Cocaine Use

in America:

Epidemiologic

and Clinical

Perspectives

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration
Cocaine Use in America:

Epidemiologic and Clinical

Perspectives

Editors:

Nicholas J. Kozel, M.S.

Edgar H. Adams, M.S.

Division of Epidemiology and Statistical Analysis

National Institute on Drug Abuse

NIDA Research Monograph 61

1985

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland 20857

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, DC. 20402
NIDA Research Monographs are prepared by the research divisions of the

National Institute on Drug Abuse and published by its Office of Science. The

primary objective of the series is to provide critical reviews of research problem

areas and techniques, the content of state-of-the-art conferences, and

integrative research reviews. Its dual publication emphasis is rapid and targeted

dissemination to the scientific and professional community.

Editorial Advisors

MARTIN W. ADLER, Ph.D.

Temple University School of Medicine

Philadelphia, Pennsylvania

SYDNEY ARCHER, Ph.D.

Rensselaer Polytechnic lnstitute

Troy, New York

RICHARD E. BELLEVILLE, Ph.D.

NB Associates, Health Sciences

Rockville, Maryland

KARST J. BESTEMAN

Alcohol and Drug Problems Association

of North America

Washington, D.C.

GILBERT J. BOTVIN, Ph.D.

Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph.D.

The Johns Hopkins University School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph.D.

Washington University School of

Medicine

St. Louis, Missouri

SIDNEY COHEN, M.D.

Los Angeles, California

MARY L. JACOBSON

National Federation of Parents for

Drug-Free Youth

Omaha, Nebraska

REESE T. JONES, M.D.

Langley Porter Neuropsychiatric lnstitute

San Francisco, California

DENISE KANDEL, Ph.D.

College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER, M.D.

Yale University School of Medicine

New Haven, Connechicut

RICHARD RUSSO

New Jersey State Department of Health

Trenton, New Jersey

NIDA Research Monograph Series

CHARLES R. SCHUSTER, Ph.D.

Drector, NIDA

JEAN PAUL SMITH, Ph.D.

Acting Associate Director for Science, NIDA

Acting Editor

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Cocaine Use in America:

Epidemiologic and Clinical

Perspectives
ACKNOWLEDGMENT

This monograph is based upon papers presented at a technical

review of patterns of cocaine use in the United States which took

place on July 11-13, 1984, at Bethesda, Maryland. The conference

was sponsored by the Division of Epidemiology and Statistical

Analysis, National Institute on Drug Abuse.

COPYRIGHT STATUS

All material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors.

Citation of the source is appreciated.

Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the

National Institute on Drug Abuse or any other part of the U.S.

Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific

commercial product or commodity. Trade or proprietary names

appearing in this publication are used only because they are considered essential in the context of the studies reported herein.

DHHS Publication No. (ADM)90-1414

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1985, Reprinted 1987, 1990

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics

Index, Biosciences Information Service, Chemical Abstracts,

Current Contents, Psychological Abstracts, and Psychopharmacology

Abstracts.

iv
Foreword

Over the past 10 years, cocaine, which has been characterized as

powerfully addictive, has evolved from a relatively minor problem

into a major public health threat.

In the early 197Os, evidence on the reinforcing potential of

cocaine suggested that if the use of the drug became widespread

major social and public health problems could ensue. Fortunately,

NIDA had epidemiologic surveys and surveillance systems in place

which enabled it to monitor the prevalence of drug use, cocainerelated emergency room cases, and treatment admissions. These

efforts have documented dramatic increases in the use of cocaine

in the general adult and high school populations of the United

States. As the use of cocaine increased, parallel increases in

emergency room visits, overdose deaths, and clinical problems

reflected by increased treatment admissions were noted. Although

the prevalence of cocaine use in the general population appears to

have leveled off since 1979, the adverse consequences have continued to increase dramatically. Several explanations, including

increased combination drug use, a shift to more dangerous routes

of administration, and the lag time from first use to entry into

treatment have been offered to explain this phenomenon. There is

evidence to suggest that each of these explanations may in fact

contribute to the increased negative consequences associated with

cocaine. Yet, as much as we know about the epidemiology of

cocaine use, many questions remain. It is unknown, for example,

whether the increasing number of freebase users seen by clinicians

reflects an increase in the numbers of people smoking freebase or

a reflection of the increased risk of this route of administration. While our surveys have given us good estimates of the

number of people who have used cocaine, we still need an estimate

of the proportion of the using population who have experienced

problems due to their drug use. In contrast, clinicians often see

the problem users but may not collect sufficient drug histories so

that risk may be assessed and have no contact with users who are

not experiencing problems. The dialogue between epidemiologists

and clinicians at the technical review on which this monograph is

based increased the awareness of these issues and the benefits to

be derived from increased interaction between epidemiologists and

clinicians. One result of the technical review was the inclusion

of a problem measurement section in the 1985 National Household

Survey on Drug Use. Another is the publication of this monograph

which represents an important contribution to our understanding of

cocaine use and abuse.

Charles R. Schuster, Ph.D.

Director

National Institute on Drug Abuse

V

Contents

Foreword

Charles R. Schuster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V

Cocaine Use in America: Introduction and Overview

Edgar H. Adams and Nicholas J. Kozel . . . . . . . . . . . . . . . . . . . 1

Cocaine Use in the United States: In a Blizzard or Just

Being Snowed?

Richard R. Clayton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

A Decade of Trends in Cocaine Use in the Household Population

Herbert I. Abelson and Judith Droitcour Miller . . . . . . . . . 35

Cocaine Use Among American Adolescents and Young Adults

Patrick M. O'Malley, Lloyd D. Johnston and

Jerald G. Bachman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Cocaine Use in Young Adulthood: Patterns of Use and Psychosocial Correlates

Denise B. Kandel, Debra Murphy and Daniel Karus . . . . . . . . 76

Patterns and Consequences of Cocaine Use

Dale D. Chitwood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Cocaine Abuse: Neurochemistry, Phenomenology, and Treatment

Mark S. Gold, Arnold M. Washton and Charles A. Oackis . . 130

Reinforcement and Rapid Delivery Systems: Understanding

Adverse Consequences of Cocaine

Sidney Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Characteristics of Humans Volunteering for a Cocaine

Research Project

C. R. Schuster and M. W. Fischman . . . . . . . . . . . . . . . . . . . . . . 158

Characteristics of Cocaine Abusers Presenting for Treatment

Sidney H. Schnoll, Judy Karrigan, Sarah B. Kitchen,

Amin Daghestani, and Thomas Hansen . . . . . . . . . . . . . . . . . . . . . 171

vii
Cocaine Use in a Treatment Population: Patterns and

Diagnostic Distinctions

Frank H. Gawin and Herbert D. Kleber . . . . . . . . . . . . . . . . . . . 182

Cocaine: Treatment Perspectives

Donald R. Wesson and David E. Smith . . . . . . . . . . . . . . . . . . . . 193

New Patterns of Cocaine Use: Changing Doses and Routes

Ronald K. Siegel ....................................... 204

Cocaine Use in America: Summary of Discussions and

Recommendations

Nicholas J. Kozel and Edgar H. Adams . . . . . . . . . . . . . . . . . . . 223

List of NIDA Research Monographs . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

viii
Cocaine Use in America:

Introduction and Overview

Edgar H. Adams and Nicholas J. Kozel

In the mid-1970s, as the reinforcing potential of cocaine was

being demonstrated in the laboratory, the prevalence of cocaine

abuse in the general household population of the United States was

increasing dramatically. The fourfold increase from 5.4 million

in 1974 to 21.6 million in 1982 in the number of people who

reported having tried cocaine at least once has been well documented (Blanken et al. 1985; Adams and Durell 1984). Based on

data from the National Household Survey on Drug Abuse (1974-1984),

lifetime prevalence of cocaine use continued to increase into the

early 1980s. The number of current users (used in the past 30

days), however, remained stable between 1979 and 1982.

Recent reports of increasing emergency room cases associated with

cocaine, increasing deaths, and rising treatment admissions for

cocaine problems have heightened concern that the incidence (new

use) of cocaine use may be increasing once again.

On the other hand, it has been suggested that this increase in

untoward effects of cocaine use Is the result of changing routes

of administration and more intensive patterns of use, including

the use of cocaine In combination with other drugs. It has been

noted also that the median time from first use of cocaine to entry

into treatment for cocaine related problems is approximately 4

years. Thus, the increase in untoward effects may not reflect new

incidence of cocaine use, but rather more destructive patterns of

use in the prevalence pool, the size of which stablized 3 to 4

years ago.

Whether we are talking about increases in the size of the

prevalence pool of abusers of cocaine or shifting patterns of use

within a relatively stable prevalence pool has clear implications

for the prevention programs designed to deal with this problem.

In the former case, a program would be designed to prevent the

initiation of cocaine use, while in the latter the approach would

attempt to alter any progression or intensification of use.

1
That we are in a situation of providing plausible hypotheses to

explain the apparent paradox of stable prevalence pools with

increasing consequences reflects our lack of knowledge of drug use

patterns in the general population. Specifically, data from

clinic populations indicate a shift to more dangerous routes of

administration, i.e., intravenous use and smoking freebase, more

frequent administration, increased dosages, and use of cocaine in

combination with other drugs. Yet, in the general population,

little is known about these patterns or about the probability of

progression from occasional to more intensified patterns of use.

This monograph results from a technical review which attempted to

explore these issues.

The subtitle of Clayton's paper "In a Blizzard or Just Being

Snowed?" is reflective on this question which so pervades the

popular press. Clayton poses a number of questions about the

prevalence of cocaine use, characteristics of users, the length of

time between first use and regular use, and the proportion of

users suffering problems which can be attributed to their cocaine

use. While these types of questions have been proposed for other

drugs, the emphasis on cocaine is due to the perception that

cocaine use has permeated all strata of our society. Using a

variety of data sets, Clayton attempts to address these questions.

He notes that while prevalence has increased sharply during the

past decade, cocaine use is clearly not normative in our society.

Perhaps more importantly, he demonstrates that not only are

cocaine users likely to abuse multiple drugs, but that they are

not naive users in the sense that most have used other drugs,

especially marijuana, prior to the use of cocaine. Thus, the

population at greatest risk of cocaine use is that population

which has used marijuana, especially those individuals who have

used marijuana 100 or more times.

From a temporal perspective, it is noted that the epidemic of

cocaine use began in 1976 and continued through 1981. The extent

to which the epidemic continues to increase remains open to question.

The National Survey on Drug Abuse began in 1971 under the auspices

of the National Commission on Marihuana and Druq Abuse. This is

significant in that, unlike the case with marijuana, the implementation of the National Survey predated the epidemic increases in

cocaine use. Thus, Abelson is able to trace this increase in

cocaine use in the household population from the mid-1970s through

1982. He notes that there were increases in use among all age

groups from 1976 to 1979, but that use, at least among youth aged

12 to 17 and young adults aged 18 to 25 appears to have reached a

plateau since 1979. Abelson goes on to suggest that cocaine use

among those 18 to 25 is more likely to include residents in large

metropolitan areas of the Northeast or Western part of the United

States, as well as white college educated males. He points out,

as did Clayton, that the cocaine user is a multidrug user who

often uses more than one drug on the same occasion.

2
Analyzing data from a survey of graduating high school seniors and

a panel of high school graduates beginning with the class of 1976,

O'Malley demonstrates a doubling of annual prevalence between 1975

and 1979 with subsequent leveling since that time. Consistent

with data cited by Abelson from the National Survey, cocaine

prevalence predominates among males, and those indivfduals residing in the Northeast and West, and in urban areas.

Perhaps more Importantly, followup data from various classes indicate increasing prevalence of use with each successive year following graduation. These increases are striking because other

illicit drugs show little change or even decrease in use subsequent to graduation. This suggests that the age of risk for

initiation into cocaine use continues beyond that for other drugs.

This finding is consistent with that reported by Kandel in this

monograph, i.e., the hazard rate or age-specific incidence rate

for cocaine increases through the midtwentles. Adams et al.

(1985) also have shown that increases in annual prevalence of

cocaine use in the 26 and older group in the National Survey are

the result of new use and not just aging of the population.

The issue of progression, that is, the extent to which cocaine use

at one point leads to more frequent and/or intensive use patterns

In the future is addressed in this monograph. Siegel, for

example, describes the use patterns of 99 volunteers who have been

followed since 1974. tie describes five levels of cocaine use

patterns: experimental use, social recreational use,

circumstantial-situational use, intensified use. and compulsive

use. The 99 volunteers were all social-recreational users when

recruited in 1974. While some users remained social-recreational

users the overall pattern of use from 1978 through 1982 marked an

escalation in dosages and dose regimes in this population. Using

another approach, both O'Malley and Chitwood have constructed

indices of cocaine use and have attempted to look at transitions

between levels of use. Using an index based on frequency of use,

O'Malley analyzes use patterns beginning in the base year, that is

graduation year up to 3 to 4 years postgraduation. The base year

measurement shows that only 1.2% of the responding population had

used cocaine 10 or more times during the previous year, while the

second followup in a population now aged 21 to 22 shows that 4.7%

had used cocaine 10 or more times in the previous year. It is

interesting to note the transitions that take place between and

among the various frequency of use categories in this population.

Using retrospective data in a population of cocaine users,

Chitwood developed an index based on self-reported route of ingestion, frequency of use, and quantity of use. Overall, there was a

progression in level of cocaine use from the initial year of use.

For example, in the initial year only 7% of the population were

considered high level users, whereas 27% of the population were

high level users during the most recent time frame. As with the

case of the data obtained from graduating high school seniors,

there was migration between various use levels. Thus, while in

general there appears to be some progression in the use of

cocaine, progression is not inevitable.

3
Using data derived from a population who have been followed since

they were in the 10th and 11th grades in 1971 and 1972, Kandel

assesses patterns of cocaine use and developmental patterns of

involvement in drug use in this population now in their midtwenties. Kandel compares five groups ranging from "no illicit

drug use" to "used cocaine plus other illicit drugs." The two

cocaine groups included "use of cocaine with marijuana" as the

only other illicit drug "used" and "use of cocaine plus other

illicit drugs." Interestingly, more that 80% of the cocaine users

fell into the latter category.

The groups were examined in six areas of lifestyle and level of

functioning. Those who had used cocaine plus other illicit drugs.

were the most deviant of all groups, including those who had used

other illicit drugs except cocaine. This finding tends to be consistent with the findings by Kaufman (1982). who has noted greater

pyschopathology in multidrug users.

Drawing on yet another population, in this case, a purposive

sample of cocaine users in treatment plus a snowball sample of

users not in treatment, Chitwood examines two key questions:

(1) problems associated with measuring patterns of cocaine use,

and (2) consequences of cocaine use.

Problems measuring patterns of cocaine use can be viewed from a

variety of perspectives, including the way in which the data are

collected (e.g., self-report or toxicologic analysis) as well as

the operational definitions and measures employed in the analysis.

For example, use and nonuse measures can be used to answer questions about exposure, but cannot be used to relate consequences to

intensity of use or, more specifically, dose effect relationships.

As with the measurement of drug patterns, consequence data can

also be collected either as self-report or through clinical examination. Consequences can be either the result of acute effects of

the drug or debilitating effects resulting from chronic administration. Chitwood examines these issues and relates the consequences not only to level of drug use but also to route of administration.

Individuals calling into "Hotlines" constitute another useful

population from which patterns and consequences of cocaine use can

be described. These data are the subject of discussion by Gold

and his colleagues. The large number of phone calls, now in

excess of 450,000, provide an invaluable source of data on a selfselected sample of users motivated to call a hotline and report

their problems and concerns.

Gold and his colleagues discuss drug use patterns and selfreported consequences on three separate populations, based on a

national survey of a subset of callers, upper income users, and

adolescent users. In addition, Gold and his colleagues discuss

the neurochemistry of cocaine and treatment issues, including

pharmacological adjuncts to treatment.

4
In making the transition from the general population and subsets

of the general population to clinical populations. Cohen reviews

the reinforcing properties of cocaine and consequences based on

these reinforcing properties, as well as other factors including

toxicity, route of administration, and interaction with other

diseases and drugs. The reinforcing properties of cocaine,

coupled with effective delivery systems and a relatlvely short

biological half-life, lead many to a pattern of compulsive use

which ultimately can cause disruptions in families and job performance as well as physical and mental deterioration. These

patterns may lead to the use of more dangerous routes of administration and/or higher dosages in which the risk of untoward

effects due to, for example, the cardiovascular actions of

cocaine, is increased.

Characteristics of fntravenous cocaine users volunteering for a

cocaine research project are reported by Schuster and Fischman.

The extent of

than half (57%) of the volunteers accepted into the experiment had

olydrug use in this population is strfkfng. More

used drugs from four or more classes of drugs in addition to

cocaine. Only 10% used cocaine alone. An important aspect of the

data provided in this chapter is that they were gathered from

individuals volunteering for research projects and not seeking

treatment. It is suggested that screening data of this type may

provide an important source for information about drug use in nontreatment populations.

Schnoll et al. and Gawfn and Kleber report on populations seeking

treatment for cocaine abuse. The population reported on by Gawin

and Kleber was 80% white, while Schnoll et al. reported an approxlmately equal distribution (45.3% black). The routes of administratfon generally considered to be more reinforcing, i.e., intravenous use and freebasing, were reported by more than 60% of these

populations. In each of these populations, freebase cocaine

smokers used more cocaine than either intranasal or intravenous

users.

Schnoll et al. suggest that since cocaine users In his treatment

population had long histories of use of other drugs, but did not

seek treatment, they may have been able to control their drug use

prior to using cocaine.

Gawin and Kleber looked at psychiatric diagnosis by route of

adminfstratfon and abuse patterns and suggest that the dangers of

fntranasal use have been underestimated since the highest proportion of subjects with diagnoses were cocaine snorters (fntranasal

users). The subjects had low weekly cocaine use but high intensity of use over short duration. This suggests not only the

potential danger of intranasal use, but also that more attention

must be given to collecting data on the patterns of use, including

whether binges occur, how often they occur, how long they last,

etc.

5
An overview of treatment perspectives, including signs and symptoms of cocaine dependence as well as recommendations for the

management of cocaine dependence, is provided by Wesson and Smith.

They also note that a large proportion of this population Is

involved in the stimultaneous use of sedative hypnotics in combination with cocaine. The effect is that the population entering

treatment is often dually dependent on cocaine and a sedative

hypnotic, often alcohol. This can, of course, Increase the

severity of withdrawal as well as Increasing the complexity of the

treatment. Problems in treating associated psychiatric disorders

in addition to the treatment of dependency also are discussed.

The history of cocaine use from a perspective of changing attitudes, routes of administration, and dosages Is reviewed by

Siegel. He also reports that some users are employing new routes

of administration, i.e., among select populations intranasal use

of freebase and the smoking of coca paste. He reports that contrary to user beliefs, the use of fntranasal freebase does have

risks of dependency and toxicity.

The use of coca paste, the dangers of which are well documented,

appears to be restricted to individuals associated with clandestine laboratories and trafficking. This is consistent with findings of Kozel (1985) in recent studies in Miami and New York.

Overall, there is an increasing recognition that, although

clinical populations are subsets of the general population,

clinical impressions may not reflect what is happening in the

population as a whole. Similarly, population surveys may not

adequately measure problem subgroups. For example, while only 4%

of high school students reported injecting cocaine, more than 20%

of those admitted to treatment did. Recognizing that different

populations are being measured is critical when interpretations of

the data are made.

All clinical populations, as well as those "hotline" participants

with self-identified problems, reported high rates of smoking

freebase or intravenous use; although it must be noted that intranasal use was reported by a large number of users. This is important since the dangers of fntranasal use are often overlooked due

to the increased attention paid to the "more dangerous" routes of

adminfstration.

Another factor which was consistent across all data sets was that

cocaine users are not naive users. On the contrary, many of them

have been heavily involved with other drugs and virtually all have

used marijuana.

Attempts by O'Malley, Chitwood, and Siegel to address issues of

progression and to measure levels of use represent interesting

approaches to understanding this problem. Sfmilarly, in clinic

populations, further efforts to define use patterns through grams

used, length of run, etc. will prove invaluable in identifying

risk factors and relating use patterns to consequences.

6
Finally, the need for improved problem measurement in the general

population and in clinic populations, including the use of diagnostic measures in general population surveys, is an area in which

rapid progress can be made. In this regard, some of the measurement concepts contained in this monograph represent a foundation

on which future efforts will be built.

REFERENCES

Adams, E.H., and Durell, J. Cocaine: A growing public health

problem. In: Grabowski, J., ed. Cocaine: Pharmacology,

Effects, and Treatment of Abuse. National Institute on Drug

Abuse Research Monograph 50. DHHS Pub. No. (ADM) 84-1326.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1984.

pp. 9-14.

Adams. E.H.: Gfroerer. J.C.: and Blanken. A.J. Prevalence.

Patterns and Consequences-of Cocaine Use. In: Brink, C.J., ed.

Cocaine: A Symposium, Madison: Wisconsin Institute of Drug

Abuse, 1985. pp. 37-42

Blanken, A.J.; Adams, E.H.; and Durell, J. Drug abuse: Implications and current trends. Psychiatric Medicine, in press.

Kaufman, E. The relationship of alcoholism and alcohol abuse to

the abuse of other drugs. Am J Drug Alcohol Abuse 9(1):1-17,

1982.

Kozel, N.J.. Reports of Coca Paste Smoking Field Investigations

in South Florida and New York. Rockville: National Institute

on Drug Abuse, Division of Epidemiology and Statistical

Analysis, Internal Reports, 1985.

AUTHORS

Edgar H. Adams, M.S.

Division of Epidemiology and

Statistical Analysis

National Institute on Drug Abuse

Rockville, Maryland 20857

Nicholas J. Kozel, M.S.

Division of Epidemiology and

Statistical Analysis

National Institute on Drug Abuse

Rockville, Maryland 20857

7
Cocaine Use in the United States:

In a Blizzard or Just Being Snowed?

Richard R. Clayton

INTRODUCTION

There has been a great deal of discussion recently about the

extent to which this country has been inundated by cocaine.

Stories abound about the incredible profits being made by the

cocaine barons. Sordid tales exist about the violence being perpetrated by the cocaine cowboys in south Florida. The sports

pages are filled with stories about newly rich athletic heroes

whose lives are being ruined by cocaine. Richard Pryor makes fun

about playing with fire as if his experience with freebasing is a

joke. Bob Woodward's biography about the fast life and times of

John Belushi and his untimely death from a speedball mixture of

heroin and cocaine creates quite a stir in the media. John

DeLorean has "name recognition" as much because of his sensational

trial for allegedly trying to set up a cocaine deal to refinance

his failing company as for his superbly engineered and innovative

automobile. It's "big news" when some glamour figure gets busted

for the possession or distributlon of cocaine or when they check

Into some well-known treatment center for a cocaine problem.

It is quite possible that Orwell may have been incorrect in

describing "big brother" as the Government spying on its citizens.

A more likely culprit is the American public, peeking through the

television set like a collective voyeur at the private lives of

public people. There is a real danger in this.

One can be easily lulled into thinking and believing that this

picture reflects reality; that the "beautiful and rich" people,

the chic, the jet-setters, and the sports stars are all caught up

in the use of cocaine. This Illogical leap in reasoning leads to

the inference that if one wants to be like his or her hero, then

one must do as they do, and what they do is okay because it is

related to *success." Simply put, cocaine use has been publicized

and glamourized to the point where some define it as a symbol of

success. an experience for those who have "arrived."

The subtitle to this paper, "In a blizzard or just being snowed?",

is a rhetorical question containing two words/terms that involve

snow, a word that has many different meanings. One of these terms

8
is "being snowed." This term usually refers to a situation in

which individuals are so impressed by another person that they are

unable to see that person for who and what he or she really is.

They are snowed blind to the other person's faults and cannot be

objective in their appraisal of them. The other term is

"blizzard," which refers to a massive snow storm that impairs

visibility and quickly covers the landscape.

The purpose of this paper is to examine some of the following

questions that illustrate the rhetorical question contained in the

subtitle of the paper.

Is cocaine use strongly correlated with "success" as

traditionally measured in our society? Stated differently, are the stories that appear in the media about

cocaine use among stockbrokers, lawyers, and other professionals more stereotypical than typical?

Are we "being snowed" into thinking that cocaine use is

widespread in the centers of finance, learning, justice,

and power in the United States?

On the other hand, is it possible that use of cocaine in

the United States is not so chic after all?

Is cocaine like most other drugs in our society, that is,

most likely to be used among those traditionally most at

risk for becoming involved with illicit drugs, the lower

class.?

IS cocaine use more prevalent among those at the lower

end of the educational, occupational, and social ladders;

those already involved with other illicit drugs; and/or

those not particularly flush with money to buy such commodities?

Who in the "general" population uses cocaine?

What characteristics distinguish cocaine users from nonusers?

Some of these questions can be addressed with data from existing

epidemiological surveys. However, it would be virtually impossible to determine if cocaine use is disproportionately higher in

some very restricted occupational groups (e.g., professional

athletes, entertainers, those who are Independently wealthy)

because the percentage of the population in these categories is

so small. Unfortunately, these persons receive such an inordinate amount of attention from the media that anything they do is

reported in great detail. Further, there is a tendency in the

mass media to focus on the wealth and conspicuous consumption

involved ("He went through a million dollars of cocaine in a

year!"). This type of sensationalism merely panders to the

fantasy lives of Americans and, in fact, paints what may be a

totally distorted picture of reality.

9
Are we being "snowed" about who is using cocaine and the connection of its use with indicators of success? Is it also possible

that there is a 'blizzard" of cocaine use occurring in the United

States that deserves special attention by public health authorities? Stated differently, has our society undergone an epidemic

of cocaine use that has permeated strata of society previously

untouched by the problem of illicit drug use? The best answer at

this point in time is: Perhaps. However, before we attempt to

provide answers to these types of questions, it is important to

review the reasons for giving special attention to cocaine.

REASONS FOR GIVING SPECIAL ATTENTION TO COCAINE

There may be literally hundreds of reasons for singling out the

use and abuse of cocaine as an issue of special concern. However,

there are three reasons in particular that justify the sense of

urgency and concern that has recently emerged about this drug.

These are: (1) the persistence and perpetuation of myths about

cocaine and its effects on users; (2) the "magnitude" of the problem of use and abuse of cocaine in the United States; and (3) the

potential social and economic costs that may be associated with

this drug, given the incidence and prevalence rates and the presumed sociodemographic characteristics of users and abusers.

Myths About Cocaine

Ours is a society in which there is a great deal of pride about

the sophistication of comnunications systems and the openness of

the media to competing views. However, these systems seem often

to become insulated from evidence that does not support the prevailing myths about various commodities. This has certainly been

the case with marijuana. It seems to have taken a long time for

scientific evidence concerning the harmful effects of marljuana

use to penetrate the popular media and, thus, begin to counter the

prevailing myth that use of marijuana is relatively benign

vfs-a-vis other drugs such as alcohol and tobacco.

Existing data do not provide support for the following assertions

or "myths": (1) cocaine is not addicting; (2) cocaine will

improve your sex life; (3) practically everybody is using it; and

(4) use of cocaine is a symbol of success, of having "arrived'

socially.

There is substantial evidence about how powerfully reinforcing

cocaine is (Wise 1984; Jones 1984) and its dependence liability

(Johanson 1984). There is also evidence that persons who abuse

cocaine develop tolerance, undergo withdrawal symptoms, and meet

other criteria commonly used to describe addiction (Morningstar

and Chitwood 1983). Articles In the popular press often tout the

potential of cocaine for enhancing sexual performance. However,

Chitwood (this volume) presents data to show that the greater the

involvement with cocaine, the lower the interest in sex. In fact,

impotence is not an unusual consequence of the abuse of cocaine.

As to the claim that practically everybody is using cocaine, one

10
need only examine the epidemiological data to know that this is

not true. For example, among national samples of high school

seniors, 9% in the class of 1975 had used it. There was a steady

increase in the percent having ever used cocaine up to 1981, when

the rate was 16.5%. In the classes of 1982 and 1983 some 16%

reported use of cocaine. Among seniors in the class of 1983, some

11.4% report having used cocaine in the previous year and 4.9% in

the previous 30 days. The last time the annual and 30-day prevalence rates were this low was in the class of 1978 (Johnston

et al. 1984). Data from the 1982 National Survey on Drug Abuse

(table 1) indicate lifetime, annual, and past month prevalence

rates by sex and age group.

TABLE 1

COCAINE PREVALENCE RATES BASED ON

THE 1982 NATIONAL SURVEY ON

DRUG ABUSE

Percent Who Used Cocaine

Past Past

Ever Year 30 Days

Males

Youth, 12-17 years old 7 5 2

Young Adults, 18-25 years old 35 25 9

Mid-Adults, 26-34 years old 26 13 4

Older Adults, 35 or older 7 3 1

Females

Youth, 12-17 years old 6 3 2

Young Adults, 18-25 years old 22 13 5

Mid-Adults, 26-34 years old 18 9 3

Older Adults, 35 or older 2 1 0

It is clear from these data that use of cocaine Is not normative,

at least not statistically, in any of these age and sex groups.

However, it is equally clear from a public health perspective that

the rates of use of cocaine are far too high, particularly among

young and mid-adults.

With these facts-versus-myths in mind, it is important for us as

drug abuse specialists to weigh carefully what is said about

cocaine. We have a special responsibility to "demythologize"

cocaine for the American public. In addition, as public health

specialists, we must begin to anticipate and develop plans for

deallng with emerging health problems. It Is quite possible that

use and abuse of cocaine is emerging as a problem.

11
Magnitude of the Problem

There seems to be general agreement that an "epidemic" of cocaine

use has occurred or is occurring in the United States, and perhaps

in other countries as well (Adams and Durell 1984). Because it is

emergent, we do not yet know the scope of the problem, whether it

has peaked or is still on the upswing, or when it might level out

and begin to decline. It will be important for epidemiologists to

compare the cocaine epidemic of the 1980s with the cocaine

epidemic that occurred in the 1880s. Will this new epidemic die

out rather quickly as did the epidemic of the last century, or

will it follow a different course and produce a sizable population

of chronic cocaine users (Mandell 1984)?

We know from laboratory studies that animals given unlimited

access to cocaine will keep using it until they pass out from

exhaustion or convulsions or until they die from overdose (Deneau

et al. 1969; Johanson et al. 1976). Even if one is extremely

cautious in extrapolating from these data to humans, It is clear

that the reinforcement properties of cocaine make it imperative

that we understand better the parameters of the cocaine epidemic

of the 1980s. The following exercise in logical inference is

based on data from the 1982 National Survey on Drug Abuse and

illustrates rather dramatically the potential magnitude and scope

of the cocaine problem in the United States, justifying a sense of

urgency about it.

* Of all persons in the household population in the

United States who were 12 years old or older, 22 million persons had used cocaine at some time during

their life.

* The "biggest" step in the process of drug use is from

nonuser to user. Given the reinforcing properties of

cocaine, it is likely that very few people ever use

cocaine only once and never try it again. Therefore,

at least 22 million Americans were vulnerable to a

continuation of use or a progression to more Intensive

use of cocaine. This is clearly an underestimate

because the National Survey is based on a sample of

the "household" population and excludes persons who

are transients and those who live in institutional

settings such as college dormitories, on milltary

bases, and in jails and prisons.

* Of the 22 million who have used cocaine, let's assume

that only 10% have used it more than occasionally.

This would mean that there are 2.2 million Americans

who are even more vulnerable or *at risk" for continuation of use or progression to abuse of cocaine. This

Is not an unreasonable estimate.

12
* Let's assume that one-half of those who have ever used

cocaine more than occasionally are seriously at risk

for continuation of use or even progression to abuse

of cocaine. We are now talking about 1.1 million

persons in the overall household population, 5% of

those who have ever tried cocaine.

* To make our estimates of the magnitude of the potential cocaine problem even more conservative, let's

assume that only one-half of the 1.1 million seriously

at risk for continuation of use or progression to

abuse are at risk for having "significant" problems

from their involvement with cocaine. This would equal

550,000 persons in the general household population--

only 2.5% of the 22 million Americans who have ever

tried cocaine.

The estimate of 550,000 Americans who may be significantly at risk

for experiencing problems from their use and abuse of cocaine is a

conservative one, an "underestimate" of the "true" prevalence of

the number of problem users of cocaine in this society.

From an historical perspective, the estimate of 550,000 is significant. When it was estimated in the early to mid-1970s that the

number of heroin addicts in the United States was about 500,000,

the Federal response was swift. In terms of order of magnitude,

the estimates generated above for problem cocaine users justify a

sense of urgency at the Federal level to focus more attention on

the "cocaine problem" in the United States.

There are a number of important research questions that emerge

quite naturally from the inferential process outlined above.

* What are the patterns of use of cocaine in this

society and how do these patterns vary across relevant

groups (male versus female, youth compared to the

three adult groups, whites compared to members of

racial minority groups, etc.)?

* How long does it usually take to move from first use

of cocaine to the onset of "regular" or "habitual" use?

* What proportion of "regular" users seem to be able to

moderate their use without progressing to abuse of

cocaine? What distinguishes those who are able to

moderate their use from those who progress to abusive

patterns?

* At what point in a cocaine-using career do problems or

consequences directly attributable to cocaine usually

begin to appear?

13
* What proportion of users or abusers of cocaine are

exhibiting problems or consequences from their use of

the substance? What kinds or types of users are

exhibiting the various consequences? What are the

treatment and other needs of users and abusers of

cocaine?

* If prevention and intervention efforts are developed,

who should be targeted (i.e., youth versus adults),

with what emphasis, using what techniques, and in what

kinds of settings?

These questions take on added significance when it is reported

that the price of cocaine on the streets has been going down

dramatically while the purity has been going up. Further, clinicians who specialize in the treatment of drug-abusing patients

report that the number of persons seeking help for cocaine abuse

seems to be increasing (Kleber and Gawin, this volume; Schnoll,

this volume).

Social and Economic Costs

The preceding section revealed in a rather simple fashion the possible extent of cocaine use in the United States. If these estimates are close to being "within the proverbial ball park," there

are two very practical political and economic issues that need to

be addressed. The first concerns macroeconomic estimates of a

cocaine industry generally thought to be worth $50 to $70 billion

annually. Even if these estimates of the size of the cocaine

trade are inflated, the amount of money moving in the gray economy

because of cocaine must exert a significant impact on the entire

economic structure of our society. Regardless of their accuracy,

such estimates point to the need for knowing the number of users

and the levels of consumption that generate such large sums of

money. This requires better epidemiological data and a fusion of

these data with police and other types of intelligence data concerning drug trafficking. The second practical political and

economic issue concerns the costs of drug abuse to American

society in terms of treatment dollars, hospitalizations, and lost

productivity and foregone earnings because of illness, disability,

death, crime, and other consequences of cocaine use. From a cold,

hard, and rational economic perspective, the productivity and

foregone earnings lost to society because of the premature death

of a street level heroin addict may be relatively small. This

will be true especially if the addict has been chronically unemployed, in and out of treatment and jail, often involved in crime

to support his or her habit, and receiving various kinds of transfer payments from the welfare system.

Let's assume, at least for a moment, that the reports of extensive

cocaine use within professional and managerial categories of

employment are not too exaggerated. Suppose a stockbroker, a

Madison Avenue advertising executive, or a lawyer in a top firm

dies prematurely from an overdose of cocaine. In this case, from

14
a cold, hard, and rational economic perspective, the foregone

earnings loss to society of such a death could be substantial.

It is therefore imperative that the stories of personal tragedy

that alert clinicians and health care personnel to the problems of

cocaine abuse be linked with treatment data from other sources,

with epidemiological data on the patterns of use, and with drug

intelligence data, so that we can begin to understand better the

social and economic costs to society of cocaine abuse.

It is clear at this point in time that there is a dearth of reliable data from all sectors of the drug abuse community from which

the parameters and essential components of the cocaine problem can

be validly assessed. It is equally clear from what little we know

for certain, and from what we think we know, that cocaine is

emerging as a public health problem requiring considerably more

attention and anticipatory planning than it has received thus far.

We must also begin to weave together into a more coherent picture

the somewhat conflicting images of the problem of cocaine use and

abuse coming from different segments of the community of specialists who study and treat drug abuse. When one examines the incidence and prevalence curves from epidemiological surveys of the

general population, there seems to be a leveling out of use. At

the least, a plateau of use seems to have been reached (Abelson,

this volume). However, as noted earlier, clinicians seem to be

reporting a substantial increase in the number of middle class

clients seeking therapy because of their dependence on cocaine

(Kleber and Gawin, this volume; Schnoll, this volume). Some

experts (Washton and Gold, this volume) claim the cocaine problem

is concentrated in the more affluent segments of the class structure. However, even a cursory examination of data from clients in

traditional drug treatment settings reveals a large proportion

using cocaine (Craddock et al. 1982). Wish (1985) reports that

over 40% of arrestees in central Harlem have the metabolites of

cocaine in their urine. These are people at the bottom of the

social class ladder, people who have very few skills to trade in

the marketplace and who often exist on a subsistence budget. How

can they afford to use the so-called "rich man's drug?"

How can these seemingly disparate findings be reconciled? Are we

in the midst of an epidemic of cocaine use in the United States?

Does the epidemic resemble a full blown blizzard, a snow storm, or

just some snow flurries? Are we being snowed into believing a

blizzard exists when, in fact, cocaine is just the latest fad drug

to appear on the drug scene and is creating just a "temporary"

fuss? Is the use of cocaine strongly associated with high social

status or are we being snowed into believing this is so by narrow

and biased reporting?

In the section that follows, we begin to address some of these

questions with existing data from a variety of sources. The first

data to be examined come from the treatment system and hospital

emergency rooms (ERs).

15
PROBLEMS WITH COCAINE: EMERGENCY ROOM AND TREATMENT DATA

It would be fair to say that most seasoned observers of the drug

scene see evidence of a cocaine epidemic occurring in the early to

mid-1980s. Everyone is just waiting to see which direction it

will take and what its eventual proportions will be. This can be

seen most clearly in a report from the 15th Community Epidemiology

Work Group covering the 6-month period from June through December

1983. In it, the following overall appraisal appears.

Cocaine continues its high visibility in the drug scene.

Of note is its emergence and increasing use among all

socio-economic levels of the population. Reports from

most cities indicate that cocaine is readily available

with increasing purity levels and decreasing prices.

In a section of the same report dealing specifically with cocaine

on a city-by-city basis, the following assessments appear.

Once considered an upper class drug, cocaine use has

crossed social class lines and is now becoming popular

among all segments of society.

San Francisco. Despite the apparent leveling off of use

during 1983, there has been widespread and increasing

prevalence of the more intensive usages of cocaine,

particularly freebasing, injection, and a tendency to use

the drug in a polydrug context.

Los Angeles. The upsurge in cocaine indicators is

dramatic--emergency room mentions continued to rise,

police seizures almost doubled, and cocaine related overdose deaths increased by almost 50% between 1981 and 1983.

Chicago. Cocaine is the only drug which shows a definite

pattern of increasing use with indications of a significant increase in purity.

St. Louis. Use of cocaine is increasing primarily among

intravenous addicts. Police cases show steady increases,

from 90 in 1981 to 120 in 1982, while treatment

admissions for primary cocaine use rose dramatically from

35 during all of 1982 to 35 during the first 6 months of

1983.

Denver. The police department reports that the major

drug abused on the streets of that city is cocaine.

Miami. Cocaine is the leading drug of those entering

drug free treatment. There has been no change in the

upward movement for cocaine use in Miami--ER mentions

were up 23% and among those entering treatment, 50%

reported cocaine as their primary drug of abuse.

16
In both Newark and New York, cocaine use has increased,

particularly when reported as the primary drug of abuse

at admission.

Washington, D.C. There is a significant increase of 33%

in emergency room mentions for cocaine and a 20% increase

in treatment admissions.

The figures reported above are rather high and alarming and seem

to reflect a similar phenomenon in different regions of the

country. At face value, they indicate agreement among trained

observers about sharp increases in cocaine-related problems, e.g.,

emergency room episodes in which cocaine is the primary drug mentioned, overdose deaths related to cocaine abuse, and seizures of

cocaine by the police. The skills and experience of these observers, as well as their sensitivity to what is happening in their

own cities, is not subject to question. The consistency of findings speaks well for the reliability of these community-based

reports.

However, two sets of existing data might lead one to question the

magnitude of the reported increases and the role played by cocaine

in the consequences. First, cocaine was mentioned as the

"primary" drug of abuse in 6,190 out of 199,093 episodes in data

from the Drug Abuse Warning Network sample of emergency rooms in

1982. As the data in table 2 show, this means that cocaine

accounted for only 3.1% of all emergency room drug-related

episodes. While there may have been large increases in some

locales in the number of episodes associated with cocaine, overall, the magnitude of the cocaine problem evidenced in emergency

room data is not large compared to the number of episodes associated with other drug classes. Furthermore, close examination of

the cocaine data in table 2 indicates that for 71% of the

instances where cocaine is the primary drug of abuse, at least one

other drug was implicated in the episode. Stated differently,

persons presenting themselves in emergency rooms in 1982 who list

cocaine as the primary drug of abuse were quite likely to be abusing a number of other drugs at the same time.

Second, the Treatment Outcome Prospective Study (TOPS) is another

data set that has relevance for the reported dramatic increases in

cocaine use and the consequences of use. Using data from the 1979

TOPS cohort, only 125 or 3.7% of the 3,389 clients listed cocaine

as their primary drug problem. As the data in table 3 show, 69%

of those listing cocaine as their primary drug problem reported

weekly or more frequent use of alcohol. The respective figures

for weekly or more frequent use of other drugs were: marijuana,

71.5%; heroin, 27.2%; minor tranquilizers, 20.9%; and amphetamines, 22.7%. In other words, drug abuse treatment clients in the

1979 TOPS cohort who reported cocaine as their primary drug of

abuse were essentially multiple drug users. This finding is

clear, regardless of which drug is singled out by the clients as

their primary drug problem. It is also clear that those clients

who entered treatment because of heroin abuse--the largest group

17
(n = 1,439)--were not unfamiliar with cocaine in spite of its

general reputation as a very "expensive" drug. Some 42% of the

heroin abusers reported weekly or more frequent use of cocaine.

TABLE 2

Percent Distribution of Drug Mentions

by Number of Other Drugs Used in

Combination According to Drug Class:

Drug Abuse Warning Network (DAWN):

1982 Emergency Room Data

Drug Class

Tranquilizers

Narcotic/Analgesics

Nonnarcotic/Analgesics

Nonbarbiturate/

Sedatives

Antidepressants

Antipsychotics

Barbiturates/Sedatives

Amphetamines

Hallucinogens

Alcohol in

Combination

Cocaine

Marijuana

Total Drug Mentions

Number of Other

Drugs in Episode

0 12 3+

30 39 25 7 100 21,968

47 31 17 5 100 22,503

39 33 20 7 100 17,557

36 34 25 6

40 32 21 7

46 30 20 5

25 39 29 7

35 30 30 6

51 28 17 4

** 70 27 4

29 40 26 5 100

22 38 36 5 100

32 38 23 6 100

Total

100

100

100

100

100

100

100

Number of

Mentions

14,499

8,346

8,336

7,256

5,081

7,163

29,348

6,190

5,295

199,093

It should be noted that the clients in the TOPS survey were in

"traditional" drug treatment modalities. They fit the prevalent

stereotypical image of the heroin addict: undereducated,

frequently unemployed, and when employed, working in unskilled

jobs; involved in crime to support their habit; and involved in

the use and abuse of multiple drugs. The results from the TOPS

survey support the first part of an observation made by David

Smith (1984, p. 5) of the Haight-Ashbury Free Medical Clinic: "In

1965, cocaine was perceived as a drug of high abuse potential,

confined primarily to the hard core drug culture and closely associated with heroin." The second part of Smith's observation is

somewhat more tenuous and is subject to some debate: "Dramatic

shifts in attitude occurred in the late 1960s and early 197Os, and

now the drug is perceived in many circles as a benign substance of

low abuse potential with wide acceptance through all strata of our

society."

18
Primary Drug

of Abuse

Alcohol

Marijuana

Cocaine

Heroin

Minor Tranquilizers

Amphetamines

Totals

TABLE 3

Weekly or More Frequent Use of Various Drugs by

Primary Drug of Abuse for the 1979 TOPS Cohort:

An Abbreviated Table

No. of

Subjects

188

239

125

1,439

88

125

2,204*

54% 60% 9% B% 75% 18%

66% 75% 13% 6% 28% 83%

3,389 57% 65% 27% 45% 25% 18%

Drugs Used Weekly or More Often

Alcohol Marijuana Cocaine Heroin Tranquilizers Amphetamines

90% 63% 6% 3% 18% 27%

65% 95% 11% 4% 17% 71%

69% 72% 82% 27% 21% 23%

53% 64% 42% 88% 21% 11%

*The 2,204 subjects who listed these six drug/drug classes as their primary drug problem constitute 65% of the total number of clients in the study.

Source: Bray et al. 1982, p. 34.
COCAINE USE IN THE GENERAL POPULATION:

ITS RELATIONSHIP TO USE OF MARIJUANA

Is the latter part of Smith's observation accurate in America in

the mid-1980s? Has cocaine really gained wide acceptance throughout the class structure? The answer is yes if one takes seriously

the following excerpt from a recent trade book on cocaine.

When marijuana was achieving wider social acceptance during the sixties, it became the *great differentiator" In

many social milleus . ..Cocaine has replaced the role of

pot as a great differentiator and serves the same social

purpose. (Stone et al. 1984, p. 15)

How seriously should such claims about the degree to which cocaine

has penetrated and permeated the social mores of our society be

taken? Are Stone and her colleagues correct In this claim? Or,

are they extrapolating from a very select and relatively distinct

part of the overall population? Is cocaine the "great differentiator" (i.e., the key factor that divides the population into one

group or another) throughout the United States--ln the quaint and

picturesque towns and villages of New England, the Southeast, and

the Midwest; in the medium and large cities located by the great

rivers of this country; or even in the major metropolitan centers

of this land? The answer can be found in some of the existing

epidemlological surveys of drug use and I believe the answer is

"No." Whether or not a person uses cocaine is simply not considered by the vast majority of Americans as the 'great differentiator."

National Survey on Drug Abuse, 1982

The 1982 National Survey was the seventh in a series that began in

1971. It involved a random sample of the household population in

the continental United States that consisted of 5,624 individuals

12 years old or older. The lifetime, annual, and past month rates

of use of cocaine were as follows: youth 12 to 17 years old (7%

lifetime, 4% past year, and 2% past month); young adults 18 to 25

years old (28% lifetime, 19% last year, 7% past month); mid-adults

26 to 34 years old (22% lifetime, 11% past year, 3% past month);

and adults 35 years old or older (4% lifetime, 1.4% past year,

0.5% past month).

In this sample, as in other samples of the "general" population,

use of cocaine is more prevalent among whites than nonwhites,

males than females, persons who live in major metropolitan areas

compared to rural areas, etc. One thing that does seem to differentiate best who will or will not use cocaine is use of marijuana.

