Crack/cocaine use in a rural county of England

Abstract

Crack/cocaine use is an increasing problem in the UK. This study is the first to ascertain the magnitude of the crack/cocaine problem in a rural county of the UK and to determine users’ needs for treatment services. A questionnaire on drug dependence and risk behaviour was completed by 306 users of drug treatment services, and focus groups were conducted with 45 self-selected crack/cocaine users. It is estimated that 31% (95% C.I., 26% to 37%) of drug users in treatment services have moderate/severe dependence on crack/cocaine. Factors associated with severe crack/cocaine dependence are severe dependence on benzodiazepines, increasing number of drugs used, engaging in sex work and non-white ethnicity. Those with severe dependence have a higher prevalence of hepatitis B and C compared with those with moderate or no dependence. All focus group participants describe a frenzied drug life so when entering treatment they require additional support to give structure to their lives to prevent relapse. Current service provision appears not to provide help to crack/cocaine users. Given the lack of pharmacological treatment, programmes should incorporate a wide range of activities and interventions to provide structure to clients’ lives. Learning from ex-users was perceived as an important component of treatment.

Background

Crack and cocaine use is an increasing problem in the United Kingdom. Its use has risen among people aged 16–29 years from 1% in 1996 to 3% in 1998 and 4.9% in 2000.¹ Crack is a highly addictive substance, with effects on the neurological and cardiovascular systems and has profound withdrawal effects.² Most researchers agree that crack/cocaine is associated with a pattern of obsessive-compulsive drug use and social exclusion.³ Some crack users need to support their drug use illicitly, which leads to their involvement in acquisitive crime and prostitution,^4,5 putting crack users at high risk of acquiring HIV and other sexually transmitted infections.^6,7 Furthermore, a recent report from the Health Protection Agency, based on results from the Unlinked Anonymous Prevalence Monitoring Programme (UAPMP), highlighted concerns about raised prevalence of HIV and hepatitis B and C among crack/cocaine users.^8,9 For these reasons, the government has recently focused attention on this drug.^10,11

This is the first study to conduct a needs assessment of crack/cocaine users in a rural area of the United Kingdom. In line with the rest of the United Kingdom, Norfolk, a very rural county in the east of England, has seen an increase in the proportion of people accessing drug treatment services, who indicate that crack/cocaine is their main drug, from 1.6% in 1999 to 7% in 2002.¹² Our overall objective was to conduct a needs assessment of crack/cocaine users. The first aim was to use capture–recapture techniques to determine the extent of problem drug use in Norfolk (see accompanying paper by Holland et al.). It estimated the prevalence of problem drug use in Norfolk to be 2.05%, indicating the importance of this health problem even in a rural county.¹³ The second aim, reported in this article, used a questionnaire to investigate the proportion of substance misusers who use crack or cocaine as their main or secondary substance of misuse and to determine their level of dependence on these substances. Also, focus groups investigated factors related to severe dependence on crack/cocaine and the treatment needs of this group of drug users.

Methods

This part of the study was divided into two components: a questionnaire survey and focus group discussions. All parts of the study were approved by the Norwich Research Ethics Committee.

Questionnaire survey

Although data are available from the regional drug misuse database, these are generally limited to the main drug of use. The study employed a self-completion questionnaire survey of drug users in the community. The drug users were identified through 10 National Health Service (NHS) and non-statutory drug treatment centres, where the questionnaires were distributed to new and existing clients. This questionnaire included questions on drug dependency (as used by the Office for National Statistics), which have been shown to provide valid information when compared with more detailed clinical assessment.¹⁴ Table 1 summarizes the questions asked for each of the drugs and the criteria used to assess the level of dependence. The questionnaire also covered aspects of alcohol dependence using the three question Brief Alcohol Use Disorder Identification Test.^15–17 To minimize the disruption to each agency, we carried out the survey over a 2- to 4-week period in each agency.

At the start of this study, we had no local estimate of prevalence, but national estimates suggested that the prevalence of problem drug use was 0.8% in the age range 15–54 years.¹⁸ This suggested that in Norfolk, one would expect to find approximately 3200 drug users. The proportion of those using crack/cocaine as their main drug was thought to be approximately 4.9%.¹ Thus, to estimate this proportion with 95% confidence limits of ±2%, a sample size of 393 completed questionnaires was required.

