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World Psychiatry. 2005 October; 4(3): 173–176. | PMCID: PMC1414771 |
Relationship between cocaine use and mental health problems
in a sample of European cocaine powder or crack users CHRISTIAN HAASEN,1 MICHAEL PRINZLEVE,1 MICHAEL GOSSOP,2 GABRIELE FISCHER,3 MIGUEL CASAS,4 and AND THE COCAINEEU-TEAM* 1Centre for Interdisciplinary Addiction Research, Department of Psychiatry and Psychotherapy, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany 2National Addiction Centre, Institute of Psychiatry, London, UK 3Outpatient Drug Addiction Unit, Department of Psychiatry, University of Vienna, Austria 4Free University of Barcelona, Spain *The members of the team are listed in the Appendix Numerous studies have pointed out the risks of cocaine use for mental health.
Most clinical studies report a high psychiatric comorbidity, mainly among
crack users. In this paper the association of mental health problems with
sociodemographic variables and patterns of use is analysed, based on data
from a multicentre European study including a field survey of cocaine users
in different settings. Bivariate analyses revealed that mental health problems
were influenced by all variables under consideration, i.e. age, gender, social
situation, crack use, days with cocaine use in the past month, lifetime use
of cocaine, severity of dependence, and physical health. However, in a regression
analysis, intensity of use, physical health, severity of dependence and social
situation were found to be predictors of mental health problems, while crack
use by itself was not. These findings suggest that mental health consequences
are related more to the intensity than to the form of cocaine use. Keywords: Cocaine, crack, mental health problems, intensity of use Considerable debate has surrounded the potential dangerousness of cocaine,
since many people continue to use the drug on a recreational basis without
reporting problems. The health risks of cocaine use include a number of medical
complications, such as cardiovascular or respiratory disorders, that in some
cases can lead to death. Acute cocaine use can lead to the wanted effects
of euphoria, self-assurance, increased attention, reduced appetite, less tiredness,
among others, but can also lead to unwanted effects such as anxiety and paranoia,
egocentric behaviour, dysphoria, anorexia and delusions. After cocaine withdrawal,
a typical symptom is anhedonia. A greater severity of cocaine dependence is
associated with a more severe depressive symptomatology after withdrawal ( 1). Health related effects of cocaine are largely related to the route of use.
Routes of use have important implications for pattern of use, drug effect
and risk of dependence, with smoking and intravenous use associated with greater
absorption, a shorter more intense high and a greater tendency toward a binge
pattern of use ( 2, 3). Different routes of using cocaine are associated with
different negative consequences ( 4).
Crack users have a greater number of symptoms, and higher levels of anxiety,
depression, paranoid ideation, and psychoticism ( 5, 6). Other symptoms, such as aggression and
violence, are associated more with crack than with cocaine powder. Psychiatric comorbidity among cocaine dependent users is not only increased
for other substance disorders, but also for personality disorders ( 7- 9), post-traumatic
stress disorder ( 10, 11), and depressive disorders ( 12, 13). However, there remains a paucity of
research evidence concerning the association of mental health problems with
the complex interaction of length of cocaine use, the social context and the
route of use. Design The research project Support Needs for Cocaine and Crack Users in Europe
(CocaineEU) was initiated in 2002. This multicentre, multimodal field study
was aimed at defining specific recommendations (guidelines) in order to ameliorate
the care for regular cocaine and crack users. The project was initially carried
out by research centres in nine European cities (Barcelona, Budapest, Dublin,
Hamburg, London, Rome, Stockholm, Vienna, Zurich), while a tenth research
centre (Paris) joined in during the course of the project. In each participating city, cocaine and crack users out of three different
subgroups were recruited: 70 cocaine/crack users on drug treatment, mainly
maintenance treatment; 70 socially marginalized cocaine/crack users not on
a specific drug treatment, and 70 socially integrated cocaine/crack users
not on a specific drug treatment. The treatment group was recruited mainly in outpatient maintenance clinics
or, if not possible, in other (inpatient or outpatient) addiction treatment
settings. The marginalized group was recruited at places where drug users
usually meet to sell, buy or use drugs, or in the surroundings of low-threshold
addiction facilities (e.g., needle exchange programmes or safe injection rooms).