As the data in the last column of table 4 show, the lifetime

prevalence of cocaine use is markedly different in the various age

groups. The most widespread use of cocaine occurs in the two

groups that were 18 to 34 years old in 1982 (i.e., those born

20
between 1948 and 1964). These young and mid-adults represent the

baby boom generation in the societal age structure. They were the

ones whose passage through late adolescence and young adulthood

coincided with the epidemic of marijuana use In the middle to late

1960s (O'Donnell et al. 1976).

TABLE 4

Extent of Marijuana Use Among Males by Age Group

1982 National Survey on Drug Abuse

Age Group

1-2 3-10 11-99 100 +

No Use Times Times Times Times Total

Males/Cocaine Use

Youth (12-17 years) * 4 4 27 60 7%

Young Adults (18-25 years) 2 4 27 44 73 35%

Mid-Adults (26-34 years) 2 3 15 35 70 26%

Older Adults (35 & older) 0 0 18 51 82 7%

*Less than .5%

It is equally clear from the data in table 4 that extent of use of

marijuana is strongly related to the probability that one will use

cocaine. For example, among young adult males only 2% of those

who have never used marijuana have tried cocaine. The figures

increase linearly, from 4% among those who have used 1 to 2 times,

to 27% of those who have used marijuana 3 to 10 times, to 44% for

those who have used marijuana 11 to 99 times. Of the young adult

males who have used marijuana 100 times or more, 73%. almost three

out of every four, report having used cocaine. The respective

percentages and the pattern of findings for youth, mid-adults, and

older adults are comparable in terms of the increase in cocaine

use that is associated with more extensive use of marijuana. This

finding is replicated in many studies (Yamaguchi and Kandel 1984;

O'Donnell and Clayton 1982; Clayton and Voss 1981) using different

samples and different age groups.

Monitoring the Future Studies, Class of 1980

Each year since 1975, researchers at the University of Michigan

have conducted studies of drug use among public and private high

school seniors from a randomly drawn sample of high schools in the

continental United States. The 15,000 to 18,000 seniors representing their class complete one of five forms of a questionnaire

that includes a core set of items dealing primarily with drug use

and sociodemographic variables. The remainder of each form contains Items covering a wide variety of substantive attitudinal and

behavioral topics (Johnston et al. 1984).

21
The relationship between use of marijuana and use of cocaine is

quite strong. Only 0.3% of seniors from the class of 1980 who had

never used marijuana reported having tried cocaine. The following

figures were found for cocaine use relative to extent of use or

marijuana: marijuana 1 to 2 times (1.8% cocaine); marijuana 3 to

5 times (5.6% cocaine); marijuana 6 to 9 times (5.9% cocaine);

marijuana 10 to 19 times (11.3% cocaine); marijuana 20 to 39 times

(10.7%). Among those who reported using marijuana 40 or more

times, 52.6% of the seniors in the class of 1980 reported having

tried cocaine. This pattern of the marijuana-cocaine relationship

replicates the relationship shown in table 4 for persons of

various ages.

Extent of use of cocaine was regressed against eleven predictor

variables from Form 1 of the questionnaire for the class of 1980.

Sociodemographic as well as attitudinal and other behavioral

variables were included in the equation (see Clayton and Ritter

[1985] for a more detailed discussion of these variables). The

data in table 5 show quite clearly that the two strongest predictors of cocaine use among high school seniors are extent of use of

marijuana and truancy (number of days school was cut in the past

month). It is interesting to note that cigarette smoking experience was the third variable to enter the equation for both males

and females.

These findings have significant implications in a number of areas

of the drug policy arena. For example, a substantial proportion

of the drug abuse prevention efforts in place in the United States

are curriculum centered and school based. It is tempting to claim

that the best way to prevent drug abuse among youth is to provide

them with better knowledge and skills so that their "changed"

knowledge base and newly acquired skills will affect their decisions concerning drug use. This is an appealing argument. However, the data presented in table 5 indicate that the best predictors of cocaine use may be less ephemeral than attitudes and

knowledge. E-very school system keeps records on truancy. It is

possible that special efforts to keep young people in school may

have substantial value as a drug prevention strategy. The fact

that cigarette smoking is a significant predictor of cocaine suggests that eliminating the privilege of smoking at school or on

school property could have value as a drug prevention strategy.

Certainly, when a student is "stoned" in the classroom, it is a

sign for action by the school to deal with that student's drug

problem.

From an epidemiological and etiological perspective, the data in

table 5 imply that use of cocaine in the United States may be best

understood with reference to use of other drugs, particularly the

gateway drug marijuana. At the individual level an overwhelming

majority of those who have used cocaine have previously used marijuana. The following scenario describes a common experience of

those who have started using cocaine. A person first uses marijuana at a party or with friends. It is given to him or her as a

gift. Over time, if use continues, the person's friendship group

22
increasingly is limited to other users. Larger and larger proportions of the person's social occasions are organized around the

use of marijuana. At some point, the person will buy his or her

own supply, often in order to throw a party. As time goes on, he

or she will recognize that by buying in bulk it is possible to

cover one's own consumption costs by selling some to friends and

acquaintances. A key predictor of use of drugs such as cocaine is

involvement in buying and selling (Johnson 1973; Clayton and Voss

1981). Eventually, one or both of the following will happen. The

person will be invited to a party by someone in his or her

drug-using network of frlends and will be offered some cocaine.

Or, the person's supplier of marijuana will say: "Look, you are a

great customer and friend. To show my appreciation, I want to

give you a present. I just got in a supply of some good quality

cocaine. Try it, you'll like it!"

TABLE 5

Extent of Use of Cocaine Regressed Against Predictor

Variables from Form 1 of the Questionnaire by Sex:

Class of 1980 Monitoring the Future Study

Predictor Variables in the Value

Order in Which They Entered of

the Equation by Sex Beta* b** F

Males

Marijuana use/lifetime .179 .375 596.7

Days cut school/past month .172 .188 230.9

Cigarette smoking experience .075 .083 38.5

Mother's education .033 .033 5.3

Mother worked while growing up -.030 -.026 5.0

Alcohol use/lifetime -.021 -.031 4.8

High school grade point -.027 -.043 7.4

Adjusted r2 = .253 with 11 predictor variables

Females

Marijuana use/lifetime .148 .359 409.2

Days cut school/past month .093 .117 78.2

Cigarette smoking experience .048 .068 17.5

Father's education ,033 .048 10.2

Rural-urban residence -.014 -.029 5.3

Self-perceived relative IQ +.054 +.055 9.7

High school grade point -.013 -.024 2.2

Adjusted r2 = .203 with 11 predictor variables

Cumulative

r square

change

.213

.032

.005

.002

.OOl

.OOl

.OOl

.184

.013

.002

.002

.OOl

.001

.001

*Value of the unstandardized beta weights in a stepwise multiple

regression equation with lifetime extent of cocaine use (7 categories of use) as the dependent variable.

**Standardized b values with lifetime extent of cocaine use as the

dependent variable.

23
The data presented In tables 4 and 5 do not lend support for

Smith's (1984) observation that use of cocaine has gained wide

acceptance or for the claim by Stone et al. (1984) that cocaine

has replaced marijuana as a major differentiating factor in

American society. If anything, these data provide a powerful and

persuasive argument that the best way to insure that people will

never use cocaine is to prevent them from becoming heavily

involved with marijuana. It is also quite clear that cocaine use

is widespread, particularly among those who are in the baby boom

birth cohorts. Problems resulting directly from use of cocaine

are most likely to appear among young adults 18 to 25 years old

and mid-adults 26 to 34 years old. These are the people in our

society who are the parents of young children or adolescents.

This group of mid-adults have already been through the drug

epidemic of the 1960s and 1970s. What will they tell their

children about drugs? How will they deal with personal decisions

about the use of cocaine?

THE EPIDEMIC OF COCAINE USE: NEW USERS AND THE BLIZZARD

There are several signs of the appearance of an epidemic. The

most common one is a marked increase in the number of persons having the condition who previously had been untouched by it (i.e.,

new users of cocaine). Another common sign is the spread of the

condition into subgroups of the population that previously seemed

immune to it (i.e., changes in the age at onset such that cocaine

use has spread into older age groups or into the very young age

groups). Another sign would be a marked increase in the number of

users having problems resulting from their drug use. A final sign

would be a marked increase in the annual prevalence of use of

cocaine. Unfortunately, reliable data do not exist for this last

sign of an epidemic of cocaine use. However, data do exist for

the first three signs.

The data in table 6 show the number of new users for each year

from 1954 to 1982 and the percent of all users who started using

cocaine in each year, for both the 1982 and the 1979 National

Surveys. The year of onset was obtained by adding the age at

onset to the birth year. For the 1982 survey, there was a bulking

of new cocaine users in the years 1979, 1980, and 1981. There was

a 49% increase in the number of new users from 1978 to 1979.

Furthermore, 47% of all the persons In the 1982 survey who had

used cocaine reported that they started using In one of these 3

years. It Is therefore not surprising that many seasoned observers reported the emergence of an epidemic of cocaine use in the

early 1980s. An examination of the data from the 1979 National

Survey reinforces the basis for the perception of an emerging

epidemic of cocaine use. The bulk of new users of cocaine are

found in 1977 and 1978. Some 37% of all persons who reported having used cocaine report initiation of cocaine use in one of these

2 years. In fact, there Is almost a 100% increase in the number

of new users from 1976 to 1977, from 54 to 105. It is important

to note that by fusing these two surveys there is a bulking of new

users in the 5 years from 1977 through 1981.

24
The evidence is reasonably clear at this time. It appears that

there has been an epidemic of cocaine use in the United States.

It occurred in the late 1970s and early 1980s. From the size of

the increase in the number of new users across adjacent years, it

is safe to say that the epidemic of cocaine use was not merely

snow flurries. Whether it deserves being described as a blizzard

or a snow storm requires further study. When the data are available from the 1985 National Survey, it will be possible to assess

whether the epidemic is continuing, has peaked and reached a

plateau, or is beginning to decline, at least in terms of "new"

users. What is especially needed at this time are epidemiological

data on the emergence of problems among cocaine users. How long

does it take from onset of use to onset of regular or habitual

use? The best estimates from clinicians indicate the hiatus commonly takes 3 or more years. Therefore, given the bulking of new

cocaine users between 1977 and 1981 (see table 6). it is not surprising to hear clinicians in 1984 reporting large increases in

the number of patients seeking treatment for cocaine.

The data in table 7 show the separate percentages of males and

females for each age from 12 to 40 who reported having used

cocaine, and their median age at onset of use. When one examines

the columns for percent of users by age in 1982, two findings are

apparent. First, in a large majority of the comparisons, a larger

percentage of males than females report having used cocaine.

Second, the percentage of users of cocaine is especially high in

the young adult ages, but quite high as well among those in the

mid-adult ages. Although more refined analyses are requlred, ft

is a plausible hypothesis that the epidemic of cocaine use spread

rather quickly through the part of the population already vulnerable because of prior involvement with marijuana, i.e., those in

the baby boom cohorts. The columns on median age at onset for the

mid-adults and older adults suggest that initfation of cocaine use

may be primarily an adult phenomenon. One of the problems with

median age at onset data is that they are limited by the age of

the respondents.

Another problem is the size of n for computation of the medians.

Still another is the effect of outliers on the medians when the

number of users in a birth cohort is relatively small. One or two

people with very low ages at onset can pull the overall median

down considerably. With these caveats in mind, the data in table

7 do suggest the appearance of an epidemic of cocaine use that is

more historical than individually developmental.

CHARACTERISTICS OF COCAINE USERS: ARE WE BEING SNOWED?

As noted earlier in this paper, the media seem to exert a tremendous influence on how social problems are defined and on our

understanding of the parameters of these problems. The image that

has been created for cocaine is that it is the "champagne' of

drugs. This has as much to do with who we think is using it as it

does with its presumed high price. Stories about cocaine imply

that use of this drug is considerably more likely to occur the

higher one's education, income and occupational prestige. Are we

being snowed into thinking that cocaine is a glamour drug?

25
TABLE 6

Number of New Users of Cocaine and Percent of All Users

of Cocaine Who Started That Year: 1982 and 1979

National Surveys on Drug Abuse

Note: The years which produced the largest number of new users

of cocaine are connected by the following notation:

(*******). 

*Less than .5%

26
TABLE 7

Percent Who Had Ever Used Cocaine and Median Age at

Onset of Use of Cocaine by Sex and Age:

1982 National Survey on Drug Abuse

*Medians were not computed for any age group in which

the number of users of cocaine was less than 10.

27
if cocaine use is correlated with educational attainment and other

indices of social class, there should be an almost linear increase

in the percentage reporting having used cocaine as one reads down

each set of percentage figures in table 8. Use of cocaine does

seem to be related to educational attainment. The two groups with

the largest percentage of users are those with some college and

those with a baccalaureate or higher degree. The two lowest

groups are those who never finished high school. The employed are

considerably more likely than the unemployed to report having used

cocaine. Among those who are employed, managers have the largest

percentage of users (26.6%), followed by skilled workers (19.6%),

service workers (18.3%), and then by professionals (17.1%).

Thus, the distribution of cocaine use by employment type does not

support the perception that cocaine use is considerably more

prevalent among professlonals. Among those who were unemployed in

the month preceding the survey, the lifetime prevalence of cocaine

use is considerably higher among students and those truly unemployed than it is among housewives. There is certainly no linear

relationship between reported family income and lifetime prevalence of cocaine use. The groups with the largest percentage of

cocaine users are those making $50,000 or more and those making

between $10,000 and $20,000. The rate of cocaine use in the highest income category does lend some support for the idea that the

drug is associated with wealth. However, the rather small overall

differences in the rates of use from one income category to

another suggest that too much has been made of the association of

cocaine use with various indices of "success." Simply put, these

data from a cross-section of American adults suggest that there

may be more snow than fact in the picture provided by the popular

media of the common characteristics of cocaine users.

CONCLUSIONS

What is the bottom line on cocaine use in the United States in the

198Os? Are we in the midst of a blizzard or are we being snowed?

In formulating answers to this question I am reminded of one of my

favorite children's stories, the one about the blind men of

Hindustan who encountered an elephant. Each one felt a different

part of the elephant and proceeded emphatically to claim that the

"entire animal" was like the part he touched. Are we not in a

similar position In describing cocaine use in the United States?

With this children's story in mind, the following conclusions and

observations seem warranted.

1. All of us are examining data that represent valid appraisals

of the situation. However, we are seeing different parts of

what may be a very big animal. The clinicians are encountering a part of the population in which cocaine use and its

consequences are most apparent. The epidemiologists cast a

broader net and are thus encountering a broader range on the

usage continuum. Because of this, the epidemiologists are

prone to provide somewhat more conservative estimates of the

extent of the cocaine problem.

28
TABLE 8

Percent Who Have Ever Used Cocaine by Education,

Employment Last Month, Employment Type,

Status if Unemployed Past Month,

and Family Income:

1982 National Survey on Drug Abuse (Adults Only)

Social Variables

That Might Predict

Cocaine Use

Education

8th grade or less

Some high school

High school graduate

High school plus vocational

Some college

College graduate

Weighted Percent Ever

N Used Cocaine

596

764

1,520

183

928

870

1.3

7.6

12.1

11.3

19.0

18.8

Employed Past Month

Yes

No

Employment Type

Laborer

Service worker

Semiskilled worker

Skilled worker

Retail/office worker

Manager

Professional

Status if Unemployed Past Month

Housewife

Student

Unemployed

Retired

Disabled

Family Income

None

Under $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,OOO - $39,999

$40,000 - $49,999

$50,000 or more

No answer

Not sure

2,904

2,004

184

330

290

437

472

388

753

790

159

192

668

130

23

1,185

1,192

931

560

292

308

212

209

17.5

5.6

13.9

18.3

14.0

19.6

10.9

26.6

17.1

3.0

27.2

15.4

8.4

23.5

10.6

15.3

13.8

13.0

10.0

15.7

6.8

6.4

29
2. There is probably more convergence across the studies of different populations regarding the use and abuse of cocaine than

is apparent at first glance. In fact, there is a remarkable

amount of consistency in what has been reported by the clinicians in the papers in this volume. An even greater degree of

similarity exists in the findings reported by the epidemiologists. It is worth noting that, from a methodological perspective, the only way to simultaneously reduce the probability of making both Type I and Type II errors is to replicate findings across studies. The degree to which findings

are replicated across the studies reported on in this volume

is impressive.

3.

4.

There is a tendency to think of drug epidemics in monolithic

or dichotomous terms. The society is either in or not in an

epidemic. The epidemic has either stopped or it is still

occurring. We are limited by the primitive nature of our conceptualization of epidemics. Drug epidemics are usually

described in unidimensional and real time terms. In fact, an

epidemic of drug use is best described in processual, contextual, and multidimensional terms. An epidemic of drug use

penetrates various sectors of society and segments of the

population with differing degrees of ease and intensity and

coverage. Because of history and other factors, some segments

of the population may be significantly more vulnerable to an

epidemic of cocaine use than other segments. Thus, use of

cocaine may spread like wildfire in some areas while in other

areas it may take years for the infection to reach even a

small percentage of the population.

Treatment data and data from the cocaine hotline suggest that

there is a rather long hiatus between onset of cocaine use and

the appearance of significant health or life-threatening

episodes resulting from cocaine use. This hiatus is probably

in the range of 3 to 5 years. The epidemiological data

presented by Abelson (this volume) suggest that the slope of

increase in the incidence and prevalence of cocaine use has

slowed down or flattened out. It may well be true that the

increases in the number of clients seeking treatment for

cocaine represents the FRONT end of a longer line of people.

These are the people who have used cocaine long enough to

progress far enough to have problems. If the average hiatus

is from 3 to 5 years, the appearance of large numbers of new

cases in treatment centers may be imminent (see data in table

How long is the queue behind this first batch of persons

entering the treatment system who are experiencing negative

consequences attributable to their use and abuse of cocaine?

5. If the price of cocaine remains low or drops even lower and

the purity remains high or goes even higher, this society may

experience an epidemic of cocaine use without historical equal

in terms of magnitude and coverage. Even if the price-purity

balance does not worsen, the tentacles of the cocaine epidemic

in the United States may have considerably more capacity for

30
expansion. As indicated at the beginning of this paper, there

are at least 550,000 Americans who are seriously at risk for

exhibiting negative consequences of cocaine abuse. This is

probably a conservative estimate of the number of problem

users in the United States. A much larger number are already

at risk for continuing use or progressing toward abuse of

cocaine. The percentage of all users who make the transition

from nonuser to user and then from user to abuser of cocaine

may be affected by the price-purity ratio. From a public

health perspective, far too many Americans have already used

cocaine, far too many continue using cocaine, and far too many

abuse it. Considerably more must be done to reduce the demand

for cocaine.

6. Given the prodigious amounts of money that accompany trafficking in cocaine and the precarious financial situation in the

major cocaine producing and distributing countries, it would

not be surprising to see new countries entering the lucrative

cocaine trade. We know from economics that an increase in

supply will produce a drop in price and a rise in purity.

Most of the research scientists studying cocaine use do so

from a "demand reduction" perspective. If greater attention

is not devoted to the "supply reduction" part of the policy

continuum, the problems now being encountered with cocaine in

the United States may appear small in retrospect 5, 10, or 15

years from now.

WHAT CAN BE DONE? The sad truth is that there is no simple answer

to this question. However, there are several "minimal" steps that

must be taken. First, a viable campaign must be mounted to inform

the American public of the myths surrounding cocaine, its effects,

and who uses it. Cocaine must be demythologized!

Second, a sense of realism and caution must be exercised with

regard to the development of successful treatment regimens for

cocaine abusers. It is one thing to claim a remarkable level of

success with cocaine abusing patients, it is quite another thing

to conduct a rigorous treatment outcome study. It would be

prudent to temper claims of treatment success with caveats until

credible research results have been compiled.

Third, use of cocaine is a complex behavioral phenomenon that cannot be understood if taken out of context. A substantial majority

of cocaine users and abusers use and abuse other drugs as well.

The data presented in this paper suggest that use of cocaine is

integrally connected to use of marijuana. Further, cocaine is

often used simultaneously with other drugs, particularly alcohol

and marijuana, so that these other drugs can moderate or modify

the effects of cocaine on the user. We must resist the temptation

to single out cocaine as if it is a totally unique drug. An

equally powerful temptation is to treat cocaine users as if they

are unlike users of other drugs. The data presented in this paper

provide convincing evidence that cocaine is another drug and that

its use and its users can be best understood with reference to

their drug-using behavior, not just their use of cocaine.

31
Fourth, there is an urgent need for more collaborative efforts

across disciplines within the community of scholars who specialize

in studying and treating drug users. This could and should be

facilitated by the National Institute on Drug Abuse following a

carefully constructed multidisciplinary research agenda centered

around cocaine, but not limited exclusively to it.

Fifth, from a public policy perspective, it is important to recognize that history is often an excellent teacher. Around every

corner turned in the war on drugs is usually another long, dark

hallway and then, another corner.

Finally, we must be reminded that the numbers don't lie. The data

in this paper indicate that over half a million Americans may be

seriously at risk for exhibiting negative consequences from their

abuse of cocaine, and many many more are at risk for continuation

of use or progression to abuse of cocaine. These and other numbers we are so fond of citing and noting represent real people.

In this instance, they are people who are hurting, people who need

our help, our concern, our understanding, and our love.

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Adams, E.H., and Durell, J. Cocaine: A growing public health

problem. In: Grabowski, J. ed. Cocaine: Pharmacolo

Effects, and Treatment of Abuse. National Institute on Drug

Abuse Research Monograph 50. DHHS Pub. No. (ADM) 84-1326.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1984. pp. 9-14.

Bray, R.M.; Schlenger, W.E.; Craddock, S.G.; Hubbard, R.L.; and

Rachal, J.V. Approaches to the Assessment of Drug Use in the

Treatment Outcome Prospective Study. Research Triange Park,

N.C.: Research Triangle Institute, 1982. pp. 94

Clayton, R.R., and Ritter, C.J. The epidemiology of alcohol and

drug abuse among adolescents. Adv Alcohol Subst Abuse 4:33-51.

1985.

Clayton, R.R., and Voss, H.L. Young Men and Drugs in Manhattan:

Monograph 39. DHHS Pub. No. (ADM) 81-1167 Monograph 39. Washington, D.C.:

A Causal Analysis. National nstitute on Drug Abuse Research

Supt. of Docs., U.S. Govt. Print. Off., 1981.

Clayton, R.R., and Voss, H.L. Marijuana and cocaine: The causal

nexus. Unpublished manuscript, 1982.

Community Epidemiology Work Group . Trends, Patterns, and Issues

in Drug Abuse, National Institute on Abuse, Washington

D.C.: U.S. Government Printing Office, 1984, O-421-166/4326.

Craddock, S.G.; Hubbard, R.L.; Bray, R.M.; Cavanaugh, E.R.; and

Rachal, J.V. Client Characteristics, Behaviors and Intreatment

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16:30-48, 1969.

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Johanson, C.E. Assessment of the dependence potential of cocaine

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Washington, D.C.: Supt. of DOCS., U.S. Govt. Print. Off.,

1984. pp. 54-71.

Johanson, C.E.; Balster, R.L.; and Bonese, K. Self-administration of psychomotor stimulant drugs: The effects of unlimited

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Johnson, B.D.

Wiley, 1973.

Marihuana Users and Drug Subcultures. New York:

Johnston, L.D.; O'Malley, P.M.; and Bachman, G.J. Highlights

from Drugs and American High School Students 1975-1983.

National Institute on Drug Abuse, DHHS Pub. No. (ADM)84-137.

Washington, D.C.: U.S. Govt. Print. Off., 1984. 134 pp.

Jones, R.T. The Pharamacology of Cocaine. In: Grabowski, J.,

National Institute on Drug Abuse Research Monograph 50. DHHS

ed. Cocaine: Pharmacology, Effects, and Treatment of Abuse.

Pub. No. (ADM) 84-1326. Washington, D.C.: Supt. of Docs.,

U.S. Govt. Print. Off. 1984. pp. 34-53.

Mandell, W. A preliminary inquiry into cocaine epidemics in the

United States 1885 and 1984. Paper presented at the National

Conference on Cocaine, Baltimore, M.D., 1984.

Moringstar, P.J., and Chitwood, D.D. The Patterns of Cocaine

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O'Donnel, J.A., and Clayton, R.R. The stepping-stone

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4:229-241. 1982.

O'Donnell, J.A.; Voss, H.L.; Clayton, R.R.; Slatin, G.T.; and

Room, R.G.W. Young Men and Drugs: A Nationwide Survey.

National Institute on Drug Abuse. DHEW Pub. No. (ADM) 76-311.

Washington, D.C.: Supt. of Docs;, U.S. Govt. Print. Off.,

1976. 144 pp.

Smith, D.E. Diagnostic, treatment and aftercare approaches to

cocaine abuse. J Substance Abuse Treatment Vol 1:5-9, 1984.

Stone, N.; Fromme, M.; and Kagan, D.Cocaine Seduction and

Solution. New York: Crown, 1984. 276 pp.

Wise, R.A. Neural mechanisms of the reinforcing action of

cocaine. In: Grabowski, J., ed. Cocaine: Pharmacology,

Effects, and Treatment of Abuse. National Institute on Drug

Abuse Research Monograph 50. DHHS Pub. No. (ADM) 84-1326.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1984. pp. 15-33.

Wish, E.D., Brady, E. and Cuadrado, M. Drug use and crime in

arrestees in Manhattan. Paper presented at 47th Annual

Scientific Meeting of the Committee on Problems of Drug

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33
ACKNOWLEDGMENT

York on this paper was completed under the auspices of Grant

DA-03584 and Contract No. 271-84-7301 from the National Institute

on Drug Abuse and a Universlty of Kentucky Research Professorship

for 1984-85.

AUTHOR

Richard R. Clayton, Ph.D.

Professor

Department of Sociology

Unlversity of Kentucky

Lexington, Kentucky 40506

34
A Decade of Trends in Cocaine Use

in the Household Population

Herbert I. Abelson and Judith Droitcour Miller

INTRODUCTION

The National Survey on Drug Abuse provides data on current trends

and current prevalence, as well as patterns and correlates of drug

use for a broad spectrum of substances. The National Survey is a

series of nationwide studies that began in 1971 and 1972 under the

sponsorship of the National Commission on Marihuana and Drug Abuse

and conducted by Response Analysis Corporation. Then, from 1974

through 1982, five subsequent National Surveys were conducted

jointly by The George Washington University and Response Analysis

Corporation, sponsored by the National Institute on Drug Abuse.

Each of these surveys has utilized a National Area Sample. The

sample design insures that each household in the coterminous

United States has a known chance of selection. Sample households

in the locations for the study are predesignated and a sample of

youth and a sample of adults are identified from among the designated households. The sample designs have included disproportionate sampling of youth, ages 12 to 17, and young adults, ages 18 to

25.

The data are based on self-reports collected by face-to-face

interviews with designated respondents. The National Survey

utilizes a variety of data collection procedures. Information

about cocaine and other drugs has been elicited by means of a

technique in which respondents mark private answer sheets in

response to questions from interviewers. The survey procedure

calls for elaborate and conspicuous precautions to insure respondent privacy.

Response rates, which are one estimate of data quality, have

followed contract requirements, from about 70% in earlier surveys

to 80% or more in the 1979 and 1982 surveys.

Each of the last six National Surveys has included some kind of

methodological study or experiment as part of its design.

Table 1 shows the number of completed interviews for each of the

surveys for which there are data on cocaine.

35
TABLE 1

Completed Interviews, Six National Surveys*

1972 1974 1976 1977 1979 1982

Youth (12-17) 880 952 986 1,272 2,165 1,581

Younger Adults (18-25) 772 849 882 1,500 2,044 1,283

Older Adults (26+) 1,613 2,221 1,708 1,822 3,015 2,760

*The 1971 Natfonal Survey includes no data on cocaine.

This chapter reviews some of the data on cocaine from the National

Surveys. Starting with a status report from the most recent

National Survey, the paper goes on to trends in usage since 1972

among the high-risk 18 to 25 population, and then to trends for

other age groups. There are also our observations on possible

sources of error in the data.

Parts of the chapter are concerned with correlates of cocaine use:

first order demographic data which can be both crude and enlightening; and observation on concurrent and multidrug use.

COCAINE PREVALENCE

Starting with the most recent prevalence figures from the 1982

National Survey, 20 mfllfon or more Americans report having at

least tried cocaine--and about half of that number report having

used cocaine within the past 12 months.

Table 2 shows that large numbers of youth and adults in these age

groups have by now tried cocaine. Looking at the population projections, about 1 l/2 million youth have tried cocaine, as have 9

mfllfon young adults and over 10 million persons age 26 and older.

The larger proportion of the older adult users are in the 26 to 34

age group.

Percentage-wise, as well as in terms of past-year and past-month

use, the highest risk population is clearly the 18 to 25 age group:

about 19% of the respondents in this age group say they have used

cocaine within the year prior to the survey interview. And, about

one-third of these persons--nearly 7% of the entire age group--

report using cocaine during the past month.

36
TABLE 2

Prevalence Estimates and Population Projections (1982)

Ever Tried

Youth 12-17 (1,581) 6.5%

1,490,000

Younger Adults 18-25 (1,283) 28.3%

9,260,OOO

Adults 26+ (2,760) 8.5%

10,820,OOO

Older Adult Age Groups:

26-34 21.7%

7,060,OOO

35+

3,760,00O

COCAINE TRENDS

12 Months

4.1%

940,000

18.8%

6,150,000

3.8%

4,810,0OO

10.8%

3,510,000

1.4%

1,300,000

Past Month

1.6%

380,000

6.8%

2,230,OOO

1.2%

1,550,OO0

3.3%

1,080,OOO

0.5%

470,000

Tracing cocaine trends In the young adult population over the past

decade reveals three patterns that are shown in figure 1.

FIGURE 1

Trends in prevalence for adults ages 18 to 25

37
From 1972 to 1976, there was relatively low prevalence and comparative stability. For example, the percentage of young adults

reporting that they had ever tried cocaine went from 9% in 1972 to

13% in 1974 and 1976. Then, between 1976 and 1979, there were

dramatic increases in prevalence. From 1976 to 1977 to 1979, lifetime prevalence increased from 13% to 19% to 27.5%--thus, doubling

in a period of 3 years. During these years, trends in past-year

and past-month cocaine use were equally dramatic. From 1976 to

1977 to 1979, past-year prevalence increased from 7% to 10% to 20%,

and the percentage reporting past-month use went from 2% to 4% to

9%.

More recently, between the 1979 and 1982 National Surveys, there

has been a leveling off of the cocaine trend lines. During this

period, the high prevalence levels of tne late seventies have, for

the most part, been maintained.

25 population group.1

This is the picture for the 18 to

Discussion

Why the sharp rise in reported usage between 1976 and 1979? First,

of course. higher proportions of the population have had experience

with cocaine. And as a corollary to experience, we assume that the

substance must have been more widely available during these years

than previously. However, other dynamics, which are also observed

in consumer response to other, less exotic products, may be occurring here.

One is a response to increased name awareness. A higher proportion

of the population may have been familiar with cocaine in 1979 than

In 1974. This, In turn, may facilitate second artifact, mistaken

identity or "look alikes." As the drug becomes more widely

adopted, more people may think that what they are using is cocaine,

and it may not always be so. And third, of course, is whatever

component of social desfrabllfty there may be in having an answer

sheet know that you are using cocaine.

One source of reassurance--or despair--is to compare data which

have been collected independently from a comparable population. Ye

turned to Johnston's annual studies of high school seniors to compare trends in use of cocaine between 1976 and 19792. Johnston's

high school seniors and the National Survey cohort of young adults

are roughly comparable, but by no means identical. Johnston's data

show the same trends as those which we have been examfnfng. This

could mean that responses in both surveys reflect some of the same

types of errors. It is more likely, however, that reported

behavior about the use of cocaine--and other drugs--mostly reflects

actual experience, and that nonsampling sources of error contribute

in only a minor way. We find these possible sources of error

useful to keep In mind when examining survey data.

There is a parallel in the trends for cocaine and marijuana use

among young adults, although the years of maximum growth recorded

by the National Surveys are different for each drug. The most

38
rapid years for increased use of marijuana were probably the late

sixties and early seventies. The 1971 and 1972 National Surveys

caught the "tail end" of what might be termed a wave of a drug use

epidemic. For example, between 1971 and 1982, the percentage of

young adults who had tried marijuana went up from 39% to 48%, and

current prevalence followed from 17% to 28%. During the midseventies, the National Survey data show relatively little change.

During this period, 1972 to 1976, roughly half of young adults

reported ever using marijuana, and approximately half of those

reported current use. This midseventies plateau was also seen for

cocaine, but at a different level of adoption.

Starting in 1976, experience with both drugs reflected the beginning of another dramatic rise, with both cocaine and marijuana

reaching their highest prevalence levels in 1979. The prevalence

estimates from the 1982 National Survey document another plateau

for both drugs.

FIGURE 2

Marijuana: Past month use, and cocaine:

Three types of prevalence for adults 18 to 25

39
Figure 2 is figure 1 with 30-day marijuana prevalence added at the

top. The bottom trend line is the complete one for cocaine. The

prevalence parallels are readily apparent.

As we have just suggested, the Johnston studies of high school

seniors evidence the same pattern of plateau and increase for both

cocaine and marijuana as do the young adult national samples.

Thus, the pattern of stability and change in cocaine use during the

1970s appears to be part of a larger drug use picture among young

adults. For cocaine and marijuana, and perhaps for other drugs as

well, the plateau revealed by the 1982 National Survey data may

indicate a permanent leveling off of usage, or it may follow the

observed pattern throughout the 1970s of leveling off followed by

another increase.

A comparison of trends In lifetime prevalence of cocaine use for

three ages groups from 1972 to 1982 is shown in figure 3.

FIGURE 3

Trends in lifetime prevalence of cocaine use

for three age groups (1972-1982)

40
For the youth population, increases have occurred during the

decade; for example, in 1972, only 1.5% of the 12 to 17 age group

reported having tried cocaine. During the midseventies, this

figure increased to about 3.5% or 4%, then went up to about 5.4% in

1979 and 6.5% in 1982. Thus, there have been relatively small

changes for any one interval, but the general pattern is one of

increasing exposure of youth to cocaine.

For the older adult population, prevalence rates have been consistently low and there was little change until the late seventies.

About 2% of older adults reported experience with cocaine until the

1979 and 1982 surveys when the lifetime prevalence figure for the

population aged 26 and older increased from about 2.6% to 4.3% and

then to 8.5% In 1982.

As reflected in table 2, which shows percentage and projections for

three age groups, most of the older adult cocaine users are in the

26 to 34 age group. Obviously, these persons were ages 18 to 25

during the mid-1970s. An examination of cohort patterns, from data

on reported age at the time of first use of cocaine, suggests that

older adult trend lines are the result of the maturation of key

cohorts. In other words, during the midseventies many young adults

began using cocaine; those young persons have now passed their 26th

birthdays and are in the 26 to 34 age cohort. So, while some new

cocaine use does occur among persons over 25 years of age, much of

the recent increase in prevalence for older adults reflects the

earlier expansion of cocaine in the young adult population.

As table 3 shows, between the 1979 and 1982 surveys, the projected

number of youth and young adults who had ever tried cocaine did

increase somewhat, but the most dramatic increases are in the older

age groups.

TABLE 3

1979-1982 Projections for Lifetime Prevalence

1979 1982

Youth 12-17 (1,581) 1,260,OOO 1,490,000

Adults 18-25 (1,283) 8,700,OOO 9,260,OOO

Older Adults (2,760)

26-34 4,040,000 7,060,OO0

35+ 1,150,000 3,760,000

Even if the present cocaine plateau continues for young adults, the

passage of the birth cohorts into the older population will result

in greater and greater numbers of adults who have tried cocaine--

41
and at least some of these persons will continue some level of

cocaine use as they move into the older age ranges. In other

words, even if there is no increase in risk to younger population

age groups, the total number of persons who have used and are using

cocaine can be expected to increase in coming years.

CORRELATES OF COCAINE USE WITHIN THE 18 TO 25 COHORT

Table 4 shows that within the 18 to 25 cohort in the 1982 National

Survey, above-average cocaine prevalence rates exist for a number

of population subgroups.

TABLE 4

Prevalence Data Among Geographic Subgroups

of Younger Adults

(1982)

Ever 12 Past

Tried Months Month

Adults 18-25 (1,283) 28.3% 18.8% 6.8%

Population Density

Large Metropolitan (374) 35.0% 24.0% 10.0%

27.0 18.0 6.0

Nonmetropolitan (437)

 Small Metropolitan (472)

22.0 13.0 5.0

Region

Northeast (251) 35.0% 25.0% 13.0%

North Central (310) 25.0 13.0 3.0

South (494) 21.0 12.0 4.0

West (228) 38.0 30.0 9.0

Geographically, young adults who live in large metropolitan areas,

and those who live in the northeastern and western regions of the

country are more likely than others to have had experience with

cocaine. For example, 35% of the young adults In large metropolitan areas have now tried cocaine and 24% report past-year use.

These rates are considerably higher than those for nonmetropolitan

areas. Turning to regional data, 38% of young adults who live in

western States have tried cocaine and 30% report use In the past

year. These rates are high in comparison with the South and

Midwest.

The geographic patterns are generally similar to what is observed

for young adult marijuana use--at least, the lower the population

density, the lower the drug use rate. However, regional differences are dwindling for marijuana. And, again, these geographic

42
patterns are strikingly similar to those reported by Johnston

et al. for high school seniors.

Continuing this demographic examination, table 5 describes pastyear and past-month prevalence rates for young men and young

whites, which are about twice as high as those for women and nonwhites.

TABLE 5

Prevalence Data Among Sex, Race, and Educational Groups

of Younger Adults (1982)

Ever

Tried

Adults 18-25 (1,283)

Sex

28.3%

12

Months

18.8%

Past

Month

6.8%

Male (574)

Female (709)

Race

35.0%

22.0

25.0%

13.0

13.0%

5.0

White (1,106)

Black and Other (174)

Education

30.0%

18.0

20.0%

10.0

7.0%

3.0

Not High School Graduate (242) 23.0% 15.0% 4.0%

High School Graduate (545) 28.0 17.0 6.0

Completed l-3 Years of College (327) 30.0 20.0 7.0

College Graduate (151) 34.0 27.0 13.0

And, finally, prevalence rates increase with education level, going

from, for example, 15% for past-year use among those who are not

high school graduates to, at the other end of the scale, 27% for

those who are college graduates. Of course, for this age group

education is not as clear a measure of socioeconomic status (SES)

as it is for older persons--simply because many 18 to 25 year olds

are still in school or may have temporarily dropped out.

The demographic pattern for cocaine does not hold when we look at

marijuana. For example, among young adults who are not hfgh school

graduates there is different usage for the two drugs: 4% report

past-month cocaine use, whereas 35% report past-month marijuana

use. However, for young adults who are college graduates, pastmonth prevalence rates are closer for the two drugs: 13% for

cocaine and 19% for marijuana.4

43
In sum, the demographic profile of cocaine use among young adults

includes residence In large metropolitan areas, residence In the

northeast or western part of the country, and being male, as well

as white and college educated. The geographic correlates and the

sex pattern are generally consistent with what we have observed for

marijuana. But the race and education data from the 1982 survey

present a reverse pattern.

PATTERNS OF CONSUMPTION AND THE DRUG USE CAREER

Turning to patterns of cocaine consumption, first, the cocaine user

is an occasional user. Looking first at lifetime frequency

(table 6), the total number of times that a person has

used cocaine during his other life, most young adults who have

tried this drug stop short of using it on 100 or more occasions.

TABLE 6

Lifetfme Frequency of Cocaine Use by Young Adults (1982)

Base: 1,283

Once or twice

3 to 10 times

11 to 99 times

100 or more times

Total Ever Used

7.4%

9.2

9.1

2.5

28.2%

Seven percent of the age group or about one-fourth of the young

adults who have tried cocaine say they have used the drug only one

or two times in their lives. The rest of the ever-users are about

equally divided into those who have used 3 to 10 times and those

who have used 11 to 99 times. Only 2.5% of the age group, or

roughly 1 in 10 ever-users, say they have used this drug on 100 or

more occasions.

Just as a point of comparison, if we look at the same data for

marijuana, the model category for young adult marijuana use would

be 100 or more times, and the least likely outcome would be 1 or 2

times. For young adults, 9.5% used marijuana 1 to 2 times in life;

12.6% used 3 to 10 times; 17.4% used 11 to 99 times; and 24.0 used

100 or more times.

In terms of frequency of cocaine use within the past 30 days, most

current cocaine users have consumed this drug on just 1 or 2 days

out of the past 30 (table 7). Again, at least as compared to marijuana, cocaine appears to be a drug of occasional use. (Fewer than

one-third of current marijuana users in the young adult group

report use on just 1 or 2 days out of the past 30.)

44
TABLE 7

Frequency of Cocaine Use in Past 30 Days

by Young Adults (1982)

Base: 1,283

1 or 2 days

3 or 4 days

5 to 19 days

20 or more days

Total past month users

*Less than .05%.

4.3%

1.0

1.3

 * 

6.6%

Second, the cocaine user is a multidrug user. As has been indicated in several studies, notably Kandel and her colleagues (this

volume), a young person typically tries cocaine on1y after he or

she has already used marijuana as well as alcohol and cigarettes.

Virtually all current cocaine users are also current alcohol users,

and the majority of these current cocaine-and-alcohol users are

also current marijuana users. In fact, the experience of the

current cocaine user is in many cases domfnated by the use of

alcohol and marijuana rather than by cocaine.

Comparing the number of days on which concurrent cocaine and marijuana users say they consume each of these drugs, three-fourths of

these dual users say they use marijuana on more days than cocaine.

Then, comparing the number of use days for concurrent cocaine and

alcohol users, nine-tenths say they drank alcohol on more days (out

of the past 30 days) than they used cocaine. Turning to combined

use, in the 1982 survey, marijuana users were asked to report how

often they had combined alcohol with marijuana. Similarly, cocaine

users were asked how often they had combined cocaine with marijuana.

The specific question on alcohol with marijuana was: "On the

occasions when you have used marijuana or hash, about how often did

you use alcohol at around the same time?" Interviewers explained

that "around the same time" means within a couple of hours of each

other. A similar question was asked about marijuana with cocaine

use. Table 8 describes the results.

About one-third of the 18 to 25 age group who have ever tried

cocaine report that they combined it with marijuana every time that

they used it. Moreover, it turns out that many of those reporting

infrequent combined use or no combined use are the cocaine users

who had used the drug fewer than 10 times. So that when only

experienced cocaine users are considered (that is, only those who

45
have used cocaine more than 10 times), the distribution shifts so

that a majority of the more experienced users fall into the first

two categories shown here, i.e., at least half-the-time they have

combined marfjuana with cocaine.

TABLE 8

Marijuana Use With Cocaine Use, Young Adults (1982)

Base: 1,283

Nearly every time I used cocaine 9.6%

About half the time I used cocaine 2.7%

Occasionally/rarely 7.7%

Never both at once 8.2%

Ever used cocaine 28.3%

A comparable situation exists with respect to marijuana and alcohol

use. That is, a good proportion of the experienced marijuana users

say that usually or at least half-the-time that they use marijuana,

they also use alcohol.

Thus, the young adult who uses cocaine is likely to be an occasional cocaine user who consumes alcohol and marijuana more frequently

than he or she uses cocaine. As a multiple drug user, he often

uses more than one drug on the same occasion.

SUMMARY

The National Survey provides us with a number of realities about

cocaine use in the Nation today:

Twenty million or more Americans have now tried it, and

half of that number are past-year users.

Cocaine use tends to be concentrated in the high-risk 18

to 25 population group.

The hfghest prevalence rates are observed in young white

males, In young residents of the West and the Northeast,

and among white and college-educated young people.

The young adult cocaine user is likely to consume this

drug occasionally and to be a more frequent user of

alcohol and/or marijuana. It is not unusual for hfm or

her to use marijuana in combination with cocaine.

With respect to recent trends, even though dramatic increases in

cocaine prevalence among young adults have leveled off, this still

means that hfgh levels of cocaine use are being maintained by

46
young Americans. Moreover, small but steady increases in prevalence are continuing for the youth population. And, the overall

number of Americans who have used and are using cocaine continues

to increase as new cohorts of young persons begin and continue the

use of this drug--even as they move into the older age ranges.

OBSERVATIONS

The pattern of data on cocaine use since 1972 suggests that the

concept "plateau" is a more faithful descriptor of periods of

little change than is the concept "stability." Durlng the years

of Natfonal Survey measurement, cocaine and other drug use has not

stabilized, it has only shown a tendency to either smaller or

larger increases from one measurement to the next.

Until the availability of the 1985 National Survey findings, we

are cautious about concluding that there will be no more Increases

in cocaine use. Much depends upon (1) whether there is a new

consumer segment whose use of marijuana and alcohol is preparing

them to be susceptible to cocaine; (2) whether the positive image

of cocaine among young people can be changed, and the true nature

of the drug communicated to high school students and young adults;

and (3) the avaflabflity and cost of the drug itself.

FOOTNOTES

"It is our understanding that the cocaine available for buys has

been Increasing in purfty (i.e., strength) over the past several

years, which is one of the variables not accounted for by prevalence data.

2Johnston, L.D.; Bachman, J.G.; and O'Malley, P.M. Student Drug

Use Attitudes, and Beliefs, National Trends 1975-1982. National

Institute on Drug Abuse. DHHS Pub. No. (ADM) 83-1260.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1982.

Another paper prepared for this volume by Patrick O'Malley

extends the Michigan data another year; cocaine has remained on a

plateau through the 1983 measurement.

3This conclusion suggests that National Survey data in future

years Include more refined age intervals than have been presented

up to now.

4Income data are difficult to interpret for this age group; many

young adults are living with their parents and report parents'

income (perhaps in addition to thefr own) as household income.

Others are living on their own and may be attending school. Still

others may be working in what is to be their lifetime career, but

early salary may not reflect career potential. SES data in this

age group should ideally be based on a combination of education,

income, living circumstances, and occupation.

47
5Caution to the reader. Lifetime frequency data seem to be a

staple of epidemiological studies like the National Survey. We

question the validity of the upper end of such data (e.g., "more

than 100 times"). Respondents who have maintained a consumption

rate may be able to report accurately. Other respondents are not

reporting their behavior as much as they are reflecting their

self-images (e.g., "I am the kind of person who uses cocaine more

than 100 times In my life, so this is the category for me.")

Obviously, questions which ask for behavioral but invite

attitudinal responses, also invite misinterpretation of their

meanings.

REFERENCES

Figure 1:

Figure 2:

Figure 3:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

Table 8:

National Survey on Drug Abuse, Main Findings, 1982.

Table 6 (p. 17). Table 9 (p. 10). and Table 12 (p. 23).

National Survey on Drug Abuse, Main Findings, 1982.