The primary outcome was the proportion of respondents reporting moderate-to-severe dependence by drug type. A univariate analysis of possible risk factors associated with severe crack/cocaine dependence was also conducted. Those factors identified as potentially significant (at the P < 0.1 level) were included into a logistic regression model to determine the strongest predictors of severe dependence on crack/cocaine.

Finally, the study compared the self-reported prevalence of blood-borne virus infection in drug users severely dependent on crack/cocaine with those not severely dependent. For the purpose of this analysis, all questions left unanswered were considered as a negative answer (e.g. ‘have you ever tested positive for hepatitis B?’ when unanswered was interpreted as ‘no’).

Focus groups

Seven focus groups of crack/cocaine users were conducted (six in the city of Norwich and one in the town of Great Yarmouth). Participants were recruited from those who responded to leaflets and posters displayed in a wide variety of appropriate locations (e.g. treatment clinic waiting rooms and homeless hostels). To endeavour to include individuals both in contact with treatment services and unknown to the services, ‘snowballing’ techniques were used. These have been successful in researching ‘hard-to-reach’ populations.¹⁹

Individuals interested in taking part in the groups telephoned a researcher at the university. Information on whether they were current or ex-users of crack/cocaine was obtained to allocate them to the most appropriate group. Different groups were organized for younger (25 years and below) current users, younger ex-users, older current users and older ex-users. One women-only group was conducted with sex workers. All the groups interviewed were tape recorded and then transcribed. Written consent was obtained from each participant before the commencement of the discussion. The focus groups lasted between 90 and 110 minutes and were held in neutral premises central to the city or town, away from the location of treatment services (NHS clinics).

Results

Questionnaire survey

The total number of survey respondents was 306. A response rate was only provided by 6 of 10 centres. In these sites, 165 of 185 potential respondents completed the questionnaires (89%). The other four sites did not collect data on the numbers refusing to complete the questionnaire. The mean age of respondents was 29.9 years (range 15–55 years); 28% were females, and 94% were from a white ethnic background. Table 2 summarizes the demographic characteristics of the participants. A total of 208 (68%) of the respondents completed the question regarding their main drug of use. Amongst responders, heroin was the most commonly reported main drug (174, 84%), followed by cannabis (18, 9%) and crack/cocaine (17, 8%). It should be noted that 10 of the 17 individuals who used crack/cocaine as their main drug did so in combination with heroin.

The mean number of drugs used by the participants was 3.6 (range 1–8). Table 3 summarizes the proportion of clients moderately to severely dependent on different drugs. Moderate or severe dependence on heroin was identified in 82% of clients (95% CI, 78–86%). Moderate-to-severe crack or cocaine dependence was evident in 31% of clients (95% CI, 26–37%), and this was severe in 12% (95% CI, 9–17%). These proportions did not vary between new or current clients of either drug treatment services (able to prescribe treatment) or other drug agencies (Table 4).

Those severely dependent on crack/cocaine used a median of five different drugs as compared with those not severely dependent who used a median of three drugs (P < 0.001, using Mann–Whitney test). Table 5 summarizes the relationship between severe crack/cocaine dependence and a variety of risk factors. Logistic regression suggested that the following variables were independently associated with severe crack/cocaine dependence (Table 6): severe dependence on benzodiazepines (odds ratio = 2.5, 95% CI 1.1–5.6), non-white ethnic background (odds ratio = 3.6, 95% CI 1.1–11.3), greater number of drugs (this was a linear relationship with an odds ratio = 1.25, 95% CI 1.0–1.56 for each additional drug) and exchanging sex for money, drugs or favours (odds ratio = 2.3, 95% CI 1.0–5.1).

