Cocaine – the current situation in Europe (European Drug Report 2024) (2024)

Growing evidence of the health and social costs of high cocaine availability

Cocaine is, after cannabis, the second most commonly used illicit drug in Europe. Although prevalence levels and patterns of use differ considerably between countries (see Prevalence and patterns of cocaine use), the availability of this drug has been increasing for a number of years. Equally, concern has been growing that the health and social costs associated with this drug are rising significantly.The use of cocaine can result in dependent and compulsive patterns of use and is associated with a number of adverse health consequences, which can include agitation, psychosis, tachycardia, hypertension, arrhythmia, chest pain due to acute coronary syndrome and stroke. Chronic cocaine use is associated with an increased risk of coronary artery disease, cardiomyopathy and stroke. Cocaine and synthetic stimulants can induce or precipitate psychotic states, such as stimulant-induced psychosis. Longer and heavier use of stimulants delays recovery and worsens the prognosis for recovery. Among those using the drug, the combined use of cocaine and alcohol is common. The presence of the two substances in the body creates cocaethylene in the liver, which is associated with greater health risks. The management of psychiatric comorbidity among people with drug use problems remains challenging, as integrated treatment and mental health service responses are often lacking. A recent review of mortality among people with regular or problematic cocaine use found that the risk of death by suicide, accidental injury, homicide and AIDS-related mortality were all elevated when compared with non-cocaine using peers.

Cocaine is usually available in two forms in Europe. The most common is cocaine powder (the salt form) and less commonly available is crack cocaine (a smokable freebase form). Cocaine is produced from the coca plant, grown in South America. It enters Europe through various routes, but the trafficking of large volumes of cocaine through Europe’s seaports in intermodal commercial shipping containers appears a significant factor in the current high availability of this substance. In countries with large container ports known to be utilised for cocaine importation, rising levels of drug-related crime, including the corruption of staff along supply chains, intimidation and violence, have been observed. Elsewhere, there are concerns that competition within the cocaine market, both at the wholesale and retail levels, is now an important driver of drug-related crime, including gang-related violence and homicides in some countries. At the same time, cocaine use, and crack cocaine use in particular, appears to be becoming more common, especially among some marginalised communities. Taken together, this means that the growing availability and use of cocaine in Europe is resulting in greater costs, both in terms of its impact on public health and because of the criminality and violence associated with the cocaine market.

Signs of increased cocaine trafficking and innovative approaches to avoid detection

In 2022, for the sixth year in a row, EU Member States reported a record amount of cocaine seized, amounting to 323tonnes. Belgium, Spain and the Netherlands remain the countries reporting the highest volumes of seizures, reflecting their importance as entry points for cocaine trafficked to Europe. In 2023, the quantity of cocaine seized in Antwerp, Europe’s second-largest seaport, rose to 116tonnes from 110tonnes in 2022. The volume of cocaine seized in Antwerp has increased annually since 2016. In 2023, Spain reported its largest ever seizure of cocaine (9.5tonnes) in a single shipment, concealed in bananas originating from Ecuador (see Figure 3.1).

The trafficking of illicit drugs is highly dynamic and quick to adapt to geopolitical developments, regional conflicts and changes in commercial trade routes. In this context, developments in Colombia, Brazil and Ecuador are all thought to have contributed to the increase observed in cocaine trafficked to the European Union by organised crime groups (see the European Drug Market Report: Cocaine for an in-depth analysis). In addition to the use of commercial containers, a range of other methods are now used, often in combination, to evade detection (see Figure 3.2).

As interdiction measures have been scaled up at major known entry points for the drug, it appears that cocaine traffickers are increasingly targeting smaller ports in other EU countries and countries bordering the European Union, which may be more vulnerable to drug trafficking activities. Some northern European countries, including Sweden and Norway, reported record cocaine seizures at seaports in 2023. Together, these developments may help explain the fact that despite the large seizures, reported cocaine purity at the retail level remains high by historical standards and its price is stable. It is now well-established that the illicit processing of cocaine products takes place in several EU Member States, with 39 cocaine laboratories reported to have been dismantled in 2022. Cocaine processing in Europe usually involves the secondary extraction of cocaine that has been incorporated into other materials (e.g. chemically concealed in plastics), creating challenges for its detection in commercial shipments. Some relatively large-scale facilities have been detected recently. For example, a cocaine processing laboratory dismantled in Spain in 2023 was reported to have a daily output capacity of 200kilograms of the drug (see Figure 3.3).