Table 6 (p. 17), Table 9 (p. 10) , and Table 12 (p. 23).

National Survey on Drug Abuse, Main Findings, 1982.

Table 35 (p. 51).

National Survey on Drug Abuse, Main Findings, 1982.

Table 33 (p. 49). Population Projections. Based on the

National Survey on Drug Abuse, 1982.. Tables 5A and 5B.

Population Projections, Based on the National Survey on

Drug Abuse, 1982 . Tables 5A and 5B. Population

Projections, Based on the National Survey on Drug

Abuse, 1979 Tables 4A and 4B. .

Main Findings of the National Survey on Drug Abuse,

1982. Table 34 (p. 50).

Main Findings of the National Survey on Drug Abuse,

1982. Table 34 (p. 50).

Main Findings of the National Survey on Drug Abuse,

1982. Table 36 (p. 52).

Main Findings of the National Survey on Drug Abuse,

1982 Table 36 (p. 52).

Main Findings of the National Survey on Drug Abuse,

1982 Table 36 (p. 52).

48
AUTHORS

Herbert I. Abelson, Ph.D.

Response Analysis Corporation

101 Wall Street

Princeton, New Jersey 08540

Judith Droitcour Miller, Ph.D.

2510-B South Arlington Mill Drive

Arlington, Virginia 22206

49
Cocaine Use Among American

Adolescents and Young Adults

Patrick M. O’Malley, Lloyd D. Johnston,

and Jerald G. Bachman

INTRODUCTION

This chapter reports data on the prevalence of cocaine use, and

related attitudes and beliefs, among American adolescents and

young adults. Some of the results have been reported elsewhere,

as part of a series reporting on the use of a variety of licit and

illicit drugs (Johnston et al. 1984b). Here, the data on cocaine

use specifically have been collated, and some new data related to

cocaine use are reported.

STUDY DESCRIPTION

The Monitoring the Future project is an ongoing study conducted by

the Institute for Social Research at the University of Michigan.

The study design is described in detail by Johnston et al.

(1984a); briefly, it involves nationally representative surveys of

each high school senior class, plus followup surveys mailed each

year to a subset of each senior class sample. This design is

called a cohort-sequential design, one in which multiple cohorts

are followed over time.

Sampling and Survey Procedures

A three-stage national probability sample leads to questionnaire

administrations in about 130 high schools (approximately 110

public and 20 private), and yields between 15,000 and 19,000

senior respondents each year. The response rate is generally

about 80% of all selected seniors. From each senior class sample,

2,400 individuals are selected for followup, randomly divided into

two equal sized groups. The 1,200 members of one group are

invited to participate in the first year after graduation, and

every 2 years after that; those in the other group are invited to

participate in the second year after graduation, and every 2 years

after that. Respondents are paid $5 for each participation.

Generally speaking, followup rates have been around 80% of the

original group, producing approximately 1,000 questionnaires per

followup per class.

50
PREVALENCE OF USE IN 1983

In 1983, about one in every six seniors (16.2%) report having used

cocaine at some time in their lives. Annual prevalence--any use

in the past 12 months--is 11.4%. and monthly prevalence--any use

in the past 30 days--is at 4.9%. The percentage reporting use on

a daily or near-daily level in the prior month (use on 20 or more

occasions) is 0.2%. In fact, less than 2% (1.7%) report use on

more than two occasions during the month. Although 16% of seniors

report having tried cocaine, almost half (7.5%) have used it only

once or twice; and only 2.3% report having used cocaine 20 or more

times in their lives.

In sum, although cocaine use has been getting a great deal of

attention, it is not anywhere near a "common" behavior among high

school seniors. This is not to say that there is no reason for

concern. The fact that one in six seniors has tried the drug,

given its high abuse potential, is reason enough for concern. In

addition, the high cost of cocaine, which probably helps account

for its relatively low frequency of use, may be decreasing.

TRENDS IN PREVALENCE

As figure 1 shows, from 1976 to 1979 cocaine exhibited a dramatic

and accelerating increase in use: annual prevalence rose from 6%

in the class of 1976 to 12% in the class of 1979, a twofold

increase in just 3 years. Little further increase occurred in

1980 and 1981, with annual prevalences at 12.3% and 12.4%, respectively; and there were actually decreases in 1982 and 1983 (to

11.5% and 11.4%). Both annual and monthly prevalence rates are

now slightly lower than they were in 1980, but lifetime prevalence

is slightly higher (16.2% versus 15.7%).

Daily or near-daily use was less than 0.1% in 1975, and rose to

0.3% in 1980. This rate remained unchanged in 1981, and fell to

0.2% in 1982 and 1983.

USE AT EARLIER GRADE LEVELS

The initiation of cocaine use occurs at older age levels than most

other illicit drugs. Of the 16% of the class of 1983 who have

used cocaine, most users first tried it in the lOth, llth, or 12th

grade (13% of the total sample, or 81% of those who had used

cocaine by the end of the 12th grade). Unlike most other drugs,

there is less tendency for the rate of initiation to decline by

12th grade.

Initiation rates prior to 9th grade (that is, before or during the

8th grade) have remained low and stable, at less than 1% (although

there was a slight increase from 0.6% for the class of 1982 to

0.8% for the class of 1983). There was some increase in initiation rates in 9th grade for the class of 1983 (which occurred in

1980). Thus, as figure 1 shows, there has been a slightly

increasing proportion of seniors who report initiation prior to

51
10th grade. There had also been a gradually increasing proportion

through the class of 1982 who report initiation in 10th grade.

For example, 3.9% of the class of 1982 initiated use in 10th

grade, compared to 2.4% of the class of 1978; this figure dropped

back to 3.4% for the class of 1983. Initiation rates in the 11th

and 12th grades have tended to parallel overall trends in prevalence: that is, they increased through 1980-81, and have been

steady or slightly decreasing since then.

FIGURE 1

Trends in prevalence of cocaine use: Lifetime, annual,

monthly, and use prior to 10th grade

52
FRIENDS' USE OF COCAINE

The relatively low use of cocaine by seniors is also indicated by

seniors' reports of use by their friends. Considerably less than

half (38%) say some of their friends take cocaine (see figure 2).

The trend in figure 2 mirrors the data on prevalence, showing an

increase between 1976 and 1980 and a recent very gradual decrease.

The percent who say most or all of their friends take cocaine is

currently at 5%, down slightly from the peak year of 1981 (6.3%).

FIGURE 2

Trends in friends’ use of cocaine:

Percent saying some and most or all

53
EXPOSURE TO COCAINE USE

We asked seniors how often during the previous 12 months they were

around people who were taking cocaine to get high or for "kicks,"

and the results are shown in figure 3. One-third (33%) of the

class of 1983 had been exposed to such use at least once during

the prior year, but more than half of these (19%) had been exposed

only once or twice. Nine percent said they had been exposed

"occasionally." and 5% said "often." (Note that 5% also said that

most or all of their friends take cocaine.)

Trends in exposure to cocaine use closely follow the pattern of

prevalence and use by friends.

FIGURE 3

Trends in availibility and exposure to use of cocaine:

Percent reporting easy availability,

some exposure, and frequent exposure

54
AVAILABILITY OF COCAINE

Less than half (43%) of 1983 seniors report that it would be

fairly easy or very easy to get cocaine (figure 3). This statistic is down from 48% in the peak years of 1980-81, but is higher

than the low point of 33% reported in 1977. Just about one-third

(34%) of the seniors in the class of 1983 say that it would be

very difficult or probably impossible for them to obtain cocaine.

(The remaining 23% say that it would be fairly difficult for them

to get cocaine.)

To summarize, it appears that some important and dramatic changes

in both use and exposure to use of cocaine among high school

seniors were occurring prior to 1980, but that there has been

little change since then. It is possible that even in the absence

of changes in behavior, there could be important changes occurring

in attitudes toward cocaine. The next section deals with some

questions that relate to attitudes and beliefs about cocaine.

PERCEIVED HARMFULNESS OF COCAINE USE

In spite of the dramatic changes in cocaine use since 1976 and the

widely publicized dangers associated with it (John Belushi,

Richard Pryor, and McKenzie Phillips are three names from the

entertainment industry that come to mind), there has not been any

dramatic change in perceived harmfulness. Instead, there has been

a very gradual increase in the percentage of seniors who associate

"great risk" of harm with regular use, from a low point of 68% in

1977 to 74% in 1983 (figure 4). On the other hand, using cocaine

once or twice is seen as entailing great risk by fewer seniors in

1983 (33%) than in 1977 (36%).

With 74% associating great risk of harm, regular cocaine use is

viewed as somewhat more risky than regular use of marijuana (63%),

amphetamines (65%), or barbiturates (68%), but less risky than

regular use of LSD (83%) or heroin (86%).

PERCEIVED DISAPPROVAL

Regular use of cocaine does not meet with approval among high

school seniors; 93% of the class of 1983 say that they personally

disapprove of such behavior (figure 5). This statistic has not

changed much in recent years; even at its lowest point in 1979-81,

it was at 91%. Trying cocaine once or twice is also disapproved

by the great majority: 77% of 1983 seniors. And this figure has

never been lower than 75% (in 1979 and 1981).

55
FIGURE 4

Trends in perceived harmfulness of cocaine use:

Percent perceiving “great risk” of ham in use

once or twice and in regular use

56
FIGURE 5

Trends in personal disapproval of cocaine use:

Percent sayingg they personally disapprove of use

once or twice and of regular use

57
PROBABILITY OF FUTURE USE

The proportion of seniors indicating that they may use cocaine in

the future increased somewhat between 1975 and 1979, and has been

modestly decreasing since then. About 7% of 1983 seniors say they

will "probably" or "definitely" be using cocaine 5 years in the

future, whereas about 77% of the 1983 seniors say they "definitely

will not" use cocaine 5 years in the future.

COMPARISONS FOR IMPORTANT SUBGROUPS

Table 1 provides trends in annual prevalence of cocaine use by

important subgroups, classified by sex, college plans, region of

the country, and population density.

Sex Differences

Cocaine use is greater among males than females; 18.6% of senior

males have tried cocaine, compared to 13.4% of females. Similarly,

annual prevalences are 13.2% and 9.3%. respectively. The ratio of

male-female prevalence rates in cocaine use was rather large in

the mid-1970s, but has diminished somewhat since then; nevertheless, there remains a sizeable difference in use.

College Plans

Prevalence rates are higher among noncollege-bound seniors--

lifetime prevalence for 1983 noncollege-bound seniors was 18.32,

compared to 13.6% for college-bound seniors, and annual prevalences were 12.2% and 9.9%, respectively. Among the college-and

noncollege-bound seniors, differences have remained small and

roughly consistent in recent years.

Region of the Country

There are large regional variations in cocaine use, with the

lowest rates in the South (7.7% annual orevalence) and the North

Central (8.0%); the rate in the Northeast is almost twice as high

(15.2%), and the West is still higher (19.2%). There has been a

fair amount of regional fluctuation in cocaine use in recent

years. Use in the North Central region has declined steadily

since 1980. Use in the South was also declining but showed some

increase this year. In the Northeast, annual prevalence increased

through 1982 and fell off for the first time in 1983, while in the

West, use declined in 1982 but increased in 1983.

58
TABLE 1

NOTES: See Johnston et al. (1984b) for definition of variables in table.

NA indicates data not available.
Population Density

There are also large differences associated with population

density; cocaine prevalence is more than twice as high in the

large metropolitan areas (16.9% annual prevalence), compared to

the nonmetropolitan areas (7.3%). The smaller metropolitan areas

are intermediate (11.2%). The differences in cocaine use associated with population density have been consistently evident;

recently, annual prevalence appears to be declining at a faster

rate in nonmetropolitan areas.

Initiation Differences

Subgroup differences in initiation largely parallel aggregate subgroup trends.

Thus, males, noncollege-bound students, students in the West and

Northeast, and students in large metropolitan areas begin cocaine

use at earlier ages; early initiation is particularly evident in

the West.

THE YEARS AFTER HIGH SCHOOL

Trends in Use Following High School

Figure 6 shows the annual prevalence of use for the class of 1976,

followed up annually from 1977 through 1983.1 There is

obviously a dramatic increase in cocaine use, from about 6% in

1976 to 26% in 1983, when the respondents averaged 25 years old.

One of the inherent problems in research which looks at changes

related to age is that those changes are confounded with

historical time. The changes observed in figure 6 could be

maturational, that is, more people use cocaine as they get older,

i.e., between the ages of 18 and 25; or, it could be that there Is

a general historical phenomenon wherein cocaine is becoming more

popular among all ages during this time period. While this

problem of separating age effects from secular trends is by no

means easily solved, we can Improve our understanding by looking

at multiple cohorts, as illustrated in figure 7.

Unfortunately, the data are not altogether smooth. We might note

here that this illustrates a distinction between the earlier

seniors-only data on prevalence: those data were based on about

17,000 cases, while each followup prevalence point is based on

about 1,000 cases. The difference in numbers means that there is

about three or four times more sampling error in the followup data

and in addition to that, there is also the normal problem of panel

attrition; the result is that the followup data are less "wellbehaved" than the senior year data. Also, it should be remembered

that, as indicated in the section on research design, it is not

the case that the same individuals are surveyed each year--

instead, each individual is followed every other year; this

results in more year-to-year variation than if each individual

were surveyed every year.

60
FIGURE 6

Annual cocaine prevalence, Class of 1976

61
FIGURE 7

Annual cocaine prevalence, classes of 1976-83

62
From the data in figure 7, it appears that there is indeed some

age effect: cocaine use increases after high school graduation.

This is evident by an increase that always occurs between ages 18

and 19 even when there is no difference between successive

18-year-old cohorts. There also appears to be some secular trend

occurring, at least through about 1980-81, because each age group

shows increasing use. These points may be clearer if we look at

the same data in another way: in figure 8 the lines connect

same-age groups (instead of high school classes as in figure 7).

The bottom line shows all 18-year-old respondents, the next line

shows all 19-year-old respondents, and so on. The age effect is

more clearly seen here; the prevalence rates for 19-year-old

respondents is higher than that for 18-year-old groups, and the

2O- and 2l-year-old groups show still higher rates. Because of

the much smaller number of cases available for the 22 and older

age groups, the data are much less orderly; however, these older

groups generally show rather high levels of cocaine use.

It is possible to use statistical models to try to explain the

data parsimoniously in terms of various combinations of age,

secular trend, or cohort effects. One such model that fits the

data in fi

(1) a linear increase in use with age through age 21

ures 7 and 8 fairly well assumes that three effects are

present:

(3.2% per year of age) with no further age-linked change, (2) a

positive linear year effect (secular trend) through 1982 (1.3% per

year), and (3) a separate effect for 1983 (a decline in use,

-3.2%). This model generates a set of "predicted" points that

fairly well approximate the observed data (0"Malley et al. 1984).

The major point to be made from these followup data is that

cocaine does show an increase in the first few years post high

school, and that there were particularly dramatic increases in the

period between 1976 and 1981 or 1982. The combination of agelinked changes and secular trends produced disturbingly high

prevalence of cocaine use among young Americans; approximately 20%

to 25% of the 12- to 25-year-old cohorts used cocaine at least

once in the prior year. The increase in the first few years after

graduation is particularly striking because most other illicit

drugs showed little change or decreases in use during the same

time period. The data do not show convincing evidence of further

age-linked changes after about age 21.

We turn now to another issue involving the use of followup data.

The question to be addressed is: What implication does cocaine

use at an earlier point have for use at a later point?

63
FIGURE 8

Annual cocaine prevalence, ages 18-25

Longitudinal Patterns of Use

There are many ways to approach this question, and we have chosen

a simple and straightforward one for presentation here. We

restrict analysis to those respondents who have provided data at

three different time points and simply trichotomize the sample at

each time point on the basis of cocaine use in the previous 12

months: no use, use on 1 to 9 occasions, and use on 10 or more

occasions. One possible hypothesis, based on the fact that

cocaine is a drug with extremely high dependence potential

(Johanson 1984), is that there will be evidence of some progression in use. For example, individuals who report no use at the

first time point, and 1 to 9 occasions of use at the second time

64
point, might be expected to show a high rate of transition into

the 10 or more category at the third time.

Table 2 shows the pattern of use across time. The data in column

one show senior year percentages collapsed across several classes;

92% used no cocaine, 7% used on 1 to 9 occasions, and 1.2% used on

10 or more occasions. Following the top group across two followups, one can see that 84.12% did not use cocaine in the year prior

to the first followup (which occurs 1 or 2 years post high school

graduation), and 75.39% did not use cocaine in the year prior to

the second followup (which occurs 2 years after the first followup, or 3 to 4 years after graduation). In order words, by the

second followup, 75% of the total sample of respondents had

reported no use in the year prior to each of the three surveys.

(Another way of expressing the data is to say that of a hypothetical 10,000 individuals in the age group in the population, 7,539

used no cocaine at each of the three surveys.) Although the

annual prevalence may be high (25% used cocaine at least once; see

also the data in figure 7), table 2 indicates that very few 19- to

2O-year-old Americans (2.8%) were using at high rates (10 or more

times a year) in this interval, but that the number of 21- and

22-year-old users was more significant (4.7%).

One interesting group is those respondents who go from zero use in

senior year to one to nine occasions of use in the first followup;

6.85% (or 685 of our hypothetical 10,000) of the sample exhibit

this behavior. Two years later just about half of this group is

still using at that level of one to nine occasions per year (3.46%

of the total sample, or 51% of the 6.85%); about one-third have

reverted to no use, and about one-sixth have increased use.

Another interesting group is comprised of those who used cocaine

on one to nine occasions during senior year of high school (6.63%

of the sample). One or two years later, at the first followup,

just about half of them were still using at that level, and more

of the remainder had decreased than had increased (2.14% and

1.13%, respectively). And 2 years later, of those who were at the

one to nine level in the first followup, about half were again

using at that level (1.79% of 3.35%); about a quarter increased

and a quarter decreased.

The main point to be gained from table 2 is that there is no clear

evidence that there is an inevitable progression in cocaine use.

Use on a few occasions does not seem to produce any necessary

increase at a later period. Of course, this finding must be

placed into proper context: the data are based on respondents to

mail-in surveys, and the time lags are 1 or 2 years.

Post High School Role Statuses

Without presenting the data, we can briefly state that the use of

cocaine changes as a function of marital status/living arrangements following high school graduation. In particular, those who

married in the first few years after high school showed a decrease

in use of marijuana and other drugs compared to other groups

(Bachman et al. 1984); cocaine use followed a similar pattern.

65
TABLE 2

Longitudinal Patterns of Annual Use of Cocaine

Classes of 1976-1980

Base-Year Use First Followup Use Second Followup Use

75.39% (None)

84.12% (None) 7.59% (<Ten)

1.14% (Ten+)

92.18% (None) 6.85% (<Ten)

2.33% (None)

3.46% (<Ten)

1.06% (Ten+)

1.23% (Ten+)

0.20% (None)

0.55% (<Ten)

0.48% (Ten+)

2.14% (None)

1.25% (None)

0.71% (<Ten)

0.18% (Ten+)

6.63% (<Ten) 3.35% (<Ten)

0.81% (None)

1.79% (<Ten)

0.75% (Ten+)

1.13% (Ten+)

0.09% (None)

0.38% (<Ten)

0.67% (Ten+)

0.28% (None)

0.20% None)

0.08% (<Ten)

0.01% (Ten+)

1.20% (Ten+) 0.38% (<Ten)

0.05% None)

0.21% (<Ten)

0.13% (Ten+)

0.52% (Ten+)

0.03% (None)

0.22% (<Ten)

0.27% (Ten+)

Notes: Data are based on approximately 7,000 respondents who

participated in two followups.

Entries sum up to 100% within each column.

66
CHARACTERISTICS OF COCAINE USERS

We now turn back to senior-year only results, and briefly report

some data on the characteristics of cocaine users. Who are the

users of cocaine? and, Why do they use cocaine? are some of the

questions to be addressed in this section.

Predicting Use of Cocaine

Table 3 presents data on the association between cocaine use and

various measures of background and lifestyle factors; these

measures were selected as potentially important correlates of drug

use in eneral, as well as of cocaine in particular. Bachman

et al. (1981) provide more details on these measures and their

associations with smoking, drinking, and drug use. Table 3 also

provides results of multiple linear regression analyses in which

all of the background and lifestyle factors are used to account

for the variance in both cocaine use and, to provide some comparison, marijuana use. (Each dependent variable is an 11-category

measure that combines information about lifetime, annual, and

30-day use.)

One important conclusion derived from table 3 is that there is a

great deal of similarity in the variables that account for cocaine

use and marijuana use. Regional variations aside, the most

important (In terms of standardized regression coefficients)

factors are identically rank ordered: truancy, evenings out for

recreation, religious commitment, high school grades, and

political views. Cocaine is generally thought to be a drug of

particular appeal to people of high rather than low socioeconomic

status (SES). To the extent that the level of parental education

is an indicator of SES status, table 3 shows that status does have

somewhat more of an association with cocaine use than with marijuana use, but that even in the case of cocaine, the association

is weak. Another factor that might be expected to correlate well

with cocaine use is amount of money available; but total income

per week shows only a weak association with cocaine use, about the

same as for marijuana.

Only 15.9% of the variance in cocaine use is accounted for by

background and lifestyle factors; the corresponding figure for

marijuana use is 26.7%. Marijuana use is more "predictable"

largely because it is used more frequently than cocaine. (In

general, rare behaviors will show lower percentages of variance

explained than less rare behaviors.)

Cocaine Use and Use of Other Drugs

High school seniors who use cocaine tend to be consumers of other

drugs as well. For example, of the seniors In the class of 1983

who are current cocaine users (that is, used at least once in the

prior 30 days), 84% are current users of marijuana. By way of

comparison, only 24% of the other seniors are current marijuana

users. And more than a third (35%) of current cocaine users are

67
daily marijuana smokers, compared to only 4% of the rest of the

sample. Alcohol and cigarettes use is also far more prevalent

among current cocaine users. Four-fifths (80%) of them report

having had five or more drinks in a row at least once in the prior

2 weeks (the corresponding figure is 39% for the other seniors),

and half (50%) smoke cigarettes daily (compared to 19% among the

others).

The picture that emerges from the preceding analyses is that

cocaine does not seem to reflect a markedly different pattern of

use than other illicit drugs. The same variables predict its use

as marijuana, and its cross-time pattern does not reflect any

indication that it is in some way unique.

MEASURES FROM RECENT USERS ONLY

Seniors who indicated that they had used cocaine at least once in

the prior 12 months were asked a series of additional questions

regarding how high they became and how long they stayed high,

their reasons for use, situations of use, use with other drugs,

difficulty in stopping use, and methods of use.

Degree and Duration of Highs

Cocaine is associated with fairly intense, but relatively short

highs, according to seniors' reports. About one-quarter of the

recent users say they usually get "a little" high, another quarter

say "very" high, and most of the rest (37%) get "moderately" high.

(The remaining 12% say they don't get high or don't take cocaine

to get high.) Compared to other drugs, duration of the high is

short: 41% stay high about 1 to 2 hours, 34% say 3 to 6 hours,

and 10% even longer. The remaining 15% claim that they usually

don't get high.

There are some strong changes in the degree and duration of highs

associated with cocaine use: in both cases, there have been

declines in recent years. For example, in 1976, 45% said they got

moderately high and 40% got very high; the corresponding 1983

figures are 37% and 25%, which indicates that considerably fewer

users were getting moderately or very high in 1983 compared to

1976. In 1976, only 28% had said they were high for only 1 to 2

hours, and 23% had claimed to stay high 7 or more hours; in 1983,

the corresponding figures are 41% and 10%, reflecting briefer

highs.

Reasons for Use of Cocaine

Recent users were asked to indicate the most important reasons for

their use. Table 4 shows the percentage of users citing each

reason; for comparison purposes, this table also includes the

answers to similar questions asked of recent marijuana users. The

major reasons cited for use of cocaine are to see what it's like

(79%), to get high (70%), and to have a good time with friends

(50%); these are also the major reasons cited for marijuana use.

68
TABLE 3

Background and Lifestyle Variables Related to Use of Cocaine

and Marijuana: Correlations and Regression Results

Class of 1983

Cocaine Use

r

l

beta2

Marijuana Use

beta2 r 1

Background Variables

Sex (M=1, F=2)

Race (W=O, B=1)

Parents' Education

Number of Parents in Home

Urbanicity

Region

Northeast

South

West

North Central

Education Experiences

and Behaviors

Curriculum (College Prep)

College Plans

High School Grades

Truancy

Occupation Experiences

and Behaviors

Hours Worked per Week

Total Income per Week

Lifestyle Variables

Religious Commitment

Political Views

Evenings Out for Recreation

Frequency of Dating

Percent of Variance Explained

(Adjusted for degrees of

freedom)

-.068 -.019 -.llO -.031

-.039 -.029 -.033 -.024

.048 .049 .OO7 .026

-.083 -.058 -.098 -.055

.122 .061 .124 .069

.069 .068 .083 .025

-.087 .008 -.089 -.036

.117 .093 .017 -.035

-.069 NA3

.000 NA3

-.083 -.023 -.130 -.022

-.061 -.003 -.112 -.009

-.I44 -.072 -.234 -.125

.282 .175 .334 .204

.088

.124

-.198

.125

.198

.14?

.O1O

.044

-.103

.072

.105

.070

15.9%

.120 .026

.154 .040

-.292 -.179

.164 .089

.301 .182

.184 .073

26.7%

1The values in this column are product-moment correlations.

2The values in this column are standardized regression

coefficients.

3Because dummy variable regression was used, one region had to

be excluded from the regressions: the North Central was chosen

because it was closest to average for the Nation as a whole.

The number of cases is approximately 15,500. Assuming a design

effect of 3.7, an r (and beta) greater than .04 (absolute value)

would be significant at p<.01.

69
TABLE 4

Reasons for Use of Cocaine and Marijuana

Class of 1983

(Entries are percent of recent users)

Reasons for Use

To experiment, see what it's like

To feel good, get high

To have a good time with my friends

To get more energy

To relax, relieve tension

To stay awake

To increase the effects of other drug

Because of boredom, nothing else to do

To seek insights and understanding

To fit in with a group I like

To get away from my problems or troubles

To get through the day

To decrease the effects of other drug

Because of anger or frustration

Because I am hooked

Cocaine Marijuana

79.3 64.6

70.8 72.8

49.8 64.5

29.7 NA

22.5 41.8

16.5 NA

9.9 11.8

9.8 27.5

8.1 10.7

5.0 13.1

4.5 19.3

4.4 7.1

2.8 1.8

1.7 12.4

1.3 2.8

Note: The question asked is: What have been the most important

reasons for your taking [drug]? (Mark all that apply.)

70
Other reasons are to relax or to relieve tension (23%), to get

more energy (30%), and to stay awake (17%); all other reasons are

cited by fewer than 10% of users.

Reasons for use have not changed much in recent years, except that

there has been some increase in use to get more energy (up from

14% in 1976 to 30% in 1983) and to stay awake (up from 12% in 1976

to 17% in 1983).

Situations of Use

The situations in which high school seniors use cocaine are shown

in table 5; again, corresponding data from marijuana users are

included for comparison purposes. Only about 15% of seniors who

used cocaine in the prior year used it when they were alone. A

fair amount of use occurs in very small groups: 46% said they

used most or every time with only one or two other people present.

Use "at a party" most or every time was reported by 26%. (This

compares to 31% for marijuana.) About one-quarter (23%) use with

a date (or spouse) most or every time. (The figure for marijuana

is 17%.) One-third (33%) had used with someone over age 30

present at least once.

About 4 of 10 (39%) high school seniors had used at home at least

once, whereas only 1 in 10 (9.4%) had used at school. (This

latter figure is 34% for marijuana.) About 4 of 10 used in a car,

and about 1 of 8 (12%) used most or every time in a car.

The above situations show little consistent changes over time,

with one exception. In 1976, one-third (33%) of users reported

using at school, compared to about one-tenth (9.4%) in 1983.

Users of marijuana, by contrast, still frequently used at school.

Cocaine Use in Combination With Other Drugs

Cocaine is often used in combination with alcohol or marijuana.

Three-tenths (30%) of cocaine users say that they use it in combination with alcohol most or every time. But about the same proportion (32%) never used the two in combination. Similarly, 26%

reported using it with marijuana most or every time, but 35% never

used the two in combination. There is little use in combination

with other drugs.

Trends in use of cocaine In combination with alcohol parallel

trends in cocaine prevalence: increasing through 1980-81, and

down slightly since then. Use in combination with marijuana has

generally declined slightly.

71
TABLE 5

Situations of Use of Cocaine and Marijuana

High School Class of 1983

(Entries are percent of recent users)

Note: The question wording is: When you used [drug] during the last year, how often did you use it in

each of the following situations?
Inability to Stop Using Cocaine

Recent users were asked if they had ever tried to stop using

cocaine and found that they couldn't stop. Relatively few high

school seniors respond affirmatively: 3.8% of the recent users in

the class of 1983, and there has been very little change over

time. (By way of comparison, almost 7% of marijuana users said

they had tried to stop and found that they couldn't, and 18% of

cigarette smokers.)

Mode of Administration

The great majority of senior users report sniffing or snorting

cocaine (97% in 1983). Some also report smoking it (24% of

users), and quite a few say "By mouth" (31%). Four percent of the

users report having injected cocaine.

Over time, there has been some change in the percentage reporting

use by mouth, rising from about 25% of users in 1976-78 to 40% in

1980-82, and dropping back to 31% in 1983.

SUMMARY AND CONCLUSIONS

In this chapter, we have tried to provide some objective information about the levels of and recent trends in cocaine use among

America's adolescents and young adults, as well as some of their

attitudes and beliefs about the drug and their reasons for using

it. We have also examined cross-time patterns of use, certain

predictors of use, and some of the conditions of the social and

physical environments which are associated with use.

Overall, we have found levels of use to be relatively stable for

the past several years after a period of rapid increase between

1976 and 1979. We also found a strong age effect, with cocaine

use increasing in the first few years after high school. The

levels of use, though stable recently, are disturbingly high,

particularly among young adults in their early to mid twenties.

Self reported use has followed patterns that parallel exposure to

use and use by friend, as would be expected, assuming valid

measures. Perceived availability also has moved in tandem with

these other measures.

The great majority of today's seniors believe regular use to be

dangerous, and 77% disapprove of even experimenting with cocaine.

Use is found most frequently in the western and northeastern

regions of the country, in more urban areas, among males, and

among those who are not college-bound. Neither socioeconomic

status nor personal income are very strongly associated with use;

but a history of truancy, going out frequently in the evenings,

and having relatively low religious involvement are.

Cocaine users tend to use other illicit drugs (particularly marijuana) and to be cigarette smokers and heavy drinkers much more

frequently than nonusers. Thus, there is little evidence that

73
cocaine involves a separate drug-using syndrome. In fact, it is

not uncommon for cocaine users to use marijuana or alcohol concurrently.

When taking cocaine, high school students most often snort it,

though some (24% of recent users) smoke it while only 4% of the

users inject it. It is almost always used with other people

present, often at a party but more often with just one or two

people present. Most use occurs in the evening, with very few

young people using at school and a minority ever using at home or

in a car.

Among the reasons most often cited for using cocaine use are: "to

see what it's like," "to get high," and "to have a good time with

my friends." Only about 1% of recent users say they use it

because they are "hooked," and only about 4% say they have tried

to quit and been unable to do so. In fact, most of those who used

in high school do not show a cross-time progression to heavier use

in the 3 to 4 years following graduation, which suggests that

dependence either develops rather slowly or develops with relatively low frequency among moderate and light users.

FOOTNOTE

1Estimation of Followup Prevalences: While the senior year data

provide very good estimates of population values, the followup

data are less accurate, due to the lower numbers of cases, random

selection bias, and panel attrition. To estimate prevalence in

the follow-up samples, participating followup respondents are

weighted so that each followup panel has (when weighted) the same

senior year prevalence as the total senior year sample for that

class year. The followup prevalence rates are derived by applying these weights to the followup data; the adjustments provided

by this procedure are generally small, as would be expected, given

the high participation rates.

REFERENCES

Bachman, J.G.; Johnston, L.D.; and O'Malley, P.M. Smoking, drinking, and drug use among American high school students: Correlates and trends, 1975-979. Am J Public Health 71:59-69, 1981.

Bachman, J.G.; O'Malley, P.M.; and Johnston, L.D. Drug use among

younq adults: The Impacts of role status and social environment: J Per Soc Psych 47:629-645, 1984.

Johanson, Assessment of the dependence potential of cocaine.

In: Grabowski, J., ed. Cocaine: Pharmacology, Effects and

Treatment of Abuse. National Institute on Drug Abuse Research

Monograph 50. DHHS Pub. No. (ADM) 84-1326. Washington, D.C.:

Supt. of Docs.. U.S. Govt. Print. Off.. 1984. pp. 54-71.

Johnston, L.D.; Bachman, J.G.; and O'Malley, P.M. "Monitoring the

Future: Questionnaire responses from the nation's high schoo1

seniors, 1983. Ann Arbor, MI: Institute for Social Research,

1984a.

74
Johnston, L.D.; O'Malley, P.M.; and Bachman, J.G. Highlights from

Drugs and American High School Students: 1975-1983. National

Institute on Drug Abuse. DHHS Pub. No. (ADM) 84-1317.

Washington, D.C.: Supt. of DOCS., U.S. Govt. Print. Off., 1984b.

O'Malley, P.M.; Bachman, J.G.; and Johnston, L.D. Period, age,

and cohort effects on substance use among American youth. Am J

Public Health 74:682-688, 1984.

ACKNOWLEDGMENTS

This work was supported by National Institute on Drug Abuse

research grant number RO1-DA-01411.

AUTHORS

Patrick M. O'Malley, Ph.D.

Survey Research Center

Institute for Social Research

University of Michigan

Ann Arbor, Michigan 48016

Lloyd D. Johnston, Ph.D.

Survey Research Center

Institute for Social Research

University of Michigan

Ann Arbor, Michigan 48016

Gerald G. Bachman, Ph.D.

Survey Research Center

Institute for Social Research

University of Michigan

Ann Arbor, Michigan 48016

75
Cocaine Use in Young Adulthood:

Patterns of Use and Psychosocial

Correlates

Denise B. Kandel, Debra Murphy, and Daniel Karus

INTRODUCTION

The use of cocaine increased sharply nationwide through the

seventies, but appears to have stabilized in the last 2 or 3

years. The best documentation of this trend is provided by the

repeated national surveys of high school seniors (Johnston et al.

1984) and of the general population (Miller et al. 1983). The

trend is especially striking among young adults aged 18 to 25.

The proportion reporting having ever experimented with cocaine

increased from 9% in 1972, when the first in a series of national

surveys of the general population was initiated, to 29% in 1982

(Miller et al. 1983). Similar trends have been reported for high

school seniors, although rates of use have stabilized at lower

levels (about 16%) for this younger age group. The popular

interest and concern with abuse of cocaine is reflected in the

mass media and is not limited to the United States (see Lentin

1984). Through vivid case histories of cocaine abusers, the media

depict in detail the lifestyles of users and the mainly painful

effects the drug has had on their lives. These cases are probably

selected because of the sensational aspect of the users' experiences. It is difficult to ascertain from these reports how comnon

these experiences are.

This chapter is an attempt to provide an overview of the use of

cocaine in an unselected cohort of young adults and examines the

lifestyles of young men and women who use the drug in such a

general population sample. In particular, we address the following three questions:

1. What are patterns of cocaine use and the development

patterns of involvement from adolescence to young adulthood in this population of young adults?

2. What are the lifestyles of the cocaine users and how do

they compare to the lifestyles of other types of drug

users and of young adults who have never used any illicit

drugs?

3. Can we predict which adolescents will be most at risk for

subsequent involvement in cocaine by early adulthood?

76
In order to provide a broader context for these issues, cocaine

users are in many instances compared and contrasted to users of

other illicit drugs.

THE DATA

The data derive from a followup of a cohort of young adults carried out in 1980-81. The cohort is representative of adolescents

formerly enrolled in grades 10 and 11 in public secondary schools

in New York State in 1971-72 (the high school classes of 1974 and

1973). The original high school sample was a random sample of the

adolescent population attending public secondary schools in

New York State in fall 1971, with students selected from a stratified sample of 18 high schools throughout the State. The target

population for the adult followup was drawn from the enrollment

list of half the homerooms from grades 10 and 11 and included

students who were absent from school at the time of the initial

study. The inclusion of these former absentees assures the representativeness of the sample and the inclusion of the most deviant

youths. As we confirmed subsequently from data derived from

school records, these absentees can be considered to be truants

(Robins and Ratcliff 1980). In the school year 1971-72, the

average number of school absences reported for the former regular

students who had participated in the initial survey was 12 days as

compared to 19.5 days for the former absentees.

With an 81% completion rate of those subjects still alive, 1,325

young adults were interviewed at a mean age of 24.7 years. Each

personal interview took, on the average, 2 hours to administer and

consisted almost exclusively of structured items with closed-end

response alternatives. An unusual component of the schedule consisted of two charts designed to reconstruct on a monthly basis

the respondents' life and drug histories (figure 1). In order to

reduce the respondent's burden, the drug histories were ascertained only from persons who reported having used a given drug at

least 10 times in their lives. Thus, measures could be obtained

of the timing and number of events and of the continuity or discontinuity of participation in drugs and various social roles.

Although the retrospective data have various limitations in that

they ar

recall,1

subject to various distortions, such as telescoping of

they still provide unique information that is not

otherwise available.

PATTERNS OF COCAINE USAGE AND RISK PERIODS

Patterns of Cocaine Use in Young Adulthood

It is useful to consider the epidemiology of cocaine use in young

adulthood in the context of the use of other drugs by members of

the cohort. The lifetime prevalence of legal and illegal drugs,

and the use of various mood changing substances, with and without

a prescription, are displayed in table 1.

77
FIGURE 1

Drug History Chart
TABLE 1

Lifetime Prevalence of Legal, Illegal, and Medically

Prescribed Psychoactive Drugs in New York State

Young Adult Cohort at Age 24.7 (1980)

Proportions Who Ever Used

Males Females Total Total

By Followup By Age 18

Alcohol (beer, wine, or

distilled spirits)

Cigarettes

Marijuana

Psychedelics

Cocaine

Heroin

Nonprescribed:

Methadone

Minor Tranquilizers

Sedatives

Stimulants

Major Tranquilizers

Antidepressants

Prescribed:

Methadone

Minor Tranquilizers

Sedatives

Stimulants

Major Tranquilizers

Antidepressants

99

80

31

37

5

1.0

18

23

28

3

1

2

19

9

3

2

1

Total N (706)

98 99

79 79

68 72

20 25

23 30

1 3

0.1 0.5

15 17

15 19

18 23

0.4 2

0.5 0.8

0.3 1

28 24

6 8

9 7

2 2

3 2

(619) (1,325)

95

68

54

18

8

1

0.1

7

10

10

0.7

0.1

0.5

7

2

2

0.9

0.8

(1,325)

Confirming epidemiological findings from other surveys, the prevalence of use of drugs in this cohort follows traditional patterns.

The most frequently used drugs are the legal drugs: cigarettes

and alcohol. Marijuana is the most prevalent illicit drug, having

been used by 72% of the cohort. Cocaine is next in prevalence:

30% of the cohort have experimented with the drug, the proportion

among men (37%) being 1 1/2 times as high as among women (23%).

Among young men, this proportion is not only higher than that of

those who have used illicit drugs other than marijuana, it is also

higher than the proportion who have been prescribed mood changing

drugs. Among young women, more report having been prescribed

minor tranquilizers (28%) than report having used cocaine (23%).

These prevalence rates refer to the proportion of young adults who

report having ever used each drug. However, cocaine use appears

to be experimental in nature and to involve few experiences for a

substantial portion of those who report any lifetime experience

with the drug. One-half (53%) of the male users and two-thirds

79
(67%) of the female users have used cocaine less than 10 times in

their lives; 34% and 28%, respectively, have used 10 to 99 times,

9% and 3% have used 100 to 999 times, and 3% and 2% have used

1,000 or more times. Not only do more men than women experiment

with cocaine, but more men than women progress to heavier involvement with cocaine, as will be further documented shortly. This is

a pattern that is common to many drugs, particularly in the early

stages of their popularity and if their usage is considered to be

especially deviant.

Of all the persons who reported any experience with cocaine, about

two-thirds (68% among men and 61% among women) reported having

used it in the last year preceding the survey. Such recency of

use is related to overall extent of involvement. Those reporting

use less than 10 times in their lives are less likely to be using

within the last year (56% among men, 48% among women) than those

who reported using cocaine at least 10 times in their lives (81%

and 86%, respectively).

When cocaine is used, how frequently and regularly is it used?

Respondents who reported having used cocaine at least 10 times in

their lives were asked how frequently they had used it within the

last year and in the period in their lives when they had used it

most intensively. Modal frequency of use is "several times" a

year (table 2) among both sexes; 44% of men and 55% of women use

the drug less than once a month. Even in their period of highest

use, very few users among those who used the drug at least 10

times in their lives used the drug every single day: only 5%

among men and 4% among women; one-third used it once a week or

more frequently.

Through the drug histories, we recorded periods of use and nonuse

of each drug inquired about. A continuous period of use was

defined as a spell. Male and female users report on the average

1.8 and 1.6 spells of cocaine use, respectively. The first spell

of use covered approximately 3 years--39 months for male users and

33 months for females users. For those who had two spells, the

interval between the first and second spells lasted over 1 year

and was longer for women than for men by about 5 months (19 versus

14 months).

Periods of Risk for Initiation to Cocaine From Adolescence to

Young Adulthood

In this cohort, men and women initiated the use of cocaine at 21

years of age on the average: 20.8 years among men and 21 years

among women. It should be kept in mind, however, that these data

are based on a cohort followed to age 25. If the risk for initiation did not terminate by that age, the average age of initiation

would increase as a function of a longer followup interval in

which the entire risk period would be covered.

80
TABLE 2

Frequency of Cocaine Use in the Last Year and in Period

of Highest Use, Among Men and Women Who Used Cocaine

at Least 10 Times in Their Lives

Furthermore, the average age of initiation does not inform as to

whether there exist specific periods of risk for initiation to

cocaine from adolescence to early adulthood. Such periods of risk

can be identified from the continuous observations obtained retrospectively on the use of drugs for the period of time elapsed

between the initial and the followup interviews. Orug behavior

can be examined as a dynamic process and hazard rates can be estimated.

The hazard rate estimates the incidence of drug use during a

specified period, namely, the rate of occurrence of a particular

event within a period among those estimated not to have undergone

the event during the interval. One year was the time interval

defined for the analyses. As applied to drug initiation, the

hazard rate provides the proportion of individuals initiating use

of a drug within a 12-month period among those estimated never to

have used the drug during the interval. To provide a simplified

illustration, if there are 100 adolescents who by age 21 have not

used cocaine and 20 of them begin to use cocaine between the ages

of 21 and 22, the hazard rate for the annual interval would be .20.

81
The existence of an age-specific risk factor makes the interval in

which the factor operates different both from prior and from subsequent periods. A transition between periods characterized by a

smooth progression, such as a systematic increase or decrease in

the hazard rates, would be attributed to a gradual developmental

maturational process. On the other hand, a substantial degree of

discontinuity in the curve would be attributed to the existence of

an age-specific risk factor. A maximum point in the function during the period under observation is interpreted as a developmental

process in which risk increases and in which maturation occurs

after a certain point in time.

Periods of risk over yearly intervals were examined through early

adulthood. The pattern for cocaine is one of slowly increasing

and continuing risk through the period of observation covered by

the interview at age 24.7. This pattern in which risk does not

terminate and continues to increase contrasts sharply with patterns observed for other drugs, legal and illegal.

Figure 2 displays hazard rates through age 25 for five drugs:

alcohol, cigarettes, marijuana, psychedelics, and cocaine. The

rates are displayed for the total cohort without differentiation

by sex, since the trends are almost identical among men and women.

It should be kept in mind that, because the data are based on a

single cohort, maturation changes associated with age may be confounded to some extent with historical changes.

The rates for initiation into cigarettes, alcohol, marijuana, and

psychedelics increase sharply through the teens. The rates begin

to decline very rapidly at age 18, with slight differences among

the drugs. In particular, the decline for cigarettes begins

sooner than for the other substances. The pattern for cocaine is

very different. Rather than declining, cocaine shows a steadily

increasing rate of risk through age 24. The contrast between

cocaine and marijuana is shown more clearly in an enlarged section

of the graph that only displays these two drugs (figure 3).

Cocaine is the only illicit drug which shows continuing increases

in the risk of initiation through the period of the lifespan

covered by the followup. This probably reflects historical trends

in the popularity of the drug.

The contrast among the drugs is documented further by the age by

which 90% of the users of each drug in this cohort were initiated

into the drug (table 3). This occurs at age 20 for marijuana but

at age 24 for cocaine. Given the fact that there is no censoring

in marijuana initiation, we can conclude that the period of risk

for initiation to marijuana terminates at least 4 years earlier on

the average than for initiation to cocaine.

Data on additional cohorts would be required to determine the

extent to which the cocaine pattern is truly maturational or

reflects historical trends in the popularity of the drug.

82
FIGURE 2

Hazard rates by age for alcohol, cigarettes,

marijuana, psychedelics, and cocaine

83
FIGURE 3

Hazard rates by age for cocaine and marijuana

TABLE 3

Age by Which 90% of Users of Each Drug

Have Been Initiated Into the Drug

Drug Age Total Users

Alcohol 18 (1,305)

Cigarettes 19 (1,049)

Marijuana 20 (955)

Psychedelics 21 (335)

Cocaine 24 (392)

Minor Tranquilizers - Own use 23 (216)

Sedatives - Own use 23 (245)

Minor Tranquilizers - Prescribed use 24 (311)

Sedatives - Prescribed use 23 (100)

LIFESTYLES OF COCAINE USERS

Having described patterns of cocaine use in this cohort of young

adults, we consider a related question. Who are these young

people who experiment with cocaine?

84
In order to answer this question, members of the cohort were classified into five drug-using groups that took into account not only

their cocaine experiences, but also their experiences with other

illicit drugs. Rather than simply contrasting cocaine users to

noncocaine users, three contrast groups were defined: group 1,

those who had never used any illicit drugs; group 2, those who had

only used marijuana; and, group 3, those who had used other

illicit drugs but not cocaine. In order to assess the effect of

cocaine independently of the use of other illicit drugs, cocaine

users were divided into those who had not used any other illicit

drugs besides marijuana (group 4) and those who had (group 5).

The last group includes 83% of all cocaine users among men and 80%

among women. Because of the cumulative nature of drug involvement

(Kandel 1975; Yamaguchi and Kandel 1984a), most of the persons

included in the last three groups had also used marijuana.

The lifestyles and levels of functioning of these young adults

were examined in six areas: use of other drugs; sociodemographic

characteristics; participation in social roles of adulthood,

including continuity of participation; health; degree of conventionality, as reflected in participation in conforming and delinquent activities; and drug use in their social networks. To

simplify the presentation, documentary evidence is presented for

males only. While the same trends generally characterize women,

divergences that occur will be noted.

