Europe, Harm Reduction and the cocaine challenge
Dr. Bertrand Lebeau
Chairman of the Association Francaise de Réduction des Risques (AFR) infos@a

The increasing use of narcotics in Europe is raising new public health issues in which harm reduction is directly involved.
The extremely wide range of cocaine-using audiences mean that programmes focusing on heroin addicts need to be thought back through.
This is a difficult issue to handle. But the battle might turn out to be a crucial one.

Cocaine started to be used in Europe at roughly the same time as the American cocaine craze began to decline.

No other product of abuse illustrates the famous slogan "drug, set and setting" (meaning the product, the personality and the context) better than cocaine. The substance itself is surely the only common factor between the golden boy given to recreational bouts of sniffing the "champagne of all drugs" and the outcast crack addict with his craving and his compulsive, self-destructive habitual use of the smokable variety

For a long time, cocaine had quite a positive image (it reputedly made users more dynamic, enhanced performance and favoured success) and was consumed by an in-crowd (show business and media circles) or else it was the second choice of drug among addicts whose main problem was making sure they had enough heroin. In both cases, cocaine consumption was virtually invisible and was not really thought to constitute a breach of the narcotics laws. Its socially integrated users did not run up against selective control by the police, the judicial system or health authorities. They had discreet access to the product, and cocaine sniffing raised very few problems because the users were said to be in control of their own use. This was not the case with heroin addicts: their abuse of heroin, with its burden of physical dependency and criminal status, set them apart.

That is precisely what has changed in Europe since the mid nineteen nineties. At roughly the same time, the American craze (which began in the early eighties) reached its apex -with ten million regular consumers- and started to wane.

Belatedly, a new wave of widespread cocaine consumption has swept over Europe, involving four main audiences. These developments can be roughly summarised as follows. In the wake of the AIDS epidemic and the widespread development of methods of treatment based on heroin substitutes, some heroin injectors who were unable to get along without syringes and the strong sensations they induce became heavy cocaine users. With this first audience came the crack (smokable cocaine) epidemics, which up to then had been restricted to some socially precarious groups (such as street prostitutes) or ones with strongly ethnic backgrounds (Africans and West Indians). Some of these users later became hooked on heroin, which they took in order to handle coming off cocaine during the period immediately following the withdrawal of the drug, which is one of intense anxiety and deep depression. These groups were quantitatively quite insignificant, although this could not be said of their levels of consumption, and it is in this context that harm reduction and efforts to prevent the damage resulting from drug use ran into some unusual problems.

The use of cocaine actually developed most strongly among two much larger audiences. The first consisted of young people who liked to attend rave party or teknival-type festivities, as well as night clubs, discotheques and private parties. Cocaine, which was usually sniffed, had fairly logically been added to the list of popular stimulants such as ecstasy or amphetamines* and hall ucinogenics* such as LSD. So it was in an environment where many different kinds of drugs were being commonly used that the use of cocaine developed, and this drug was all the more popular since tobacco, cannabis* and alcohol had become too commonplace. In addition, the social profile of the young people attending these events had changed: along with the socially integrated smokers (such as high school and university students and young workers), another much less socially integrated group appeared, especially at free parties. These included young vagabonds and youths from the poorer city outskirts, whose drug-taking habits were far more chaotic and out of control. Cocaine* consumption is also developing nowadays among the middle classes, but very little is know so far about this invisible audience.

The way the drug is taken plays an essential role. Injected cocaine* produces a short but intense flash and the rate at which the injections are performed can become staggeringly high: one hit every thirty minutes until there is no product left. The user's veins quickly become severely damaged. Transmission of the hepatitis viruses (HBV and HCV) as well as HIV is facilitated. Many studies have shown the existence of a high prevalence* of viruses transmitted via the blood among cocaine injectors. In addition, sniffed cocaine and smoked crack can increase the risk of HCV transmission when users are sharing the same "sniffer" (a straw or a rolled up piece of cardboard) or crack pipe. Lastly, unprotected sexual intercourse, especially among crack users involved in prostitution, favours HIV transmission.

There exist no substitutes for cocaine, and the compulsive craving it arouses often makes health workers feel as if they are having to fight it with their bare hands.

Overdoses of injecting cocaine and the ensuing complications (convulsions, heart attack) are the main causes of drug related emergency hospitalisation in the United States. These cases are on the rise in Europe, although they are still unfamiliar to medical staff. Cocaine abuse also causes serious psychiatric disorders: hallucinations, paranoid states and violence. These consequences are all the more frequent when the context of drug use itself is problematic and disturbing, or at least disturbs the peace and quiet of those who inhabit the places where open practices have developed.

Now it so happens that although much intensive research which has been carried out, no substitution therapy is yet available for cocaine abusers. There is no such thing as "cocadone", and the compulsive craving cocaine arouses sometimes gives care-givers the desperate feeling of having to fight this uncontrollable urge with their bare hands. Users themselves, including those who are in contact with the health care system, avoid talking about their cocaine intake, either because they are afraid of not being admitted to a methadone programme, for example, or because they feel that nothing can be done to help them. Some go so far as to say that simply mentioning cocaine to the health providers causes the desperate craving for it to surge up again.

Viral contamination, overdoses, psychiatric complications and social exclusion: these are the problems that harm reduction has to deal with. Let us stress a few main points. Teams working in syringe exchange programmes have to know how cocaine injectors consume the product, and be aware that re-using injection equipment is the rule, that cocaine is often consumed in a group setting and that sharing syringes is often involuntary (people think they are re-using their own syringe, but in fact it has been switched with that of a neighbour). Within this framework, it is rather pointless proclaim the single preventive message: "one injection, one syringe" as can be done with heroin. On the other hand, anything that can help the users to avoid involuntary sharing must be encouraged, including tatooing the syringes, which some users already do spontaneously. On the same lines, distributing straws and information about the harms of HCV transmission via the sharing of straws must feature among the tools used by drug prevention teams working at festive events. European health structures, which have long focused on providing care for heroin addicts, are cruelly short of places that would give users in danger a place of shelter. We need fewer post-cures with their long waiting periods, and more places where people could be sent out to the country quickly for short periods to help them to get over their craving and breathe freely (places where they can sleep, eat and get a foothold in reality again). Apart from the inevitable relapses into the habit, time must be allowed to help the process of growth which will one day enable the users to stop.

When they take their first sniff of cocaine, users often have the feeling that this drug is quite harmless.

Lastly, the prevention of cocaine use needs to bethought through again. The task awaiting harm reduction, which is at the cross-roads between those who demonise drug users and those who apologise for them, consists of telling the truth about the drugs themselves so that people who are not yet users can compare their first experience of cocaine with what they have been told about it. When users first sniff cocaine, they often find it rather harmless, and are even a little disappointed at not experiencing any of the spectacular effects they had imagined. That is why it is necessary, even more than with other drugs, to stress the difference between use and abuse, and to make it known that the price to be paid for the energy one gets from cocaine is depression, and that although it is possible to use cocaine with moderation, it is completely wrong to believe that its consumption is easy to control: this has been confirmed time and again by experienced users.