Crack cocaine remains one of the most persistent and complex challenges in England’s treatment system, yet much of the way services are still organised reflects models built primarily around opioid dependence rather than stimulant use. In England, 32,399 adults starting treatment in 2024 to 2025 reported problems with crack cocaine use, representing 19% of all new treatment presentations [1]. This is not a marginal issue but a substantial part of frontline practice.

National data reinforce the breadth of the problem. Dame Carol Black’s Independent Review of Drugs estimated that the 300,000 people using opiates and crack in England account for 86% of the £19 billion annual cost of illicit drug use, equivalent to around £58,000 per user per year [14]. Yet the same review found that the number of people in treatment had fallen since 2014, partly due to a 17% real-terms cut to adult treatment budgets and a loss of skilled practitioners from the workforce [15]. Crack cocaine presentations to treatment, both with and without opiates, increased by 32% between 2013/14 and the review date, while successful completion rates for crack users declined [26].

Crack use often presents differently from opioid use: binge-and-crash patterns, rapid destabilisation, paranoia, and a very narrow window in which someone may be ready to engage. As the older specialist literature and later national evidence both suggest, the central challenge is often not simply what treatment is offered, but whether people can be engaged quickly, credibly, and intensively enough to stay with it...