The questions about diagnosis of hepatitis B, C or HIV were completed by 54% of the participants, with the rest either leaving them blank or stating not to know the result. There was no difference in the prevalence of self-reported HIV infection in those with or without severe dependence on crack/cocaine within our sample of drug users in treatment (Table 7). However, respondents severely dependent on crack/cocaine had twice the prevalence of infection with both hepatitis C (P = 0.04) and hepatitis B, although the latter was non-significant (P = 0.19).

Focus groups

There were six focus groups held in Norwich and one in Great Yarmouth, with 45 participants; 17 of whom were females. The mean age was 30.2 years (range 20–53). Most participants had had some experience with local drug services. Similar themes emerged in all the groups. Tables 8 and 9 summarize a selection of representative quotes from the themes discussed below.

Crack/cocaine use

Most people were introduced to crack through their other drug use. Participants described a drug ladder from cannabis, through other drugs, to finally heroin and crack use. Crack/cocaine and heroin use were entwined. Crack/cocaine was generally available from the same dealers who provided them with heroin. The women-only group described a link between prostitution and crack use. Most had been introduced to crack through dealers who posed as boyfriends and, once dependent, were subject to demands for payment for the drug. Commercial sex work was then used to fund their drug habit. All participants describe a hectic and chaotic lifestyle, referred to as a ‘24/7 crack-life’, revolving around drug use, crime or prostitution. In all the groups, crack/cocaine use was seen as more likely to lead to risky or extreme behaviour than other drugs.

Treatment services

Most participants believed that there was no help currently available for crack/cocaine dependence. The general belief was that clinical treatment services were able to deal with heroin dependence but had little to offer for crack dependence. They were critical of the accessibility and flexibility of existing treatment services to help with crack/cocaine dependence.

One of the main issues identified was the lack of a suitable substitute for crack/cocaine or one that could block the cravings or effects of crack/cocaine. Because crack/cocaine users described a life revolving around their need to ‘feed the habit’, participants reported a need to occupy their time, filling in the gap left by their drug use. As a result, users valued services that could facilitate their involvement in activities, training and assistance into employment or that offered help with practical problems such as housing, benefit advice and personal or family issues. Social and personal skills training, including anger management, was also seen as important in the rehabilitation process.

Another theme that emerged strongly was the value placed on involving ex-users in the support and care of those attempting to come off drugs, as they are seen as people that users can relate to and who can better understand their needs. This was identified as a gap in current service provision.

Discussion

Main findings of this study

This study has already reported an estimated prevalence of problem drug use of 2% in the population aged 15–54 years in Norfolk.¹³ Two-thirds of the respondents used crack/cocaine, almost one-third of the respondents reported moderate or severe dependence on crack/cocaine, and 8% reported using it as their main drug. The study found no variability in the prevalence of moderate or severe dependence among those from clinical treatment agencies versus those from non-treatment agencies, which suggests that the prevalence estimate is applicable to all ‘known’ drug users. If these proportions are applied to the Norfolk population estimate of problem drug use, this would represent a prevalence of 1.2% (i.e. approximately 4900 people) in people aged 15–54 years for crack/cocaine use or 0.6% (i.e. approximately 2450 people) for moderate or severe crack/cocaine dependence. The latter assumes that the hidden population of drug users in Norfolk are using drugs in a similar way to those attending drug services. In reality, it could be argued that those not attending services may be less chaotic and use less crack/cocaine. Alternatively, it may be that as treatment services are considered to focus almost exclusively on opiate addiction (as exemplified by the data from our focus groups), use of crack/cocaine is in fact likely to be greater amongst the problem drug use population not seen within treatment services.

All the groups highlighted the progression to crack/cocaine from other drugs, often describing a ‘drug ladder’ from cannabis through other drugs finally to heroin and crack/cocaine. Similar findings have been reported in large urban areas.^20,21 This was also consistent with the survey finding that crack use was associated with multiple other drug use, suggesting that tackling drug problems early on may prevent progression to use of crack/cocaine.