The integrated group was recruited at different party places (e.g., discos,
nightclubs or pubs), or through private contacts. To exclude an overlap between
the three target groups, each centre deter- mined specific recruitment locations,
e.g. treatment facilities and places typically attended by the two other groups.
Besides affiliation to the respective target group, the inclusion criterion
was the use of cocaine powder or crack cocaine at least once in the last month. The three target groups were consecutively recruited according to a criteria
oriented sample strategy. Subjects at the determined recruitment locations
were first asked with regards to the inclusion criteria. If these were met,
and after the subject gave informed consent, the interview took place. Measures Structured face-to-face interviews were conducted to assess the consumption
behaviour, social and health status. The instrument used was an adjusted version
of the Maudsley Addiction Profile (MAP) ( 14),
including a 10 item physical health symptom scale (adapted from the Opiate
Treatment Index, OTI, 15) and a 10
item scale to assess mental health problems (derived from the anxiety and
depression subscales of the Brief Symptom Inventory, BSI) ( 16). Dependence upon cocaine was assessed using the Severity
of Dependence Scale (SDS) ( 17). The MAP is a brief, interviewer-administered questionnaire that measures
problems in four domains: substance use, health risk behaviour, personal/social
functioning, and physical and psychological health. The adjusted version included
items concerning patterns and history of cocaine and crack use, and some items
concerning the social situation. In addition to the current drug use data,
lifetime data assessed according to the European Addiction Severity Index
(ASI) ( 18) were reported for cocaine
powder and crack cocaine. Subjects Because of the low prevalence of cocaine in Stockholm ( 19), it was not possible to recruit a sufficient number of
cocaine users who met the inclusion criterion of having used cocaine powder
or crack cocaine at least once in the past month. Therefore, the following
analysis is based on data from nine European cities. The total number of subjects was 1855, with 34% belonging to the treatment
group, 33% to the marginalized group, and 33% to the integrated group. There
were small deviations from the originally intended sample size of 70 cocaine
users in each group and each city. In the treatment group, 81% were recruited
in maintenance clinics, 9% in other drug treatment services. The marginalized
group was mainly recruited in low-threshold facilities (58%), on the drug
scene (16%), or via snowballing (10%). The integrated group was recruited
mainly at night-life sites (38%), or via snowballing (40%), and the rest at
different medical services or public places. The patterns of use varied greatly
between cities and between the three target groups ( 20). Thirty-two percent of the sample were female. The average age of the whole
sample was 30.8 (± 7.4) years, ranging from 16 to 62 years. On average,
males (31.7 ± 7.5 years) were older than females (28.8 ± 6.6
years). Eighty-six percent of all subjects had used cocaine powder in the 30 days
prior to the interview, 27% had used crack cocaine (73% had used cocaine powder
alone, 14% crack cocaine alone, 13% cocaine powder as well as crack cocaine).
About 90% of the crack cocaine users were smoking, about 10% were injecting.
