191 Chapter 7 The fast and furious — cocaine, amphetamines and harm reduction Jean-Paul Grund, Philip Coffin, Marie Jauffret-Roustide, Minke Dijkstra, Dick de Bruin and Peter Blanken ‘The role of the state is not to make people happy but to relieve avoidable suffering.’ (Sir Karl Popper, 1945) Introduction Cocaine and amphetamines (‘stimulants’) are distinct central nervous system stimulants with similar effects (Pleuvry, 2009; Holman, 1994). Cocaine is a crystalline tropane alkaloid extracted from coca leaves. Amphetamines are a subclass of phenylethylamines with primarily stimulant effects, including amphetamine, methamphetamine, methcathinone and cathinone and referred to as ‘amphetamines’ in this review (Holman, 1994). MDMA (3,4-methylenedioxy-N-methamphetamine or ecstasy) is a substituted amphetamine known for its entactogenic, psychedelic, and stimulant effects (Morgan, 2000). Stimulants can produce increased wakefulness, focus and confidence, elevated mood, feelings of power, and decreased fatigue and appetite; stimulants also produce nervousness or anxiety and, in some cases, psychosis and suicidal thoughts (Holman, 1994; EMCDDA, 2007f; Hildrey et al., 2009; Pates and Riley, 2009). Although there is little evidence that stimulants cause physical dependence, tolerance may develop upon repetitive use and withdrawal may cause discomfort and depression (EMCDDA, 2007f; Pates and Riley, 2009). Users may engage in ‘coke or speed binges’ alternated with periods of withdrawal and abstinence (Beek et al., 2001). Epidemiology of stimulant use in the European Union The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA, 2009) estimates that at least 3.9 % of the total adult population (15–64 years) in European Union (EU) Member States has used cocaine at least once in their lifetime (lifetime prevalence, LTP), but variations in prevalence and patterns are found between countries, demographic and social groups, and specific settings. Higher levels of cocaine use are found in western and southern countries, notably Denmark, Spain, Italy, Ireland and the United Kingdom, with relatively low LTP in most other European countries, ranging from 0.1 % to 8.3 % (EMCDDA, 2009). Cocaine use is concentrated among young adults (15–34 years), with an average LTP of 5.3 %, and more so among young men, with an LTP over 10 % and last year prevalence (LYP) over 5 % in Denmark, Spain, and the United Kingdom (EMCDDA, 2007b). LYP for all EU adults is 1.3 %, ranging from 0 % to 3.1 % by country. LYP among young adults is 2.2 %, ranging from 0.1 % to 5.5 %. Last month prevalence (LMP) for all adults range from 0 % to 1.1 %, two-thirds of whom are young adults (EMCDDA, 2007f).