Striking differences emerge among the five groups regarding the

use of other drugs and lifestyle variables. To anticipate our

findings, young adults who have experimented with any kind of

illicit drugs, including the exclusive use of marijuana, are quite

different from those who have not used any illicit drugs. In most

instances, the exclusive users of marijuana are ranked between

those who have never used other illicit drugs and those who have

used them. Those who have used other illicit drugs but not

cocaine and those who have used cocaine but no other illicit drugs

besides marijuana are similar to each other, except in their

reported illicit drug use. Those who have used cocaine as well as

other illicit drugs besides marijuana are the most deviant of all

young adults, especially among men. The most striking differences

appear in connection with lowered participation in social roles of

adulthood, greater participation in deviant activities and

especially in the use of other illicit drugs, and involvement in

an intimate relationship with another cocaine user.

Use of Other Drugs

Users of any types of illicit drugs are much more likely to have

used all other types of drugs than those who have never used any

illicit drug (table 4a and 4b). While exclusive users of

marijuana generally show the lowest degree of drug involvement, in

every instance among men and in almost every instance among women,

those who have used cocaine and other illicit drugs report higher

lifetime involvement in other drugs than any other group of young

adults. However, those who have not used cocaine and those who

85
have used cocaine exclusively do not show a consistently relative

ranking across the use of various drugs. For certain drugs, young

adults who have used cocaine exclusively are as likely or even

more likely to have experimented with them than users of illicit

drugs other than cocaine. For certain other drugs, the exclusive

cocaine users report rates of use lower than not only those who

have used cocaine and other illicit drugs but also lower than

those who used other illicit drugs but not cocaine, as is observed

for cigarettes, beer, and marijuana among women. By definition,

the exclusive cocaine users report no experience at all with

psychedelics, heroin, and nonprescribed minor tranquilizers,

sedatives, and stimulants.

The users of cocaine and other illicit drugs are much more likely

to have used any of the other types of illicit drugs than illicit

drug users who have not used cocaine. For example, four times as

many of the male users of cocaine and other illicit drugs (36%)

report having used psychedelics at least 10 times in their lives

as compared to users of other illicit drugs who have not used (9%)

(table 4a and 4b); the corresponding percentages among women are

23% and 7%. Similarly, only among men and women who have used

cocaine and other illicit drugs does one find individuals who

report having used heroin at least 10 times in their lives.

Striking differences also appear among the groups with respect to

the use of psychoactive substances that can be used under medical

prescription. At noted above, by definition, young adults who

have used no illicit drugs as well as those who have used

marijuana or cocaine exclusively do not report any nonmedical use

of tranquilizers, sedatives, or stimulants. But, by and large,

they are also less likely to report prescribed use of these

drugs. The highest rates of use of these drugs, both use on one's

own and by prescription, is generally reported by young adults who

have used cocaine and other illicit drugs. The differences

between this group and those who have not used cocaine are

especially striking with respect to nonprescribed use of

stimulants. Of the cocaine users who also used other illicit

drugs, 40% among males and 31% among females have used stimulants

on their own more than 10 times. These proportions are more than

twice as high as observed among individuals who have used other

illicit drugs but have not used cocaine.

The differences between cocaine users who have not used other

illicit drugs and those who have are attenuated with respect to

the prescribed use of psychoactives. The same proportions in each

group report to have used prescribed sedatives among men and

prescribed minor tranquilizers and stimulants among women.

These data clearly document the greater involvement in all drugs

of those individuals who use cocaine as well as other illicit

drugs besides marijuana.

86
TABLE 4a

Lifetime Frequency of Use of Licit and Illicit Drugs

by Cocaine Usage in New York State Followup Cohort

*Differences among groups significant at p<.05; **p<.Dl; ***p<.001.

aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
TABLE 4b

Lifetime Frequency of Use of Psychoactive Drugs That Can Be Medically Prescribed

by Cocaine Usage in New York State Followup Cohort

*Differences among groups significant at p<.05; **p<.O1; ***p<.OO1.

aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
Age of Onset Into Drugs

Important differences among young adults also appear regarding the

age of initiation into different drugs. Those who have used other

illicit drugs in addition to cocaine started using cocaine 1 year

earlier on the average than those who used cocaine exclusively,

and have used the drug for a much longer period of time (table 5).

Those who used cocaine exclusively, on the average, used cocaine

for 18 fewer months than those who also used other illicit drugs,

although the differences are not statistically significant,

Even greater differences among the groups appear with respect to

their use of marijuana and other illicit drugs (table 5). Cocaine

users who also used other illicit drugs started using marijuana at

an earlier age than any other group. The differences are substantial, amounting to more than 2 1/2 years among men and women when

compared with those who used marijuana exclusively, and 1 to 2

years when compared with cocaine users who did not use other

illicit drugs or users of other illicit drugs besides marijuana

who never used cocaine. Not only is marijuana use a precursor to

the use of cocaine and other illicit drugs (Yamaguchi and Kandel

1984a, 1984b). but early marijuana onset is associated with the

multiple use of cocaine and other illicit drugs.

Similarly, cocaine users who used illicit drugs other than marijuana are more likely to have started the use of such 4 years

earlier than those who used cocaine but no other illicit drug

besides marijuana (table 5).

Summary

Strong differences emerge, not only in the use of drugs but also

in many lifestyle characteristics, between young adults who have

experimented with illicit drugs, even if only marijuana, and those

who have not used these drugs. On most attributes that were considered, those individuals who have used any illicit drug other

than marijuana are much more deviant than those who have used

marijuana exclusively. Among men, the differences are consistently strongest among those who have used cocaine and other illicit

drugs. Among women, the differences are sometimes strongest among

those who have used cocaine but no other illicit drugs other than

marijuana.

Sociodemographic Characteristics

No systematic differences appear regarding sociodemographic

characteristics, with the exception of race and the proportion on

public assistance (table 6). The proportion on public assistance

is two to four times higher among male users of cocaine and other

illicit drug users than among any other category of young adults.

Among women, there is an excess on welfare among those who use

cocaine exclusively. As regards race, blacks are much less likely

than nonblacks to report the use of other illicit drugs in the

absence of cocaine. Although the differences are statistically

89
TABLE 5

Ages of First and Last Use and Total Duration of Use Until Interview for Cocaine and Marijuana

and Age of First Use of Illicit Drugs Dther Than Marijuana by Cocaine Usage

in Mew York State Followp Cohort

***Differences among groups significant at p<.001.

a

Includes psychedelics, heroin. and nonprescribed use of methadone, stimulants, sedatives, minor

and major tranquilizers, and antidepressants.

bRestricted to those who used cocaine or marijuana at least 10 times ever.
TABLE 6

Sociodemographic Characteristics by Cocaine Usage

in New York State Followup Cohort

*Differences among groups significant at p<.05; ***p<.001. aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
significant only among women, not a single black man is characterized by such a pattern of use. Black men and women are much more

likely than nonblacks to report use of cocaine and one other

illicit drug, except marijuana.

Participation in Roles of Adulthood

We examined participation in the two major roles of adulthood:

work and family, as well as current student status. Consistent

differences appear only in participation in the social roles of

young adulthood revolving around the family (table 7). Cocaine

users, whether or not they use other illicit drugs, are less

likely to be married and more likely to be currently living with a

partner or to have ever lived with a partner than any other group.

The differences regarding a cohabitation experience increase among

cocaine users who have also used other illicit drugs. Women who

used cocaine exclusively are less likely to have had a child

(table 7).

No systematic differences appear concerning current employment

status among men and women or current student status among men.

Among women, those who used cocaine but no other illicit drugs are

much more likely to be currently in school (33% as compared to 14%

among those who never used any illicit drugs). (See table 7.)

Another aspect of social functioning besides level of participation in social roles of adulthood pertains to the stability of

participation. Lives can be characterized by different degrees of

continuity in social participation. Individuals may move in and

out of the labor force, or they may break up their relationships

with spouse and partner. Differences among types of drug users on

the dimensions of stability are greater than on participation

itself. Cocaine users who have also used other illicit drugs are

much more likely than any other groups to have life histories

characterized by discontinuous rather than continuous patterns of

participation in all social roles of adulthood, employment as well

as close interpersonal relationships expressed in marriage or

cohabitation, but not schooling (table 8). While continuous

patterns are also more frequent among young adults who used

marijuana exclusively and those who also used one or more other

illicit drugs but not cocaine, they are accentuated among the

cocaine users who also used other illicit drugs. This group

experiences increased movement in and out of the labor force, as

well as increased periods of unemployment. A higher proportion of

users of cocaine and other illicit drugs have experienced four or

more job changes in their lifetime , and a higher number of spells

of unemployment. Among men, separation or divorce is highest in

this group and among those who have used other illicit drugs

without cocaine, while among women, separation and/or divorce is

highest among those who used cocaine exclusively (table 8).

Termination of unmarried cohabitations among men and women, as

well as the experience of abortions among women, are highest among

the cocaine users who also used with other illicit drugs. Thus,

women who used cocaine and other illicit drugs are more than five

92
TABLE 7

Current Role Participation by Cocaine Usage

in Mew York State Followup Cohort

*Differences among groups significant at p<.05; **p<.O1; ***p<.OO1. aIncludes psychedelics, heroin. and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
times as likely to have had at least one abortion than women who

never used any illicit drugs, but only four times as likely if

they only used cocaine (table 8).

Conventionality

Users of illicit drugs are generally more likely than nonusers to

be involved in lifestyles that reflect lesser attachment to

conventional institutions and greater participation in delinquent

activities, although on certain criteria there are no differences

among the three subgroups of users of illicit drugs other than

marijuana.

This is especially the case as regards political attitudes,

attendance at religious services,

(table 9).

and moving traffic violations

However, young adults who have used cocaine and other

illicit drugs are more likely than any other group to report being

involved in auto accidents while drunk or stoned (men only), and

having ever been arrested by the police, except for a traffic

violation (men and women) (table 9). These young men and women

also score highest on an index of lifetime delinquent involvement.

The males are not any more likely than users of other illicit

drugs to have ever been convicted of a crime.

Health

Somewhat different patterns of association between cocaine and

health-related criteria appear among men and women.

Among men, there are no significant differences among groups of

young adults concerning self-related health, reports of disability

due to health problems, and medical hospitalizations during the

last 12 months (table 10). Women who used cocaine exclusively,

however, are least likely to rate their health as excellent.

The most important relationships among men and women pertain to

mental health variables. While men and women who use any type of

illicit drugs report feeling less happy about life than young

adults who have not used any illicit drugs, the least happy among

men are the users of illicit drugs without cocaine experience, but

the least happy among women are the cocaine users who have used no

other illicit drug besides marijuana. Among men, two groups show

much increased rates of having ever consulted a mental health

professional and of psychiatric hospitalizations: those who used

illicit drugs other than marijuana, with or without cocaine (20%

for consultations, and 3% and 5%, respectively, for psychiatric

hospitalizations). Men who used cocaine exclusively have low

rates on these two variables, equivalent to those who have never

used illicit drugs or those who used marijuana exclusively. Among

women, however, consultation with a mental health professional

increases dramatically with exclusive use of marijuana and is as

high among the exclusive cocaine users as among those who used

illicit drugs other than cocaine; the rate is highest among those

who used cocaine and other illicit drugs. Psychiatric hospitalizations among women are reported only among cocaine users, whether

94
TABLE 8

Continuity of Role Participation by Cocaine Usage

in New York State Followup Cohort

*Differences among groups significant at p<.O5; ***p<0O1. aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
Attachment to Social Institutions, Accidents, and Delinquency by Cocaine Usage

in New York State Followup Cohort

TABLE 9

*Differences among groups significant at p<.O5; **p<.01; ***p<.001. alncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
TABLE 10

Health Status by Cocaine Usage In New York State Followup Cohort

*Differences among groups significant at p<.05; **p<.O1; ***p<.OO1. aIncludes psychedelics, heroin, and nonprescribed use of methadone. stimulants, sedatives, minor and major

tranquilizers, and antidepressants. bExcluding hospitalizations related to pregnancies for women.
or not they have also used other illicit drugs (4% lifetime in

each group).

Social Context of Use

One of the strongest relationships is that of cocaine use with

increased use of various illicit drugs by spouse or partner and

friends (table 11). (Unfortunately, a question about friends'

cocaine use was not asked in the interview.) The proportion of

friends reported to have used marijuana or other illicit drugs

increases dramatically among the five groups being compared, as

does the proportion of marijuana-using spouses or partners.

However, use of cocaine or illicit drugs other than marijuana by

the spouse or partner is reported only among young adult males who

are also involved in other illicit drugs in addition to cocaine.

Almost a quarter of such men report that their spouse or partner

use cocaine. Among women who use cocaine, their partners or

spouses are also much more likely to be using cocaine whether or

not these women also use other illicit drugs, although the proportion of spouses or partners who use cocaine is highest among women

who use other illicit drugs.

In young adulthood, as in adolescence, drug users are embedded in

a social network of friends and intimates who are themselves

consumers of illicit drugs and sustain the focal respondent's drug

use. The congruence in cocaine use among young adults and their

spouses or partners is stronger among women than among men.

Can One Account for Differences in Lifestyles Among Drug-Using

Groups?

Young adults who have experimented with cocaine as well as other

illicit drugs are clearly the most deviant of all young adults,

with some exceptions among women. These young adults are more

deviant than those who used cocaine exclusively or who have used

other illicit drugs without using cocaine. What accounts for

these differences? The answer, we believe, lies in the overall

pattern of drug involvement of these various subgroups. Those who

use cocaine and other illicit drugs are much more heavily involved

than other individuals not only in cocaine but in a variety of

drugs. This latter relationship persists even when one controls

for their degree of cocaine involvement.

Respondents were asked how many times in their lives they had used

each drug or class of drugs. We noted earlier that the majority

of cocaine users have used cocaine fewer than 10 times altogether.

Those who have used other illicit drugs in addition to cocaine are

much more likely to report using cocaine more than 10 times than

those who have only used cocaine, 50% versus 29% among men, for

example. The respective extent of cocaine involvement by those

who have used cocaine exclusively and those who have not may

account in part for the differences in lifestyles characterizing

98
TABLE 11

Social Context of Cocaine Usage in New York State Followup Cohort

*Differences among groups significant at p<.O5; **p<.O1; ***p<.OO1.

aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
TABLE 11 (Continued)

Social Context of Cocaine Usage in New York State Followup Cohort

*Differences among groups significant at p<.05; **p<.O1; ***p<.OO1. aIncludes psychedelics, heroin. and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
the two groups. An additional and crucial factor, however, is the

increased involvement of the last group in other illicit drugs,

especially marijuana, psychedelics, and heroin.

The two groups of cocaine users were divided according to whether

they had used cocaine fewer than 10 or more times. Because of the

relationship between use of other illicit drugs and extent of

cocaine involvement, certain resulting cells are extremely small

among cocaine users who have used other illicit drugs but have

used cocaine fewer than 10 times. There are only 11 such cases

among men and 7 among women. Table 12 displays selected drug use

of five groups of users: those who have used other illicit drugs

but not cocaine, and the two cocaine groups divided according to

whether each had used cocaine fewer than 10 times in their lives

or at least 10 times.

The differences are striking. Among men who used illicit drugs

other than marijuana, including using cocaine at least 10 times,

the proportion reporting at least a thousand lifetime experiences

with marijuana (73%) is more than 3 1/2 times higher than among

those who never used cocaine (21%), or 2 1/2 times hi her than

among those who used cocaine fewer than 10 times (28%).

Similarly, although the very small sample size must lead to

caution in interpretation, those who have used cocaine

exclusively, but more than 10 times, report much higher lifetime

experience with marijuana than those who used cocaine fewer than

10 times. Similar trends appear among women. Heroin users are

found only among those men and women who used cocaine more than 10

times and also used other illicit drugs. Substantial differences

are also found in the nonprescribed use of minor tranquilizers,

sedatives, and stimulants. The differences are somewhat

attenuated regarding prescribed use of these drugs among men; and

prescribed use is in fact higher among the seven women who used

cocaine exclusively, but more than 10 times, than among those who

also used other illicit drugs. But these differences may be

unstable because of the extremely reduced size of the sample.

While the issue needs to be further investigated, these

preliminary results suggest that the heavier involvement in a

variety of drugs by individuals who use cocaine and other illicit

drugs may partly account for their less favorable outcomes and

lifestyles.

ADOLESCENT PREDICTORS OF COCAINE USE

Finally, let us turn to the third theme. Can one predict in

adolescence which youths are especially at risk for cocaine

involvement by the time they reach young adulthood?

101
TABLE 12

Use of Illicit and Medically Prescribed Drugs by Various Groups of Cocaine Users

in New York State Followup Cohort

*Differences among groups significant at p<.01; **p<.OO1. aIncludes psychedelics, heroin, and nonprescribed use of methadone, stimulants, sedatives, minor and major

tranquilizers, and antidepressants.
In order to answer this question, we capitalized on the

longitudinal design of the research and examined cocaine

experience in young adulthood as a function of what was known

earlier about these individuals during their adolescent years.

Regression analyses were carried out with selected characteristics

measured in adolescence entered in the equations as predictors of

lifetime cocaine experience. The dependent variable was whether

the respondent had ever used cocaine. The analyses were

restricted to those who had not initiated cocaine by the time of

the initial survey--the overwhelming majority of the users.

Indeed, of the 391 young adults who ever used cocaine, only 6.3%

had done so by the time of the initial survey at age 15 to 16.

The variables included in the analyses measured sociodemographic

factors as well as factors from three important domains of

variables: family factors, peer factors, and adolescent

individual attributes (table 13). These variables were selected

because they capture important aspects of adolescent life, in

particular components of the socialization process, such as role

modeling, social reinforcement, and quality of the parentadolescent relationship, as well as degree of commitment to school

and other social institutions. These factors were found in

earlier analyses carried out when the subjects were adolescents to

predict initiation into various stages of drug use over a shortterm interval (Kandel et al. 1978; Kandel and Andrews 1984).

Although these variables as a group account for 22% of the

explained variance in cocaine initiation among men and 16% among

women, very few specific variables have a statistically

significant predictive effect when all other factors are entered

in the equations. Because of strong multicollinearity among the

drug-related variables, especially those indexing self-use and

friends' use, a reduced set of variables was retained in a final

model in order to obtain more stable estimates of the effects of

specific variables. Variables retained in the final model are

indicated with an asterisk. The reduced set accounts for a

slightly lower proportion of the variance, 20% among men and 13%

among women. Zero-order correlation coefficients and standardized

regression coefficients between the significant predictors and

cocaine initiation are presented for men and women separately

(table 14).

Controlling for other factors, very few variables show significant

regression effects. One factor shows significant and consistent

effects on cocaine initiation both among men and women, namely

frequency of marijuana use in adolescence by the time of the

initial survey 9 years earlier, when respondents were 15 to 16

years old. This is the only significant predictor among men.

Among women, an additional factor, father's educational level, is

significant. The higher the education of the father, the greater

the likelihood of initiating cocaine subsequently. Other factors,

which show significant zero-order correlations with cocaine

initiation, have no significant effect once all other factors,

especially frequency of marijuana involvement, are simultaneously

103
TABLE 13

Adolescent Predictors Entered Into Equation

Background Characteristics

*Race

*Religion

*Father's education

Parental Factors

*Father hard liquor use

*Mother frequency psychoactive drug use

*Parent tolerant of marijuana use

Peer Factors

Number of friends perceived to be using marijuana

Number of friends perceived to be using other illicit drugs

Friends' approval of drug use

*Degree of peer orientation

*Degree of peer activity

Number of people who could sell marijuana

Individual Characteristics

*Number classes cut

*Participation in political demonstrations

*Church attendance

*Participation in minor delinquency

Participation in major delinquency

*Depressive symptoms

*Conformity to adult expectations

Believes regular marijuana use harmful

Agrees marijuana should be legalized

*Extent of cigarette use

*Extent of use of hard liquor

*Extent of marijuana use

*Ever used illicit drug other than marijuana or cocaine

*Retained in final model.

104
controlled. The factors that show a significant zero-order

correlation reflect increased peer orientation and less conventionality in adolescence. The peer-related factors include the

degree to which adolescents were oriented to their peers rather

than to their parents, and the extent of their interactions with

friends. The factors related to nonconformity include cutting

classes; participation in delinquent activities and in political

demonstrations; decreased church attendance; and use of legal and

illegal drugs besides marijuana. For men, the other drugs whose

use in adolescence is significantly correlated with subsequent

cocaine initiation include alcohol, other illicit drugs, and

cigarettes, in that order. For women, the highest correlations

next to marijuana include adolescent use of cigarettes, with

alcohol and other illicit drugs being tied for third place. Among

men and women, Jews have an increased risk of involvement in

cocaine and Protestants a reduced risk. Race shows no significant

association.

TABLE 14

Standardized Regression and Correlation Coefficients

for Significant Adolescent Predictors of Cocaine

Initiation by Age 24-25

Males Females

Adolescent Predictor r ß r ß

Lifetime frequency

marijuana use by Tl .361*** .249*** .293*** .242***

Father educational level .062 .050 .138** .131**

R

2

.20 .13

**p<.01; ***p<.001.

In an attempt to capture the potential effects of variables within

a particular conceptual domain, analyses were carried out in which

the total and unique variances contributed to cocaine initiation

by each domain were assessed. The total variance accounted for by

each domain was ascertained by entering the relevant variables as

exclusive predictors in the equation. Unique variances were

ascertained from the additional variance contributed in turn by

each particular domain, once the other four had been entered in

the equations. While each domain, except parental variables, has

a significant total variance, only a single domain, that of

adolescent drug use, makes a unique significant contribution to

the explained variance (see table 15). Among men and women, drug

use in adolescence accounts for more total variance by far than

any other domain--twice as much as the next important domain among

105
men, and three times as much among women. Among men, individual

attributes and involvement with peers are next in importance to

adolescent drug use; among women, the two domains as well as

sociodemographic background factors share equal importance.

TABLE 15

Total and Unique Variances Contributed by Five Domains

of Adolescent Variables to Subsequent Cocaine

Initiation by Early Adulthood

Domains of Variables

Sociodemographic

Parental

Peer

Males Females

Total Unique Total Unique

Variance Variance Variance Variance

.03* .02 .03** .02

.O1 .00 .O1 .00

.06*** .00 .04*** .00

Individual Characteristics .08*** .01 .03* .O1

Drug Use and Attitudes .16*** .07*** .10*** .04***

Total .20 .13

*Significant at p<.05; **p<.O1; ***p<.OO1.

The preeminence of drug use in adolescence as a predictor of subsequent initiation to cocaine is consistently substantiated by

these results.

CONCLUSION

In conclusion, we would like to emphasize the major inferences we

draw from this examination of cocaine use in a general population

cohort. Although experience with cocaine is widespread among

adults by the time they reach their midtwenties--involving more

than one-third of the men and one-fifth of the women--for most

individuals this experience is very limited, amounting to fewer

than 10 trials of the drug. Those who use cocaine more than on an

experimental basis and have also experimented with illicit drugs

other than marijuana display the most deviant lifestyles of all

young adults, more deviant than of those who have only experimented with marijuana or with other illicit drugs but not with

cocaine. Users of cocaine and other illicit drugs are most likely

to be unmarried, to have had unstable work and marital histories,

to have been involved in car accidents while drunk or stoned, to

have been arrested by the police, and to have suffered psychiatric

106
problems. The behavior of these individuals seems to be sustained

by a receptive interpersonal environment, since by their own

accounts they are married to spouses or living with partners who

themselves use cocaine, marijuana, and other illicit drugs and

move in social circles where the use of illicit drugs is extensive. In part, these divergent lifestyles can be accounted for by

the more extensive involvement of the users of cocaine and other

illicit drugs than those of other young adults in legal and

illicit substances.

The attempt to identify early risk factors that would predict subsequent cocaine involvement implicates marijuana use as the major

factor. Frequency of marijuana use in adolescence, both for men

and women, is the most significant predictor of subsequent cocaine

initiation, and in the case of men the only significant predictor.

Parallel analyses using different analytical techniques based on

life event histories (Yamaguchi and Kandel 1984a, 1984b) have

similarly identified marijuana as a crucial link in the progression from legal drugs to the use of all types of other illicit

drugs. Controlling for other variables, marijuana use consistently emerges as a crucial predictor of subsequent involvement in

other illicit drugs.

Many questions are left unresolved. In particular, what accounts

for the link between the use of marijuana and of other illicit

drugs? Would the link disappear were experience with marijuana

precluded? There certainly is a self-selection factor involved.

Young people who experiment with marijuana are different initially

from their peers who do not experiment. But self-selection is not

a sufficient explanation, since the link persists even when

initial differences are controlled for. Do individuals get

involved in social networks of users which further sustain these

drug-using patterns? Are there pharmacological effects of the

drug itself that could account for the link? One point is clear,

however: early onset into marijuana greatly increases vulnerability to subsequent progression to other illicit drugs. To recall

one of the findings we noted above, young women and men who subsequently experimented with other illicit drugs in addition to

cocaine had initiated the use of marijuana 2 to 3 years earlier on

the average than those who experimented with marijuana exclusively. Early onset into drugs is emerging as a consistently

crucial risk factor for progression to other drugs (Robins 1984;

Yamaguchi and Kandel 1984b). Early onset into drug use lengthens

the period of time during a formative period of the life cycle

when young persons experience the effects of a drug. The issue of

self-selection, however, cannot be dismissed. Early initiators

self-select themselves into early use and are already different

from their peers. Therefore, can one naively assume that by

postponing initiation into drugs one will simultaneously change

adolescents in such a way that their chances of subsequent

involvement in other drugs will be substantially reduced, or will

one simply shortcut a process in which risk-taking and nonconforming tendencies will express themselves eventually in the use

of drugs other than marijuana or in other ways?

107
The true challenge of prevention efforts is to address this

issue. These efforts have to be designed in such a way that the

postponement of initiation into drugs, and especially marijuana,

is accompanied by changes in individuals, on the one hand, and the

social environment, on the other hand, so that the delay will

truly reduce the risk for subsequent participation in the use of

various drugs and self-destructive behaviors on the part of young

people. In this respect, the comprehensive approach suggested by

Perry and Jessor (1984) involving a merging of the principles

underlying the promotion of health and the prevention of drug

abuse appears most promising.

FOOTNOTE

1Although validity of recall has been previously established for

reports of certain drug use patterns (Ball 1967; Parry et al.

1970-71), underreporting, telescoping, and distortions have

generally been shown to affect recall of various life events

(Uhlenhuth et al. 1977). However, as stressed by Featherman

(1980), distortions in retrospective reports may not necessarily

be greater than those in contemporaneous reports. In the earlier

phase of the research carried out in high school, we found that

inconsistencies in self-reported patterns of drug use over a

6-month interval were associated with light patterns of use

(Single et al. 1975).

In order to assess the validity of retrospective reports in the

followup interviews, we relied on two strategies. We compared

(1) reports in 1980 for similar events reported on in 1971, and

(2) rates of retrospective self-reported drug use for 1977 with

rates for the same age cohort interviewed contemporaneously in

1977 in the General Household Survey (Fishburne et al. 1980).

The majority of recalled use patterns are consistent with those

reported in 1971, especially for marijuana: 79% of males and 85%

of females give consistent reports, although young people who

reported not using as high school students are more consistent

than those who reported using. The marginal distribution in

reported lifetime prevalence is identical at both points in time

(27%), but only because an equal number of persons gave inconsistent reports from the initial nonusing (N=88) and using (N=86)

groups. However, while in 1971, 259 adolescents reported to have

already used 1980, only 173 (67%) of these same persons remembered

having done so. The inconsistencies are larger for cigarettes and

for alcohol than for marijuana. Thus, the distributions of selfreported users in 1971 were 71% for cigarettes and 86% for

alcohol, whereas only 49% and 68%, respectively, recalled being

users in 1980. Most of the inconsistencies represent failures to

recall Time 1 use at Time 3. Similarly, there are discrepancies

in the ages of onset of use recalled in young adulthood by those

who had indicated in 1971 that they were already using certain

drugs, with a greater proportion reporting a later age of onset

than was reported initially.

108
Although there appears to be a consistent telescoping and foreshortening of time in the recall process, there must be gradual

adjustments over the lifespan being recalled. The annual

prevalence of marijuana use (44%) reported retrospectively for

1977 at age 12 to 22, 3 years prior to the 1980 interview, is

almost identical to that reported contemporaneously by members of

parallel birth cohorts in the General Household Survey (Fishburne

et al. 1980: Table 18). In 1977, 41% of persons aged 18 to 21

and 36% of those 22 to 25 reported using marijuana in the last

year. (Given the tabulations in the report on the General Household Survey, more exact age comparisons cannot be made.)

REFERENCES

Ball. J.C. The reliabilitv and validity of interview data obtained

from 59 narcotic drug addicts. Am J Socio 72:650-665, 1967.

Featherman. D. Retrospective longitudinal research:

Methodological considerations. J Econ Business 32:152-169, 1980.

Fishburne, P.; Abelson, H.; and Cisin, I.. The National Survey on

Drug Abuse:

Abuse. DHHS Pub. No. (ADM) 80-976. Washington, D.C.: Supt. of

Main Findings, 1979. National Institute on Drug

Docs., U.S. Govt. Print. Off., 1980.

Johnston, L.D.; Bachman, J.G.; and O'Malley, P.M. Highlights from

Drugs and American High School Students, 1975-1982. National

Institute on Drug Abuse. DHHS Pub. No. (ADM) 84-1317.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1984.

Kandel, D.B. Stages in adolescent involvement in drug use.

Science 190:912-914, 1975.

Kandel, D.B., and Andrews, K. Processes of adolescent socialization by parents and by peers. Int J Addict Special Issue, in

press.

Kandel, D.B.; Kessler, R.C.; and Margulies, R.Z. Antecedents of

adolescent initiation into stages of drug use: a developmental

analysis. J Youth Adolesc 7:13-40, 1978.

Lentin, J.P. La Cocaine a Cent Ans. Actuel 56:108-115, 1984.

Miller, J.O.; Cisin, I.H.; Gardner-Keam.; Wirtz, P.W.;

Abelson, H.I.; and Fishburne, P.M. National Survey on Drug

Abuse: Main Findings 1982.

DHHS Pub. No.(ADM) 83-1263.

National Institute on Drug Abuse.

Washington, D.C.: Supt. of Docs.,

U.S. Govt. Print. Off., 1983.

Parry, H.J.; Balter, M.B.; and Cisin, I.H. Primary levels of

underreporting psychotropic drug use (with and without the use

of visual aids). Public Opin Qrtly 34:582-592, 1970-71.

Perry, C., and Jessor, R. The concept of health promotion and the

prevention of adolescent drug abuse, 1984. Revised version of

Doing the cube: preventing drug abuse through adolescent health

promotion. In: Glynn, T.J.; Leukefeld, C.G.; and Ludford, J.P.

eds. Preventing Adolescent Drug Abuse: Intervention

Strategies. National Institute on Drug Abuse Research Monograph

47. DHHS Pub. No. (ADM) 83-1280. Washington, D.C.: Supt. of

Docs., U.S. Govt. Print. Off., 1983, pp. 51-75.

Robins, L.N. The natural history of adolescent drug use. Am J

Public Health 74:656-657, 1984.

109
Robins, L.N., and Ratcliff, K.S. In: Herson, L., and Berg, I.,

eds. The long-term outcome of truancy. Out of School.

New York: John Wiley & Sons, 1980. pp. 65-83:

Single, E.; Kandel, D.; and Johnson, B. The reliability and

validity of drug use responses in a large-scale longitudinal

survey. J Drug Issues 5:426-443, 1975.

Uhlenhuth, E.H.; Haberman, S.J.; Balter, M.D.; and Lipman, R.S.

Remembering life events. In: Strauss, J.S.; Babigan, H.; and

Roff, M., eds. The Origins and Course of Psychopathology.

New York: Plenum, 1977.

Yamaguchi, K., and Kandel, D.B. Patterns of drug use from

adolescence to young adulthood - II. Sequences of progression.

Am J Public Health 74:668-672, 1984a.

Yamaguchi, K. and Kandel, D.B. Patterns of drug use from

adolescence to young adulthood - III. Predictors of progression. Am J Public Health 74:673-681, 1984b.

ACKNOWLEDGMENTS

This research was partially supported by grants DA 01097,

DA 02867, and DA 03196 and by Research Scientist Award DA 00081

from the National Institute on Drug Abuse.

AUTHORS

Denise B. Kandel, Ph.D

Department of Psychiatry and School of Public Health

Columbia University College of Physicians and Surgeons and

New York State Psychiatric Institute

Box 20

722 West 168th Street

New York, N.Y. 10032

Debra Murphy, Ph.D.

Division of Sociomedical Sciences

School of Public Health

Columbia University

600 West 168th Street

New York, N.Y. 10032

Daniel G. Karus, M.S.

Department of Psychiatry

Columbia University College of Physicians and Surgeons

722 West 168th Street

New York, N.Y. 10032

110
Patterns and Consequences of

Cocaine Use

Dale D. Chitwood

INTRODUCTION

The significant public health issue involving cocaine is: "What

are the consequences of cocaine use?' This question has received

a variety of inconsistent answers during the last 100 years.

Praised as a wonder drug by physicians in the late 18OOs, reviled

as the demon drug of black Americans by persons caught up in the

racial fear and bigotry of the first quarter of this century, and

touted as the ultimate aphrodisiac in various eras, cocaine has

entered the mid-1980s with an abundance of mythology still intact

(Siegel 1984; Phillips and Wynne 1980; Musto 1973). During the

popularization of cocaine in the 197Os, some commentators emphasized, albeit cautiously, the more benign aspects of the drug

(Ashley 1975). Recent investigations indicate that cocaine use

has produced serious adverse effects (Mittleman and Wetli 1984;

Siegel 1984; Washton and Tatarsky 1984). Because illicit cocaine

use occurs in settings that do not readily lend themselves to

experimental inquiry, additional nonexperimental investigation is

needed to further differentiate reality from the mythology that

surrounds cocaine use.

Knowledge about the consequences of use is limited, and many questions about the relationship between use and consequences remain

unanswered. Nonexperimental research into that relationship will

advance more rapidly as researchers begin to apply more precise

definitions to concepts of cocaine use. Unfortunately, terminology used to describe drug-using behavior has not been standardized

(Cisin et al. 1978), and labels for use patterns, such as "chronic

abuser," have been defined in various ways without being defined

at all. A decade ago the National Commission on Marihuana and

Drug Abuse concluded that "drug using behavior is described by

such an array of non-specific, unscientific and judgmental terms

that it is often difficult to ascertain who is being described and

what kind of behavior is being evaluated" (1973, p. 93). This

problem is directly applicable to cocaine research. The

assessment of cocaine use, beyond a use/nonuse determination, is

complex and involves issues of initiation and cessation, route of

ingestion, dose, frequency of use, use over time, and use in

combination with other drugs.

111
The investigation of consequences is in an embryonic phase, and

most inquiries have been exploratory studies which generate

hypotheses but are not designed to test them. The failure to

recognize the limitations of specific research designs of exploratory investigations can cause confusion. A case in point is the

question of the dose-effect of cocaine--the relationship between

degree of exposure (often referred to as pattern of use) and consequences. Disparate reports have surfaced about the role of

route of ingestion, frequency, and quantity of use in the occurrence of adverse consequences. Experimental observations reported

by Van Dyke and Byck (1982) indicate that acute consequences are

related to these three elements of the pattern of cocaine use.

Siegel (1984) concurs that persons who smoke freebase are more

likely than intranasal users to report adverse health consequences. Conversely, Washton and Tatarsky (1984) observed no

measurable dose-effect when they analyzed data from 55 phone

interviews with users who called a hotline because they were

experiencing adverse consequences. These researchers noted that

equally substantial numbers of consequences were reported by

respondents regardless of their route of ingestion, frequency, or

auantitv of cocaine use. Earlier. Helfrich et al. (1983) had

studied the use patterns and consequences of 136 treatment clients

who met the Diagnostic and Statistical Manual III criteria for

cocaine abuse. They concluded that differences in the occurrence

of consequences were associated with quantity of use but were not

associated with route. At first blush, these latter two investigations appear to contradict the former studies which observed a

dose effect, but this is not the case. Closer examination reveals

that the principal intent of both studies was to demonstrate

empirically that intranasal use, as well as infrequent use and use

of small quantities, of cocaine can produce adverse consequences.

Each did this by documenting, for example, that study participants

who used cocaine intranasally reported the same number of consequences as were reported by intravenous users and freebase

smokers. Confusion arose when the observed "no difference" in

consequences by route of ingestion was interpreted as an indicator

that there was no dose-effect. That conclusion would be inappropriate because the population of each study was by design so

homogeneous in its "consequence" experience that users of each

route of ingestion who were part of those populations would by

definition reflect very similar consequences. The study designs

were appropriate for addressing the question of whether intranasal

users are part of the population that experiences adverse consequences, but were not appropriate to address the issue of whether

intranasal users are as likely as freebase smokers or intravenous

users to experience consequences.

Both exploratory and hypothesis-testing investigations of cocaine

use and consequences will be enhanced to the extent that

researchers carefully define how use and consequences of use are

conceptualized and measured. This chapter addresses these issues

by discussing:

112
1. Problems with the measurement of patterns of cocaine use,

and

2. Problems with the measurement of consequences of use.

Data about patterns of cocaine use and physical consequences of

use which are relevant to these issues are presented.

METHODOLOGY

The data reported in the paper are part of an investigation of a

cocaine-using population in south Florida (Morningstar and

Chitwood 1983). The primary purpose of the study was to describe

differences in patterns of cocaine use. Between April 1980 and

June 1981, a structured interview schedule was administered to a

purposive sample of 95 treatment clients and 75 nonclients, all of

whom were at least 18 years of age and reported cocaine to be a

primary drug of use. Treatment clients were selected from the

existing population of cocaine users who recently had entered a

traditional drug treatment program, and nontreatment respondents

were drawn through a network sampling procedure which enrolled

respondents from several different user networks. Respondents

were stratified on selected demographic variables (ethnicity, sex)

and included Hispanic (primarily Cuban), non-Hispanic black, and

non-Hispanic white male and female users of primarily middle and

working class occupational cohorts. There were no statistically

significant differences in the ethnicity, sex ratio, or occupational level of treatment and nontreatment respondents (Chitwood

and Morningstar 1985). Treatment clients reported information for

the time period preceding entry into treatment, while nontreatment

respondents provided data for the time period preceding the interview. (Data are presented as percentages in all tables, and P

values for Chi-square are reported in tables 3 through 6.)

PROBLEMS WITH THE MEASUREMENT OF PATTERNS OF USE

Patterns of cocaine use have been approached from a variety of

perspectives in nonexperimental research, including self-reported

dichotomous use/nonuse measures (O'Donnell et al. 1976); multidimensional typologies based upon cocaine users' characterizations

of themselves (Morningstar and Chitwood 1984) or upon the five

categories of the National Commission on Marihuana and Drug Abuse

(Siegel 1984); postmortem toxicological analyses for cocaine

benzoylecgonine, a major metabolite (Mittleman and Wetli 1984);

and self-reported use histories, including questions of lifetime

use and specific items about route of administration, quantity,

and frequency of use (Chitwood and Morningstar 1985; Washton and

Tatarsky 1984). Experimental studies define exposure in terms of

precise quantities of cocaine administered via specified routes

under experimental conditions (Van Dyke and Byck 1982).

Each of these approaches is potentially useful in its own right,

but each one also has limitations. A dichotomous use/nonuse

measure is essential to address the question "DO cocaine users

113
manifest more consequences than nonusers?" But, such a measure is

not relevant to the dose-effect question which requires more

extensive analyses about those who use cocaine. Cocaine users'

perceptions of types of users provide insight into user beliefs

about exposure and effect, and multidimensional typologies, based

upon the National Commission's work, present a broad perspective

of the lifestyle of users. However, both of these typological

approaches are problematic for dose-effect research, because they

incorporate concepts of exposure and consequences into the definitions of the categories of types. The use of these definitions to

measure exposure would produce a tautology. Experimental measures

are ideal for investigations of acute, nonlife-threatening effects

but are neither feasible nor ethically acceptable in studies of

the relationship between longtime use and severe consequences.

Toxicological approaches are technologically sophisticated, are

useful in assessing quantity of cocaine ingested immediately prior

to the testing, and provide valuable data on cocaine-related

deaths. This approach, like the experimental design, is not

feasible for assessing amount of cocaine ingested by users in the

community over an extended period of time. Self-report measures

avoid the restrictions of experimental settings but surrender the

precision of the experiment. Epidemiologists have successfully

used self-reported exposure to investigate the relationships

between tobacco smoking and lung cancer (Doll and Hill 1954), and

a similar approach would enhance the investigation of cocaine use.

Self-Reported Exposure to Cocaine: Patterns of Use Data

Exposure to cocaine encompasses a person's total history of use.

Specific characteristics of initiation of use, use in combination

with other drugs, temporary cessation of use, level of cocaine

use, and use over time presented in this section document the complexity of data that should be considered when developing a

measure of exposure.

Initiation of cocaine use. The ages of the study respondents when

they first tried cocaine are recorded in table 1. alona with the

mean ages at which respondents first used other drugs." Most

respondents initiated cocaine use in their late teens; 70%

reported first use of cocaine between the ages of 16 and 22. When

compared with the initiation of other drugs, cocaine had the

second oldest mean age at initiation of use, 19.2 years. Other

researchers also have reported that initiation of cocaine use

usually occurs after the initiation of certain other categories of

drugs (Clayton and Voss 1981; O'Donnell et al. 1976; Kandel and

Faust 1975). Widespread availability of cocaine is a relatively

recent phenomenon, and late age at initiation may decline among

cohorts to whom cocaine is available during their initial years of

drug use.

Initial use usually occurred at a party (15%) or other informal

social setting (72%). Very few first used cocaine on a street

corner (8%) or at work or school (5%). The introduction to

cocaine for both men and women was dominated by men. Male

114
initiates were introduced primarily by male friends (68%) or male

relatives (10%). Female initiates usually were introduced by a

spouse or intimate male friend (34%) or other male friend (43%).

In contrast to these friendship/intimate/other relationships, only

5% obtained their first cocaine from dealers and another 2% from a

coworker. This pattern of male-dominated behavior did not end at

the point of initiation, but remained a part of the career pattern

of cocaine use for a majority of respondents. More than four out

of five (82%) ingested cocaine intranasally on their first use

experience, while the remaining 18% injected cocaine. On that

occasion, most respondents ingested very small quantities of

cocaine. Fifty percent used about one-tenth of a gram or less,

and only 20% used one-quarter of a gram or more. When asked if

they "got high" on that first use occasion, 82% said they had.

TABLE 1

Age at Initiation of Cocaine and Other Drug Use

Age at Initiation of Cocaine

Age <16 16 17 18 19 20 21 22 >22 Totala

(%) 15' 11 10 17 12 7 7 7 15 101%

Mean Age at Initiation of Use

of tleven Categories of Drugs

Drug Type

Alcohol 168 13.6

Marijuana 170 15.3

Inhalants 100 16.4

Hallucinogens 115 17.7

Other Stimulants 133 18.0

Sedative-Tranquilizers 162 18.1

PCP 104 18.2

Heroin 107 18.6

Other Narcotics 112 18.8

COCAINE 170 19.2

Methaqualone 147 19.7

Number Who

Ever Used

Mean Age at

Initiation

aRounding causes total percentage to vary from 100

in some tables.

Cocaine in combination. Table 2 contains data about the frequency

with which various drugs were used in combination with cocaine.

115
TABLE 2

Frequency With Which Respondents Use

Other Drugs When They Use Cocaine (N=170)

(Percentages)

aMay vary from 100 due to rounding.
Respondents were asked, "When you use cocaine, how frequently do

you use (each drug) in combination with cocaine?" The data indicate that when these respondents used cocaine:

More than one-half (53%) used marijuana at least 75% of the

time;

More than one-third (35%) used alcohol at least 75% of the

time;

One-fifth used methaqualone at least 75% of the time;

Eleven percent used heroin at least 75% of the time, but 6 out

of 10 never used heroin in combination; and

Most respondents did not use other stimulants (82%), hallucinogens (85%), inhalants (86%), or PCP (86%) in combination.

The majority of the study respondents were polydrug users whose

drug of choice was cocaine or cocaine in combination. Note that

three of the drugs most frequently combined with cocaine were

central nervous system depressants. The combination of cocaine

and heroin has been popular for many years in the heroin user subculture and is known as a "speed ball." This combination produces

a rollercoaster effect. Several respondents stated that they used

alcohol or sedatives at the end of a cocaine session to come down,

reduce agitation, ease crash effects, or facilitate sleep. Since

cocaine is frequently combined with depressants, increases in

cocaine use may be accompanied by increased use of these drugs.

The use of cocaine in combination introduces a problem of confounding, i.e., the possibility that observed associations between

cocaine use and the occurrence of an adverse consequence is not

the result of cocaine use but the product of the ingestion of

another drug used in combination with cocaine. The present study

was designed to describe patterns of cocaine use among various

user groups. One finding was that most cocaine users were polydrug users, but the untangling of the effects of cocaine used

alone from cocaine used in combination with other drugs will

require a followup study which will stratify the sample to insure

that a sufficient number of respondents who only use cocaine are

enrolled.

Voluntary cessation of cocaine use. Respondents also were asked

if they voluntarily had stopped using cocaine for 1 month or

longer. Two-thirds of the study sample had stopped using cocaine

on at least one occasion, and approximately four out of ten

reported voluntary cessation on at least three occasions. Of

those who had voluntarily stopped using cocaine, 18% did so out of

fear of negative health consequences, 3% suspended use because of

existing health problems, 12% were pressured by family or friends

to cease use, and another 12% stopped because the cost of cocaine

was too high. About half of those who had temporarily stopped

using cocaine reported other unspecified reasons.

117
Level of cocaine use index. The level of cocaine use index used

in this paper is a summated 13-point index which gives equal

weight to self-reported route of ingestion, frequency of use, and

quantity of use. These three factors were previously identified

as variables which are associated with variation in physiological

effects (Gay 1982; Van Dyke and Byck 1982; Spotts and Shontz 1980;

Resnick and Schuyten-Resnick 1976; Grinspoon and Bakalar 1976).

Each has been identified by users as a discriminating characteristic of indigenous typologies of cocaine use (Morningstar and

Chitwood 1984). Criterion validity was established by item

analysis, and inter-item correlations indicated that each of the

three components makes an independent contribution to the index.

A complete description appears elsewhere (Morningstar and Chitwood

1983).

Respondents were asked to recall specific timespans of use, e.g.,

initial year, heaviest use period, and past 3 months. A series of

questions was asked about use during each period, and index values

were calculated for each time period. In this chapter, index

scores are collapsed into three categories:

Low-Level Use: Primarily intranasal ingestion no

more than weekly of less than 1 gram

per occasion.

Medium-Level Use: Usually intranasal ingestion more

than weekly of more than 1 gram per

occasion or intravenous ingestion up

to once a week of less than 1 gram

per occasion.