Impact of cocaine availability on public health increasingly visible

For a number of practical and methodological reasons cocaine-related health problems can be challenging to monitor, but there are increasing signals that the high availability of this drug is having a growing negative impact on public health in Europe. Cocaine is the second most frequently reported illicit drug, both by first-time treatment entrants and in the available data on acute drug-toxicity presentations to sentinel hospital emergency departments. European drug checking services, although not nationally representative, reported that cocaine was the most common substance they screened in 2022. The available data also suggest that the drug was involved in about a fifth of drug overdose deaths in 2022. As cocaine use can aggravate underlying cardiovascular problems, it is likely that the overall contribution this drug makes to mortality in Europe is not sufficiently recognised.

Cocaine residues in municipal wastewater also increased in two thirds of cities with data for 2023 and 2022. This, together with other information, suggests that as cocaine has become increasingly available, so too has its geographical and social distribution. Of particular concern is that cocaine use appears to be becoming more common in more marginalised groups in some countries. Both the smoking and injection of cocaine are associated with greater health problems, and it is therefore worrying that cocaine injection and the use of crack cocaine are reported in a growing number of countries. Stimulants such as cocaine are associated with a higher frequency of injection and have been involved in localised HIV outbreaks among people who inject drugs in 7 European cities over the last decade (see Injecting drug use in Europe – the current situation).

Treating people with problems associated with their cocaine use is challenging, whether they are clients that are more socially integrated and involved in casual or episodic use of powder cocaine, or more marginalised groups injecting the drug or smoking crack cocaine. Most of the chronic harms related to the use of stimulants such as cocaine are associated with intensive, high-dose or long-term consumption. Acute problems can also affect people who use stimulants experimentally, but they are likely to be less common when the stimulant use is infrequent and low-dose. Although our understanding of what constitutes effective treatment for stimulant problems is growing, it remains relatively limited. The current evidence available is indicative of the use of psychosocial interventions, including cognitive behavioural therapy and contingency management. Currently, there is insufficient evidence to strongly support any pharmacological treatment, although some potentially useful new pharmacotherapies are in development. Treating cocaine problems among more marginalised groups can be particularly challenging, as clients may also be experiencing problems with a range of other drugs, including opioids or alcohol. For injecting cocaine and smoking crack, existing harm reduction responses, to a large extent those originally developed for opioid problems, are likely to be appropriate to reduce route-specific harms. However, further work is needed to develop more comprehensive interventions, and greater investment is needed to ensure services are appropriate to the growing needs observed in this area in some countries.

Key data and trends

• Analysis of 1849 used syringes by the ESCAPE network of 12 cities in 11 EU Member States between 2021 and 2022 found that, overall, a third of syringes contained residues of two or more drug categories, indicating frequent polydrug use or re-use of injecting paraphernalia. The most frequent combination was a mixture of a stimulant and an opioid. Cocaine was detected in over 50% of syringes analysed in Athens, Cologne, Dublin and Thessaloniki, with a mixture of cocaine and heroin being the most frequent combination found.

Harms related to cocaine use

• Cocaine was the second most common substance reported by Euro-DEN Plus sentinel hospitals in 2022, mentioned in 28% (1739) of acute drug-toxicity presentations. Where recorded, most presentations were associated with co-ingestion of alcohol.
• Among the 19 European countries providing data for both years, cocaine, mostly in the presence of opioids, was involved in 996 (23%) drug-induced deaths in 2022 (807 or 20% in 2021).
• In Spain, cocaine was involved in more than half (52%) of the drug-induced deaths reported in 2021. In France, the forensic network reported that the number of drug-induced deaths involving cocaine doubled from 130 cases (22% of all drug-induced deaths) in 2020 to 259 cases (39%) in 2021.

Crack cocaine

• Just 6 EU countries accounted for 90% of the estimated 8100 crack-related treatment entries in 2022 (7500 in 2021), of which 3000 were first-time entrants. A caveat here is that the term ‘crack’ may not be used consistently by all countries.
• The number of first-time treatment entrants with crack cocaine as primary drug increased by about 42%, from 1900 clients in 2017 to 2750 clients in 2022.
• Data from drug consumption rooms in Lisbon and Porto, Portugal, and in Paris, France, in 2022 indicate that crack cocaine, either alone or with heroin, accounted for a significant proportion of the drug consumption episodes facilitated. In both countries, half of all crack cocaine consumptions involved smoking and the other half involved injecting crack, alone or with heroin. No crack cocaine use was reported by drug consumption rooms in Barcelona, Athens or Bergen in 2022.
• A 2021 analysis of municipal wastewater in 13 European cities, by the EU-funded EUSEME project, found crack residues in all cities on all sampling days, with the highest loads reported in Amsterdam and Antwerp.

Cocaine market data

Source data

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