Overshadowed by the Opioid Crisis: A Comeback by Cocaine

The following originally appeared on The Upshot (copyright 2018, The New York Times Company).

The opioid epidemic just keeps getting worse, presenting challenges discussed at length at a White House summit last week. But opioids are not America’s only significant drug problem. Among illicit drugs, cocaine is the No. 2 killer and claims the lives of more African-Americans than heroin does.

In a recent study published in the Annals of Internal Medicine, researchers from the National Cancer Institute and the National Institute on Drug Abuse found that drug-related deaths have grown across all racial groups and among both men and women. The analysis found that between 1999 and 2015, overdose deaths of any kind of drug for Americans 20 to 64 years old increased 5.5 percent per year.

For the most recent years of analysis (2012-15), the study found that deaths of men from heroin exceeded those from any other type of opioid, such as those found in pain medications. For women, deaths related to opioid medications were the most common.

But among non-Hispanic black Americans, cocaine has been a larger problem than heroin for nearly 20 years. For example, over 2012-15, cocaine overdoses claimed 7.6 per 100,000 black men. In contrast, heroin overdoses claimed 5.45 per 100,000 black men. Black women use both drugs at lower rates than men, but cocaine overdoses exceed those from heroin for them as well.

“We have multiple drug problems in the U.S.,” said Keith Humphreys, a professor at Stanford University School of Medicine who advises governments on drug prevention and treatment policies. “We need to focus on more than one drug at a time.”

That doesn’t mean opioids aren’t also a problem in the black population. They are. When you combine all types of opioids — including heroin, prescribed opioids and fentanyl — they claim more lives than any other drug from every racial group.

For a time, it appeared cocaine didn’t require as much attention. A study by RAND found that cocaine consumption fell 50 percent between 2006 and 2010. But in the past few years, the cocaine supply from Colombia has climbed to a record high in part because of a peace settlement that includes payments to farmers who stop growing coca. To be in a position to qualify for those payments in the future, many farmers started growing it. As a result, Mr. Humphreys said, cocaine prices have fallen, leading to an increase in cocaine use in the United States and some European countries.

Mr. Humphreys said one pathway to cocaine use is encountering the illegal drug market through an opioid addiction and then adding cocaine.

The surge in cocaine deaths has received relatively little attention. The trouble is, there’s a lot less we can do for cocaine than opioids. In contrast with addiction to opioids, there is no medication to treat addiction to cocaine. Though substantial investments have been made in search of drugs to treat cocaine addiction — including a vaccine — none are yet available.

Harm-reduction approaches — like syringe exchanges — focus mainly on injectable drugs. But injecting cocaine is uncommon.

Having fewer solutions doesn’t mean we can’t do anything about cocaine. Cognitive behavioral therapy can be effective in treating cocaine addiction, as well as other substance-use disorders. The defining feature of this therapy is learning to recognize patterns of thought that lead to problematic behavior and redirect them toward more positive behavior. Contingency management is also effective in treating cocaine addiction. In this approach, patients receive small rewards contingent on positive behavior (a cocaine-free urine test, for example).

Kicking cocaine with these treatment methods works only if access and staffing are adequate. Multiple federal laws, most notably the Affordable Care Act, made major strides by extending coverage and including substance-use disorder treatment as an essential benefit that health insurance plans had to cover.

But the new tax law undermines the A.C.A. by repealing the individual mandate. And changes to Medicaid being considered in many states — like adding work requirements or increasing premiums and other cost sharing — would also erode coverage. If insurance support is withdrawn, some addiction treatment agencies will lose staff or close, and some desperately needy addicted people will be cut off from care.

At the White House opioid summit, President Trump said his administration would be “rolling out policy over the next three weeks, and it will be very, very strong.”

But, as the evidence shows, even if we do respond to the opioid epidemic, it isn’t the only drug problem worthy of attention.


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