research terms might lead some to conclude that in practice too, when it comes to cocaine and crack, ‘nothing works’. But unlike many drug trials with their placebo controls, research on psychosocial treatments is usually about what works better than an established or alternative therapy, not what works at all. The findings can be interpreted to mean that just about any bona fide counselling or therapeutic approach helps some people some of the time, often many much of the time, and usually to roughly the same degree. It doesn’t have to be very sophisticated, though severe cases may need continuing support and residential care (1 2). In the latest English national drug treatment study, primary users of crack and cocaine powder were more likely to stop using than were primary heroin users. Of the heroin users who could be followed up (many patients were not), three to five months after starting treatment 44% had stopped using, and about a year after starting treatment, 49%. Corresponding figures for stopping crack use were higher at 53% and 61% respectively, and for cocaine powder, 75% and 68% chart.

Routinely collected statistics tell a similar story. In England in 2013/14, reviews of patients about six months after starting treatment showed that two-thirds whose primary drug problem was cocaine powder and 60% for whom it was crack had become abstinent, the two highest figures given for that year, and a contrast to the 48% for opiate users not also using crack. When cocaine treatment numbers peaked in England in 2008/09, a special analysis showed that reductions in cocaine use had not been at the expense of increased use of other drugs. In Wales and Scotland too, treatment reviews tell a story of abstinence as most common known outcome for cocaine-dependent patients. In Wales in 2013/14, 71% of cocaine users were no longer using at their treatment exit reviews, while in Scotland, reviews three months after treatment entry recorded that 80% of powder cocaine users and all the (small number of) crack users were no longer using these drugs.

Review statistics are dependent on patients being available for review, the review being conducted, recorded and notified to the relevant database system, and the patient and their keyworker accurately and honestly documenting the patient’s drug use. Many patients are lost track of along the way, a major limitation not applicable to the same degree to records of treatment exit and re-entry. In England we know that by the end of 2013/14, 44% of primarily crack-dependent patients (re)starting treatment since 2005/06, and 55% whose prime problem was cocaine powder, had been recorded as completing their treatments free of dependence and not returned, much higher than the 27% for opiates. Add in what was probably a substantial number of patients who left treatment prematurely but nevertheless overcame their dependence, and a clear majority once dependent on cocaine can be presumed to no longer be dependent and no longer in need of continued treatment to sustain their recovery.

Proportion of dependent users in the US population in remission after 1 or 10  years and predicted over lifetime: shows that remission rates are higher for formerly dependent cocaine users than for those formerly dependent on alcohol, tobacco or cannabis

For the USA we can broaden the picture beyond treatment to the general population of cocaine users. Among the general US population, within a year of first becoming dependent nearly 9% of cocaine/crack users were in remission and within ten years, 76%, both substantially higher remission rates than for drinking, smoking or using cannabis chart. That black Americans were half as likely to be in remission from cocaine/crack dependence as their white counterparts suggests that the resources available to the individual to make and sustain their break from cocaine are a critical factor. For users of cocaine powder, in the UK these are on average relatively high. They are less likely to have had their resources eroded by conviction and imprisonment and more likely to be in paid employment or education. Alongside the US figures, it can be inferred that the relatively good prognosis of the average cocaine user is partly due to their having a better stock of ‘recovery capital’ resources to haul themselves out of dependence.

In redressing the balance tipped so graphically the other way by Robert Stutman and others, this hot topic entry does not mean to imply that controlling cocaine/crack use is easy or that addiction to these drugs is a trivial issue; for many, cocaine use has been central to a damaged and damaging pattern of behaviour. The argument here is that cocaine dependence is not uniquely destructive of the resources needed to recover from dependence, and that even among treatment populations, most do so relatively quickly compared to the general treatment caseload largely dependent on opiate-type drugs.

Last revised 27 April 2015. First uploaded 01 March 2010

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