High-Level Use: Primarily intravenous ingestion daily

of more than 1 gram per occasion.

This index represents a first step in the development of a replicable measure of cocaine use and is not without limitations. Questions concerning the cutting points may be raised and the summation of items which technically are more ordinal than interval in

nature may be challenged. Nevertheless, as the item analysis and

inter-item data indicate, the index appears to include independent

contributions from three important elements of cocaine use.

Variation in use across time. Individual variation was assessed

by calculating a level of use index score for each user's initial

year, heaviest period of use, and past 3 months of use (figure 1).

The data indicate that users tended to initiate at a low level of

use and progress to higher levels in subsequent years. Approximately one-half (48%) were currently using at a level that was

higher than that of their initial year of use. One-fifth of the

study population had remained low-level users, but nearly as many

(18%) had progressed from low-level use during their first year to

high-level use at some time subsequent to that year. Forty

percent had been high-level users some time during their use

118
FIGURE 1

Levels of cocaine use over time

119
career. One-quarter of the respondents currently maintained a use

level below that of their heaviest use period.

Because considerable variation in level of use across time was

reported, a dilemma exists concerning the period of exposure that

one chooses to use in the analysis. The solution requires

specific information about the consequences being investigated,

because the selection of the measure of exposure is predicated

upon the nature of the dependent variable, consequences of use.

PROBLEMS WITH THE MEASUREMENT OF CONSEQUENCES OF USE

Most studies of illicit drug use have focused upon drug use as the

dependent variable, but in studies of consequences, cocaine use is

the independent variable. It is essential that the definition of

consequences specify whether one is investigating incident

effects, i.e., new cases of consequences which occur during a

specified period of time, or prevalent effects, i.e., consequences

present in the study population either at a specific point in time

(point prevalence) or present at some moment within a specified

period of time (period prevalence) (Lilienfeld and Lilienfeld

1980). Measurement also needs to be clearly delineated. Consequence data could be collected by means of clinical verification

(at a physical examination or by a review of clinical records) or

by self-report.

Self-Reported Consequences: Lifetime Prevalence Data

The lifetime prevalence of consequences of cocaine use, reported

in tables 3 through 6, is defined as the proportion of people who

report ever having the disease or an adverse health condition

which they attribute to the use of cocaine. Lifetime prevalence

is reported because one purpose of this exploratory study was to

describe the extent to which users had ever experienced specific

consequences of use. The existence of certain consequences

reported here, such as an abscess, potentially is clinically verifiable. However, clinical verification of lifetime prevalence

would necessitate a retrospective review of clinical records and

could capture only those episodes for which the user received

medical care. Other consequences of interest, such as nausea,

seldom are clinically verifiable because they are transitory, are

defined to a considerable extent by the user, usually are treated

by the user who does not seek professional care, and are not

readily externally verifiable. Data reported here were collected

by self-report because the spectrum of consequences being investigated and the timespan of interest made clinical verification

impractical.

The measure of exposure reported in tables 3 through 6 is the

level of cocaine use during the respondent's period of heaviest

use. This exposure was selected upon the supposition that doseeffect for lifetime prevalence would more likely be associated

with heaviest use than with current use.

120
Physical Health Consequences. Respondents were asked to report

the presence of a variety of physical health problems during their

lifetime and to indicate whether each condition was related to

cocaine use. Five "route of ingestion related" and five "general

health" consequences attributed to cocaine use are reported in the

following two paragraphs. For each health condition, lifetime

prevalence by level of heaviest cocaine use is reported in

table 3, and lifetime prevalence by route of ingestion, frequency

of use, and quantity of use is presented in table 4. The following discussion of health consequences includes data from both

tables.

No significant differences were observed in the proportion of

low-, medium-, and high-level users who reported ever experiencing

rhinitis or an ulcerated (or perforated) nasal septum (table 3).

These conditions are known to be produced through intranasal

ingestion, and data in table 4 indicate that persons who had used

cocaine intranasally during their heaviest use period were almost

twice as likely to report rhinitis and three times as likely to

report an ulcerated septum. Abscesses, other skin infections, and

hepatitis (consequences identified with the use of nonsterile

needles) were reported most often by high-level users. Route of

ingestion was associated with the presence of these problems;

intravenous users were four times more likely to report these consequences.

High-level users were considerably more likely to report a

physically rundown condition, lack of appetite, insomnia, and a

lack of sexual interest (table 3). Similarly, persons who used

1 gram or more on each use occasion were more likely to have

experienced each of these health conditions (table 4). This also

was true for intravenous users (although differences in insomnia

were not significantly different) and for persons who used more

than once a week. Cocaine has been alleged to possess aphrodisiacal qualities, but ironically, 3 out of every 10 respondents

had experienced a lack of sexual interest as a result of their

use. Users of high levels of cocaine (43%) were five times more

likely than low-level users (8%) to have experienced this symptom.

One out of every ten respondents, none of whom were low-level

users, reported overdosing on cocaine. High-level users were the

most likely group to report an overdose episode. Overdose was

much more common among persons who used intravenously, used more

than once a week, or used 1 gram or more per occasion. Specific

overdose symptoms are reported in the next section.

Side Effects. Respondents were asked the same question about each

possible effect. "Tell me how freauentlv. if ever, YOU have had

the following side effects or after effects when you used

cocaine?" The lifetime prevalence of 12 side effects by level of

use are reported in table 5, and lifetime prevalence of side

effects by route, frequency, and quantity are presented in table 6.

121
TABLE 3

Health Effects: Lifetime Prevalence by

Level of Cocaine Use (N=170)

Heaviest

*p < .05

**p < .O1

***p < .001

122
TABLE 4

Health Effects: Lifetime Prevalence by Route of Ingestion, Frequency of Use,

and Dose During Period of Heaviest Use (N=17D)
Gay (1982) has outlined three stages of the "cocaine reaction."

He characterizes the early stimulation stages of the cocaine

reaction by excitement, headache, nausea, cold sweats, twitching,

changes in blood pressure, and increased respiratory rate. Ten of

the side effects reported in table 6 are indicators of this early

stimulative phase. The least reported symptom in this phase,

tremor, was noted by half of all respondents. Nearly threefourths of all users in the high level of use category had

experienced all 10 early phase side effects.

The advanced stimulative phase is characterized by convulsion

resembling grand ma1 seizure; increased pulse rate and increased'

blood pressure; cyanosis; and rapid, gasping, or irregular respiration. Convulsion is probably the symptom of this phase which

can be most validly and reliably elicited in a self-report situation. Twelve percent of the sample had convulsed on at least one

occasion, and one-fifth of the high-level group of cases reported

a convulsion.

The depressive phase includes symptoms of muscular paralysis, loss

of reflexes, unconsciousness, circulatory and respiratory failure,

and death. Once again, it is difficult to collect accurate selfreport data on many of these symptoms. However, 15% of all

respondents and 22% of the heavy use group reported loss of consciousness.

The most serious physical effect of cocaine use is the overdose, a

somewhat elusive phenomenon since several users tended to equate

overdose with death, and moderate or even severe overdose symptoms

sometimes were not recognized as such by users. Many users said

that they did not know it was possible to overdose. For example,

while 10% of the respondents reported that they had overdosed on

cocaine (table 3). 12% had experienced convulsions, 15% reported

loss of consciousness (table 6), and 17% had experienced at least

one of the latter two overdose symptoms.

Data from table 5 indicate level of use is positively associated

with all 12 side effects. Data from table 6 indicate intranasal

users are less likely to report these side effects. The same

observation is true for persons using less than 1 gram (with the

exception of dry or cotton mouth) and persons using less than once

per week (with the exception of teeth grinding).

CONCLUSION

These data demonstrate that (at the zero order level of analysis)

the level of cocaine use during heaviest use period and the route

of ingestion, frequency, and quantity of use are associated with

the lifetime prevalence of several self-reported health consequences and side effects. The findings of this exploratory

investigation are consistent with other reports.

124
TABLE 5

Side Effects: Lifetime Prevalence by Heaviest

Level of Cocaine Use (N=170)

Side Effects

Early Stimulative Phase

Dry Mouth or Cotton Mouth

Sweating

Irregular or Increased

Heart Beat

Visual Distortion

Grind Teeth

Headache

Change in Breathing

Nausea

Dizziness

Tremors

Advanced Stimulative Phase

Convulsions

Depressive Phase

Unconsciousness

Level of Cocaine Use

Medium Total

N=66 

High

N=68 N=170

Low

N=36

(%) (%) (%) (%)

P

67 86

60 85

64 88

22 61

47 67

22 58

31 62

18 52

11 48

25 42

0

3

9

14

93

100

100

75

75

79

82

90

75

71

21

22

85

86

88

58

66

59

63

60

52

50

12

15

***

***

***

***

**

***

***

***

***

***

**

**

*p < .05

**p < .01

***p <.001

125
TABLE 6

Side Effects: Lifetime Prevalence by Route of Ingestion, Frequency of Use,

and Dose During Heaviest Period of Use (N=170)
Nonexperimental research into the relationship between patterns

and consequences of cocaine use will advance as we employ more

precise terminology and more rigorous study design in our investigations. Medical epidemiologists have considerable experience

examining the relationship between exposure to risk factors and

the onset of disease that occurs in a nonexperimental, natural

setting. Their investigations of the relationship between tobacco

and lung cancer (or other respiratory disease) have overcome many

of the problems that also are encountered in investigations of the

relationship between patterns of cocaine use (as well as other

drugs) and consequences of use.

The methodologies used in these investigations could be applied to

the question of consequences of cocaine and other drug use.

Although evidence from experimental and nonexperimental research

indicates that adverse consequences have occurred following

cocaine use, knowledge about relative and attributable risks of

severe health and social consequences related to cocaine use

remains unknown. The utilization of carefully designed casecontrol (Schlesselman 1982) and cohort studies will enable us to

adequately address these public health questions.

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Doll. R., and Hill. A.B. The mortalitv of doctors in relation to

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1:1451-1455, 1954.

Gay, G.R. Clinical management of acute and chronic cocaine

poisoning: Concepts, components and configuration. Ann Emerg

Med 11(10):562-572, 1982.

Grinspoon, L., and Bakalar, J.B. Cocaine: A Drug and Its Social

Evolution. New York: Basic Books, 1976.

Helfrich, A.A.; Crowley, T.J.; Atkinson, C.A.; and Post, R.L. A

clinical profile of 136 cocaine abusers. In: Harris, L.S., ed.

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Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off.,

1983. pp. 343-350.

Kandel, D.B., and Faust R. Sequence and stages in patterns of

adolescent drug use. Arch Gen Psychiatry 32:923-932, 1975.

127
Lilienfeld, A.M., and Lilienfeld, D.E. Foundation of Epidemiology.

2d ed. New York: Oxford University Press, 1980.

Mittleman, R.E., and Wetli, C.V. Death caused by recreational

cocaine use. JAMA 252:1889-1893, 1984.

Morningstar, P.J., and Chitwood, D.D. The Patterns of Cocaine

Use - An Interdisciplinary Study. Final Report No. ROl DA03106

submitted to the National Institute on Drug Abuse, Rockville,

Maryland, 1983.

Morningstar, P.J., and Chitwood, D.D. Cocaine users' view of

themselves: Implicit behavioral theory in context. Human

Organization 43(4):307-318 1984.

Musto, D.F. The American Disease. New Haven: Yale University

Press, l973.

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America: Problem in Perspective. Washington, D.C.: Supt. of

Docs., U.S. Govt. Print. Off., 1973.

O'Donnell, J.A.; Voss, H.L.; Clayton, R.R.; Slatin, G.T.; and

Room, R.G.W. Young Men and Drugs: A Nationwide Survey.

National Institute on Drug Abuse Monograph 5. DHHS Pub. No.

(ADM) 76-311. Washington, D.C.: Supt. of DOCS., U.S. Govt.

Print. Off., 1976.

Phillips, J.L., and Wynne, R.D. Cocaine: The Mystique and the

Reality. New York: Avon, 1980.

Resnick, R.B., and Schuyten-Resnick, E. Clinical aspects of

cocaine: Assessment of cocaine abuse behavior in man. In:

Mule , S.J., ed. Cocaine: Chemical, Biological, Clinical,

Social, and Treatment Aspects. Cleveland: CRC Press, 1976.

pp. 219-228.

Schlesselman, J.J. Case-Control Studies. New York: Oxford

University Press, 1982.

Siegel, R.K. Cocaine: Recreational use and intoxication. In:

Peterson, R.C., and Stillman, R.C., eds. Cocaine: 1977.

National Institute on Drug Abuse Research Monograph 13. DHHS

Pub. No. (ADM) 77-471. Washington, D.C.: Supt. of Docs., U.S.

Govt. Print. Off., 1978. pp. 119-138.

Siegel, R.K. Changing patterns of cocaine use: Longitudinal

observation, consequences and treatment. In: Grabowski, J.,

ed. Cocaine: Pharmacology, Effects, and Treatment of Abuse:

National Institute on Druq Abuse Research Monoqraph 50. DHHS

Pub. No. (ADM) 84-1326. Washington, D.C.: Supt. of DOCS., U.S.

Govt. Print. Off., 1984. pp. 92-110.

Spotts, J.V., and Shontz, F.C. Cocaine Users: A Representative

Case Approach. New York: The Free Press, 1980.

Van Dyke, C., and Byck, R. Cocaine. Sci Am 246(3):128-141 1982.

Washton. A.M., and Tatarsky, A. Adverse effects of cocaine'

abuse. In: Harris, L.A., ed. Problems of Drug Dependence

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U.S. Govt. Print. Off., 1984. pp. 247-253.

ACKNOWLEDGMENT

This research was supported in part by the National Institute on

Drug Abuse grant R0l DA03106.

128
AUTHOR

Dale D. Chitwood, Ph.D.

Center for Social Research on Drug Abuse

Medical Arts Building, Room 309

1550 N.W. 10th Avenue

Miami, FL 33136

129
Cocaine Abuse: Neurochemistry,

Phenomenology, and Treatment

Mark S. Gold, Arnold M. Washton, and Charles A. Dackis

INTRODUCTION

This chapter addresses three separate but related aspects of

cocaine abuse problems. The first section summarizes some of the

basic neurochemical aspects of cocaine, focusing on the

noradrenergic, serotonergic, and dopaminergic systems in the

central nervous system (CNS). The second section presents the

results of several recent surveys of cocaine users who called our

national telephone helpline, 800-COCAINE. These surveys highlight

the nature of the current cocaine epidemic in the United States,

providing data on demographics, patterns of use, and drug-related

consequences in the largest samples of users to date. The third

and final section of this chapter deals with clinical issues. We

offer the benefit of our experience in treating cocaine abusers as

inpatients and outpatients, with specific suggestions for effective treatment of the chronic cocaine abuser.

Some of the information in this chapter has appeared in other publications by our research group and the reader is referred to the

original sources for further details.

NEUROCHEMISTRY

Norepinephrine

Adrenergic effects of cocaine were first reported in 1910 by

Frohlich and Loewi, who demonstrated enhanced sensitivity to

epinephrine in tissue exposed to cocaine. It now appears well

established that cocaine blocks the reuptake of norepinephrine

(NE) at adrenergic nerve endings (Langer and Enero 1974; Muscholl

1961; Just et al. 1977; Hawks et al. 1974; Whitby et al. 1960) as

well as facilitates NE release (Farnebo and Hamberger 1971). This

blockade of NE reuptake by cocaine is competitive (Langer and

Enero 1974) and does not appear to result from its anesthetic

action (Muscholl 1961). Furthermore, peripheral and central NE

reuptake blockade is seen with cocaine concentrations which are

consistent with those found in human cocaine abuse (Just et al.

1977; Hawks et al. 1974). Thus, while cocaine activates postsynapt c NE receptors and their associated target cells, NE

130
neurons themselves may be inhibited by this exogenous agent's

activation of inhibitory presynaptic alpha-2 receptors located on

NE neurons (Langer et al. 1980; Cedarbaum and Aghajanian 1977).

This may explain how acute administration of cocaine causes an

elevation in NE brain concentrations at 10 minutes, followed by

marked reductions below normal levels at 20 minutes (Pradhan

et al. 1978b). Similarly, receptor binding studies have demonstrated increased beta-receptor populations 12 hours following a

single dose of cocaine (Banerjee et al. 1979). However, chronic

cocaine administration produces even greater increases in betareceptor density as well as increased alpha-receptor population

(Banerjee et al. 1979; Chanda et al. 1979; Pert et al. 1979).

Increased receptor sensitivity may explain some of the sensitization effects seen with chronic cocaine use. This would imply that

cocaine administration leads to reduced NE turnover and inhibition

of NE neurons--the predominant cocaine effect on this system (see

table 1).

TABLE 1

Cocaine and Norepinephrine

(Tachycardia, Hypertension, Vasoconstriction,

Mydriasis, Diaphoresis, Tremor)

1. Blocks reuptake

2.

3.

Facilitates NE release

Activates tyrosine hydroxylase

4. NE cell bodies inhibited (d-2 effect)

5. Increased B-cell populations

6. Increased receptor sensitivity with chronic use

Net Effect: Decreased NE

Certain physiological effects of cocaine intoxication appear to

result from sympathetic activation and can be explained by acutely

potentiated central and peripheral NE neurotransmission. These

include tachycardia, hypertension , vasoconstriction, mydriasis,

diaphoresis, and tremor (Ritchie and Greene 1980). These

autonomic signs can be produced in monkeys by electrically stimulating the pontine nucleus locus coeruleus (LC), which is the

major NE nucleus of the brain (Redmond et al. 1976; Gold et al.

1980).

Dopamine

Dopamine (DA) neurons appear to mediate the euphoric response to

cocaine and are thereby critical in self-administration of cocaine

and the development of addictive use patterns. Certain effects of

cocaine are dependent upon the integrity of DA systems. If a

lesion in the nucleus accumbens is produced by the DA toxin

6-hydroxydopamine, animals will cease to self-administer cocaine

131
(Iversen 1966). Pretreatment with reserpine, which depletes

catecholamines, will block cocaine-induced stereotypies and

locomotor hyperactivity (Sayers and Handley 1973). Thus, cocaine

effects which involve DA mechanisms are not produced by direct

stimulation of DA receptors, but indirectly through presynaptic

effects on DA neurons. Cocaine is a potent inhibitor of DA

reuptake and appears to release this neurotransmitter (Whitby

et al. 1960). DA reuptake inhibition has been confirmed in a

number of studies (Iversen 1966; Ross and Renyi 1966;

Trendelenburg and Graefe 1975; Taylor and Ho 1978; Scheel-Kruger

1971) and is consistent with acutely increased DA neurotransmission. A further reflection of increased synaptic availability of

DA is the finding of elevated 3-methoxytyramine (DiGiulio et al.

1978) but normal homovanillic acid (HVA) concentrations (Fekete

and Borsy 1971) after cocaine administration. Cocaine also causes

reductions in brain DA concentrations with repeated administration

(Taylor and Ho 1977). Cocaine elevates brain DA concentrations

acutely, followed by reductions below normal levels several

minutes later (Pradhan et al. 1978b).

Several studies have measured DA binding following chronic

(Borison et al. 1979; Taylor et al. 1979) and acute (Memo et al.

1981) administration of cocaine. Memo and coworkers found a 37%

increase in the number of DA receptors following a single dose of

cocaine in rats. Consistent with increased binding sites was

their finding that cocaine significantly potentiated DA-induced

adenylate cyclase activity. Taylor and coworkers found that the

increased DA receptor binding with repeated cocaine doses

paralleled sensitization to gnawing behavior and locomotor

changes. Thus, postsynaptic supersensitivity resulting from

increased DA binding sites could underlie a number of cocaine

effects in which sensitization has been reported. Interestingly,

amphetamine induces the opposite effect, leading to decreased DA

receptor binding (Hanbauer et al. 1979, 1980) and a reversal of

haloperidol-induced DA supersensitivity (Haracz and Tseng 1980),

underscoring that caution should be taken when comparisons to

cocaine are made. Cocaine has also been shown to inhibit DA

vesicle binding, thereby exposing it to intracellular metabolism

(Carlsson et al. 1963). As with receptor studies and DA brain

concentration studies, the concept of DA depletion was again

invoked to explain the neurochemical findings (see table 2).

It would appear that, although cocaine acutely blocks DA reuptake

and produces increased DA neurotransmission, as well as increased

DA brain concentration (Pradhan et al. 1978b), there follows a

functional reduction in DA activity (Dackis and Gold 1985a; Gold

and Dackis 1984). DA receptor studies imply chronic reductions of

available synaptic DA with compensatory supersensitivity of postsynaptic receptors over time. Thus, the predominant DA disruption

appears to be of compromised DA function. We have previously

reported elevated prolactin levels in 15 male and 5 female cocaine

abusers (Dackis et al. 1984). Since reporting this original pilot

data, we have expanded the group of male cocaine abusers (N=18)

132
and studied 20 normal,

1985).

age-matched male controls (Dackis et al.

Prolactin levels in the recently abstinent cocaine

patients were significantly greater than those of the controls.

These elevations slowly decrease, but do not appear to normalize

completely, after 2 weeks of cocaine abstinence. This finding is

consistent with decreased functional DA tone (Gold and Dackis

1984).

TABLE 2

Cocaine and Dopamine

(Self-stimulation, Anorexia, Stereotypies,

Hyperactivity, Sexual Excitement)

1.

2 .

3.

4.

5.

6.

7.

8.

Blocks reuptake

Facilitates DA release

Activates tyrosine hydroxylase

Acute increase DA availabilitylneurotransmission

Increased DA receptors

Increased DA receptor sensitivity

Reduced brain DA concentrations (chronic)

Inhibits DA vesicle binding

Net Effect: Decreased DA

This DA depletion hypothesis could explain why chronic cocaine

addicts repeatedly self-administer cocaine, often many times

daily, as a way of transiently increasing synaptic DA. Postsynaptic DA deficiency is temporarily corrected by acute cocaine

use. This availability is amplified by the supersensitivity of DA

receptors. However, as the acute effects of cocaine wear off,

further DA depletion may result with perpetuation of the cycle.

This DA depletion could be experienced by the addict as craving

for cocaine, which would explain the perceived need for successive

cocaine doses throughout the day. Consistent with this hypothesis, we have observed intensified craving in recently abstinent

cocaine addicts who were given DA blocking neuroleptics.

Woolverton and Balster (1981) demonstrated that when low-dose

haloperidol was given to rhesus monkeys who were lever pressing

for cocaine, self-administration actually increased. This

apparent attempt to overcome DA receptor blockade could parallel

compulsive and repeated cocaine use by addicts as DA depletion

develops (see table 2). These data and our clinical experience

suggests that neuroleptics should be used with caution.

Cocaine-induced DA disruptions may also relate to several of its

other clinical effects (Gold and Dackis 1984). The sexual excitement produced by cocaine may result from amygdaloid and DA effects

(Gatz 1966). In fact, cocaine administration has reportedly

caused spontaneous ejaculation without genital stimulation

(Dimijian 1974). Chronic cocaine use can lead to impotence and

133
frigidity (Siegel 1982). Cocaine also appears to inhibit appetite

via DA neurons in the lateral hypothalamus (Gropetti and DiGiulio

1976). Finally, the psychomotor activation characteristically

seen with cocaine intoxication probably is a DA effect. This DA

depletion and the previously mentioned NE depletion serve as the

neurochemical basis for the open trials of tyrosine in cocaine

withdrawal (Gold et al. 1983).

Serotonin

Repeated administration of cocaine markedly reduces both the concentrations of 5-hydroxytryptamine (5-HT) and its metabolite

5-hydroxyindoleacetic acid (5-HIAA) (Taylor and Ho 1977). Pradhan

and coworkers (1978a) found that when rats were pretreated with

5-hydroxytryptophan (5-HTP) in order to reverse 5-HT depletion by

cocaine, the subsequent administration of cocaine failed to produce behavioral stimulation. Other studies have elaborated on the

5-HT depleting effects of cocaine and found a reduced synthesis of

5-HT from its precursor, tryptophan (Knapp and Mandell 1972;

Schubert et al. 1970). Knapp and Mandell reported an inhibition

of the high affinity tryptophan uptake pump by cocaine, leading to

reduced 5-HT synthesis on the basis of insufficient precursor

levels. The rate-limiting enzyme in the synthesis of 5-HT from

tryptophan is tryptophan hydroxylase. Soluble tryptophan

hydroxylase activity is inhibited by cocaine (Taylor and Ho 1977),

which further compromises the biosynthesis of 5-HT. This effect

of cocaine on tryptophan hydroxylase is interestingly opposite to

that seen with tyrosine hydroxylase, which was markedly activated

(Taylor and Ho 1977). Thus, unlike the enhanced turnover found in

NE and DA systems, 5-HT neurons respond to cocaine administration

with reduced turnover.

The reduction in 5-HT turnover secondary to cocaine exposure has

been hypothesized to result from the direct stimulation of postsynaptic 5-HT receptors (Taylor and Ho 1977; Friedman et al.

1975). This would represent a compensatory inhibition of 5-HT

neurons, perhaps via a transsynaptic feedback system (Anden et al.

1971).

800-COCAINE: SURVEYS OF USERS

On May 6, 1983, we established the 800-COCAINE helpline to provide

information crisis intervention and treatment referral to cocaine

users, their family members, and treatment professionals. The

large volume of calls to the helpline, frequently over 1,000 per

day and now over 450,000 in its first 18 months of existence, has

provided a unique research opportunity by allowing access to large

numbers of cocaine users who would otherwise not be available for

scientific or public analysis. We have now completed several

surveys based on random samples of helpline callers who consented

to an anonymous 30 to 40 minute telephone interview in which an

extensive research questionnaire was administered to gather data

on demographics, drug use, and drug-related consequences on the

user's health and functioning. The results of these surveys have

134
formed the basis of several reports and publications (Gold 1984;

Washton et al. 1983, 1984), some of which are sumnarized below.

NATIONAL SURVEY

This survey was conducted during the first 3 months of the helpline's existence using a simple random sample of 500 callers.

While callers to the helpline may not be representative of all

cocaine users, the sample included callers from 37 different

States across the United States, with the majority (63%) from

New York, New Jersey, California, and Florida. Data from the

research questionnaire administered to callers revealed that 67%

were male and 33% were female.

years (X=30 years).

Their ages ranged from 22 to 59

Eighty-five percent were white and 15% were

black or Hispanic. Their level of education was 14.1 years.

Forty percent had annual incomes over $25,000 (see table 4).

Their preferred route of cocaine administration was: intranasal

(i.n.) 61%; freebase smoking (f.b.) 21%; and, intravenous (i.v.)

18%. Estimates of weekly cocaine use ranged from 1 to 32 grams

per week. Frequency of cocaine use averaged 5.7 days per week;

48% used daily. At prices of $100 to $125 per gram, the average

amount of money spent per week on cocaine was over $637 and ranged

from $100 to $3,150.

TABLE 3

Incidence of Adverse Physical and Psychological Effects

(N=500)

Physical Effects N %

Sleep problems 410 82

Chronic fatigue 380 76

Severe headaches 300 60

Nasal sores, bleeding 291 58

Chronic cough, sore throat 228 46

Nausea, vomiting 193 39

Seizure, loss of consciousness 70 14

Psychological Effects

Depression 415

Anxiety 416

Irritability 408

Apathy, laziness 328

Paranoia 326

Difficulty concentrating 323

Memory problems 287

Sexual disinterest 265

Panic attacks 248

83

83

82

66

65

65

57

53

50

135
Sixty-six percent said they felt addicted to cocaine, 75% said

they had lost control over cocaine use, and 83% said they were

unable to refuse cocaine when it was available. Despite repeated

attempts to stop cocaine use, those that felt addicted said they

were unable to stay away from cocaine for as long as 1 month.

Sixty-eight percent reported using tranquilizers, marijuana,

alcohol, or heroin to reduce the stimulant effects of cocaine or

to relieve the dysphoric "crash" when cocaine effects wore off.

Over 90% reported adverse physical, psychological, and social/

financial consequences associated with their cocaine use. The

incidence of specific consequences are shown in table 3. In addition, they reported numerous personal losses which they attributed

to cocaine use, including loss of: job (25%). spouse (25%),

friends (44%), and all monetary resources (34%). They also

reported automobile accidents (11%), fighting and violent arguments (59%). and attempted suicide (9%). Callers reported stealing from work, family, or friends (20%). and dealing cocaine (36%)

to support their drug habit.

No consistent relationship was found between the type of reported

consequences and either the weekly dose or frequency of cocaine

use. Contrary to expectation, i.n. users reported patterns and

consequences of cocaine use comparable to those of f.b. and i.v.

users. This survey provides dramatic evidence of addictive

patterns of cocaine use and severe drug-related dysfunction in a

large sample of users.

Upper Income Users

Although cocaine use has now spread to virtually all levels of

society, and particularly to the middle class (Stone et al. 1984;

Gold 1984), cocaine is still, for the most part, associated with

the "privileged" members of society--those with high incomes.

Publicized drug use by famous athletes, entertainers, politicians,

and other public figures has served not only to further glamourize

the drug, but also to convey the notion that problems of drug

dependency know no social or economic boundaries.

One phase of the survey (Washton et al. 1984a) focused on a subgroup of cocaine users who called the helpline and reported

incomes over $50,000 per year. The purpose of this survey was to

assess the negative impact of cocaine use in persons who have a

high level of access to the drug by virtue of their high incomes.

We were particularly interested in determining whether greater

access to cocaine would be associated with higher levels of use

and more severe drug-related problems. Toward this end, we compared selected aspects of the present data with an earlier hotline

survey of primarily middle income cocaine users (Washton and

Tatarsky 1983).

Our subjects were 70 callers to the 800-COCAINE helpline who were

seeking assistance for their cocaine problem and reported an

annual income over $50,000. Most were corporate executives,

136
salesmen, business owners, or professionals. Callers in this

income bracket represent approximately 15% of the total population

of cocaine-using callers to the helpline.

The sample consisted of 57 males (82%) and 13 females (18%) with a

mean age of 31 years and an average of 16 years of education.

Their annual income averaged $83,000. Eighty-five percent were

white. They had been using cocaine for an average of 4 years,

ranging from 3 months to 7 years. Current use averaged 15 grams

per week (range 2 to 30 gms/wk) at an average cost of $100 per

gram. Sixty-four percent were i.n. users, 21% were f.b. smokers,

and 15% were i.v. users. Seventy percent reported using sedative/

hypnotics or alcohol to counteract the overstimulation or rebound

dysphoria (crash) from cocaine use. The initial pleasurable

effects of cocaine that subjects considered the most desirable

included feelings of euphoria, self-confidence, sexual arousal,

increased energy, mental alertness, and instant relief of boredom

or fatigue.

Similar to results of our earlier survey, over 70% said they felt

addicted to cocaine, could not refuse the drug when it was available, found themselves unable to stop for at least 1 month,

experienced significant distress without cocaine, and preferred

cocaine to food, sex, family, friends, or recreational activities.

Adverse physical, psychological, and social/financial consequences

included: chronic fatigue (84%), health deterioration (57%),

insomnia (91%), headaches (52%), loss of sexual desire (61%),

depression (83%), irritability (87%), memory/concentration

problems (71%), paranoid feelings (65%), impaired job functioning

(14%), impaired relationships (60%), and depletion of all finances

(26%). Cocaine-related suicide attempts (5%), automobile accidents (21%), and brain seizures with loss of consciousness (19%)

were also reported.

Despite their high income, 19% were dealing cocaine and 18% were

stealing from work, family, or friends to support their cocaine

habit. Five percent had been arrested for a cocaine-related crime

(dealing or possession), and 13% had lost their job due to cocaine

use.

Upper income subjects used nearly twice as much cocaine on a

weekly basis as the middle income users (15.0 gms/wk vs. 8.2

gms/wk) surveyed by Washton and Tatarsky (1983). This higher

level of use was associated with a higher incidence of cocainerelated automobile accidents (21% vs. 6%) and a higher incidence

of cocaine-induced brain seizures with loss of consciousness (19%

vs. 11%).

These survey results point to the role of economic factors in

determining drug access and drug-related consequences. Many of

our subjects could spend enormous sums of money on cocaine and

escalate to extremely high levels of use before encountering

financial limitations, if at all. Middle income users, on the

other hand, typically report that the high cost of cocaine is a

major factor limiting their use--if they had more money they would

137
be using more cocaine. Some say that they do not become more

severely dependent on cocaine simply because they cannot afford to

increase their use. When access to cocaine increases as a result

of lower drug prices or involvement in dealing, its usage escalates accordingly.

As compared to the average cocaine user, the upper income user is

typically not as accountable for his/her time or whereabouts and

is often able to shift responsibilities to associates or employees

to compensate for their own drug-related dysfunction. Moreover,

the typical upper income user tends to feel immune to the possibility of becoming a drug addict. Most seem to be in control of

their lives (at least superficially), continue to coordinate busy

schedules, earn substantial incomes, and have no history of

serious drug abuse problems. They start using cocaine on a

"social-recreational" basis and never expect to become dependent

on a drug that is believed to be relatively harmless and nonaddictive. Treatment is also seen as an admission of defeat, contradicting an image of themselves as competent, successful, and

invincible: qualities reinforced by cocaine. A severe crisis

situation, such as impending bankruptcy, divorce, legal problems,

or a debilitating depression is usually the precipitating factor

that drives the upper income abuser into treatment.

Adolescent Users

Drug and alcohol abuse is one of the most serious health hazards

affecting our youth. Studies of adolescent drug abuse have traditionally focused on alcohol, marijuana, and hallucinogens. Kandel

(1983) has recently reported that the incidence of cocaine and

stimulant abuse is increasing more rapidly than abuse of other

drugs. In addition, the number of high school seniors that admit

to having tried cocaine almost doubled from 9% in 1975 to 17% in

1983 (American Medical News 1984). Three percent of high school

seniors reported daily use of cocaine in the month prior to the

survey. Drug-using adolescents, as compared to those who do not

use drugs, demonstrate significantly more runaways from home, less

motivation to achieve at school, more suspensions or expulsions,

more involvement in gang activity, more time spent "hanging out,"

more time spent sleeping, and a greater need for help with vocational training and other problems (Semlitz and Gold, in press;

Gold et al., in press [1985b]).

Drug use is an important cause of adolescent mortality due to

motor vehicle accidents and death by suicide. Tragically, the

drug-abusing adolescent is less likely to seek help than a nonusing peer. A popular misconception is that adolescents do not

abuse cocaine because the drug is too expensive for them to obtain

large and regular supplies. Despite the high cost, adolescents do

indeed have access to cocaine through dealing drugs, other

criminal activity, and peer suppliers.

138
We have recently surveyed 64 adolescent cocaine users who called

the helpline in May 1984 (Semlitz and Gold 1984). These adolescent callers were primarily from New York and New Jersey (25%),

California (20%). Illinois (12%), and Pennsylvania (8%). The

sample consisted of 28 females and 32 males with a mean age of 17

years. Fifty four (90%) were white. The average caller was an

11th grader who had been using cocaine for 15 months. Fifty-one

(85%) were i.n. users, five (8%) were f.b. smokers, and four (7%)

were i.v. users. Among the f.b. and i.v. users, all had started

using cocaine by the i.n. route. At a street cost $75 to $125

per gram, callers reported spending 0 to $5,000 per month on

cocaine with an average of $440/month. While all were

self-proclaimed problematic users, only 48% were daily users.

The average caller cited 12 of 22 possible negative psychiatric

effects, including complaints of feeling jittery (70%), chronically anxious (78%), and depressed (68%). They also reported delusions (35%), exaggerated suspiciousness (70%), paranoia (72%), and

compulsive behaviors such as combing hair, tapping feet, etc.

(93%). Cognitive deficits included decreased concentration (65%)

and as memory problems (63%), as well as loss of interest in

friends (48%) and nondrug-related activity (62%). Seventeen (28%)

had active thoughts of suicide and seven (12%) reported a suicide

attempt.

They reported an average of 11 of 22 possible questionnaire items

for adverse physical effects. The most commonly cited physical

symptoms included sleep problems (78%) and chronic fatigue (68%).

They also complained of constant sniffing or rubbing their nose

(66%), runny nose (72%), sinus problems (63%), palpitations (65%),

and nausea and vomiting (50%). An alarming 20% reported brain

seizures with loss of consciousness induced by cocaine.

These adolescents also reported serious social and financial consequences from chronic cocaine use. Forty-two percent were dealing drugs and 35% had resorted to other illicit activity to obtain

cocaine. Twenty percent had been arrested for a cocaine-related

crime, 33% suffered school problems, and 18% had already been suspended or expelled from school or fired from a part-time job.

Fifty-two percent reported a loss of friends, 75% reported fighting or violent arguments, 43% were in debt, and 38% had stolen

money or property as a direct result of their cocaine use. Twelve

percent of those who had stolen a car reported a cocaine-related

traffic accident. Sixty-five percent of the callers felt addicted

to cocaine, 70% felt a real need for the drug, 85% were unable to

turn it down when it was available, and 70% were unable to remain

abstinent from cocaine for as long as 1 month. Sixty percent felt

they experienced withdrawal symptoms when they stopped using

cocaine. They preferred cocaine to food (60%), friends (50%),

family activity (68%), and sex (35%). The average caller listed

13 out of 23 dependency items. The popular belief that cocaine is

a relatively benign drug, especially if used by the i.n. route, is

challenged here and by the earlier national helpline survey of

139
adult users. Our adolescent subjects cited numerous serious

medical, psychiatric, social, and financial consequences of their

drug use. Moreover, it appears that the development of addictive

patterns of cocaine use in adolescents is more rapid than in

adults.

In the absence of preexisting family and school problems, regular

cocaine use can lead to serious psychosocial dysfunction characterized by dealing drugs, stealing and other criminal activity,

poor academic performance and suspension, loss of peer relationships, and isolation from families. This can lead to permanent

life changes. Nonetheless, parents, teachers, and clinicians

usually fail to detect use (Gold 1984). Tragically, few adolescents who telephoned the helpline wanted treatment. Seeking

treatment may be more of a function of a catastrophe occurring

than the degree of medical or psychological symptoms that are

present.

The adolescent is particularly susceptible to the spectrum of

physical effects because of his/her lower body weight and the

simple fact that he/she is a developing organism. In addition,

adolescents do not have the experience or judgment to compensate

for their behavior while intoxicated. Although 67% believe that

the medical consequences of cocaine use are moderate to severe,

only 10% stopped use because of such effects. Chronic use

typically leads to chronic depression, fatigue, and irritability.

Peak use of cocaine occurs at a time when youth must make commitments to family and work roles and negotiate a firm self-image.

Drug use is an identity, lifestyle, and 24 hour/day job. At best,

psychosocial dwarfism or failure to develop or being "frozen in

time" is the result. Consistent with other studies (Kandel 1983).

our survey suggests that adolescent cocaine users experience more

psychosocial problems than nonusers, including: school problems,

absenteeism, antisocial acts involving interpersonal aggression,

theft, traffic violations, motor vehicle accidents, and suicide.

Unfortunately, the family is typically late in associating social

and moral problems to drug use.

In this survey, we have profiled the typical adolescent helpline

caller as a 17-year-old 11th grader who is chronically irritable,

depressed, estranged from family and friends, doing poorly

academically, and is suffering from sleeplessness, weight loss,

and other health and behavioral problems. The time between first

use and contacting the helpline is 15 months. Compulsive freebase

and intravenous use is reliably preceded by "occasional" intranasal use.

New York: 1983 versus 1984

We have recently completed two separate surveys in the New York

tristate area. The first survey was conducted in May 1983 and the

second was conducted 1 year later in May 1984.

140
The more recent survey (table 4) shows a higher percentage of

females, a higher percentage of lower income users, and a shift

toward lower age groups.

$25,000 per year.

Less than 50% are now earning over

While many are business executives, business

owners, or professionals, the 1984 sample includes more students,

blue-collar workers, technicians, clerical workers, and housewives

than the 1983 sample.

TABLE 4

Demographics

(N = 200)

Males

Females

White

Black/Hispanic

Income over $25,000

Age (years)

Education (years)

1983 1984

76%

24%

81%

19%

52%

15-60x (X=31)

X=13.2

58%

42%

84%

16%

40%

12-63 (X=28.5)

X=14.1

Table 5 shows that callers had been using cocaine for periods

ranging from several months to 15 years before calling the helpline. Most were self-administering cocaine by *snorting* the drug

through their nostrils; smaller percentages were injecting cocaine

intravenously or smoking cocaine freebase Nearly all f.b. and

i.v. users started using cocaine by the i.n. route.

TABLE 5

Cocaine Use

(N = 200)

Intranasal users

Freebase users

Intravenous users

Grams per week

Cost per week

History of use

1983

3 mos-15 yrs

(X=4.6 yrs)

16%

26%

l-20 (X=5.5)

$75-$2,000

(X=$450)

66%

1984

1 mo-12 yrs

(X=3.5 yrs)

27%

13%

.5-15 (X=6.2)

$35-$1,500

(X=$430)

Other drug/alcohol use 75%

141
Table 5 shows that in the 1 year between surveys there has been an

increase in f.b. smoking as the preferred method of use coupled

with a decline in i.v. use. The popularity of i.n. use has

remained virtually unchanged. There has also been an increase in

the weekly amount of cocaine used by helpline callers and a concomitant increase in the use of other drugs or alcohol to offset

the negative aftereffects of cocaine (e.g., restlessness, irritability, depression, and overstimulation). It should be noted that

the combined use of cocaine and either alcohol or other depressant

drugs can be extremely dangerous. Thirty-four percent of the 1984

sample said they were dependent on a second drug. Moreover, when

the brief stimulant effects of cocaine wear off, the user can

become instantly stuporous or drunk from the previously ingested

depressants; sometimes this happens behind the wheel of a car or

in some other critical situation.

As shown in table 6, both surveys revealed that the majority of

callers felt they were addicted. In addition, they had lost the

ability to limit their use of cocaine, could not refuse the drug

when it was available, felt distressed without it, preferred

cocaine to the exclusion of almost everything else in their lives,

and despite their desire to stop cocaine use, they had been unable

to stay away from it for even 1 month. They felt addicted, acted

like addicts, complained of withdrawal, and made life choices

characteristic of addicts.

TABLE 6

Addiction

(N = 200)

1983 1984

Feel addicted 63%

Loss of control 74%

Cannot refuse it 85%

Unable to stop for 1 month 70%

Feel distressed without it 52%

Prefer cocaine to food,

family, friends, recreation 70%

Withdrawal Syndrome 66%

74%

85%

85%

76%

61%

73%

75%

Lastly, table 7 shows the social consequences of cocaine abuse in

our survey samples. It is surprising that among these predominantly employed, middle class samples who were typically earning

substantial incomes, so many would be resorting to illegal acts,

such as stealing or drug distribution, to support their cocaine

habit. Of particular interest is the striking increase in

cocaine-related automobile accidents reported in the 1984 sample.

This may be linked to the higher levels of cocaine use in the 1984

sample and the resulting greater use of alcohol and other sedatives to alleviate the cocaine "highs and lows."

142
TABLE 7

Adverse Social and Other Effects

(N = 200)

1983

Dealing cocaine to support habit 43%

Stealing from work 20%

Stealing from family or friends 28%

Arrested for dealing or possession 17%

Automobile accident on cocaine 9%

Loss of job due to cocaine 16%

Loss of spouse due to cocaine 30%

In debt due to cocaine 46%

1984

47%

28%

42%

14%

39%

15%

33%

57%

TREATMENT OF COCAINE ABUSE

An initial decision must be made as to whether or not hospitalization is a necessary first step in the treatment process. In

general, hospitalization is required only in severe cases where

other options (e.g., outpatient treatment) do not seem appropriate

in light of the patient's clinical status. The major indications

for hospitalization include: (1) chronic freebase or intravenous

use; (2) severe impairment of psychosocial functioning;

(3) medical or psychiatric complications; (4) concurrent physical

dependency on other addictive drugs such as alcohol, sedativehypnotics, or opiates; and (5) inability or unwillingness to stop

using cocaine as an outpatient. The primary goal of inpatient

treatment should be to break the pattern of compulsive drug use

and provide a medically safe and structured drug-free environment

for beginning the recovery process. The program must first take

complete control of the user and provide a staff intensive, drug

abuse testing, proven drug-free environment. It must slowly

relinquish control to the user and the new drug-free peer group

while providing structured outpatient aftercare treatment to

foster long-term recovery.

When hospitalization does not appear to be indicated, outpatient

treatment can be started immediately. The goal of treatment

should be complete abstinence from all mood-altering chemicals

(including alcohol, marijuana, etc.) and adoption of a drug-free

lifestyle. Most cocaine abusers are concurrently abusing alcohol

or other sedative hypnotics to alleviate the unpleasant side

effects of cocaine (i.e., the crash).

Although cocaine does not produce a stereotyped abstinence syndrome as with opiates or barbiturates, abrupt cessation of chronic

high-dose use can result in a variety of physical symptoms,

including drug craving, depression, irritability, anergia, amotivation, appetite changes, nausea, shaking, psychomotoric retardation, and irregular sleep patterns, hypersomnia, and intense urges

143
or cravings that may persist for a week or longer following cessation of use. If cocaine urges partially result from DA deficiency

states, certain treatment interventions might be considered.

TABLE 8

Pharmacological Treatments for Cocaine Withdrawal

L-dopa

Apomorphine

Bromocriptine

Tyrosine

Thyroxin

Bupropion

Clinically, these experimental interventions might be used in

patients with previous treatment failures. Urges for cocaine are

readily described by addicts, and appear most frequent and intense

during the first week of abstinence. Since these urges can lead

to cocaine use and relapse, close observation during the period of

greatest risk is certainly indicated.

Relief of these symptoms with pharmacological treatment (table 8)

might allow patients to stop using cocaine more easily and might

also be useful in the postcocaine recovery period. Although

cocaine increases DA neurotransmission acutely, we have hypothesized that chronic administration may deplete DA in the brain

(Gold and Dackis 1984). With chronic cocaine exposure, postsynaptic DA binding sites are increased (Taylor et al. 1979) and

DA brain concentration is decreased (Taylor and Ho 1977). Cocaine

abusers have hyperprolactinemia (Dackis et al. 1984), which is

also suggestive of DA depletion. While DA activation might lead

to cocaine euphoria, DA depletion states secondary to cocaine

might be the chemical basis for craving (Gold and Dackis 1984).

In order to test this hypothesis, and possibly identify a new

pharmacological treatment for cocaine urges, we administered the

DA agonist bromocriptine and placebo to two hospitalized cocaine

abusers with severe urges for cocaine (Dackis and Gold 1985b).

Both patients were contemplating leaving the hospital to use

cocaine, and each complained of depressed mood, anergia, suicidal

ideation, and poor concentration. The patients were asked to rate

the degree of craving for cocaine by marking a 100 mm line anywhere between "not at all" and "extremely." Scores were assigned

according to the point marked, ranging between 0 and 100. Bromocriptine (0.625 mg p.o.) or placebo was then administered blindly

and craving was again self-rated at varying time points. Both

patients reported marked and consistent relief from cocaine craving after bromocriptine and were able to distinguish it from

placebo in all of six trials. These preliminary data suggest that

bromocriptine may be effective in the management of cocaine abuse.

