Acute drug-toxicity presentations involving crack cocaine to Euro-DEN Plus sentinel hospitals in Europe from 2014-2022

Background: Crack cocaine use can cause chronic and acute problems. It has been reported in a number of cities across Europe in recent decades. We analysed the trends in acute drug toxicity presentations involving crack cocaine to European Emergency Departments and describe the geographical spread and characteristics of the presentations. 

Methods: We analysed 70,056 presentations to the Euro-DEN Plus network (between 01/01/2014 and 31/12/2022). The network has grown during this time period and in 2022 had 32 sentinel hospitals in 22 countries in the EU, Norway, Türkiye, the UK and Switzerland. We describe here the geographic variation and the characteristics (age, sex, other drugs involved, outcome) of the presentations. 

Results: Overall, 2168 (3.1%) presentations involved crack cocaine over the 9-year period. From 2014 to 2022, the number of presentations involving crack cocaine (119, 84, 157, 205, 308, 316, 336, 298 and 345) and the proportion of hospitals with crack cocaine presentations (6/16, 5/16, 6/21, 7/29, 14/30, 8/28, 10/28, 13/29, 12/28) increased. Eleven hospitals that had not reported crack cocaine before started to do so in 2017 (Oslo OAEOC NO)), 2018 (Bern CH, Ghent BE, Lugano IT, Mallorca ES), 2020 (Barcelona ES, Basel CH, Bratislava SK), 2021 (Drogheda IE, Geneva CH) and 2022 (Oslo OUH NO). In 2018, two hospitals in London UK and one in Paris FR reported 287/308 (93.2%) of all presentations with involving crack, compared with 212/345 (61.4%) in 2022. In 2022, the highest proportions of presentations with crack were reported in Paris (47 presentations (14.8% of all presentations to the centre), and 13.6% of all Euro-DEN Plus crack cocaine presentations); two hospitals in London (165, 9.5% and 47.8%); Msida MT (85 presentations, 7.5% and 24.6%), Geneva (23 presentations, 5.8% and 6.7%) and Antwerp BE (12 presentations, 3.6% and 3.5%). Compared to 2021, the highest increase in 2022 were in Geneva (1 to 23, 2200%), Msida (59 to 85, 44.1%) and London STMW (53 to 74, 39.6%). In 2022, most presentations were in men (267, 77%), in adults aged 25-45 years (199, 64%); alcohol was used with crack cocaine in 166/266 presentations (62%); the drugs most commonly associated with crack were heroin in Msida, Barcelona and London; cocaine in Antwerp and Geneva, and cannabis in Paris; 100 (29%) presented to the hospital during the week-end, 12 (3.5%) were admitted to intensive care unit and none died.

Discussion: The number of presentations involving crack cocaine has increased over this 9-year period and crack cocaine has spread to new centres. Triangulation of these acute drug toxicity data with other local sentinel sources (low threshold and treatment services, syringe residue data, police data) is needed to adapt the responses to this high-risk pattern of drug use. The potential misclassification as cocaine powder instead of crack cocaine and the underestimation of the harms related to crack cocaine will be discussed.