It was also observed in both the survey and focus group findings that there was an association between crack/cocaine dependence and prostitution. The focus groups highlighted the high financial cost of crack use and the need for users to undertake acquisitive crime or sex work to fund their habit. As a result of this risk-taking behaviour, an increased prevalence of HIV and other blood-borne viruses among crack/cocaine users would be expected. In the study sample, it was found that patients with dependence on crack/cocaine had twice the self-reported prevalence of hepatitis B and C compared with those not dependent, though this was only statistically significant for hepatitis C, while the prevalence of HIV was similar in both groups. Our survey may however have underestimated the prevalence of these infections because of the non-response to these questions in about half of the sample.

What is already known on this topic

Few studies have quantified the prevalence of crack/cocaine use, and these have mainly focused on large urban areas. A recent study found a prevalence of crack use in London of 1.3% of the population aged 15–44 years.²² Our study’s estimated prevalence of crack/cocaine use would appear similar to that found in London, higher than may have been anticipated for a rural county. Several studies have commented on a link between crack use and sex work and polydrug use.^4,5,20,23 These risk behaviours lead to increased rates of sexually transmitted infections, HIV and other blood-borne viruses found with crack/cocaine use in previous studies.^6,7

What this study adds

This is the first study that quantifies the prevalence and level of dependence on crack/cocaine in a rural setting in the United Kingdom. Normally, research reports state only the main drug of abuse. This may underestimate the importance of crack/cocaine, particularly if drug users perceive that treatment will only be provided to those with opiate problems. In this study sample of drug users, the majority used heroin as the main drug. However, two-thirds of the respondents used crack cocaine, and almost a third did so in a way suggestive of moderate-to-severe dependence.

The focus group discussions with crack/cocaine users shed some light on the problems faced by these users; where, in most cases, participants described a ‘crack life’ revolving around drug use and acquisitive crime or prostitution. However, when crack users enter treatment, they value the involvement in activities that can fill the gap left by abandoning the hectic and chaotic life they used to lead.

Limitations of this study

The proportion of drug users dependent on crack and cocaine was estimated using a questionnaire survey. The sample obtained was smaller than intended; nevertheless, the confidence intervals around our estimate of dependence are reasonably narrow. It should be noted that one survey question asking respondents to report their main drug was poorly completed (completed by 68% of respondents). This appeared to be due to the question’s position and phrasing. Of those who did respond, 8% reported that their main drug was crack/cocaine, in line with national findings.¹² The primary aim was however to determine the proportion of respondents whose drug use suggested moderate or severe dependence on crack/cocaine. Drug dependence questions were answered by all respondents.

The survey response rate was generally very high where recorded, but no response rate information was available from the four sites. It is possible that those surveyed did not adequately represent the population of problem drug users in the community. In particular, the widespread belief that treatment services cannot help those with crack/cocaine addiction may have biased in the direction of underestimating prevalence. Conversely, as severe dependence is related to polydrug use, this may have resulted in a larger proportion of crack/cocaine users accessing treatment services for other drugs, leading to a biased overestimate.

The focus groups were conducted with a self-selected sample of current and ex-users of crack/cocaine and are likely to have over-represented urban users, as the groups were organized in Norwich and Great Yarmouth. Also, as people with serious crack/cocaine problems are more likely to have more chaotic lifestyles, it is possible that the current user groups have attracted those users who had a more stable lifestyle.

In conclusion, this study demonstrates that estimates provided by reports of users’ main drug would appear to seriously underestimate the scale of the crack/cocaine problem. Furthermore, current service provision appears to provide inadequate help to crack users. As there is no current ‘substitute’ or ‘blocker’ to crack/cocaine, users require other forms of treatment. Successful treatment programmes should consider incorporating, as suggested by participants in our focus groups, a wide range of activities and interventions to provide structure to their daily life. Learning from ex-users was perceived to be an important component of this treatment. Further research is needed to determine the best methods of delivering acceptable and effective treatment services to this at-risk population.

Funding

This work was funded by a grant from the Norfolk Drug Action Team.

Acknowledgements

The authors thank Clive Rennie (Norwich PCT), Xany Oliver (Norfolk Drug Action Team) managers and staff of Norfolk NHS Drug Treatment Services, Norfolk Constabulary, Norfolk Probation, Norfolk Tier 3 Youth Services, Norfolk Voluntary Agencies working with substance misusers, survey respondents and participants of the focus groups.

References