144
The administration of bromocriptine would interestingly reverse

two biological alterations that are associated with cocaine

abuse--hyperprolactinemia and increased postsynaptic DA receptor

density. These alterations are consistent with the interruption

of DA neurotransmission, which may also underlie the development

of cocaine craving.

Recent studies (Gold et al. 1983; Tennant and Rawson 1983) indicate that tyrosine (an amino acid), desipramine (a tricyclic

antidepressant), and DA receptor agonist bromocriptine (Dackis and

Gold 1985b) may be effective in relieving cocaine withdrawal.

But, while they are of theoretical importance, the clinical

utility of these and other agents in the treatment of chronic

cocaine abuse remains to be determined.

Irrespective of pharmacological interventions, psychological

approaches at present remain the most important aspect of treatment for cocaine addiction. These approaches, in our experience,

are similar to those with proven efficacy for alcohol dependence.

Self-help groups and education are quite effective in treating the

vast majority of cocaine patients who are motivated for abstinence. The admission of powerlessness over cocaine is an important step for the addict, and is a prerequisite to accepting

outside help and direction. In our experience, an optimal treatment plan for most patients includes the combination of individual

therapy with participation in a cocaine recovery group led by a

professional therapist. Group sessions provide positive role

models, a ready made peer-support network, and an excellent forum

for discussing a wide range of issues that are crucial to abstinence and recovery. In group sessions, patients should be

encouraged to discuss drug urges, addictive thinking, and methods

for avoiding potential relapses. Discussions should also focus on

thoughts and feelings that may precipitate relapse, and on nondrug

alternatives for coping with stressful situations and negative

mood states. Issues pertaining to group process and interpersonal

dynamics should also be discussed when indicated, but generally

should not take priority over drug-related issues. Individual

therapy sessions complement the group meetings, but should focus

more on personal and psychodynamic issues pertaining to relationships, sexual functioning, self-esteem, family problems, and other

issues underlying the drug use. Couples and/or family therapy

sessions should also be included in the treatment plan when indicated.

Known specific and sensitive urine screening is essential to the

success of outpatient treatment. Throughout the entire course of

treatment, urine should be tested at least 2 to 3 times per week

for cocaine and other commonly abused drugs (e.g., opiates,

barbiturates, benzodiazepines, amphetamines, marijuana, etc.).

Urine testing utilizing antibody-based, gas chromatography, or

mass spectroscopy is a valuable treatment tool that helps to

promote self-control efforts and also serves as an objective

monitor of patient progress (Gold et al. 1985a). Patients are

generally relieved to find that urine testing is a mandatory part

145
of the treatment and intuitively recognize its value in deterring

drug use. Urine testing helps to identify patients who are either

unable or unwilling to stop using cocaine and those who switch to

other drugs (Gold 1984). An emerging pattern of frequent drug use

should call for a revision of the patient's treatment plan.

revision may entail more frequent visits, completion of a specified drug-free period verified by urine tests or, where indicated,

a period of hospitalization before continuing in outpatient treatment.

Our approach to outpatient treatment includes the use of specific

relapse prevention strategies, some of which have been adapted

from the earlier work of Marlatt (1980, 1982) with alcoholics.

These strategies incorporate a variety of behavioral, cognitive,

educational, and self-control techniques aimed at reducing the

potential for relapse and have been described in detail elsewhere

(Gold 1984; Washton et al. 1984).

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AUTHORS

Mark S. Gold, M.D.

Research Facilities

Fair Oaks Hospital

Summit, New Jersey 07901

Arnold M. Washton, Ph.D.

The Regent Hospital

New York, New York 10021

Charles A. Dackis, M.D.

Research Facilities

Fair Oaks Hospital

Summit, New Jersey 07901

150
Reinforcement and Rapid Delivery

Systems: Understanding Adverse

Consequences of Cocaine

Sidney Cohen

INTRODUCTION

The powerful reinforcing properties of cocaine demand constant

replenishment of supplies. This is particularly true when the

rapid delivery systems are employed, but even the slower, less

efficient absorption through the nasal mucosa can result in compulsive use. Dependence of the cocaine type produces an array of

psychophysiological and physical disorders, many of which can be

life-endangering. The prime deterrent is the inability to sustain

the practice because supplies become unavailable. The user is

then driven to obtain additional cocaine without particular regard

for social constraints. A variety of paranoid, manic, and depressive psychotic states result with accidental, homicidal, or

suicidal potentials.

Casualties are also encountered from the toxic effects of the

drug, including its sympathomimetic properties, from the techniques of introducing the drug into the organism, and the physical

depletion of the long-term, high-dose user.

In laboratory animals, the intravenous injection of cocaine serves

to initiate and maintain specific behaviors required to obtain

additional injections. Such repetitive behaviors are considered

to be the equivalent of human cocaine-seeking and compulsive use

patterns. Therefore, a brief review of how species as divergent

as rodents and primates respond to cocaine rewards may be revealing about the cocaine-human interaction.

Animals will work more persistently at pressing a bar for cocaine

than for any other drug, including opiates. They will choose the

bar that provides higher doses and an electric shock in preference

to one that offers lower doses without a shock. They will continue to self-administer cocaine despite foot shocks that are

paired with the cocaine bolus (Balster and Schuster 1977).

Hungry animals will preferentially bar press for cocaine rather

than for food (Aigner and Balster 1978). Male, nonhuman primates

will continue to work for cocaine despite the presence of a receptive female in their cage. Under unlimited access conditions,

151
monkeys will bar press until exhausted or convulsing (Deneau

et al. 1969). If the animal survives, it will return to the task

of acquiring more cocaine (Thompson and Pickens 1970). In one

experiment, the monkey continued to bar press despite the requirement that it took 12,800 presses to obtain a single dose of the

drug. After the conditioned response to cocaine is extinguished,

a single injection will reestablish the bar pressing activity.

Under limited access conditions, for example, when cocaine is

unavailable for a few hours a day, the laboratory animal is able

to regulate its bar pressing so that a fairly stable dose is

acquired each day.

Under conditions of access to large amounts of cocaine the human

response remarkably resembles that of the laboratory animal.

Cocaine-dependent humans prefer it to all other activities. They

will continue using until they are exhausted or the cocaine is

depleted. They will exhibit behaviors markedly different from

their precocaine lifestyle. Cocaine-driven humans will relegate

all other drives and pleasures to a minor role in their lives.

The drive for cocaine will compel them to perform unusual acts in

comparison to former standards of conduct. If the cocaine-seeking

behavior is extinguished, either cocaine or environmental cues

associated with prior usage will cause physiologic and behavioral

changes resembling cocaine use and will tend to result in relapse

(Bridger et al. 1982; Stewart 1983).

It is clear that cocaine is a powerful reinforcer that can lead to

life-attenuating behavior. Although certain people, because of

personality structure or life situation, might become more easily

overinvolved, it is likely that anyone with access to cocaine in

quantity is at risk. All laboratory animals can become compulsive

cocaine users. The same might be said of humans. Instances of

mature, stable, well-integrated individuals who acquired a pervasive craving for cocaine are well known.

CONSEQUENCES OF COCAINE USE DUE TO ITS REINFORCING PROPERTIES

Serious mental and physical consequences can result from the

intense reinforcing nature of the drug. With intravenous use,

coca paste smoking, or the inhalation of cocaine alkaloid vapors

(freebasing), the desired mood-altering effects are detectable in

seconds and disappear in a few minutes (Siegel 1982). This means

an immediate reward with a rapid decline to baseline mood levels

or below. Both the positive and the negative reinforcers drive

the person to consume more cocaine. When cocaine is sniffed, the

curve has a lower peak and a longer duration, but compulsive,

incessant patterns of usage with nasal absorption are increasingly

recorded in the literature (Helfrich et al. 1983).

Tolerance develops with the frequent use of large doses. A stimulant withdrawal syndrome is noted upon discontinuance, the major

manifestation of which is a marked psychological depression

152
(the "coke blues"). The depression demands more cocaine for symptomatic relief, despite the transient nature of the mood elevation.

Finally, because of cortical dopaminergic exhaustion (Goeders and

Smith 1983), or a refractory state of the receptors in the

mesolimbic system, or both, cocaine can no longer evoke the hopedfor euphoria. Instead, dysphoria dominates. The same inability

to achieve feelings of pleasure in response to ordinarily rewarding events extends into the postcocaine period. Anhedonia, the

inability to enjoy, can persist for weeks.

The prognosis for successful treatment is obviously diminished

when every aspect of the conditioning process serves to intensify

a return to cocaine-using behavior: the desire for euphoria, the

effort to avoid dysphoria, the self-treatment of depression, and

the painful, anhedonic period. If we were to design deliberately

a chemical that would lock people into perpetual usage, it would

probably resemble the neurophysiological properties of cocaine.

The fact that cocaine does not ensnare everyone into compulsive

use makes it even more insidious. Those who employ it only

occasionally proclaim that it is a safe drug.

Why does the animal continue working for cocaine until emaciated,

convulsing, or dead? Why does the human continue to persist in

its use long after it has become a punishing experience? Is it

possible that the reinforcing behavior becomes so fixed that it

persists in the absence of any reward? Or is it the vain hope

that the next fix will bring euphoria?

The strong reinforcing propensity of cocaine leads to other difficulties, most of which are caused by the large amounts of the drug

placed into the biological system over time. Considerable weight

loss and general debility can result. It is speculated that

cocaine use evokes a diminished immune response due to the

unphysiologic lifestyle or to the impact of cocaine upon the

immune system.

The paranoid thought mode almost invariably seen in consistent

users has led to accidents and homicides. Once manifest, the

psychosis tends to recur on subsequent cocaine exposures (Kramer

et al. 1967). Manicky behavior, insufficiently mentioned in connection with cocaine abuse, is common in the "coke head." Cocaine

users have many of the criteria used to diagnose mania: impulsivity, distractibility, an expansive or irritable mood, overactivity, loquaciousness, a flight of ideas, and insomnia. Some

of these can lead to a variety of maladaptive behaviors. The

postcocaine depression, previously mentioned, can terminate in

suicide in a few instances.

Serious disruptions within the family, on the job, and in social

situations occur in out-of-control users. When cocaine becomes an

obsession, thought is disorganized, judgment fails, and existence

becomes dismal.

153
When someone is locked into obligatory cocaine use, overdose is

always a hazard; but since other causes of overdose exist, they

will be dealt with separately.

CONSEQUENCES OF COCAINE USE DUE TO TOXICITY

Infrequent reports of individuals who did not survive a small dose

of cocaine (20 mg) before surgery have been published in the

anesthesia literature. These deaths are due to a congenital blood

and liver esterase deficiency.

Large amounts of cocaine cause death by a variety of mechanisms.

Ventricular fibrillation, cardiac arrest, and apnea are the common

modes of death (Nanji and Filipenko 1984). Pulmonary edema and

congestion of the viscera may be the only abnormalities found at

autopsy.

Repeated convulsions can be lethal following cocaine use. This

may be due to obstruction of the airway, severe lactic and respiratory acidosis, a serious failure of the heart rhythm, or inactivation of the respiratory center (Jonsson et al. 1983).

A few cases of cerebral hemorrhage resulting from the acute hypertension are recorded (Lichtenfeld et al. 1984; Caplan et al.

1982). The rupture is usually at the site of an aneurysm or

anomalous vascular formation.

Rarely, the hyperthermia which is induced by hyperactivity, the

vasoconstrictive effects of cocaine, and a specific action on the

temperature-regulating center is sufficiently severe to cause

death.

A surprising number of serious complications or deaths are caused

by body packing, bringing cocaine across a border concealed in the

gastrointestinal tract or vagina. A report from Miami (Caruana

et al. 1984) records 50 instances within a 6-month period of

cocaine-containing foreign bodies concealed in body cavities, and

another from Los Angeles mentions 47 cases (McCarron and Wood

1983). Most of these were managed successfully by conservative

measures; others developed intestinal obstruction and required

surgery. Rupture of the container--which is usually a finger cot,

condom, or machine-packaged device--is much more serious because 5

to 30 grams can be packed in each unit. Breakage of the latex

sheath can produce death before the patient can be brought to a

hospital or shortly thereafter. As much as 750 grams has been

retrieved from the feces of a single body packer.

Hepatotoxicity is often observed in certain species, but it has

not been reported with any frequency in humans. The explanation

is probably that the breakdown of cocaine is variable. In humans

and animals that esterify cocaine, a hepatotoxin is not formed.

In those species in which the major metabolic pathway is norcocaine, the toxic norcocaine nitroxide is formed in sufficient

quantities to produce a norcocaine-liver protein binding that is

hepatotoxic (Kloss et al. 1984).

154
CONSEQUENCES OF COCAINE USE DUE TO THE ROUTE OF ADMINISTRATION

The intravenous delivery of cocaine is associated with all the

hazards that accompany the unsterile introduction of other drugs

into a vein. Thrombophlebitis, hepatitis, AIDS, and bloodstream

infections are all documented. Fungal cerebritis has been found,

and the authors (Wet1i et al. 1984) speculate that a diminished

immune responsivity caused the opportunistic infection.

The practice of inhaling or smoking cocaine is reported to produce

a significant reduction of carbon monoxide diffusing capacity,

suggesting that depositing cocaine alkaloid in the alveoli damages

the pulmonary gas exchange surface (Weiss et al. 1981). This

alteration in respiratory function was found during the cocainefree interval, indicating that long-term effects of regular use of

freebase may lead to sustained pulmonary damage. Clinical reports

of hoarseness, bronchitis, and bloody expectoration are increasing.

Complications associated with snorting cocaine include rhinitis,

ethmoiditis, sinusitis, bleeding, and ulceration of the nasal

mucosa. Perforation of the nasal septum can result from prolonged

intranasal use and often requires plastic surgery.

COMPLICATIONS CAUSED BY THE INTERACTION OF COCAINE WITH DISEASES

AND OTHER DRUGS

People with coronary insufficiency are at risk when using cocaine

because the tachycardia and vasoconstriction may reduce cardiac

oxygenation while increasing oxygen demand. Sudden deaths have

occurred in people with a history of angina, with cocaine powder

still visible in their nostrils. Blood glucose levels of

diabetics tend to go out of control (either hypoglycemia or hyperglycemia), not only because of poor food intake and irregular

medication-taking, but also because cocaine sensitizes the

organism to epinephrine, which mobilizes glucose. Cocaine lowers

the seizure threshold, and is contraindicated in epileptics.

Cocaine interferes with the antihypertensive effect of guanethidine (Ismelin) and related drugs because of its sensitizing effect

on catecholamines. Using epinephrine and norephinephrine along

with cocaine will produce potentiation of the vasoconstrictive

effects.

The notion that cocaine combined with heroin or another opiate may

neutralize the untoward effects of the two drugs is unsupported by

postmortem evidence. In fact, the "speedball" is more risky

because at high doses both cocaine and the narcotics depress the

respiratory center. At present, several cities are reporting more

cocaine than heroin deaths, and about a quarter of the cocainerelated deaths reveal the presence of heroin.

155
DISCUSSION

We happen to be commemorating the centennial of an earlier cocaine

epidemic while attempting to cope with the current outbreak. A

century ago, cocaine was overused because it was the panacea of

the day. It was taken for fatigue, neurasthenia, depression,

alcoholism, and countless other disorders. Enthusiasm for it was

enormous until the same undesired conditions emerged that we are

seeing today: psychoses, paranoid states, the incapacity to

function, and the inability to extricate oneself from cocaine.

Furthermore, it cured nothing, but sometimes added to one's

problems a fixation on cocaine. The epidemic subsided. Then, the

available delivery systems were the oral and subcutaneous routes.

Today, much more rapid and hyperphoric methods are being used.

Will history repeat, or will we have to settle for a population of

chronic cocaine consumers, as we have of chronic heroin users?

We have spoken of the cocaine trap: the inability to stop using

despite the loss of pleasurable, and the upsurge of unpleasurable,

effects. The cause may be an ingrained and, in some instances,

irreversible conditioning. We have said less of the cocaine

paradox: that what starts out as elation and hypomania ends as

dysphoria and depression.

Have we reached the apogee of cocaine use? Probably not.

Supplies are plentiful and prices are down. Treatment remains

difficult, as might be predicted from our knowledge of the

neuropsychology of cocaine. How can the intense reinforcing

component be eliminated? Cingulotomies have been performed, but

they are a matter of desperation and remain completely unproven.

It is true that strong stimulant epidemics have a record of dying

out, perhaps because the user's plight is highly visible and

serves as a deterrent to those in the user's vicinity. The future

of cocaine dependence remains obscure.

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Psychiatry 138(8):1110-1112, 1981.

AUTHOR

Sidney Cohen, M.D.

Neuropsychiatric Institute

U.C.L.A. School of Medicine

Los Angeles, California 90024

157
Characteristics of Humans

Volunteering for a Cocaine

Research Project

C. R. Schuster and M. W. Fischman

During the past 10 years, research in this laboratory has concentrated on the behavioral and physiological effects of psychotropic

drugs in human volunteers. One of these ongoing projects is

investigating the effects of intravenous and intranasal cocaine on

a range of physiological and behavioral parameters, including performance and self-report measures (e.g., Fischman et al. 1976).

Prior to acceptance, volunteers are screened to exclude those who

would be inappropriate for physical or psychological reasons. In

addition, extensive drug histories are obtained at this time.

Only those volunteers with histories of intravenous cocaine use,

including a period of 6 months when it was used at least twice

weekly, are acceptable. To date, we have screened 291 volunteers

for participation in these studies. This chapter reports the drug

histories, medical problems, and other relevant demographic characteristics of volunteers who were accepted and rejected for this

study. To gain some perspective on how deviant this group of

volunteers might be, we have compared, where possible, their drug

use histories with those of volunteers screened for another experimental study involving orally administered licit psychotropic

drugs where no requirements were made on drug use history.

The data presented here were collected for purposes of screening

volunteers for drug studies rather than for purposes of analyzing

patterns of drug taking. Thus, although they are not as complete

as one might hope, the data do provide information on drug use

patterns in a unique population. More specifically, these volunteer subjects are a group of polydrug abusers with extensive

cocaine use histories, who are not currently seeking treatment for

their drug use.

PROCEDURE

Subject Selection

Volunteers for the cocaine studies were recruited via a word-ofmouth referral system. No other advertising for subjects was

used. Males or nonpregnant females between 21 and 35 years of age

who were healthy (according to medical and psychiatric examinations) and had a history of nonmedical cocaine use were eligible

158
to participate. The basic criterion for acceptance into this

study was a statement by the potential subject that he or she had

used cocaine for nonmedical purposes on a twice weekly basis for a

period of at least 6 months. To minimize the possibility that

subjects falsified their drug history in order to gain acceptance,

three interviews covering drug use issues were conducted by:

(1) the research nurse, (2) one of the investigators (MWF), and

(3) the internist who obtained a medical history and conducted a

physical examination. In addition, the following criteria were

used in subject selection:

1. Objective evidence of intravenous drug use (e.g., needle

track marks).

2. Verification that the volunteer was knowledgeable about

the community of stimulant drug abusers (subjects were

asked who referred them).

3. If there was a suspicion of dependence on other drugs

(e.g., heroin), the extent of the other habit was ascertained. Anyone known to be physically dependent on a drug

was excluded from the study.

4. A full medical history and physical examination was conducted. Testing included ECG, chest film, blood screening

(plasma cortisol, CBC, Chem-17, hepatitis), and urine

analysis.

5. A psychiatric interview by a doctoral level psychiatric

social case worker with extensive experience in diagnostics using DSM-III criteria.

We believe that we were successful in selecting only volunteers

who had extensive histories of psychomotor stimulant abuse. Our

multiple interviews about drug use revealed inconsistencies in

answers which enabled us to discriminate and reject those who did

not have the required drug history. Further, the applicants'

description of preferred routes of administration, drug effects,

etc., indicated sophistication about cocaine. Finally, among the

137 subjects who were selected and participated in this study, no

one reported ill effects or elected not to continue the experiment

because of drug effects.

A second group of subjects used as a comparison group was obtained

from those volunteering to participate in studies on the behavioral effects of licit psychotherapeutic drugs carried out by

Johanson and Uhlenhuth (e.g., 1980a, 1980b), also at the

University of Chicago. These subjects were recruited with advertisements placed in student newspapers stating that drugs would be

given orally in therapeutic doses to nonhospitalized research subjects. As a result, many of the volunteers were students. Although specific drug use histories were not required, these subjects received comparable drug history interviews. In addition,

the same physician that obtained medical histories and physical

examinations in the cocaine study also participated in screening

these subjects. Therefore, we have used these data to make comparisons between the cocaine study and licit drug study volunteers. However, we do not suggest that this group should be

159
considered a control group for the volunteers in the cocaine

experiment since their demographic characteristics differ in many

important respects (e.g., level of education). Nevertheless, they

do serve as a point of comparison for the cocaine experiment

volunteers and also provide information about a different population within the same age range.

Data Analysis

The data on volunteers for the cocaine study came from the structured interview on drug use history (conducted by the research

investigator). These data were checked for consistency with the

other two interviews, and subjects were excluded where significant

discrepancies existed. Medical data were obtained from the

physicians' reports.

Potential subjects in each of the two studies were asked about use

of specific drugs. For purposes of presentation, however, all

illicit drugs were classified into six categories: hallucinogens,

stimulants (other than cocaine), barbiturates, sedatives, opiates,

and cannabis. In addition, subjects were asked about their use of

alcohol, nicotine (any form of tobacco use), and caffeine (both

coffee and other caffeine-containing beverages). For each drug

category, two percentages were calculated as indices of drug use:

(1) subjects who had never used that type of drug, and (2) subjects who had used that type of drug in the past month.

RESULTS

Demographic Characteristics

Table 1 lists the demographic characteristics of accepted and

rejected volunteers for the cocaine experiment. The principal

reasons for rejection were: medical (N=64). inadequate reading

ability (N=22), and not meeting the criterion for cocaine use

(N=13). Approximately two-thirds of the volunteers were males.

This figure is inflated because during the first few years of this

research the FDA required that we only use males. Thus, females

were not given screening interviews. Since we have begun using

women, approximately 40% of our applicants have been females. In

general, our volunteers have been white, predominately males

between the ages of 21 and 35. About 40% of the applicants were

unemployed and an additional 12% were students. The educational

level of the volunteers was reasonably high: 60% were high school

graduates, 35% had some college, and 13% were college graduates.

The relatively low number of black applicants and the even lower

proportion of black applicants accepted into these studies

requires comment. Our original volunteers were white males who

lived in communities of people seeking alternative lifestyles

(e.g., "hippie communes" in Michigan and Southern Illinois).

Since subjects learned of these experiments from a word-of-mouth

referral system, we tapped into social groups which tended to be

racially homogeneous. Therefore, the number of blacks contacting

us to participate in these experiments was low during the first

160
years of our research. More recently we have begun to make contact with the urban black population of drug abusers. The high

rejection rate of blacks can be attributed to several reasons:

there were a number who were either currently dependent on heroin

(N=6), had poor veins because of extensive intravenous drug use

(N=5), or had medical problems associated with previous intravenous use of drugs (e.g., hepatitis, liver enzyme abnormalities,

pulmonary abnormalities).

TABLE 1

Demographic Characteristics of Volunteers

Mean Age (Range)

Sex

Unemployed

Student

Unknown

Employment

Employeed

Race

White

Black

Other

Unknown

Male

Female

69

31

Education

H.S. Dropout

H.S. Graduate

College Graduate

Unknown

Drug Use History

We have looked at

function of three

(N=73); (2) those

Accepted

N=137

27 (21-35)

Percentage

85

7

0

8

42 33

30 53

14 11

14 3

6

59

16

19

Rejected

N=150

28 (21-45)

Percentage

74

26

59

37

3

1

15

60

10

15

drug use history of the cocaine volunteers as a

variables: (1) males (N=197) versus females

who were accepted into the study (N=137) versus

those rejected for medical reasons (N=64); and (3) those who completed college (N=36) versus those who dropped out of high school

(N=31).

161
TABLE 2

Drugs Used in Last Month

Drug Class

Hallucinogens

Stimulants

Barbiturates

Sedatives

Opiates

Cannabis

Nicotine

Alcohol

Caffeine

Males Females

(N=197) (N=73)

Percentage Percentage

15

63

4

14

22

84

73

87

85

15

62

1

11

18

68

64

82

84

Analysis of the drug use histories for males and females failed

to reveal any differences in the percentages of those who had

ever used any illicit drugs from each of the six categories. In

addition, as can be seen in table 2, the pattern of drug use during the month imnediately prior to the interview (presumably an

indication of current drug preference) did not differ between

males and females. There were also no marked differences in the

percentages of males and females who used tobacco, alcohol, or

caffeine-containing beverages.

A total of 64 volunteers for the cocaine study were rejected for

medical reasons. As can be seen in table 3, the principal

medical abnormalities were cardiovascular (25% high blood pressure; 11% heart disease; 9% abnormal ECGs). An additional 12%

were rejected for dependence on heroin (10%) or alcohol (2%). It

is of interest that only 7% of the rejected applicants (less than

1.4% of the total number of applicants) were rejected for a

history of or current major depression and only 5% (less than 1%

of the total number of applicants) were rejected for other

psychiatric problems.

Table 4 shows the percentage of volunteers in the accepted group

and the group rejected for medical reasons who had ever taken

substances from the six categories of illicit drugs as well as

alcohol, nicotine, and caffeine. As can be seen, all volunteers

had used a wide range of illicit drugs in addition to cocaine.

However, in this measure of drug use history, there appears to be

no difference between those accepted and those rejected for

medical reasons.

162
TABLE 3

Reasons for Medical Rejections

(N=64)

Reason

High Blood Pressure

Heart Disease

Abnormal ECG

Positive Hepatitis

Possible Liver Damage

Abnormal Chest X-Ray

Major Depression

Other Psychiatric Illness

Heroin Dependence

Alcoholism

TABLE 4

Drugs Ever Used

Drug Class Percentage Percentage

Hallucinogens

Stimulants

Barbiturates

Sedatives

Opiates

Cannabis

Alcohol

Nicotine

Caffeine

39 43

92 93

39 15

39 33

46 57

91 92

95 88

72 74

89 84

Percentage

25

11

9

5

2

2

7

5

10

2

*For medical reasons

Table 5 shows the distribution of drug use in the last month

expressed as percentages for these two groups. These data strikingly illustrate the wide variety of current drug use by this

population. Again, during the month preceding application for

the study, there appears to be no difference in the drug use

pattern for those accepted and those rejected for medical reasons.

163
TABLE 5

Drugs Taken in Last Month

Accepted Rejected*

N=137 N=64

Drug Class Percentage Percentage

Hallucinogens

Stimulants

Barbiturates

Sedatives

Opiates

Cannabis

Alcohol

Nicotine

Caffeine

15

59

5

11

19

74

87

62

80

7

61

0

16

28

79

75

72

85

*For medical reasons

Another way of determining the degree to which these volunteers

are polydrug abusers is to determine the number of different

classes of illicit drugs that each individual has used. Subjects

who were accepted and those rejected for medical reasons were

compared on the basis of the number of different types of drugs

they had ever self-administered for nonmedical purposes. Table 6

shows the percentage of people who had taken cocaine alone and

cocaine in addition to drugs from 1, 2, 3, 4, 5, or 6 of the

other classes of illicit drugs. As was shown in table 5, most

cocaine users also used a variety of other types of drugs.

Fifty-seven percent of the volunteers who were accepted into the

experiment had used drugs from four or more classes in addition

to cocaine. The group that was rejected for medical reasons

showed a somewhat smaller diversity in the types of drugs they

had used for nonmedical purposes (43% used four or more types of

drugs in addition to cocaine). The diversity of drugs used by

most of these people clearly precludes any analysis in terms of

single drugs or even drug classes. These volunteers could best

be characterized as being substance users rather than users of

any specific drug.

Two subgroups of this population, college graduates versus high

school dropouts, were compared using the same measure as above.

Table 7 shows the percentage of each group reporting ever having

used various classes of drugs. The results suggest several drug

choice differences between these two groups: More of the college

graduates used hallucinogens (67% versus 48%), whereas more of

the high school dropouts used opiates (77% versus 33%) and

nicotine (87% versus 58%). These same differences can be seen in

table 8, which shows the percentage of each group using various

164
drugs during the month prior to the interview. Again, a greater

percentage of the college graduates used hallucinogens during

that month (28% versus 6%), but the opposite was true for opiates

(6% versus 23%) and nicotine (51% versus 84%).

TABLE 6

Use of Cocaine Plus Marijuana Alone and in

Conjunction With Illicit Drugs

From 1-6 Other Classes

Accepted

(N=137)

Rejected*

(N=61)

Cocaine Alone/

Combination Percentage

Cocaine Alone 10

1 5

2 13

3 15

4 24

5 20

6 13

Percentage

0

9

28

20

23

16

4

*For medical reasons

TABLE 7

Drugs Ever Used

College Grads H.S. Dropouts

(N=36) (N=31)

Drug Class Percentage Percentage

Hallucinogens 67 48

Stimulants 89 100

Barbiturates 28 42

Sedatives 44 39

Opiates 33 77

Cannabis 86 87

Alcohol 94 74

Nicotine 58 87

Caffeine 86 90

165
TABLE 8

Drugs Taken in Last Month

College Grads H.S. Dropouts

(N=36) (N=31)

Drug Class Percentage

Hallucinogens 28

Stimulants 61

Barbiturates 6

Sedatives 11

Opiates 6

Cannabis 86

Alcohol 89

Nicotine 51

Caffeine 81

Percentage

6

61

3

10

23

71

68

84

90

The high school dropout group and the college graduate group were

compared to determine whether there were any differences in the

diversity of drugs used by each of them. The percentages of each

group with histories of cocaine use alone and cocaine in addition

to drugs from 1 to 6 of the other classes of illicit drugs are

compared in table 9. As can be seen, both high school dropouts

and college graduates had used a broad variety of illicit drugs,

and there do not appear to be any differences between these two

groups in this measure of polydrug abuse.

TABLE 9

Use of Cocaine Plus Marijuana Alone and

in Conjunction With Illicit Drugs

From 1-6 Other Classes

Cocaine Alone/

 Combination

Cocaine Alone

1

2

3

4

5

6

College Grads

(N=31)

Percentage

0

9

36

13

10

29

3

H.S. Dropouts

(N=36)

Percentage

8

9

22

17

19

22

3

166
Comparison of Volunteers for the Licit Drug Studies

As stated previously, a number of licit drug studies by Johanson

and her colleagues obtained information on illicit drug use histories as well as complete psychiatric and medical evaluations.

These studies advertised for volunteers in student lounges and

campus newspapers. The advertisement stated that therapeutic

doses of commonly prescribed psychoactive drugs would be tested

orally in these experiments. We selected 91 volunteers from this

pool of applicants who were approximately matched in age to our

volunteers for the cocaine study (27.6 versus 27.3 years of age)

and in the proportion of males (67% versus 72%) and females (33%

versus 28%). It was impossible, however, to match the volunteers

from the two studies in terms of education level. As would be

expected, the volunteers for the licit drug studies were mainly

college graduates (76% versus 13%), with a high percentage (30%)

having graduate training. It is highly probable that there are a

number of other important demographic differences between the

volunteers for the cocaine studies and for these licit drug

studies. Nevertheless, the drug use patterns of both groups of

volunteers are of interest.

Of the 91 applicants for the licit drug studies, 6 (approximately

6%) were rejected for medical reasons, in comparison to 64 out of

the 291 (22%) applicants for the cocaine study. Although this

large difference cannot necessarily be ascribed to differences in

drug use, it is of interest that of the six applicants for the

licit drug studies who were rejected for medical reasons, three

had a history of extensive and frequent use of illicit drugs.

Table 10 shows the drug use history of the applicants for the

licit drug study. As can be seen, a wide variety of illicit

drugs was used by a substantial proportion of this population.

Thirty-two percent reported that they had used cocaine at some

time in the past. None, however, had taken cocaine on a continued basis. We did not ascertain the frequency and recency of

this use of cocaine. As would be expected, 95% of this group

used alcohol and 94% reported using it in the last month. In

addition, 87% reported having used cannabis in the past, but only

21% reported using it in the last month. This is in striking

contrast to the applicants for the cocaine studies, where 76%

reported using marijuana during the last month. There was a substantially smaller percentage of applicants for the licit drug

study than for the cocaine study who had ever used hallucino ens

(29% versus 40%), barbiturates and sedatives (13% versus 33%),

and opiates (13% versus 50%). The most striking difference

between the two groups relates to tobacco use, where 73% of the

cocaine versus 29% of the licit drug study applicants reported

ever having used tobacco. It is of interest to note, though,

that virtually all of those reporting that they had ever used

tobacco also reported tobacco use in the last month. This is in

marked contrast to marijuana, for example, where the percentage

reporting ever having used is 87% but only 21% report using it in

the last month. This suggests that those who try tobacco run a

very high risk of going on to use it regularly.

167
TABLE 10

Drug Use Histories of Applicants

for Licit Drug Studies (N=91)

Drug Class

Hallucinogens

Stimulants

Sedatives

Opiates

Cannabis

Alcohol

Nicotine

Caffeine

"Not asked

Percentage Percentage Used

Ever Used in Last Month

29

44

13

13

87

95

29

94

*

*

*

*

21

94

28

94

In summary, as would be expected from the recruiting procedures,

the applicants for the licit drug studies showed illicit drug use

histories that would be predicted on the basis of their age and

educational level. Nearly all of them drank alcohol (95%), most

had tried marijuana (87%), and a smaller percentage had tried

other illicit drugs. Overall, they appeared medically healthier

than the volunteers who applied for the cocaine project. Whether

this is because of differences in drug use or general lifestyles

cannot be ascertained from the available data.

CONCLUSIONS

The information obtained from volunteers for these behavioral

pharmacology research studies was for purposes of screening, not

to provide epidemiological data. In retrospect, it is clear that

the data, at least from the cocaine study, may be an important

source of information about drug users who are not seeking treatment and who in general do not appear to be experiencing serious

psychiatric consequences because of their drug use. This, of

course, is in marked contrast to those cocaine users who are

seeking treatment. It is important to note that, although the

volunteers we have screened for the cocaine study are moderately

heavy polydrug users (67% have used illicit drugs from four

pharmacological classes), none seem to have currently "lost control" over their drug use. This statement is based not only on

the interview data, but on the fact that no subject ever withdrew

because of a need for more drug than was received in the experiment. In many instances, these research subjects were given only

very low doses of cocaine on every second or third day during

their Z-week hospital stay. Since we analyzed blood samples for

cocaine and its metabolites every day, it is very unlikely that

subjects were taking any cocaine except that which we administered. Further, they were monitored either by our research

staff or the nurses at the Clinical Research Center where they

168
were housed. Thus, our subjects were able to go without cocaine

(as well as other illicit drugs) for days without showing any

psychological or physical disturbance. Further, these subjects

did not report experiencing any precipitated craving following

single injections of cocaine. It is quite likely that most individuals who are highly dependent upon cocaine or other drugs

would not volunteer for experiments such as these since they

could not be certain when and what kinds of drugs or dosage

levels they would receive. It is also conceivable that "craving"

for drugs may in part be environmentally triggered and, therefore, not experienced by our subjects in the novel hospital setting.

As noted previously, the volunteers for the cocaine research

project had used a broad variety of illicit drugs on a frequent

basis. When differences in physical or psychological health are

found between such a population and those having minimal illicit

drug use histories (e.g., volunteers for the licit drug studies),

it is virtually impossible to determine which drugs or combinations of drugs are responsible. Tobacco and marijuana use in

conjunction with freebasing of cocaine, for example, could clearly produce pulmonary problems. It would be unrealistic to

attempt to delineate which of these substances was primarily

responsible. A more realistic alternative is to deal with the

psychiatric and physical health problems associated with illicit

polydrug abuse. Prevention efforts which attempt to ascribe

specific health problems to specific drugs often lead to fruitless debates about the degree of certainty of causality. What

can be stated unequivocally is that polydrug abuse with attendant

lack of attention to health and general lifestyle clearly places

an individual at risk for serious physical and psychological consequences.

In conclusion, we would like to suggest that more attention be

paid by laboratory researchers to the use of screening data that

could provide interesting information on patterns and consequences of illicit drug use. It is obvious from the data presented that collaborative research protocols with epidemiologists

would be fruitful and might allow these data to be collected more

productively. Meetings, such as the one which resulted in this

monograph, should stimulate the interaction of laboratory

researchers, clinicians, and social scientists so that all relevant sources of illicit drug use information can be fully

utilized.

REFERENCES

Fischman, M.W.; Schuster, C.R.; Krasnegor, N.A.; Shick, J.F.E.;

Resnekov. L; Fennel, W.; and Freedman, D.X. Cardiovascular and

subjective effects of intravenous cocaine in humans. Arch Gen

Psychiatry 33:983-989, 1976.

Johanson, C.E., and Uhlenhuth, E.H. Drug preference and mood in

humans: d-Amphetamine. Psychopharmacology 71:275-279, 1980.

Johanson, C.E., and Uhlenhuth, E.H. Drug preference and mood in

humans: Diazepam. Psychopharmacology 71:269-273, 1980.

169
AUTHORS

C.R. Schuster, Ph.D.

The University of Chicago

Department of Psychiatry

5841 S. Maryland Avenue

Chicago, Illinois 60637

M.W. Fischman, Ph.D.

The Johns Hopkins Medical School

Department of Psychiatry

Phipps Building, E-2

601 N. Wolfe Street

Baltimore, Maryland 21205

170
Characteristics of Cocaine Abusers

Presenting for Treatment

Sidney H. Schnoll, Judy Karrigan, Sarah B. Kitchen,

Amin Daghestani, and Thomas Hansen

With the ever-changing patterns of chemical dependence problems,

it has become increasingly evident that there is a current

increase in cocaine abuse. Despite widespread publicity about

this phenomenon in the lay press, there is little data available

describing the characteristics of cocaine users. Chambers et al.

(1972) studied the incidence of cocaine abuse among methadone

maintenance patients in Philadelphia in 1969. In a similar paper,

Gay et al. (1973) looked at the incidence of cocaine use in heroin

users who were in treatment at the Haight-Ashbury Clinic during

1971 to 1972. The patients in both of these studies did not

present for cocaine treatment specifically, but their cocaine use

was studied in relation to their opiate abuse. Only in the past

few years have a large enough number of primary cocaine abusers

entered treatment to permit adequate study of this population.

Anker and Crowley (1982) have described a population of users who

presented for outpatient treatment in a contingency management

program for cocaine abuse. Siegel (1982) studied a population of

cocaine freebase smokers in the Los Angeles area. Both of these

studies were based on information collected from outpatients and

they presented limited information on the characteristics of the

cocaine abusers.

In order to determine the directions necessary for future cocaine

research, a detailed review of patients having received treatment

for cocaine dependence in the Chemical Dependence Program of

Northwestern Memorial Hospital in Chicago was undertaken.

The Chemical Dependence Program is a comprehensive treatment program providing treatment for all chemical dependencies, including

alcohol. The program consists of an acute inpatient unit with an

average length of stay of 18 days, a partial hospitalization program with an average length of stay of 4 weeks, and an outpatient

clinic. In all components of the program, individual, group, and

family therapy are provided along with educational seminars and

peer support groups. Treatment is individualized as much as possible. During treatment, the primary focus is on the broad problem of addiction. There is no separation of patients based on

their drug(s) of abuse.

171
METHODS

A detailed form was developed to generate information on patient

demographics, cocaine use, other drug and alcohol use, employment

status, education, previous psychiatric treatment, previous drug

treatment, legal history, psychiatric diagnoses, medical diagnoses, laboratory data, medical sequelae, and behavior during

treatment. All charts of patients admitted to the inpatient program with a diagnosis of cocaine dependence from September 1979

through June 1983, or admitted to the partial hospitalization component between March 1982 (when the partial program first started)

and December 1983, were studied retrospectively. Patients who

received treatment in both components of the program were not

counted twice, but were reviewed as a single treatment episode.

Where information was not available on the charts, it was recorded

as missing. Patients were not contacted for followup information.

The data presented in this paper are the combined data from the

two program components based on a total of 172 patients.

RESULTS

During the period studied, there was an enormous increase in the

number of patients with cocaine dependence presenting for treatment (table 1). No specific attempt was made to recruit cocaineusing patients. Over 50% of the patients studied were treated

during 1983. This represents 55% of the patients admitted for

inpatient treatment during that time period. The patients were

predominantly male (69.2%). with 45.3% black and 45.3% white. The

mean age at time of treatment was 30.384 years, with a range of 17

to 64 years (table 2).

TABLE 1

Percent of Patients Presenting With

Primary Diagnosis of Cocaine Dependence

September 1979 - December 1983

Year N Percent

1979 1 .6

1980 5 2.9

1981 15 8.7

1982 62 36.0

1983 89 51.8

172
TABLE 2

Demographics

(N=172)

Sex

Males

Females

Mean Age

N

119

53

30.384

(range 17-64)

Percent

69.2

30.8

Race

Black 78 45.3

White 78 45.3

Hispanic 15 8.7

Asian 1 .6

Only 30% of the population studied was married. Of those remaining, 36% had never married and 34% were separated, divorced, or

widowed. Despite the large number of unmarried patients, only 41%

of them were living alone. Of the unmarried patients living with

persons other than their own children (51%). many were living with

parents or friends/lovers because of financial problems which prevented them from living alone.

Over 83% of the patients had graduated from high school, with

60.9% having had some college education. Over 25% of the patients

were college graduates, and over 4% had doctoral level degrees

(table 3). Consistent with the educational level of the patients,

63.4% of the population was employed at the time of admission.

Less than 16% of the population was receiving public assistance or

disability payments (table 4). Of those who were employed, 52.4%

were holding jobs in skilled positions, with 31.4% at managerial

or professional levels (table 5).

Twenty-seven patients (15.7%) gave histories of dealing cocaine,

with equal percentages of employed and unemployed reporting dealing. No data on dealing were available on 98 of the 172 patients.

However, of the patients who did respond, 36.5% were dealing

cocaine.

The smoking of cocaine freebase is the most efficient method of

delivering high concentrations of cocaine rapidly to the central

nervous system and was the most frequently used route of administration by the patients at the time of admission (43.9%)

(table 6). The majority of patients were using cocaine daily

(56.3%); the mean frequency of use was three to four times a week,

and over 80% of the patients used the drug two to three times a

week or more.

173
TABLE 3

Education

Level

Less than high school

Some high school

High school graduate

Some college

College graduate

Masters

Postmasters

Doctorate

No information

TABLE 4

N

1

27

39

61

29

4

3

7

1

Employment Status

Status N

Employed 86

Public aid 26

Unemployed 34

Self-employed,

working 23

Self-employed,

not working 2

Disability 1

TABLE 5

Type of Employment

Type N

Blue collar skilled 27

Manager/administrator 25

Clerical 19

Professional/technical 18

Sales 15

Blue collar unskilled 14

Service 13

Full-time homemaker 12

White collar skilled/

semiprofessional 11

Commodity broker 8

Not working 5

Student 4

Rehab work 1

Percent

. 6

15.8

22.8

35.7

17.0

2.3

1.8

4.1

Missing

Percent

50.0

15.1

19.7

13.4

1.2

.6

Percent

15.7

14.5

11.0

10.5

8.7

8.1

7.6

7.0

6.4

4.7

2.9

2.3

.6

174
TABLE 6

Route of Cocaine Administration

at Time of Admission

Route

Freebase

Insufflation

Intravenous

No information

N Percent

75 43.9

59 34.5

37 21.6

1 Missing

During the time period studied, cocaine had a street value of $100

to $120 a gram (gm). The average cost for cocaine reported by

patients was $800 weekly. This is consistent with the reported

amount of cocaine taken each time it was used and the weekly

frequency of use (table 7). Patients reported a range of less

than 1 gm to up to 30 gm each episode of use. The mean amount of

cocaine used was 2 to 3 gm each episode (table 8). The patients

using the largest quantities of cocaine at each episode were those

smoking cocaine freebase. Most patients reported they would have

used larger quantities of cocaine had they not consumed all that

was available or had they not run out of money to purchase additional cocaine.

TABLE 7

Frequency of Cocaine Use

Frequency N Percent

Daily

4-5 times/week

3-4 times/week

2-3 times/week

1-2 times/week

Weekends only

Occasionally

No information

56.3

6.6

6.6

10.8

7.8

9.0

3.0

Missing

175
TABLE 8

Quantity Used at Each Administration

Quantity N Percent

1/4-3/4 gm

1-2 gm

2- 3 gm

3- 4 gm

4-5 gm

5-10 gm

10-20 gm

20-30 gm

No information

34

46

27

24

9

13

5

3

11

21.1

28.6

16.8

14.9

5.6

8.1

3.1

1.8

Missing

Despite an increase in cocaine's popularity over the past few

years and the belief that cocaine abuse is a recent phenomenon,

more than 9% of the patients had been using cocaine for over 5

years (table 9). However, over 87% had been using for less than 4

years, with 37% using for less than 6 months prior to entering

treatment. Although the majority of patients had used cocaine for

a relatively short period of time, over 65% of those on whom

information was available (114) had tried to stop using cocaine at

least once, and 17% had tried to stop three or more times without

success. Of those who had tried to stop, information on the duration of the longest drug-free period was available on 101 subjects. Fifty-nine subjects (58.4%) were unable to remain drug

free for more than a week. Seven patients had been able to remain

drug free for over 2 years before returning to regular cocaine use.

TABLE 9

Duration of Use

Time N

Less than or equal

to 6 months

7-12 months

13-24 months

25-48 months

49-60 months

5-10 years

10-20 years

No information

61

30

19

34

6

9

6

7

Percent

37.0

18.2

11.5

20.6

3.6

5.5

3.6

Missing

176
Cocaine users often report using other drugs to modify the effects

of their cocaine, usually to reduce excessive stimulation. The

drug most commonly used to titrate cocaine's effects was alcohol.

Of the 160 patients on whom we were able to collect the necessary

information, only 10.6% reported no current use of alcohol. No

current usage data was available on 18.8% (table 10). The

patients who had provided information were often unaware of how

much alcohol was consumed weekly until the information was

requested. Over 36% of the patients were consuming more than two

drinks of an alcoholic beverage daily, and 60% were consuming more

than two drinks twice a week or more.

TABLE 10

Past and Concurrent Use of Other Drugs

Drug

Alcohol

Current

Past use only

Never used

No information

Heroin

Regular use with cocaine

Occasional use with cocaine

Occaslonal use without cocaine

Past use with cocaine

Past use without cocaine

No past use

No information

Marijuana

Daily

4-5 times per week

2-3 times per week

1 time per week

Occasionally

Current use but no information

Past use only

No past use

No information

N

143

9

8

12

38

7

2

8

20

72

25

69

6

10

4

30

4

1 8

20

11

Percent

89.4

5.6

5.0

Missing

25.9

4.8

1.4

5.4

13.6

49.0

Missing

42.9

3.7

6.2

2.5

18.6

2.5

11.2

12.4

Missing

Sedative-hypnotics (barbiturates, sleeping pills, benzodiazepines)

are also used to modify the effects of cocaine, and 32.9% of the

149 patients with sufficient information on the chart reported

using these medications three or more times a week.