In the last 30 days, the average number of days with cocaine use was 14.4
(±11.1). The severity of dependence (according to SDS) was 5.5 (range:
0-15, SD=4.1). Fourteen percent of the sample reported no period of regular
cocaine use (period of at least six months with a use of more than two times
per week) in their lifetime. In those with a period of lifetime regular use,
the average duration of regular use was 6.1 years (±5.1). With respect
to problems with physical health, the sample reported an average of 12.0 (±7.6)
on the OTI subscale (range 0-40). With respect to mental health problems, the sample showed an average BSI
score of 14.3 (range 0-40, SD=8.89). Only 4% had a sum score of 0, reporting
no mental health problems. The mental health problems score showed highly
significant differences for gender, social situation, present crack use and
regular cocaine use (Table 1). The
mental health problems score also correlated significantly with age (r=.124,
p<0.001), days with cocaine use in the last 30 days (r=.370, p<0.001),
years of regular use (r=.109, p<0.001) and severity of cocaine dependence
(r=.502, p<0.001). A very highly significant correlation was found between
the mental health problems score and problems with physical health (r=.623,
p<0.001). | Table 1Differences in mental health problems (Brief Symptom Inventory score) |
In order to understand which variables best predict mental health problems
in this sample of cocaine users, a multiple linear regression analysis was
performed, including the variables gender, age, social situation, days with
cocaine use, crack use, length of regular use (those with no lifetime regular
use were set at 0 years), severity of dependence and problems with physical
health. Results of this regression analysis are found in Table 2, indicating that mental health problems are related to physical
health, severity of dependence and intensity (frequency) of cocaine use, as
well as the social situation of the user. However, crack use by itself and
the length of regular cocaine use do not predict the extent of mental health
problems. | Table 2Regression analysis summary for variables predicting mental health problems |
In the past, numerous studies have shown the risks of cocaine use for both
physical and mental health. The focus with respect to mental health risks
has come mainly from clinical studies, reporting a high proportion of psychiatric
comorbidity. Many studies have concentrated on the specifically high risk
of health problems related to crack use. This paper is based on a field survey of cocaine users and explores the
association of mental health problems with sociodemographic factors as well
as patterns of use. Since not only clinical cases were included in the survey,
the study allows for a much wider view of cocaine use in the population, including
users who do not consider their cocaine use a problem. Although not assessing
a representative sample of the population, the survey includes a large sample
of all the main subgroups of cocaine users in the society. The main result of the study is the association of mental health problems
with various sociodemographic factors as well as patterns of use. This included
the variable of crack use, with a significantly higher mental health problems
score for crack users than for users of cocaine powder. However, the regression
analysis was then able to show that crack use by itself was not a predictor
of higher mental health problems. Predictors of mental health problems were
the intensity of use, physical health and the social situation. These findings
suggest that the severe consequences are related more to the intensity than
the form of cocaine use. Although this position has been stated in a review
in the past ( 3), there have been numerous
studies since then which all focus on the form of cocaine use (crack cocaine
versus cocaine hydrochloride) rather than on the intensity of use. With respect to the prevention of mental disorders among cocaine users,
the high correlation of mental health problems and physical health problems
points to the importance of screening for mental health problems among cocaine
users in other medical settings such as general practitioners and emergency
rooms, similar to the Drug Abuse Warning Network system implemented in the
USA ( 21). The results with respect to the severity of dependence and the social situation
emphasize the necessity of implementing harm reduction measures. Severity
of cocaine dependence, as assessed by means of the SDS, mainly refers to psychological
components of dependence, such as impaired control over drug taking and preoccupation
and anxieties about drug use. Hence, harm reduction measures that are aimed
at safer, more controlled, less intensive use of cocaine may decrease mental
health problems. Similarly, stabilising the social situation of drug users
may have the same effect. Furthermore, the higher risks for female users,
in line with the findings of McCance-Katz et al ( 22),
need to be addressed in prevention, treatment and research. The members of the CocaineEU-Team are: C. Haasen, M. Prinzleve, H. Zurhold,
M. Krausz (Hamburg, Germany); M. Casas, J.L. Matali, E. Bruguera (Barcelona,
Spain); J. Gerevich, E. Bacskai (Budapest, Hungary); G. Cox, N. Ryder, S.
Butler (Dublin, Ireland); M. Gossop, V. Manning (London, UK); A.-M. Pezous
(Paris, France); A. Verster, A. Camposeragna (Rome, Italy); B. Olsson, M.
Ekendahl, P. Andersson (Stockholm, Sweden); G. Fischer, R. Jagsch, A. Primorac
(Vienna, Austria); J. Rehm, F. Guettinger (Zurich, Switzerland). This research
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