Review
Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: A comprehensive narrative overview of English-language studies

https://doi.org/10.1016/j.drugpo.2015.01.002Get rights and content

Highlights

  • Crack/cocaine abuse is a major global problem with extensive health/social burdens.

  • Secondary prevention measures show mixed/limited effects on drug use and health.

  • Psycho-social and pharmaco-therapeutic treatment options are extensively studied.

  • Psycho-social treatments feature limited but best currently available effectiveness.

  • Widely effective interventions are absent; improved measures need to be developed.

Abstract

There are an estimated several million crack-cocaine users globally; use is highest in the Americas. Most crack users are socio-economically marginalized (e.g., homeless), and feature elevated risks for morbidity (e.g., blood-borne viruses), mortality and crime/violence involvement, resulting in extensive burdens. No comprehensive reviews of evidence-based prevention and/or treatment interventions specifically for crack use exist. We conducted a comprehensive narrative overview of English-language studies on the efficacy of secondary prevention and treatment interventions for crack (cocaine) abuse/dependence. Literature searches (1990–2014) using pertinent keywords were conducted in main scientific databases. Titles/abstracts were reviewed for relevance, and full studies were included in the review if involving a primary prevention/treatment intervention study comprising a substantive crack user sample. Intervention outcomes considered included drug use, health risks/status (e.g., HIV or sexual risks) and select social outcome indicators. Targeted (e.g., behavioral/community-based) prevention measures show mixed and short-term effects on crack use/HIV risk outcomes. Material (e.g., safer crack use kit distribution) interventions also document modest efficacy in risk reduction; empirical assessments of environmental (e.g., drug consumption facilities) for crack smokers are not available. Diverse psycho-social treatment (including contingency management) interventions for crack abuse/dependence show some positive but also limited/short-term efficacy, yet likely constitute best currently available treatment options. Ancillary treatments show little effects but are understudied. Despite ample studies, pharmaco-therapeutic/immunotherapy treatment agents have not produced convincing evidence; select agents may hold potential combined with personalized approaches and/or psycho-social strategies. No comprehensively effective ‘gold-standard’ prevention/treatment interventions for crack abuse exist; concerted research towards improved interventions is urgently needed.

Section snippets

Background

Based on recent studies, 0.3–0.5% (or 14–21 million people) of the global population aged 15–64, are estimated to be cocaine users (Degenhardt and Hall, 2012, UNODC, 2014). The prevalence of cocaine use is estimated to be highest – (1.4%) with some national surveys indicating even higher ‘past year’ prevalence rates – in the region of the Americas where it is recorded as the second most common type of illicit drug use following cannabis (Carlini et al., 2006, Health Canada, 2014, SAMHSA, 2013).

Methods

The present overview reports on the results of a series of literature searches, involving the principal search terms “crack cocaine”; “use” or “smoking” or “abuse” or “dependence”; and “prevention” or “intervention” or “treatment” or “harm reduction”, were conducted on journal-published English-language literature from 1990 up to March 2014, searching major medical and health-related databases – i.e., Embase, PubMed®, PsycINFO® – for relevant English-language journal publications. In addition

Secondary prevention interventions

Literature identified on secondary prevention interventions was heterogeneous, and further sub-categorized into behavioral/psycho-social and environmental/material interventions.

Discussion

We comprehensively reviewed the English-language evidence on secondary prevention and treatment interventions for crack-cocaine users.

A fairly substantive body of largely controlled studies on innovative or tailored behavioral – largely brief/outreach based – targeted prevention measures targeting crack users focused mainly on HIV-risk and crack use outcomes, indicating mixed evidence on efficacy slightly in favour of experimental over standard/control (e.g., NIDA HIV) interventions. While some

Acknowledgements

The authors acknowledge Chantal Burnett, Yoko Murphy, Steve Peat, Katherine Rudzinski and Maija Tiesmaki for their various contributions at different stages of this work. Dr. Fischer acknowledges funding/salary support from a CIHR/PHAC Chair in Applied Public Health, as well as international collaboration support funding from the Association of Universities and Colleges of Canada's (AUCC) LACREG program.

Conflict of interest: The authors have no conflict of interest to report.

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