177
A drug often associated with cocaine use is heroin. Heroin can be

used in combination with cocaine as an intravenous mixture (speedball) in which the cocaine is used to potentiate the effects of

heroin. Heroin can be used also to reduce the stimulant effects

of cocaine. Twenty-six percent of the 147 patients on whom data

was available reported regular use of heroin with cocaine.

Fifty-one percent of the patients reported current or past use of

heroin either in conjunction with cocaine or separately.

Another drug often used to modify cocaine's effects is marijuana.

Seventy-six percent of the patients reported current use of marijuana, with 42.9% reporting daily use of the drug. Besides smoking marijuana, 72.9% of the patients reported smoking cigarettes

daily, with a mean usage of one pack a day for 7 years. Of all

the drugs on which information was available, alcohol was the most

frequently used in conjunction with cocaine (89.4%).

In contrast to other drugs, the cocaine users report little use of

other stimulants. Over 68% report never having used stimulants

other then cocaine, over 55% report no previous use of the hallucinogen lysergic acid diethylamide-25 (LSD), and less than 6%

report any current use of LSD (or of stimulants).

As would be anticipated from the relatively short duration of

cocaine use and the extensive use of other drugs among the study

subjects, 97.9% reported using other drugs for a longer period of

time than they had used cocaine. One-third of those on whom we

had data reported loss of job due to cocaine, with 10.7% reporting

an arrest for cocaine possession and over 5% reporting an arrest

for cocaine dealing.

Despite the long history and high proportion of other drug use by

the cocaine users seeking treatment, over 75% reported no previous

inpatient or outpatient treatment for chemical dependence problems. Although 31.4% have had previous psychiatric outpatient

treatment, less than 10% have ever had any inpatient psychiatric

treatment.

It is generally believed that chemical dependence patients are

unreliable and resistant to treatment efforts. However, this

impression is not consistent with our experience with the cocaine

users while they were in treatment. Less than 16% of the patients

relapsed during treatment as defined bv (a) having a urine toxicology positive for drugs or alcohol, or (b) reporting using drugs

or alcohol during treatment. Over 65% of the patients were

reported by staff to be cooperative during treatment and compliant

with treatment recommendations. Seventy-two and one-half percent

of the patients completed their inpatient or partial hospital

treatment, with over 74% accepting the recommendation for continued treatment.

178
DISCUSSION

The data presented are helpful in attempting to develop a profile

of the cocaine user who presents for treatment. Although increasing numbers of cocaine users are requesting treatment, it is

important to remember that this is a skewed population and may not

be representative of the cocaine user who is not presenting for

treatment. In addition, there is no way of knowing what proportion of cocaine users the treatment population represents.

The population of users we are seeing have tended to use other

drugs for a longer period of time than cocaine. Their cocaine use

is relatively new, most often within the past 4 years. They view

cocaine as the precipitant which brings them into treatment at

this time. Since close to half the patients we have treated smoke

freebase cocaine, this method of use may be an important factor in

their seeking treatment. We have reported elsewhere on the pulmonary complications associated with cocaine smoking (Itkonen

et al. 1984).

Despite the long history of using other drugs by most of the

patients, few have sought or required previous treatment for their

use of these drugs. However, they have entered treatment for

cocaine dependence. Since it is well known that cocaine has

powerful reinforcing properties (Aigner and Balster 1978; Johanson

and Schuster 1975), the users may have been able to control their

use of other drugs but not cocaine. The high cost of cocaine use

(approximately $800 a week for those entering treatment) also may

have contributed to the problems causing patients to seek treatment.

Once in treatment, the cocaine users are cooperative and tend to

follow treatment recommendations. This cooperation during treatment may be related to the large percentage of patients who are

employed in skilled and professional positions. Their employment

status would indicate a strong ability to function within the

rules of our social system, and problems in treatment could result

in a loss of job. It has been well documented that patients who

have the most to lose with a treatment failure have the best prognosis.

From this preliminary study, three roups of cocaine-dependent

patients appear to be emerging: (1) patients who have no previous

drug treatment experience but have broad experience with substances of high abuse potential; (2) patients who have a previous

drug treatment history with cocaine being the most current drug in

a long career of chemical dependency; and (3) patients with no or

minimal previous drug experience who are older than the patients

in groups 1 and 2 and seek treatment after a very short duration

of cocaine abuse.

Additional research is needed to determine if the above groupings

are supported by prospective studies of cocaine abusers. Other

areas of research should focus on medical consequences of cocaine

179
use, comparison of cocaine-abusing patients with patients who

abuse substances other than cocaine, personality characteristics

of cocaine users, treatment approaches, and treatment outcome.

Since this population has had little previous exposure to the

chemical dependence treatment system, they present a unique opportunity for future studies.

REFERENCES

Aigner, T.G., and Balster, R.L. Choice behavior in rhesus

monkeys: Cocaine vs. food. Science 201(4355):534-535, 1978.

Anker, A.L., and Crowley, T.J. Use of contingency contracts in

specialty clinics for cocaine abuse. In: Harris, L.S., ed.

Problems of Drug Dependence: 1981. National Institute on Drug

Abuse Research Monograph 41. Rockville, MD: The Institute,

1982. pp. 452-459.

Chambers, C.D.; Taylor, W.J.; and Moffett, A.D. The incidence of

cocaine abuse among methadone maintenance patients. Int J

Addict 7:427-441, 1972.

Gay, G.R.; Sheppard, C.W.; Inaba, D.S.; and Newmeyer, J.A.

Cocaine in perspective: "Gift from the sun god" to "the rich

man's drug." Drug Forum 2(4):409-430, 1973.

Itkonen, J.; Schnoll, S.; Daghestani, A.; and Glassroth, J.

Accelerated development of pulmonary complications due to

illicit intravenous use of pentazocine and tripelennamine. Am J

Med 76:617-622, 1984.

Jolson, C.E., and Schuster, C.R. A choice procedure for drug

reinforcers: Cocaine and inethylphenidate in the rhesus monkey.

J Pharmacol Ex Ther 193(2):676-688, 1975.

Siegel, R.K. Cocaine smoking.

1982.

J Psychoactive Drugs 14:277-359,

AUTHORS

Sidney H. Schnoll, M.D., Ph.D.

Chemical Dependence Program

Institute of Psychiatry of

Northwestern Memorial Hospital

Chicago, Illinois 60611

and

Department of Psychiatry and

Behavioral Sciences

Northwestern University Medical School

Chicago, Illinois 60611

and

Department of Pharmacology

Northwestern University Medical School

Chicago, Illinois 60611

Judy Karrigan, B.S.W.

Chemical Dependence Program

Institute of Psychiatry of

Northwestern Memorial Hospital

Chicago, Illinois 60611

180
Sarah B. Kitchen

Chemical Dependence Program

Institute of Psychiatry of

Northwestern Memorial Hospital

Chicago, Illinois 60611

Amin Daghestani, M.D.

Chemical Dependence Program

Institute of Psychiatry of

Northwestern Memorial Hospital

Chicago, Illinois 60611

and

Department of Psychiatry and

Behavioral Sciences

Northwestern University Medical School

Chicago, Illinois 60611

Thomas Hansen, M.D.

Chemical Dependence Program

Institute of Psychiatry of

Northwestern Memorial Hospital

Chicago, Illinois 60611

and

Department of Psychiatry and

Behavioral Sciences

Northwestern University Medical School

Chicago, Illinois 60611

181
Cocaine Use in a Treatment:

Population: Patterns and

Diagnostic Distinctions

Frank H. Gawin and Herbert D. Kleber

There has been little systematic or detailed study of cocaine use

patterns in abusers. While there is a relative abundance of survey literature on cocaine use (Gold, this volume) and detailed

case report data are available on cocaine abusers (Siegel 1982;

Smith and Wesson 1980), the former does not enhance understanding

or treatment of individuals and the latter often lacks generalizability and objective data collection techniques. Descriptions of

abuse patterns in users appearing for treatment usually have been

limited to documenting routes of administration. More detailed

descriptions of the way cocaine is used could provide a basis for

increasing our understanding of the spectrum of cocaine use and

abuse. If the way cocaine is used differs consistently for different types of abusers, this might lead to specific insights or

interventions in particular treatment subpopulations. This

chapter describes data on amounts, routes, and temporal characteristics of cocaine use in an outpatient population, taken from

periods immediately prior to treatment and during the early stage

of treatment. The population was given extensive psychiatric and

drug abuse characterization, enabling a preliminary assessment of

possible relationships among all these factors.

METHODS

Subjects were 30 consecutive admissions to the Cocaine Abuse

Treatment Program at the Drug Dependence Unit of Yale University

School of Medicine and the Addiction Prevention Treatment Foundation. This outpatient program serves a middle-sized urban community as part of a comprehensive community mental health center.

On admission to the program, subjects completed a 72-item demographic questionnaire and a 11O-item drug and cocaine use history.

They also were asked to complete a 28-item cocaine craving scale

and cocaine use inventory each week during treatment and for each

of the 2 weeks prior to admission. The inventory generated

information on their cocaine use for a l-week period including the

total amount of use, days on which cocaine was used, number of

discrete episodes of cocaine use separated by sleep (runs), length

of cocaine run, and route(s) of administration.

182
Data were collected for the present study for 2 to 6 treatment

weeks. If a period of abstinence, defined as greater than 2 weeks

without any cocaine use, was achieved early in treatment, then

data were counted only for those weeks before abstinence occurred.

There were 182 data weeks for the entire sample. This included 2

pretreatment weeks and at least 2 weeks of active abuse for every

subject. These methods were chosen following pilot investigations

which showed that subjects' abilities to provide specific details

for past usage was limited to the 2 to 4 weeks preceding admission. Estimates by subjects of earlier specific past usage patterns were unreliable.

An approximation of natural abuse patterns was thus obtained.

This approximation assumed that patterns of abuse just before

entering treatment and during the early treatment phase reflected

typical street abuse.

DSM-III axis 1 psychiatric diagnoses were available on 17 of these

subjects from associated studies of abstinence symptomatology and

pharmacotherapy (Gawin and Kleber 1984a, 1984b). These diagnoses

were obtained via structured interviews with the NIMH diagnostic

interview schedule. The remaining 13 subjects did not receive

structured interviews, but were also diagnosed using DSM-III

criteria. Diagnostic patterns between the two groups were similar.

Before diagnoses were made, all subjects were required to meet

additional criteria which were designed to minimize the influence

on diagnosis of short-term dysphoric effects from a recent episode

of cocaine use. The timing of diagnostic procedures in cocaine

abusers is an important determinent of diagnostic reliability and

validity because the postcocaine "crash" that follows an episode

of substantial use can mimic the neurovegetative symptomatology of

unipolar or bipolar depression. In most cases, the crash ends

within 1 to 5 days and a baseline clinical state, which we have

termed phase II, of cocaine discontinuation ensues. Symptom

evaluations for diagnoses were made only during phase II; and

historical reports were considered only if the symptoms described

had occurred during prolonged (14 days) cocaine-free periods.

Diagnostic considerations in cocaine abusers and these methods are

discussed more fully elsewhere (Gawin and Kleber 1984b).

Formal statistical analyses of the data were not attempted because

of the small sample size, as well as possible pseudoprecision

stemming from numerical values generated on duration or amount of

use of street cocaine, for which actual purity might be highly

variable. We thus considered this an exploratory investigation to

provide preliminary data and an initial assessment of the value of

pursuing further investigations of this type.

RESULTS

Characteristics of the sample appear in table 1. Age, sex, race,

education, income, and employment status are similar to those

described by others for cocaine abusers in treatment (Weiss et al.

183
1983; Schnoll et al., this volume). An atypical feature of this

sample is the very high proportion of intravenous (i.v.) cocaine

users. The proportion of i.v. versus inhalation (smoking) users

is inverse to that seen elsewhere (Schnoll, this volume), providing particular opportunity to observe patterns of use. Other

features of cocaine usage for this sample are not atypical.

TABLE 1

Subject Characteristics

(N = 30)

Route of Administration:

Intranasal (I.N.) 11 (37%)

Smoking (S) 6 (20%)

Intravenous (I.V.) 13 (43%)

Age: = 28.6 (range = 19 - 37 years)

Sex: 27% Female

73% Male

Education: = 12.8 years (range = 9 - 18

Yearly Income: (excluding cocaine commerce)

ears)

x = $22,560 (range = $7,000 - $84,500)

Employment: 70% were regularly employed at entry

Duration of Cocaine Use: x = 4.8 years since first use

(range = 1.5 - 16 years)

Estimated Amount of Cocaine Use in Prior 6 Months:

x = 147.2 gms (range = 20 - 700)

Race: 6% Hispanic

13% Black

80% Caucasian

Characteristics of roups divided by administration routes (table

2) indicate few differences between the groups. Intravenous users

had a slightly lower income and a higher percentage of nonCaucasians, but no differences exhibited in education. This may

indicate different drug-using subcultures or differences in social

acceptance of various routes of administration in the urban East

as opposed to, for example, the West Coast. However, we cannot be

certain of the factors that created the high proportion of i.v.

abusers in our sample.

Over 60% of the intravenous users had tried freebase smoking and

had not preferred it. In contrast, only one of six cocaine

smokers had experimented with i.v. cocaine.

Cocaine use described for this population was very similar to that

described for methamphetamine abusers over a decade ago by Kramer

et al. (1967). That is, the predominant pattern of use in these

abusers seeking treatment was in discrete episodes or "runs."

Only four subjects described daily or near to daily cocaine use

(greater than three use episodes weekly), and two of these

184
subjects described runs of high intensity use by intravenous

injection that were interspersed with days of low use by intranasal administration. Over 50% of the entire sample reported that

milder daily use of cocaine was part of their earlier abuse

history. However, they described that as the severity of their

abuse escalated, fewer periods of mild daily use occurred, and

instead episodes of higher intensity prolonged use increased. The

sample averaged 1.9 runs weekly, used 3.6 grams per run, and had a

mean duration of 10.4 hours of cocaine use per run. ("Duration" of

a run refers only to the period during which cocaine was selfadministered, not to the duration of euphoria or of the postcocaine crash.)

TABLE 2

Subject Characteristics by Preferred

Route of Administration

I.V. I.N.

Age (years)

Sex (% female)

Income ($)

Education (years)

Employment (%)

Length of use (years)

Race (% non-Caucasian)

Prior Substance Treatment

Other DSM-III

Dependence History (%)

DSM-III Alcohol

Abuse History (%)

S

29.9

31

19,770

12.2

69

5.9

31

54

8

27.8

33

25,830

12.3

67

3.8

0

50

0

27.4

18

22,640

13.3

73

3.6

18

27

0

38 33 27

Patterns of cocaine use differed substantially according to route

of administration (table 3). Both i.v. and i.n. users used

approximately five grams of cocaine weekly, but in different

patterns: the intranasal users would use lesser amounts over

longer time periods but would have almost 50% more runs weekly.

Cocaine freebase smokers used almost twice as much cocaine weekly

as the other groups and almost twice as much per run as the rest

of the sample, but also had runs that lasted 2 1/2 times as long

as the i.v. users. These differences led us to define a term

describing abuse in grams per hour: the "intensity" of cocaine

use. As table 3 indicates, the mean intensity of use as well as

range maximums indicate that i.v. users used very large amounts of

cocaine in very short time periods. Our sample used from oneeighth to one gram per injection, with one to three injections per

hour. These substantial boluses have important implications for

our understanding of natural cocaine use patterns. In particular,

they imply that both acute and chronic tolerance may occur and

that the prior belief that a single lethal dosage of cocaine is

approximately one gram may be erroneous.

185
TABLE 3

Use Patterns by Route of Administration

I.V. S I.N.

(numbers in parentheses indicate

range, other values are means)

Grams of Cocaine:

(Weekly)

"Runs" Per Week:

Grams Per Run:

5.6 9.1 5.3

(1-20) (4-16) (1.5-10)

1.6 1.6 2.3

(.8-2.7) (1-2.5) (.5-6)

3.7 5.7

(.8-7.5) (3.6-9.6)

2.3

(1-6.5)

Duration of Run: 6.9 17.4 10.7

(Hours) (1-16) (6.7-24.8) (3.8-22)

Intensity: .54 .35 .25

(Grams per hour during use) (.12-1.) (.21-.54) (.07-.52)

DSM-III axis 1 psychiatric diagnoses, in addition to substance

abuse, were present in 54% of the sample and are presented in

table 4. The diagnoses were primarily minor affective disorders

(dysthymic and cyclothymic disorder) with major affective disorders present in only 13% of the sample. The only other diagnosis made was one case of Adult Attention Deficit Disorder

(ADD)--Utah criteria were applied to arrive at this diagnosis

(Wender et al. 1981). This distribution of axis 1 disorders is

similar to that described in an earlier report on inpatients by

Weiss et al. (1983). The highest proportion of diagnoses occurred

in intra-nasal users, almost twice that observed in the freebase

smokers.

TABLE 4

Axis 1 Diagnoses vs. Route of Administration

Sample S

(n = 6)

I.V. I.N. Total

(n=13) (n=11)

Major Depression 1

Dysthymic 1

Cyclothymic -

Adult Attention

Deficit Disorder -

None 4

Totals 2/6-33%

2 1 4

3 6

3 2 5

- 1 1

6 4 14

7/13-54% 7/11-64% 6/30-54%

186
Subjects given additional axis 1 diagnoses, with the marked exception of the subject with ADD, had relatively similar patterns of

cocaine use. The subject with ADD had a total use similar to that

of other subjects, but his intensity of use (.07 gms/hr.) was

extremely low, less than half that of the next lowest subjects in

the entire sample. That subject clearly used cocaine as selfmedication and was one of the daily users. He used cocaine as

appropriately as possible for an illicit substance, achieving

desired improvement in attention and mood regulation without side

effects or problems except for expense. He is described in detail

elsewhere (Khantzian et al. 1984). Because this subject was so

different from the remainder of our treatment population, he is

excluded from the analyses of use patterns and diagnoses which

follow.

The other subjects given additional axis 1 psychiatric diagnoses

differed consistently from the rest of the sample. Their intensity of use was greater than that of subjects who did not meet

additional diagnostic criteria (table 5), but they used less

cocaine per week. As indicated in table 6, subjects without diagnoses used almost 70% more total cocaine weekly than those with

diagnoses. Since the number of runs per week was similar for both

groups, this reveals the most striking differentiating feature in

our sample: runs in the group with effective diagnoses were far

shorter, only half the duration of runs in the rest of the

sample. An interaction between route of administration and diagnoses was examined and does not appear to account for this finding. These distinctions are consistent with clinical impressions

of differences, discussed below, in the goals of cocaine intoxication for patients with additional psychiatric diagnoses. It

should be noted that diagnoses were blind to usage since they were

generated before the data were analyzed.

COMMENTS

Cocaine usage patterns observed in this treatment sample indicated

that severe abuse occurred in discrete episodes of high intensity

use. This was particularly so in i.v. users, where amounts of

cocaine presumed to be extremely dangerous were self-administered

routinely. Mean duration of administration was also different for

different routes of administration.

A somewhat surprising but internally consistent constellation of

findings in relation to diagnoses was also evident in this sample.

These included the observation that the highest proportion of subjects with diagnoses were i.n. users and that subjects with diagnoses had low weekly cocaine use, but had very high intensity of

use and short durations of use during episodes of cocaine abuse.

The cocaine use observed in this sample approximated past descriptions of runs with amphetamine and methamphetamine (Kramer et al.

1967), although the shorter acting cocaine also appeared to be

associated with runs that were shorter in general than those

described in previous amphetamine literature.

187
TABLE 5

Distribution of Intensity of Cocaine Use (gms/hour)

vs. Diagnosis

188
TABLE 6

Cocaine Abuse Pattern vs. Axis 1 Diagnosis

(numbers in parentheses indicate range,

other values are means)

Major

Depression/ All No Extra

Cyclothymic Dysthymic Affective Diagnosis

Use per week: 3.3 5.0 4.4 7.3

(grams) (1.2-6.O) (1.5-9.0) (1.2-9.O) (7.3)

"Runs" per week: 1.2 1.7 1.5 1.8

(.7-2.O) (.7-2.7) (.7-2.7) (.5-4.6)

Grams per week: 2.7 2.9 2.8 4.1

(1.O-3.5) (1.3-9.6) (1.0-9.6) (1.1-7.8)

Duration of run: 7.3 7.2 7.3

(hours) (2.O-13.8) (2.0-18.4) (2.0-18.4)

13.0

(1.0-24.8)

Intensity of use: .39 .43 .41 .32

(grams/hours) (.15-.5) (.17-1.0) (.15-1.0) (.12-.8)

Past presumptions that "daily" cocaine use is tantamount to severe

abuse may consequently require reassessment. Based on these data

and our clinical experience, daily use of less than two-tenths of

a gram of cocaine intranasally does not appear to represent severe

abuse but may instead represent a potential stage that precedes

the development of severely dysfunctional cocaine use which occurs

in extended binges. It is only when the latter have occurred, at

least in this sample, that users consider themselves unable to

regulate cocaine use and sufficiently impaired to require treatment. Hence, particular factors, such as whether binges occur,

how often they occur, how long they last, and how much cocaine is

used, all need to be examined as possible determinants of both

abuse severity and of treatment needs.

The assumption that decreased binge use occurs in recreational or

controlled users who do not seek treatment requires naturalistic

assessment. If our findings hold following such assessment, then

the extent of cocaine binges, as well as the ability for controlled abstinence when indicated by psychosocial circumstances,

may represent a basis to distinguish degrees of cocaine use

severity. Finally, our assumption that early treatment effects

did not substantially alter typical street abuse patterns also

requires confirmation by naturalistic assessments.

189
Within the part of the spectrum of cocaine use occupied by

abusers, there may be major differences in use patterns based on

route of administration. In our sample, cocaine smoking involved

greater use in longer runs, but was not as substantially different

in intensity of use during runs, as early reports (Siegel 1982)

had implied. We do not feel that the problems associated with

freebase smoking have been overemphasized, but rather that problems of i.n. abuse have been underemphasized.

In addition, based on our sample, i.v. cocaine use remains prevalent in this era in use patterns of very high intensity. It has

not been supplanted by cocaine freebase smoking. We do not think

that the large boluses administered by i.v. users are inflated by

low cocaine purity, since several of our i.v. subjects were

involved in cocaine commerce high in the distribution hierarchy

and have submitted samples of very high quality cocaine for

analysis. Our impression, instead, is that subjects built up

gradually to 1 gram i.v. boluses during their abuse history,

beginning at 1/16 to 1/8 gram maximum boluses. Further, these

users reported that they very seldom used amounts over .25 gram at

the beginning of a run and started with doses of .05 grams early

in their intravenous use. They then escalated to larger amounts

1.5 to 3 hours into a run. Combined with reports by some users

that individual runs can conclude with as much as 1 gram of i.v.

cocaine every 40 minutes for the last 40 hours, these clinical

data indicate both that acute tolerance consistent with experimental evidence (Zahler et al. 1982) occurs during a binge and

that chronic tolerance, reflected in increased initial doses, also

occurs in street cocaine use. Further, lethal dosages in chronic

abusers could far exceed amounts generally accepted as being

lethal for the general population.

The diagnostic distinctions we observed are subject to current

limitations in diagnostic validity in cocaine abuse. Followup

studies in subjects who are drug free will be necessary before the

validity of diagnoses such as those made here can be ascertained.

Nonetheless, we believe the diagnoses reported are meaningful

descriptors of clinical state and may have implications for treatment. Clear demarcation of distinct subsamples occurred for our

population only along the dimensions of psychiatric diagnoses and

route of administration. Subjects in this sample with diagnoses

(i.e., those who displayed greater symptomatic impairment during

the periods described above in the methods section) used somewhat

less cocaine overall, but used it for far shorter time periods and

less frequently than the rest of the sample, such that they

actually used high quantities during the shorter periods that they

self-administered cocaine. While this finding requires replication in larger samples, it is difficult to ignore.

We believe that until more data are available, a self-medication

hypothesis best organizes these results on use patterns and diagnoses. Elsewhere we have described that abusers with psychiatric

diagnoses have less substantial histories of cocaine use before

190
appearing for treatment than other abusers (Gawin and Kleber

1984b). When combined with the findings that such subjects used

less cocaine and reported a larger proportion of i.n. rather than

i.v. or freebase use, the conclusion is suggested that they

experience increased psychic distress with less severe cocaine

abuse. It is not clear whether they began with increased

symptomatology or whether this reflects a greater sensitivity to

the negative effects of cocaine. Further, these subjects

described a goal of cocaine use that distinguishes them from the

remainder of the sample. Our clinical impression is that other

cocaine users seek a particular rewarding, euphoric state that

they wish to maintain for prolonged periods and which is clearly

an end in itself; while those with greater psychological distress

use cocaine as an intermittent escape from chronic dysphoria, as a

means towards returning to, and marginally tolerating, a

persistently dysphoric existence. If so, alleviation of such

dysphoria through appropriate social, psychological, and

pharmacological interventions could have substantial impact in

these subjects.

These impressions on goals of cocaine use are speculative. Their

validation requires extensive and detailed research on large

samples that is not easy to carry out. Consequently, they are

likely to remain working hypotheses. In contrast, our finding

that clinical characteristics differentiate subgroups of cocaine

abusers is not speculative and is easier to test. This warrants

replication and, if substantiated, further work on defining the

extent as well as the clinical significance of differing clinical

characteristics in cocaine abusers.

REFERENCES

Gawin, F.H., and Kleber, H.D. Cocaine abuse treatment: An open

pilot trial with lithium and desipramine. Arch Gen Psychiatry

41:903-909. 1984a.

Gawin, F.H., and Kelber, H.D.: Abstinence symptomatology

and psychiatric diagnosis in cocaine abusers: clinical

diagnosis. 1985, submitted.

Khantzian, E.J.; Gawin, F.H.; Riordan, C.; and Kleber, H.D.

Methylpenidate treatment of cocaine dependence - a preliminary

report. J Substance Abuse Issues Vol. 1. pp. 107-112, 1984.

Kramer, J.C.; Fischman, V.S.; and Littlefield, D.C. Amphetamine

abuse - pattern and effects of high doses taken intravenously.

JAMA 201:305-309, 1967.

Siegel, R.K. Cocaine smoking. J Psychoactive Drugs 14:321-337,

1982.

Smith, D.E., and Wesson, D.R. Cocaine. In: Jeri, F.R., ed.

Cocaine 1980. Lima: Pacific Press, 1980.

Weiss, R.D.; Mirin, S.M.; and Michael, J.L. Psychopathology in

chronic cocaine abusers. Paper presented at the 136th Annual

Meeting of the American Psychiatric Association, New York, NY,

May 4, 1983.

Wender, P.H.; Reimherr, F.W.; and Wood, D.R. Attention deficit

disorder (minimal brain dysfunction) in adults. Arch Gen

Psychiatry 38(4):449-456, 1981.

191
Zahler, R.; Wachtel, P.; Jatlow, P.; and Byck, R. Kinetics of

drug effect by distributed lags analysis: An application to

cocaine. Clin Pharamcol Ther 31(6):775-782, 1982.

AUTHORS

Frank H. Gawin, M.D.

Departments of Pharmacology and Psychiatry

Yale University School of Medicine

New Haven, Connecticut 06510

Herbert D. Kleber, M.D.

Department of Psychiatry

Yale University School of Medicine

New Haven, Connecticut 06510

and

APT Foundation

904 Howard Avenue

New Haven, CT 06519

192
Cocaine: Treatment Perspectives

Donald R. Wesson and David E. Smith

As with the use of any psychoactive drug, cocaine use is influenced by sociocultural factors: availability, legality, cost,

beliefs about its safety or dangerousness, desirability, and

status. Before the 196Os, when cocaine was primarily associated

with heroin and the hard-core drug culture, cocaine users were

generally regarded as criminals, and treatment of cocaine abusers

occurred primarily in public drug treatment facilities.

But, in the late 1960s and 197Os, many people changed their attitude about cocaine use. This attitude shift occurred for many

reasons. Most important was a general liberalization of attitudes

about recreational drug use--a spinoff of wider acceptance of

marijuana. Like marijuana, possession of cocaine was acknowledged

to be illegal, but many people did not view its use as criminal.

The media played a significant role in shaping attitudes. By publicizing and glamorizing the lifestyle of affluent, upper class

drug dealers and the use of cocaine by celebrities and athletes,

all forms of mass media created an effective advertising campaign

for cocaine, and many people were taught to perceive cocaine as

chic, exclusive, daring, and nonaddicting. In television specials

about cocaine abuse, scientists talked about the intense euphoria

produced by cocaine and the compulsive craving that people (and

animals) develop for it. Thus, an image of cocaine as being

extraordinarily powerful and a (therefore desirable) euphoriant

was promoted. Since people don't really believe they will become

"victims" (the same denial mechanism that allows people to smoke

cigarettes), the addictive potential is not a deterrent. In fact,

cocaine has many appealing attributes for the adventuresome: it

is illegal, powerful, and dangerous. Its extravagant cost further

serves to reinforce its elite and privileged status.

The issue of abuse potential has been confounded by professional

and lay misunderstanding of the relationship between physical

dependence and addiction. Models of addiction have used opiates

as the prototype: addiction requires tolerance and physical

dependence. Since cocaine has no obvious withdrawal syndrome in

animals, it has been labeled nonaddicting. The notion that

cocaine is not addicting because it does not induce physical

dependence has been important in fostering widespread acceptance.

193
With cocaine's increasing social acceptance, the number of users

increased among a diverse group of people--from professionals to

street junkies. A national household survey of drug use conducted

in 1982 showed that 28% of young adults, 18 to 25 years of age,

had used cocaine on one or more occasions (Miller et al. 1983).

The high morbidity that always occurs when a culture first incorporates a new intoxicant also occurred with cocaine.

Increase in frequency of cocaine abuse among drug addicts is being

observed in both the public and private treatment sectors.

Cocaine abuse is becoming increasingly conspicuous to private

physicians because greater numbers of people are seeking treatment

for complications of cocaine abuse, such as dependency and

toxicity.

Although more people are coming to treatment for cocaine abuse (as

well as attending cocaine support groups and Cocaine Anonymous),

this does not necessarily reflect increasing prevalence of cocaine

use in the total population. Some people use cocaine for several

years before they develop dependency or medical complications from

their use, and many people experiment with cocaine when it becomes

fashionable among their peer group but quit without ever requiring

medical attention. Many cocaine abusers now seeking treatment are

mutiple drug abusers with cocaine being the pivotal drug bringing

them to treatment.

Proprietary drug treatment programs have responded resourcefully

to the emerging cocaine casualties of the affluent and medically

insured, and they have devised treatment modalities specifically

tailored to cocaine abuse: cocaine recovery support groups,

resort retreats, aversive therapy, and short- and long-term

residential treatment.

In spite of the availability of private treatment clinics and

hospitals (many of which now advertise that they provide treatment

for cocaine abuse), growing numbers of middle and upper class

people are seeking treatment in alternative health care facilities, such as the Haight Ashbury Free Medical Clinic. These

patients have a different profile than other patients treated at

the Haight Ashbury clinic: most are white, employed, and have had

no previous drug treatment. People may seek help in such clinics

because they are fearful that treatment in hospitals (with billing

for medical services to insurance policies which are often through

their employer) will compromise their confidentiality. For the

same reason, many cocaine abusers will not seek treatment from

their private physicians or in a public drug treatment program.

The following case history illustrates many features common to

cocaine addicts now being treated in private facilities:

A 36-year-old male attorney from southern California

sought treatment in a northern California chemical

dependency recovery hospital for his cocaine abuse. He

194
had used cocaine for 2 1/2 years. Cocaine use was

common among his attorney friends at parties, where it

was typically available buffet style, put out in lines

by the party host. After using cocaine several times at

parties, the attorney began purchasing cocaine himself

and using it when he was working alone at night in his

office. Initially, he used cocaine sparingly and during

periods of unusually high work loads. Cocaine allowed

him to allay fatigue and facilitated his preparation of

briefs and paperwork. He soon recognized that his

recreational use of cocaine was not social-normative for

his peer group. At parties where cocaine was available,

he would often bring his own, which he would snort in

the bathroom to supplement what the host would supply.

(The usual custom among his friends was to use one or

two lines at the party. To use more of the host's

cocaine would be considered rude and "piggish.") His

use of cocaine at his office became more frequent and,

for the 6 months before treatment, daily. Although

cocaine initially facilitated his capacity for work, as

the dosage increased and use became regular, he accomplished less work and spent most of his nights at the

office looking at pornography, masturbating, and snorting cocaine. As his addictive disease progressed, he

worked less and spent most of his time obsessed with his

next episode of use or recovering from his last binge.

He began to drink heavily to get to sleep after heavy

cocaine use and to medicate increasing agitation and

irritability. During the 6 months before entering the

hospital, he spent $36,000 of his personal business

funds on cocaine. He knew the exact amount because he

purchased his cocaine from another attorney and showed

the cocaine purchases on his books as "professional consultations." His office associates, whose cocaine use

was episodic, social-recreational and social-normative

for their peer group, pressured him to seek treatment

for his cocaine addiction before their practice suffered

irreparable damage. They encouraged him to seek treatment in a program geographically distanced from their

area of practice. At the time he entered treatment, he

had a perforated nasal septum, had lost 40 pounds of

weight, and his marriage was in serious trouble. He

initially hoped that treatment could teach him controlled use of cocaine, i.e., he would be able to continue to use cocaine within socially acceptable limits

like his friends. With 28 days of inpatient, recoveryoriented treatment, he eventually accepted the necessity

of relinquishing all psychotropic drug use, actively

participating in a recovery program and, after returning

to practice, attending a cocaine recovery support group

near his home.

195
COCAINE AVAILABILITY

Deception is the rule in the illicit drug marketplace, and pure

cocaine is not generally available unless diverted from medicinal

use. Illicit cocaine may be cut with lidocaine, tetracaine,

mannitol, caffeine, and amphetamine; and the dosage of cocaine in

street samples is highly variable. The toxicity of contaminants,

cuts, and substitutes is one factor that must be considered in

treating acute overdoses.

Since cocaine is available for medicinal uses through pharmaceutical suppliers, one might suppose that physicians who personally

use cocaine for recreational purposes would acquire their supply

of cocaine from pharmaceutical sources. Except for ear-nose-andthroat specialists and anesthesiologists, most physicians acquire

cocaine for their personal use through the illicit marketplace

because they are concerned that ordering cocaine would invite discovery of their drug use. Hospital pharmacists who work where

large amounts of cocaine are used for surgery or for preparation

of Brompton's solution (an oral pain-relieving medication for

terminal cancer patients which contains a narcotic--usually methadone or morphine-- in addition to cocaine and alcohol) have easier

access to pure cocaine.

Cocaine Look-Alikes

Substances simulating the properties of cocaine (sold under names

such as Peruvian Flake, Snocaine, and Hard Rock Crystal) are

nationally advertised for mail-order purchase in "skin flick" and

"biker" magazines. Cocaine look-alikes are also sold in drug

paraphernalia shops. They may contain, alone or in combination,

lidocaine, tetracaine, caffeine, or phenylpropanolamine. They are

sold as incense and labeled with a reverse disclaimer, "not for

drug use," in an effort to elude regulations applicable to drugs.

DIAGNOSIS OF COCAINE ABUSE

The third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM III) states

that a diagnostic category for cocaine dependence is not included

because the withdrawal symptoms are transitory. Therefore, only a

category of cocaine abuse is included. Cocaine abuse requires a

pattern of pathological use (inability to reduce or stop use,

intoxication throughout the day, and episodes of cocaine

overdose), impairment of social or occupational functioning, and a

duration of disturbance for more than 1 month.

PATTERNS OF COCAINE ABUSE

Most cocaine abusers do not use only cocaine. Cocaine abusers

(particularly those using high dosages) usually use sedativehypnotics (i.e., barbiturates, methaqualone, benzodiazepines, or

alcohol) to self-medicate insomnia, agitation, and irritability.

Thus, they develop an upper-downer syndrome similar to that associated with amphetamine use (Smith and Wesson 1973).

196
The simultaneous use of intoxicating amounts of stimulants and

sedative-hypnotics can produce disastrous consequences. The

intoxicated individual has the gross impairment of judgment and

motor skills produced by the sedative-hypnotic and has the energy

to remain awake and active due to the stimulant.

The use of alcohol or other depressants to relieve cocaine's side

effects can result in a secondary dependence on sedatives. People

with combined alcohol dependence and cocaine abuse often seek

treatment in alcohol treatment centers where they may encounter

inadequate information about treatment of cocaine abuse and

ambivalent attitudes toward treatment of mixed drug and alcohol

addiction. Dual dependence on cocaine-alcohol or cocaine-opiate

combinations increases the severity of withdrawal.

Instead of, or in addition to, sedatives, some high-dose cocaine

abusers also medicate the side effects of cocaine with narcotics

such as heroin and meperidine (Demerol) or other prescription

drugs.

Cocaine Freebase

The cocaine alkaloid is known as freebase. It volatilizes at a

low temperature, and the user inhales the vapor. Smoking of

cocaine freebase in the United States was predated by the smoking

of coca paste in Peru (Jeri et al. 1978). Cocaine freebase use is

associated in the San Francisco Bay area with a parallel increase

in the smoking of Persian heroin (Inaba et al. 1980). Initially,

cocaine users smoke Persian heroin to reduce the agitation produced by cocaine. However, as a consequence of using heroin, they

may acquire narcotic hunger and a desire for heroin--thereby

evolving into primary heroin abusers or mixed heroin and cocaine

abusers. Many freebase users are middle class, have no previous

experience with the drug treatment system, and have short addiction histories. Because many of these people believe that "if you

don't stick a needle in your arm, you can't be a cocaine or heroin

addict," they often present for treatment unaware of their

physical dependence.

Most cocaine freebase users prepare their own freebase from

cocaine hydrochloride, although recently cocaine freebase called

"rock" has found a market in Los Angeles and Oakland, California.

Intravenous Injection of Cocaine

Cocaine hydrochloride can be dissolved and injected. Some cocaine

abusers figure out that the injection mode is a more efficient way

of using a limited drug supply. Although cocaine may be the first

drug ever injected, intravenous cocaine abusers are usually

already familiar with injection because they are also heroin

users. When heroin and cocaine (or heroin and amphetamine) are

injected simultaneously, it is called "speedballing." The risk

for acute overdose reactions increases with speedballing, either

because of the stimulant effect or the depressant effect.

197
COMPLICATIONS OF COCAINE USE

Cocaine alone and in combination with other drugs can produce many

serious medical and psychiatric complications. The cardiac consequences of cocaine use include tachycardia, hypertension, and

ventricular arrhythmias. Coleman et al. (1982) reported a case of

myocardial infarction associated with snorting cocaine in a

38-year-old male.

In most fatal cocaine overdoses, the mechanism of death appears to

be respiratory arrest or cardiac arrhythmia. Although most

fatalities have occurred among those who injected cocaine or

smoked it in its freebase form, deaths also occur with cocaine

snorting. Deaths from body-packing (a practice whereby cocaine

smugglers conceal the drug in their stomach or intestinal tract)

also have occurred when the storage containers burst and the

smuggler's body receives a massive amount of cocaine (Wetli and

Mittleman 1981).

An acute massive overdose of cocaine can produce seizures. Intravenous diazepam and support of the cardiorespiratory system for

status epilepticus or postseizure depression are the appropriate

techniques for management of the cocaine-induced seizure. Betablockers such as propranolol are appropriate pharmacological

treatment for cocaine-induced hypertensive crisis and other

cardiovascular dysfunctions, as well as the acute anxiety reactions linked with the hyperadrenergic storm associated with

cocaine abuse (Gay 1981).

Cocaine can produce a broad range of psychological effects, ranging from acute anxiety to full-blown cocaine psychosis with paranoia, and auditory and visual hallucinations. These toxic reactions are dose related and depend on physical tolerance to the

drug, psychological set, and sociocultural setting. Acute anxiety

reaction or the "overamp" described by the cocaine abusers usually

can be managed in an outpatient setting with reassurance, a supportive environment, and oral sedative-hypnotic medications such

as diazepam.

As with amphetamine, high-dose, prolonged administration of

cocaine in the dosage range of 1 to 4 grams a day is associated

with sleep deprivation and cocaine psychosis--with auditory and

visual hallucinations, paranoia, and ideas of reference. We have

seen a substantial increase in cocaine psychosis at the Haight

Ashbury Free Medical Clinic due to abuse of cocaine freebase.

Qualitatively, the cocaine psychosis is similar to the amphetamine

psychosis but shorter in duration. With a structured outpatient

setting, we have been able to manage these cocaine psychoses with

the use of haloperidol (Haldol), 2 mg every 4 hours. If this

regimen does not control paranoia and other psychotic symptoms,

psychiatric hospitalization and higher dosages of haloperidol are

indicated.

198
Combined Psychiatric Disorders and Cocaine Abuse

Occasionally, an individual with an underlying thought disorder

has a cocaine-precipitated, more prolonged psychotic reaction.

Often there is a family history of schizophrenia, and the prolonged psychosis probably is cocaine precipitated. These cases

are also frequently complicated by multiple drug abuse.

In our experience with cocaine abusers, over 90% who have cocaine

abuse as the primary addictive disease do not have underlying

major psychopathology. A few patients had a primary depressive

disorder which predated cocaine abuse. Most of these patients

also had a family history of affective disorders or schizophrenia.

For that minority with major underlying psychopathology, such as

endogenous depression, the treatment of choice is usually

tricyclic antidepressants (e.g., imipramine and desipramine) in

association with problem-oriented counseling.

Sexual Dysfunction

Cocaine affects sexual functioning similarly to amphetamine. At

low doses, cocaine enhances sexual desire and is highly rated as

an aphrodisiac in the drug culture, especially by males. However,

as the dosage increases and use becomes chronic, particularly if

the route of administration is freebase smoking or injection, a

male may experience impairment of ejaculatory and erectile

ability. Women have difficulty achieving orgasm. An ethnographic

study of cocaine uses by masseuses found that males valued cocaine

because of delayed ejaculation, but often erectile performance was

so impaired that erection would not occur (Wesson 1982). Since

cocaine-induced sexual dysfunction is one motivation for seeking

treatment, awareness of sexual dysfunction is important for treatment personnel (Smith et al. 1984).

High doses of cocaine, like high doses of amphetamine, also can

facilitate sexual behavior that the individual self-defines as

aberrant and unhealthy, e.g., compulsive masturbation or multipartner marathons.

Dependency

Although the issue of physical dependence on cocaine is still controversial--especially among animal pharmacologists--experienced

clinicians have observed two types of reactions which are probably

withdrawal reactions: (1) following a short high-dose binge of

cocaine use, there is a 2- to 4-day period in which the person is

apathetically depressed, fatigued, and exhausted; and (2) following chronic high-dose use of cocaine, the withdrawal period is

characterized by an agitated depression, lethargy, insomnia, and

irritability.

In open label studies, we find L-tryptophan, the amino acid precursor to serotonin, in dosages of 2,000 mg to 6,000 mg per day,

effective in reducing a patient's anxiety, agitation, and insomnia

199
associated with stimulant withdrawal. We do not employ tricyclic

antidepressants for treatment of cocaine withdrawal depression

unless there is clear evidence for a depressive disorder unrelated

to cocaine use.

Addiction

We define addiction as compulsion to use the drug, loss of control

over the amount used, and continued use in spite of adverse consequences. Using this definition, cocaine is unquestionably addicting. The cocaine patients we have treated used cocaine compulsively; and during a use episode only cocaine availability or

development of legal, medical, or psychiatric complications

limited use. They continued to use despite compromise of their

personal or business financial resources, negative impact on

marriages and families, and compromise of their work capacity or

employment. Even within the structure of an outpatient recovery

program, many cocaine abusers have great difficulty remaining

cocaine free.

MANAGEMENT OF COCAINE DEPENDENCE

If a DSM-III diagnosis of cocaine abuse can be made, it is important to establish complete abstinence from all psychotropic drugs

as the treatment goal. Many cocaine addicts hope to establish

controlled use of cocaine or are reluctant to relinquish use of

alcohol or other psychotropic drugs which have not resulted in

addictive behavior. In patients who repeatedly become toxic with

cocaine and are unable to resist cocaine hunger, the greatest

single reason they relapse is the belief that they can return to

controlled use of cocaine. Like other addictive diseases, once

the line into compulsive use has been crossed, even if that

compulsive use is episodic, the person has lost the ability to

return to controlled use.

Recovery

For the majority of cocaine abusers, the focus of treatment is the

toxic consequences of cocaine, with cocaine-free recovery as the

goal of treatment. This is best accomplished through a combination of individual and group therapy. If the cocaine abuser is

unable to maintain abstinence as an outpatient, a period of

inpatient treatment is necessary. Principles of recovery and constructive alternatives as a way of dealing with cocaine hunger are

stressed. A positive approach to recovery, in contrast to "white

knuckle sobriety," is fostered. The recovery process requires

substantial education of the client on addictive disease generally

and on cocaine abuse specifically. Active allies also are

required for this process to succeed, including family members

whenever possible. Many times, recovery is enhanced by family

therapy.

200
Group therapy is a vital component of the recovery program. There

are many types of groups which may be useful: cocaine recovery

support groups, Cocaine Anonymous, and psychotherapy groups.

Cocaine recovery support groups, in which previous cocaine abusers

support one another in maintaining abstinence, have proven effective for many patients. The cocaine recovery groups are composed

of patients who are in different stages of recovery: some

recently abstinent and some who have a year or more of abstinence.

The mix of patients in early recovery with those who have substantial periods of abstinence is important. Early in recovery, the

recovering cocaine abuser may not real1y believe that long-term

abstinence is possible. Having people with periods of of

abstinence in the group reinforces the possibility of continued

abstinence, and people with long-term abstinence usually lend support to the notion that cocaine hunger becomes less frequent and

less intense the longer one is abstinent.

Cocaine Anonymous is another group model which is helpful for many

cocaine abusers. As it is not as widely available as Alcoholics

Anonymous (A.A.) or Narcotics Anonymous (N.A.), some cocaine

abusers also attend A.A. and N.A. to maintain their recovery.

Since cocaine abusers may abuse other drugs, particularly alcohol,

participation in A.A. and N.A. groups may be especially desirable.

Other important aspects of recovery may include an exercise program in which the person uses exercise not only to improve general

health, but also to deal with cocaine hunger. Exercise that produces cardiopulmonary stimulation for more than 20 minutes can

produce an increase in the release of endogenous endorphins followed by a reduction in drug hunger and anxiety. We regularly use

the exercise alternative as part of the cocaine recovery program

to reduce cocaine hunger and enhance self-image.

It is important to emphasize that the patient's recovery program

is a positive health and image-enhancing process aimed at making

the individual cocaine-free. Attempts to return to controlled use

must be defined as a slip or a relapse. During the recovery

period, anticipatory guidance should be given to the patient

regarding handling of cocaine dreams, cocaine drug hunger, and

addictive thinking. Relapse does not usually happen as a single,

isolated event. The relapse to use is almost always preceded by a

period of "addictive thinking." The patient begins to view himself or herself as "cured" and no longer in need of constant

vigilance and peer support. The patient begins to believe that

the need to maintain abstinence from all psychotropic drugs is no

longer necessary. Sooner or later, the person will try cocaine

once to "test" his ability to control use. If loss of control is

not immediate, the notion of the "cure" is reinforced, and the

person is further estranged from recovery support peers who will

challenge the developing "addictive thinking."

Silence is the enemy of recovery. Open discussion supplemented

with positive alternatives is necessary to interrupt this sequence

201
and thereby prevent first use and relapse. The term "cure" in the

sense that the person can return to controlled cocaine use has no

place in an effective recovery program. Instead, it is important

to stress that recovery--meaning no psychoactive drug use and

active participation in relapse prevention through peer support--

is not only possible, it is a positive, life-enhancing process.

REFERENCES

American Psychiatric Association. Diagnostic and Statistical

Manual of Mental Disorders (3d ed.). Washington, D.C.:

American Psychiatric Association, 1980.

Coleman, D.L.; Ross, T.; and Naughton, J. Myocardial ischemia

and infarction related to recreational cocaine use. West J Med

136:444-446. 1982.

Gay, G. You've come a long way, baby! Coke time for the new

American lady of the eighties. J Psychoactive Drugs

13(4):297-318. 1981.

Inaba, D.; Johnson, G.; Smith, D.E.; and Newmeyer, J.A. Persian

heroin in the San Francisco Bay Area. 1977-1980: The new

wave? California Society for the Treatment of Alcoholism and

Other Drug Dependencies Newsletter 7(2), 1980.

Jeri, F.R.; Sanchez, C.; del Dozo, T. and Fernandez, M. The

syndrome of coca paste: Observations in a group of patients in

the Lima area.

1978.

J Psychedelic Drugs 10(4):361-370, Oct.-Dec.,

Miller, J.D.; Cisin, I.H.; Gardner-Keston, H.; Harrell, A.V.;

Wirtz, P.W.; Abelson, H.I.; and Fishburn. P.M. National Survey

on Drug Abuse: Main Findings 1982. on Drug

Abuse. DHHS-Pub. No. (ADM) 83-1263. Washington. D.C.: Supt.

National Institute

of DOCS., U.S. Govt. Print. Off., 1983.

Smith D.E., and Wesson, D.R. Uppers and Downers. Englewood

Cliffs: Prentice-Hall, Inc., 1973.

Smith, D.E.; Buxton, M.; and Dammonn, G. Amphetamine abuse and

sexual dysfunction. In: Smith, D.E.; Wesson, D.R.; Buxton,

M., eds. Amphetamine Use, Misuse and Abuse. Boston: G.K. Hall

& Co., 1979.

Smith, D.E.; Wesson, D.R.; and Apter-Marsh, M. Cocaine- and

alcohol-induced sexual dysfunction in patients with addictive

disease. J Psychoactive Drugs 16(4):359-360, 1984.

Wesson, D.R. Cocaine use by masseuses. J Psychoactive Drugs

14:75-76, 1982.

Wetli, C.V., and Mittleman, R.E. The 'body packer syndrome'--

toxicity following ingestion of illicit drugs packaged for

transportation. J Forensic Sci 26:492, 1981.

Wetli, C.V., and Wright, R. K. Death caused by recreational

cocaine abuse. JAMA 241:2519-2522, 1979.

202
AUTHORS

Donald R. Wesson, M.D.

Department of Psychiatry

San Francisco Veterans Administration

Medical Center

San Francisco, California 94121

David E. Smith, M.D.

Research Director

Merritt Peralta Institute

Chemical Dependency Recovery Hospital

Oakland, California

and

Founder and Director

Haight Ashbury Free Medical Clinic

San Francisco, California 94117

203
New Patterns of Cocaine Use:

Changing Doses and Routes

Ronald K. Siegel

INTRODUCTION

During the twilight hours of the 19th century, Chicago socialite

Annie C. Meyers took a scissors and pried loose one of her gold

teeth. With blood streaming down her face and drenching her

clothes, she pawned the tooth for 80 cents; the money was needed

for her daily purchase of "Birney's Catarrh Remedy," an over-thecounter cocaine snuff. After 8 years in a self-described "cocaine

hell," Meyers was successfully treated and became the first

cocaine abuser and first woman in the world to write a drug confession (Meyers 1902).

The experiences of Annie Meyers marked a turning-point in the use

of cocaine and illustrated how abuse of cocaine, even when it was

inexpensive and legal, could produce effects and behaviors uncannily similar to contemporary headlines. For example, Meyers

became a thief and forger to support her lo-dollar-a-day habit,

although a month's supply of preparations like "Coca Smoke Ball"

and "Coca Bola" chewing paste was only 50 cents (Ashley 1975).

Indeed, the first recorded purchase of a cocaine product in the

United States was for a 50-cent bottle in 1860. The time of that

purchase, 5 years after the alkaloid was isolated from coca by

Gaedecke and 1 year after Albert Nieman named it "cocaine,"

signaled the start of new preparations, doses, and routes of

cocaine use. Prior to this time, only coca products were available and the patterns of their use had not changed substantially

in over 4,700 years.

Historically, South American natives administered coca orally,

topically, and via smoking with low, albeit effective, dosages'.

When used orally, the leaves were chewed, sucked, and swallowed.

Studies on contemporary coca chewers suggest that this pattern of

administration results in an average daily ingestion of 200 mg to

500 mg of cocaine, with plasma cocaine levels similar to those

achieved from intranasal (i.n.) administration (Holmstedt et al.

1979; Paly et al. 1980). Quids of partially chewed leaves were

used as local anesthetics for trephining operations (Hrdlicka

1939) and to relieve posttrephining distress (Moodie 1923). The

juice of chewed leaves is still used to treat eye and throat

204
irritations (Grinspoon and Bakalar 1976) and the dosages necessary

for effective local anesthesia could be as low as just a few

milligrams (Martindale 1982). The sacrificial burning and smoking

of coca leaves and seeds for magico-religious practices, both past

and present, as well as for the relief of upper respiratory problems probably delivered less than 25 mg of cocaine (Siegel 1982).

ORIGINS OF CONTEMPORARY ABUSE: PROMOTION OF MEDICAL MYTHS

Coca was introduced to Europe in reports by 16th century

explorers, 17th century chroniclers, 18th century naturalists, and

19th century botanists (Mortimer 1901). After Mantegazza's 1857

and 1859 essays on the virtues of coca, medical and nonmedical

coca products appeared and use initially followed the same low

dose patterns observed in South America. The first coca wines and

tonics were introduced in France in the 1860s and, eventually,

were advertised throughout the rest of the world. These promotions, lacking medical or scientific proof, encouraged changing

patterns and increased dosages that inevitably led to abuse.

Recent analysis of these historical patterns and dosages, heretofore ignored by most contemporary studies, reveals that historical

use, often glorified and celebrated, was inextricably tied to

abuse.

An analysis of representative pharmaceutical bottles and formulas

in the author's collection has revealed that these tonics and

extracts contained approximately 3 mg to 160 mg of cocaine per

dosage unit. The coca wines and related alcoholic beverages contained approximately 35 mg to 70 mg of cocaine per dosage unit

(glass). Some, like Vin Mariani, were concentrations of two

ounces of leaves in 18-ounce bottles of wine. The coca leaves

themselves were not standardized for cocaine content and may have

varied from less than .01% to 1.5% cocaine (Hanna 1970; Novak

et al. 1984; Plowman and Rivier 1983; Rivier 1981). The leaves

used in manufacturing wines and tonics averaged .65%X a concentration remarkably similar to assays of contemporary cultivated

coca leaves (Coca wines 1886; Plowman and Rivier 1983; Rusby

1888). Mariani's Elixir was three times more concentrated than

the wine, and his coca tea was eight times more concentrated

(Mariani 1888, 1892). Nonetheless, recommended doses of these

preparations would have resulted in daily ingestion of little more

than 450 mg of cocaine. Most wines available in the 1890s contained approximately 10 mg of cocaine per fluid ounce and recommended doses were from one-half a wine glass (2 oz. or 20 mg) to a

full wine glass (4 oz. or 40 mg) per administration (Coca wines

1886). French Wine Coca, the original name for Coca-Cola, was an

imitation of these French coca wines and reportedly contained less

than one-half ounce of coca leaves per gallon.1

Initially, physicians, pharmacists, and chemists recommended a

pattern of use for drinking coca products that would have resulted

in less daily intake of cocaine than from chewing the leaves, but

with the same stimulating properties. For example in the first

commercial book advertising coca and its products,2 Chevrier

205
(1868) claimed a wide variety of therapeutic applications for coca

preparations which were equal to the chewed leaves but did not

have to be used as often. Indeed, most coca fluid extracts and

wines, the most popular preparations recommended by physicians

(Mortimer 1901), were formulated on the basis of their equivalence

in leaves.

The second book on the subject, Erythroxylon Coca: A Treatise on

Brain Exhaustion as the Cause of Disease by British physician

William Tibbles (1877), recommended use of coca for a variety of

physical and mental diseases. The third book, La Coca du Perou,

was the first in a long series of publications by chemist Angelo

Mariani (1878) which expanded the therapeutic applications of his

many coca products. The fourth book, published by New York

physician W.S. Searle (1881). endorsed medical use for all problems of life and as an alternative to tobacco, tea, coffee, and

wine. The coca dosage regimes recommended by Tibbles, Searle, and

their colleagues would have resulted in daily ingestion of no more

than 65 mg to 160 mg of cocaine. Coca-Cola, promoted as a "Brain

Tonic" for exhaustion, went through several changes in its formulas (Louis and Yazijian 1980) and, from the 1890s to 1903, contained approximately 60 mg of cocaine per 8-ounce serving. By the

time the fifth book on coca was published (Thudichum 1885), it was

an accepted medical fact that coca, and its alkaloid cocaine,

represented the power to relieve suffering.

Concomitant with the escalation of new coca products on the

market, advertisements promoted their use for a wide variety of

nonmedical purposes. The following example of a coca advertisement illustrates this change in pattern of use:

Public Speakers, Singers, and Actors have found wine of

coca to be a valuable tonic to the vocal cords.

Athletes, Pedestrians, and Base Ball Players have found

by practical experience that a steady course of coca

taken both before and after any trial of strength or

endurance will impart energy to every movement, and prevent fatigue. Elderly people have found it a reliable

aphrodisiac superior to any other drug. (Metcalf's Wine

of Coca)

However, cocaine itself was widely available at this time and the

dosage regimes recommended for use of cocaine products by Tibbles,

Merck (1885), and Martindale (1886) would have resulted in daily

ingestion of as much as 810 mg to 1,620 mg of cocaine, or approximately three times the cocaine intake of the coca chewer. Indeed,

whereas coca products and dosages were treated as roughly equivalent to the chewing of coca leaves, cocaine was advertised as 200

times stronger than coca, one grain of cocaine being the equivalent of 200 grains of coca leaves (Hammond 1887).

But little adjustment for this dose consideration was made. In

fact, the convenience of cocaine prompted even the most conservative of physicians to apply its use to virtually all medical and

206
nonmedical complaints. Using the typical medical hyperbole of the

times, Tibbles promoted a cocaine "Child Restorer" as a universal

remedy for diseases of children, a "Brain Feeder" in all cases

where an individual desired more energy, and a "Compound Essence

of Cocaine":

This is a preparation containing all the Principles of

Coca-leaf ....It thoroughly invigorates the Brain, Nerves,

and Muscles, re-energizes the failing functions of Life,

and thus imparts energy and vitality to the exhausted

nerve-force, and rapidly cures every form of nervous

exhaustion, from whatever cause.

Cocaine became available in a wide variety of base and salt preparations, some in combination with other agents including agonists

like atropine and physostigmine and narcotic-analgesics like

morphine. The increased use of cocaine was further complicated by

the increasing popularity of the highly efficient intranasal and

injection routes of administration. Inhalant and intranasal doses

of 65 mg were commonly used and injection doses as high as 32 mg

to 1,200 mg were employed. Some asthma and hay fever snuffs were

pure cocaine and users were instructed to take them as needed

(Ashley 1975). Recommended doses via smoking of coca cigarettes

and cigars could have been as high as 225 mg per day (Parke, Davis

& co. 1885). By 1894, cocaine was being used topically on the

penis as well as rectally and vaginally (Martindale 1894).

It is not surprising that widespread availability of cocaine

marked the decline of coca as a medicine. But the parallel

increases in cocaine dosages, routes of administration, and

medical and nonmedical abuses just as quickly arrested cocaine's

development as a therapeutic agent. Daily dosages of cocaine

"addicts" sometimes reached over 12 grams (Meyers 1902), doses

almost impossible to achieve with coca products and ones that

would not be seen again until the discovery of smoking cocaine

freebase. Changes in legislation and medical practices effectively prevented any further changes in patterns of cocaine use

until a century after the first bottles were purchased.

CONTEMPORARY PATTERNS: 1970-78

The first contemporary book on cocaine appeared in 1972 (Chasin

1972) and marked a resurgence in nonmedical cocaine use. The book

noted that 90% of users preferred i.n. administration, a pattern

of use illustrated in several motion pictures released that same

year (Go Ask Alice, Dealing, Superfly, and The Discreet Charm of

the Bourgeoisie). In those movies, use was portrayed as discreet,

involving small i.n. hits from spoons or straws; charming, in

terms of the perception users had of their use; and, bourgeois,

finding its way into middle class lives. These patterns were not

inventions of screenwriters but simply reflections of contemporary

patterns of use at that time (Starks 1982).

207
The cocaine paraphernalia industry was just developing (Wynne

et al. 1980), and spoons and straws for i.n. cocaine use became

popular. Siegel (1977) determined that the average cocaine spoon

available at that time delivered 5 mg to 10 mg of pure cocaine.

The average amount of cocaine delivered through a straw from a

"line" was 25 mg. Since two cocaine spoons or two lines (one for

each nostril) were used, each administration consisted of 20 mg to

50 mg.

During the period 1970 to 1978, studies reported various patterns

of use ranging from experimental use of a few lines or "hits" of

cocaine to daily compulsive use of 4 grams (Siegel 1984a). Five

patterns of nonmedical cocaine use have been defined by Siegel

(1977) and these will be used for discussion here.

Experimental Use

Experimental use was defined as short-term, nonpatterned trials of

cocaine with varying intensity and with a maximum lifetime frequency of 10 times (or a total intake of less than 1 gram). These

users were primarily motivated by curiosity about cocaine and a

desire to experience the anticipated drug effects of euphoria,

stimulation, and enhanced sexual motivation. Experimental use was

generally social and among close friends but did not continue due

to a multiplicity of reasons, including economic and supply considerations, disappointment with the intensity and duration of the

drug effect, and fear of legal penalties, among others.

Social-Recreational Use

The most common pattern was social-recreational, whereby use

generally occurred in social settings among friends or acquaintances who wished to share an experience perceived by them an

acceptable and pleasurable. Such use was primarily motivated by

social factors and did not tend to escalate to more individually

oriented patterns of use. Use tended to occur in weekly or

biweekly episodes and continued primarily for three reasons:

(1) cocaine was viewed as a social drug which facilitated social

behavior; (2) cocaine was viewed as "ideal" and "safe" in terms of

convenience of use, minimal bulk, rapid onset, minimal duration,

and few side effects and after effects; and (3) cocaine was viewed

as appealing in terms of sociocultural images.

Circumstantial-Situational Use

Circumstantial-situational use was defined as a task-specific,

self-limited use which was variably patterned, differing in frequency, intensity, and duration. This use was motivated by a perceived need or desire to achieve a known and anticipated drug

effect deemed desirable to cope with a specific condition or situation. Use tended to occur in four or five episodes per week.

Motivation cited by users included the enhancement of performance

or mood at work and play.

208
Intensified Use

Intensified use was defined as long-term patterned use at least

once a day. Such use was motivated chiefly by a perceived need to

achieve relief from a persistent problem or stressful situation or

a desire to maintain a certain self-prescribed level of performance.

Compulsive Use

Compulsive use was defined as high-frequency and high-intensity

levels of relatively long duration, producing some degree of

psychological dependency. The dependence is such that the

individual user cannot discontinue such use without experiencing

physiological discomfort or psychological disruption. The compulsive patterns are usually associated with preoccupation with

cocaine-seeking and cocaine-using behavior to the relative exclusion of other behaviors. The motivation to continue compulsive

levels of use was primarily related to a need to elicit the

euphoria and stimulation of cocaine in the wake of increasing

tolerance and incipient withdrawallike effects.

THE SOCIAL-RECREATIONAL USER: 1970-78

The most common pattern of cocaine use during the contemporary

period of 1970 to 1978 was the social-recreational pattern. The

average social-recreational user studied by Siegel (1977) used 1

to 4 grams of cocaine per month. However, doses were not evenly

distributed over time. Users generally purchased cocaine in

half-gram or gram quantities and most consumed it within 2 to 7

days. During days of use, users would average daily intakes of

150 mg.

In 1974, a group of 99 such social-recreational users were

recruited for a longitudinal study (Siegel 1977, 1980a, 1984a).

These users were selected through advertisements distributed to

several million households by Los Angeles newspapers. While the

sample represents a specific geographical population, the users

appear highly similar to those sampled by smaller studies elsewhere (Grinspoon and Bakalar 1976; Resnick and Schuyten-Resnick

1976). In addition, while only 50 of these users (50%) continued

through the 9 years of the study, their changing patterns and

effects were similar to those found during this period in both

short-term and longitudinal studies involving smaller numbers of

users (Ashley 1975; Spotts and Shontz 1976, 1980). Indeed, Spotts

and Shontz (1980) have claimed that the intensive study of even a

small number of representative cases is a powerful tool in studying drug abuse. The subjects in this study also represent the

only cocaine users that have been intensively studied for most of

a decade, a decade which marked significant changes in patterns of

cocaine abuse.

While the patterns of use changed considerably over the 9 years of

the study, initial use during the first 4 years of study (1975-78)

209
appeared relatively stable. During that period, all subjects

remained social-recreational users but 75% engaged in episodes of

more frequent use. These latter episodes included circumstantial-situational and intensified patterns, but always the subjects

returned to social-recreational use as their primary pattern.

None of the users engaged in compulsive use during this period.

However, most social-recreational users also manifested a potentially toxic pattern of use which can be called "binge" use.

Binge use, also known as "runs," refers to a continuous period of

repeated dosing, usually at least once every 15 to 30 minutes,

during which users consume substantial amounts of cocaine. During

binges, users may assume some of the behavioral characteristics of

compulsive users. Binge use appears to be motivated by a desire

to maximize positive drug effects. While binging can be found

within all groups of cocaine users, social-recreational users did

not tend to binge during the period 1975 to 1978. When engaged in

episodes of intensified use, 17 users reported binges which

involved intake of an average of one-half a gram (range 0.25 to

1.25 grams) in runs averaging 4 hours (range 1 to 18 hours).

Nonetheless, for a proportion of users the social-recreational

patterns appeared relatively stable. Several variables, including

the following, contributed to this stability. Firstly, the purity

of street cocaine remained relatively the same during this period

with an average of 53% (range 43.2% to 60.8%). Secondly, these

users continued to purchase cocaine in half-gram or gram quantities for prices which averaged $75 to $100 per gram. Thirdly,

the size and nature of the cocaine spoons and other paraphernalia

remained relatively the same. Fourthly, the i.n. route remained

the most common. Users experiencing nasal problems practiced

various methods of nasal hygiene described by consumer handbooks

with the aid of nasal douches and other devices offered by the

paraphernalia industry. Fifthly, the misperception of i.n.

cocaine as a "relatively safe and ideal social-recreational

was common among users (Siegel 1977). Sixthly, physical and

drug"

psychological problems were rarely encountered by social users,

and treatment of cocaine effects with combinations of other drugs

such as diazepam or methaqualone was reported by only 4% of these

users.

CONTEMPORARY PATTERNS: 1978-82

The image of widespread patterns of cocaine use was reflected in

the films of the later 1970s.

in Annie Hall (1977), something to flaunt in the faces of the

Cocaine was something to joke about

police in The Rubber Gun (1977), something for young single women

to do in Looking for Mr. Goodbar (1977), something for sexual

stimulation in Sensations (1977) and Sharkey's Machine (1981),

something for entertaining your neighbors with in Cocaine Cowboys

(1978), for young women to snort in Pretty Baby (1978) and Wolfen

(1981), and for old men to peddle in Atlantic City (1981).

210
The patterns of use among continuing users began to change (Siegel

1982, 1984a) during this period, mirroring the expanded use in the

cinema. The users in Siegel's longitudinal study (Siegel 1984a)

averaged between 1 and 3 grams per week from 1978 to 1983. Fifty

percent (n=25) of the users still in the study (N=50) remained

social-recreational (with continuing episodes of increased use)

while 32% (n=16) of the users became primarily circumstantialsituational users, 8% (n=4) became intensified users, and 10%

(n=5) became compulsive users.

Dosages varied with pattern of use. The social-recreational users

averaged approximately 1 gram per week, circumstantial-situation

users averaged 2 grams per week, and intensified users averaged 3

grams per week. Most users engaged in some binge use characterized by the same doses and durations observed during the period

1975 to 1978.

Perhaps the most dramatic change was seen in the compulsive

pattern of use. While compulsive i.n. use has been described in

other studies (Ashley 1975; Resnick and Schuyten-Resnick 1976),

compulsive users here were all smokers of cocaine freebase.

Accordingly, they averaged 1.5 grams per day (range 1.0 to 30.0

grams). The nature and consequences of this pattern of use have

been discussed elsewhere (Siegel 1982). Most if not all compulsive use here occurred in binges involving intake of 1.5 grams

(range 0.25 to 30.0 grams) in a 24-hour period (range 1 to 96

hours).

Taken together, the period 1978 through 1982 marked an escalation

in dosages and dose regimes for these social-recreational users.

Changes in several variables were associated with this change in

pattern of use. Firstly, the purity of street cocaine declined

during this period to an average of 29.2% (range 13.9% to 48.7%).

Secondly, users tended to purchase cocaine in full gram or oneeighth ounce (3.5 grams) quantities and the half-gram unit became

increasingly scarce. Thirdly, the paraphernalia industry

introduced a variety of cocaine dispensing devices, known

collectively as "bullets," which delivered an average hit of 25 mg

(range 15 to 50 mg), more than twice the hit from a cocaine

spoon. The average size of commercial cocaine spoons themselves

actually got smaller (average 8.3 mg, range 5.0 to 24.1 mg). The

paraphernalia industry also introduced a wide variety of cocaine

smoking kits and accessories (Siegel 1982). Fourthly, the smoking

route became a preferred route of administration for many new

users. Fifthly, the perception of i.n. cocaine as a relatively

safe pattern of drug use continued in the face of increasing

negative publicity concerning cocaine smoking (Siegel 1982). And

sixthly, users increased multiple drug use in their self-treatment

of cocaine- related problems. Fully 30% of Siegel's respondents

were using methaqualone and 13% were using diazepam.

211
CONTEMPORARY PATTERNS: 1982-84

Movies with cocaine-related themes began reflecting changing

patterns of use in 1982. In his concert film Richard Pryor Live

on Sunset Strip (1982), comedian Pryor related the tragedy of his

near-death experience in a cocaine smoking accident. . -

related personality changes were the subject of films like Jekyll

& Hyde... Together Again (1982). And cocaine-related disruption of

families and marriages was woven into films such as Cocaine: One

Man's Seduction (1983) and Torchlight (1984). Finally, and most

dramatically, the violence of cocaine-related activities was the

subject of Mike's Murder (1983), Scarface (1983), and Against All

Odds (1984).

Parallel changes were seen in the patterns of cocaine users off

the screen. Numerous studies noted a dramatic increase in

physical and psychological problems associated with cocaine dependency and toxicity, and these have been discussed elsewhere

(Siegel 1984a).

A new pattern of i.n. cocaine characterized by concentrated

"binge' use emerged among both continuing users and new users.

This pattern involves the use of an entire week's supply of

cocaine during a single episode or binge or run ranging from 4 to

48 hours. Continuing users in Siegel's longitudinal study still

averaged 1 to 3 grams during these binges. But other users interviewed by the author reported using between 0.5 grams and 7.0

grams during these binges.

In addition to more concentrated dose regimes, dosages themselves

became more concentrated. The average purity of street cocaine

during 1982 to 1984 for these users was determined to be 73.3%

(range 58% to 87%). This change was undoubtedly influenced by

worldwide increases in coca and cocaine production coupled with

decreased availability of cocaine substitutes, adulterants, and

diluents due to paraphernalia legislation (Smith 1982; Drug Paraphernalia Litigation 1984). Concomitantly, the price dropped to

pre-1977 levels of $60 to $100 per gram, with an average price of

$85 per gram. The decreased availability of paraphernalia also

prevented the precise control over individual doses afforded by

the cocaine spoons and dispensers, and this often resulted in

intake of large amounts.

Many users reported that quantities of cocaine would be purchased

for use during specific episodes or binges that would terminate

only when supplies were exhausted. In Los Angeles, young users

(12 to 17 years of age) reported the availability of small quantities for purchase at clubs and schools. These quantities

included single doses selling for $10 and one-eighth grams selling

for $25.

The decline of the paraphernalia industry has also resulted in a

shortage of cocaine-smoking accessories. Thus, the most common

method of preparing cocaine freebase is now the baking soda

212
method (Siegel 1982) whereby the need for special chemicals and

glassware is eliminated. The reduced supply of cocaine pipes has

resulted in an increase in smoking cocaine freebase in combination

with tobacco. The increase in importation of coca paste into the

United States has already led to reports of coca paste smoking,

and these reports are discussed below.

During the period 1982 to 1984, users reported a wide variety of

experimental patterns in order to avoid rhinitis and other problems of i.n. cocaine use and also to avoid the dependency and

toxicity associated with cocaine smoking. Some users have

reported experimenting and maintaining regular use of cocaine

hydrochloride vaginally, rectally, and sublingually. Others have

adopted a regular pattern of smoking cocaine hydrochloride (Siegel

1982). Still others have employed regular use of subcutaneous

injections of cocaine hydrochloride. A few users have employed

the i.n. route of administration for cocaine freebase and some are

smoking coca paste.

Two of these patterns, i.n. cocaine freebase and coca paste smoking, represent the newest methods to appear in the United States

and they are discussed below.

An important caveat is that these methods have only appeared in a

few communities and the number of users appears relatively small.

However, it is also important to note that more widespread practices, like the smoking of cocaine freebase, were initially detected among a small number of users in these same communities, areas

that lie within trafficking corridors. Like those initial smokers

of cocaine freebase, most coca paste smokers are individuals from

the producing or trafficking countries that service these corridors.

INTRANASAL COCAINE FREEBASE

Cocaine freebase is only slightly soluble in water (1 in 600 of

water) as compared to the high solubility of cocaine hydrochloride

(1 in 0.5 of water). Thus, when used i.n., cocaine freebase has a

slow absorption in mucous membranes, resulting in a slow onset of

effects but a sustained duration of action. Clinically, this

property has been utilized to obtain a prolonged therapeutic

effect in ointments, oily solutions, and topical preparations.

Intranasal cocaine freebase was first developed as an experimental

treatment for rheumatoid arthritis (Bingham 1980). Patients were

treated with a maximum of 600 mg per day (Bingham and Somers 1981)

and this experimental program received considerable publicity

throughout California in the period 1982 to 1984. Most users from

the following study learned of this new route of administration

from the program publicity, while others reportedly "invented" the

technique themselves.

213
The Sample

A small group of i.n. cocaine freebase users were recruited from

cocaine treatment centers, through word-of-mouth advertisements,

and from a previously studied population of cocaine smokers

(Siegel 1982). Users were initially screened by a telephone

interview and a subsequent drug-history questionnaire. While 175

users reported past or present experimental use, most users mixed

i.n. cocaine freebase with other methods of cocaine administration. Twelve users, seven male and five female, were eventually

selected for representative case study by meeting the requirement

of exclusive i.n. cocaine freebase use for at least 2 months. The

subjects ranged in age from 25 to 69 and were examined and tested

in a private office. Examination procedures included both

physical and psychological tests described elsewhere (Siegel 1977).

Preparation and Purity

Subjects prepared cocaine freebase from cocaine hydrochloride

using a variety of extraction procedures (Siegel 1982). The most

preferred procedure was the sodium bicarbonate/water method

because it was infrequently associated with nasal complaints.

This procedure can effectively convert at least 56% of the existing cocaine hydrochloride to its freebase while removing some, but

not all, adulterants and diluents (Hisayasu et al. 1982, procedure

5). Other procedures can convert 96% of the cocaine hydrochloride

to its freebase. Allowing for variations in purity of street

cocaine hydrochloride and extraction procedures, the resulting

purity of cocaine freebase samples used by some of these subjects

was determined to be 95% (Siegel 1982).

Methods and Dosages

Subjects reported administering the cocaine via a straw, commercial "tooter." or cocaine spoon. Any given dose would be administered in two equal portions, one for each nostril.

Users reported administering amounts of cocaine freebase which

appeared (visually) to approximate amounts of cocaine hydrochloride that they had previously used (Siegel 1977). However,

because of the increased density, moisture content, and purity of

the freebase resulting from the sodium bicarbonate/water extraction procedure, the actual dosages were considerably greater. It

was estimated that users here were administering cocaine freebase

approximately four times per day for total daily doses of 400 mg

(range 200 to 1,000 mg). An important caveat is that initial

doses of cocaine freebase were quite high while users experimented

with its effects. As users became accustomed to the slow onset

and long duration, they reported titrating dosages to those

described here.

214
Patterns of Use and Effects

All subjects here reported intensified (daily) patterns of use

whereby self-prescribed levels of stimulation and mood elevation

were achieved. Unlike intensified users of i.n. cocaine hydrochloride who repeatedly dose themselves throughout the day in

response to tolerance and withdrawal effects (Siegel 1977), subjects here reported infrequent dosing unaccompanied by tolerance

and withdrawal. Most subjects attributed the lack of these

effects to the sustained action of i.n. cocaine freebase. Surprisingly, dosing became routinely patterned and subjects reported

using cocaine at approximately the same times each day. Motivations cited for use included (in descending order of frequency):

to alleviate fatigue and depression; to increase performance at

work; to suppress conditions of chronic pain and discomfort; and

to suppress appetite.

Physically, effects reported by subjects included increased heart

rate, rhinitis and other nasal problems, acute insomnia, loss of

appetite, suppression of pain and discomfort, tremors, throat

numbness and thirst, blurred vision, skin problems, and increased

bowel movements. Psychological symptoms reported by subjects

included stimulation and increased performance, mood elevation,

anxiety, attention and concentration problems, irritability, and

hypervigilance. Examinations and tests confirmed these reported

effects. Other symptoms observed included loquacity, mydriasis,

dysarthria, ataxia, and less than desirable weight.

The most striking aspect of i.n. cocaine freebase use is that such

use was maintained despite little if any euphoria, and users were

deceived into believing this method minimized negative effects.

Unlike users who smoke cocaine freebase, i.n. subjects here did

not experience a rapid reinforcing euphoria because of the slower

absorption in the nasal mucosa. Nonetheless, negative reactions

were still reported. Contrary to user beliefs, i.n. cocaine freebase did not alleviate the nasal problems associated with sniffing

cocaine hydrochloride. In addition, i.n. cocaine freebase was

associated with reports of psychosocial dysfunction including

interpersonal, financial, and legal problems. Furthermore, the

continued use of i.n. cocaine freebase, albeit patterned by doses

which did not increase in frequency or amount, suggests that there

are risks of dependency and toxicity.

COCA PASTE SMOKING

Coca paste is a crude extract of the coca leaf which contains 40%

to 91% cocaine sulfate along with companion coca alkaloids and

varying quantities of benzoic acid, methanol, and kerosene. In

South America, coca paste, also known as cocaine base and, therefore, often confused with cocaine freebase in North America, is

relatively inexpensive and is widely used by low-income populations. The coca paste is smoked in tobacco or cannabis cigarettes

and use has become epidemic in several Latin American countries

(Jeri 1984). Chronic coca paste smoking results in a clinical

215
syndrome that is identical to the mental disorders associated with

cocaine freebase smoking (Siegel 1982, 1984b).

Traditionally, coca paste has been relatively abundant in South

American countries such as Colombia where it is processed into

cocaine hydrochloride ("street cocaine") for distribution to the

rest of the world. Since 1980, there has been an increase in the

number of illicit laboratories in the United States that process

coca paste (Drug Reinforcement Report 1984). This has generated

domestic supplies of coca paste, some of which are not refined but

smoked by individuals associated with the clandestine laboratories

and trafficking.

The Sample

A total of 45 coca paste smokers in three States were identified

through contact with drug treatment centers, the criminal justice

system, and private attorneys in 1984 and 1985. Eleven users (10

male and 1 female) in south Florida and six users (all male) in

Arizona were given interviews and drug-history questionnaires.

Twenty-eight additional users (25 male and 3 female) in southern

California were given an extended series of face-to-face interviews including a mental status examination. The subjects ranged

in age from 22 to 43. Twenty-seven were citizens of the United

States (22 white, 3 Hispanic, 2 Asian). Four were documented

aliens from Venezuela (2), Colombia (1), and Peru (1). The

remaining 14 were undocumented aliens from Colombia (11),

Argentina (1), Cuba (1), and Peru (1).

Use and Effects

Eight users reported initial use of coca paste in South America

while the others were introduced to it in the United States.

Users smoked tobacco cigarettes mixed with an estimated 250 mg of

coca paste or cannabis cigarettes mixed with an estimated 100 mg

of coca paste. Most users described experimental or social

patterns of coca paste smoking alternating with circumstantialsituational or intensified use of i.n. cocaine hydrochloride. The

remaining users described past or current histories of smoking

cocaine freebase but engaged in binge use of coca paste when

cocaine freebase or its associated paraphernalia were unavailable.

While coca paste smoking is rare, it is used as an alternative to

smoking cocaine freebase. Coca paste smokers report that the

physical and psychological effects are similar to those achieved

via smoking of cocaine freebase (Siegel 1982). In addition, most

users also reported respiratory problems as well as unpleasant

tobacco or cannabis effects. Fourteen users were diagnosed as

having a "cocaine smoking disorder" (Siegel 1984b).

DISCUSSION

The history of coca and cocaine has been a history of increasing

doses, increasingly effective routes of administration, and

216
increasing incidence of dependency and toxicity. It is clear that

cocaine has a high potential for abuse and the effects are neither

predictable nor controllable, despite the claims of advertisements

and aficionados.

The first commercial book on coca, by Chevrier in 1868, introduced

the Old World to a New World medicine. Not surprisingly, the book

contained a leaf of advertisements for a variety of coca products.

These and subsequent products delivered relatively low doses via

relatively slow-acting routes of administration. Few nonmedical

uses and abuses were noted during the subsequent era of coca

patent medicines. As cocaine replaced coca, products became as

much as 200 times more concentrated, intranasal and injection

routes delivered the drug faster and more effectively, and both

medical and nonmedical abuses grew.

One hundred years later, James Servais, an underground film maker,

released a short film entitled Coke (1968) which was little more

than a commercial for nonmedical use of cocaine (Starks 1982). As

if in response to this advertisement, the contemporary patterns of

cocaine use began to evolve throughout the 1970s and 1980s.

The 1970s began with social-recreational patterns of intranasal

cocaine use. This pattern involved use of 1 to 4 grams per person

per month, consumed in several episodes. The decade ended with

these same users consuming 1 to 3 grams per week in far fewer

eoisodes. In addition. manv users escalated doses and dose

regimes as they changed to patterns of circumstantial-situational,

intensified, and compulsive use. The pattern of cocaine smoking

also appeared at this time.

The 1980s began with increased availability of cheaper cocaine and

a changing pattern of binge use wherein users continued cocaine

use until their supplies or bodies were exhausted. Doses still

averaged 1 to 3 grams per week, but they were consumed in only one

or two binge episodes per week. The 1970s observations of users

titrating self-administration of cocaine, thereby circumventing

negative and adverse reactions, appeared less common in the 1980s.

Starting in 1982, several new patterns were emerging, including

increased use of cocaine smoking and topical routes of administration. These doses and routes associated with these patterns make

controlled use difficult if not impossible and substantially

increase the risks of dependency and toxicity. The new phenomenon

of intranasal cocaine freebase appears to recapture the slow onset

and long duration of action previously associated with coca products. But the relative paucity of extreme reactions with i.n.

cocaine freebase does not imply that this method has the relative

safety seen with coca use. Rather, the intensified patterns of

i.n. cocaine freebase use are characterized by nasal complaints

and psychosocial dysfunction.

Contemporary Peruvian Indian coca users interviewed by the author

believe that chewing and smoking coca is enjoyable, healthy, and

safe. The coca they use contains an average 0.6% cocaine, an

217
alkaloid whose function is to warn insects and herbivores through

bitter and intoxicating experiences to stay away. The Peruvian

Indians may have learned the lessons as they refrain from using

cocaine itself, which they consider unhealthy and dangerous.

Similarly, contemporary tobacco users chew and smoke tobacco but

most would agree that using the purified nicotine alkaloid is

unhealthy and dangerous; tobacco contains a similar percentage of

its nicotine alkaloid which performs the same chemical defensive

function as cocaine. By liberating cocaine from the protective

envelope of its leaf, contemporary users have concentrated its

effects, its promises, and its problems. Intranasal and other

routes of administration bypass the bitter tastes, minimize the

nausea and emesis, and maximize the intoxication. Thus, contemporary users not only circumvented nature's lessons to avoid the

alkaloids, they made them stronger and faster with these changing

doses and routes.

From Mama Coca, who gave coca as a divine gift to Inca man, to the

Inca prophecy that cocaine would destroy the white man, the

history of the cocaine problem can be seen as a result of changing

doses and routes of administration. From coca wines to cocaine

wars (Axthelm 1984); from Metcalf's coca wine prescriptions for

baseball players to modern ball players basing and wining (Johnson

1984); from Vin Mariani's Gold Medal award from the Academic

Nationale (Mariani 1892) to Dr. Gold's (this volume) nationally

recognized hotline for cocaine users; from the numbing effects of

cocaine eyedrops to the paralyzing fear of cocaine smugglers in

modern novels (Sabbag 1976; Stivers 1985); from the burning and

offering of coca leaves in Bolivian mines to ward off the Devil

(Nash 1979) to contemporary Bolivian cocaine production (Orellana

and Zannier 1983), Miami dealers who "burn" each other (Montalbano

and Hiaasen 1983) and cocaine smokers who fight with imaginary

devils (Siegel 1982); from a 19th-century pest poison that

promised to annihilate its victims with a greater attraction "than

has cocaine for a dope fiend"3 to 20th-century users who feel

poisoned with cocaine bugs (Siegel 1978); from an economy of 50

cents to 50 billion dollars;4 from the favorable review of coca

by physicians at European trade exhibitions (Mariani 1889) to the

review of the health consequences of cocaine and coca paste smoking by the World Health Organization 100 years later;5 the

promise of coca, like Claude Rains who went both mad and invisible

with cocaine (Starks 1982) in The Invisible Man (1933), has all

but disappeared.

A more ominous promise, forecast by Annie Meyers' confession and

novels of contemporary women trapped in their own private cocaine

hells (Braverman 1979; Pendleton 1985), still remains.

SUMMARY

The history of coca and cocaine use is reviewed in terms of

medical and nonmedical patterns of use. Use of coca leaves and

coca extract products involved daily use of no more than 200 mg to

500 mg of cocaine. When cocaine became available after 1860,

218
daily doses increased to as much as 1,620 mg and the oral route of

administration became supplemented by intranasal, injection,

topical, and smoking administration. Contemporary patterns of use

between 1970 and 1978 involved social-recreational intranasal

doses of 1 to 4 grams per month. From 1978 to 1982, doses

increased to 1 to 3 grams per week with increased use of smoking

cocaine freebase. Between 1982 and 1984, episodes of concentrated

binging became more common, as did the development of experimental

practices including intranasal cocaine freebase and the smoking of

coca paste. These patterns are discussed in terms of several

variables, including purity, dosages, dose regimes, routes of

administration, paraphernalia, and changing perceptions of cocaine.

FOOTNOTES

1Unpublished raw data and archival information obtained from B.

Hester, Khoka Productions, Inc., Jacksonville, Florida.

2Several earlier works, beginning with a 1787 dissertation

(Julian, P.A. Disertacion Sobre Hayo o Coca dans la Perla de la

America. Lima, 1787, are cited by Chevrier (1868) and referenced

in the bibliography by Mortimer (1901).

3The product was "Rat-Annihilator" manufactured by G.P.

McDermott, Indianapolis.

4Estimate calculated from the National Narcotics Intelligence

Consumers Committee, Time (April 11, 1983), and Newsweek

(August 22. 1983). Other sources estimate the street value of

cocaine imports into the United States in 1984 at $17 billion

(R.C. Shreckengost, personal communication).

5World Health Organization Advisory Group Meeting on Adverse

Health Consequences of Cocaine and Coca Paste Smoking, Bogota,

Colombia, September 10-14, 1984.

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AUTHOR

Ronald K. Siegel, Ph.D.

Department of Psychiatry and

Biobehavioral Sciences

School of Medicine

University of California

Los Angeles, California 90024

P.O. Box 84358

Veterans Administration Branch

Los Angeles, California 90073

222
Cocaine Use in America:

Summary of Discussions and

Recommendations

Nicholas J. Kozel and Edgar H. Adams

The expressed purpose of the technical review sponsored by the

National Institute on Drug Abuse on July 11-13, 1984, was to

increase the understanding of the epidemiology and clinical

aspects of cocaine abuse. Scientists who participated in the

meeting provided a current foundation of knowledge regarding a

type of drug-abusing behavior which, in a few short years, has

reached epidemic proportions and which threatens to become the

most destructive drug in recent history. The state-of-the-art

knowledge reflected in the chapters contained in this manuscript

attests to the fact that much is known about cocaine abuse. During the course of the 3-day technical review, findings were presented that were based on sophisticated analysis and clinical

observation regarding etiology, pharmacology, risk factors,

patterns of use, treatment, and adverse health consequences associated with cocaine abuse. Perhaps just as important as these

documented findings were the suggestions and conclusions which

emanated during discussions following each presentation. While

the research presentations reflected how much we know about

cocaine, the discussions revealed how much more we need to learn.

Many of the issues that emerged during discussion involved basic

questions, such as whether cocaine is, indeed, addictive. This

question was raised in reference to the occurrence of a withdrawal

syndrome following cessation of cocaine use. It was agreed that

there is a difference between cocaine and the opiates and that,

while one talks about "withdrawal" from opiates, the term

"rebound" is more appropriate for certain other kinds of drugs.

However, there was concern that this difference in terminology

perhaps was overshadowing the real issue. The scientists were

willing to accept the concept of stimulant withdrawal and, indeed,

concluded that chronicity of use , as opposed to binge episodic

use, is a critical determinant of the onset of agitation and

depression following cessation of cocaine use. Based on clinical

observation, these withdrawal symptoms were most prominent in

daily freebasers, followed by intravenous users, then intranasal

cocaine users. In addition to route of administration, the

severity of withdrawal is believed to be dose dependent. There

was also general agreement that there probably is no protracted

223
withdrawal from cocaine; that even with the heaviest freebasers

withdrawal is completed within 5 to 10 days. It also was

generally concluded that patterns of use are changing, a tendency

toward a significant subpopulation who ingest large quantities of

cocaine--up to 5 to 10 grams daily among some intranasal users and

up to an ounce daily among freebase users. These are the people

most at risk for experiencing withdrawal syndrome. At the same

time, low-dose users do not appear to exhibit this effect. However, conclusions are clouded by the absence of baseline "predrug"

data, and it was recommended that experimental conditions be

established to study the problem of cocaine withdrawal. These

studies should include animal models as well as human testing, and

a specific recommendation was made that rapid eye movement (REM)

suppression and REM rebound effect be experimentally studied following cessation of cocaine use. Since the technical review was

held, cocaine has been characterized as powerfully addictive since

it was acknowledged that compulsive drug-seeking behavior may be a

more important criteria for addiction than the physical withdrawal

assumed by the opiate model.

In addition to the basic issue of withdrawal as a major criterion

for establishing physical dependency, tolerance to cocaine also

was discussed. There have been clinical reports that people have

overdosed after a period of several weeks of abstinence, suggesting the loss of tolerance. At the same time, clinicians reported

seeing patients who had acute psychotic episodes with cocaine and,

after a period of abstinence, reinstituted cocaine use at previous

levels without experiencing overdose effects. These apparently

conflicting observations led to the recommendation that the

scientific community study the issue of tolerance versus sensitization to cocaine's effects and, in particular, study the impact

of kindling which is a phenomenon characterized by increased

neural responsivity. Kindling as a learned behavior should be

studied, especially as it relates to the onset of paranoid states.

It was suggested during discussion that some cocaine users appear

to engage in a conditioned response following ingestion of cocaine

and use the drug as an inhibition releaser, granting them a

license to engage, for example, in masochistic fantasies or other

types of usually self-proscribed behavior.

Another basic issue which emerged during discussion involved the

possibility that certain psychiatric disorders might be exacerbated by cocaine use. While limited clinical data exists, it was

speculated that certain types of individuals, for example, schizophrenics and hypomanics, might be at special risk for cocaine use.

In the latter case, a limited number of hypomanics who were in

treatment for cocaine use reported that they titrated cocaine to

maintain the hypomanic state when they started to become depressed.

However, it was thought that excessive cocaine use could precipitate a full-blown mania in these people.

One of the most puzzling aspects of cocaine use brought out during

the discussions was continued use despite the absence of euphoria,

even to the point that the effect of cocaine became primarily

224
dysphoric. A question was raised whether there was fear of withdrawal among cocaine users similar to that reported by opiate

addicts. It was pointed out that some patients reportedly recognized that cocaine had impaired their functioning, but their overriding fear was that cessation of cocaine use would result in

further detriment. A suggestion was made that this subgroup of

cocaine users who originally used the drug to facilitate performance is at great risk for continued use even though performance

becomes impaired. In addition, use of cocaine may be implicated

in expanded loss of judgment. This should become an area of

research, as should the question of where cocaine fits in the continuum of substances of abuse, that is, whether the majority of

cocaine users eventually will become compulsive and dysfunctional.

While we have access to clinical populations as a result of the

problems developed from cocaine use, additional information based

on large-scale epidemiologic studies is needed.

Cocaine once again was singled out as the most reinforcing drug

for conditioning animals in laboratory experimentation. The

subtle, seductive properties of the drug which make it so highly

reinforcing underlie the very problems that it causes in the human

population. The development of problems directly attributable to

the use of cocaine may not be apparent to the users and, in fact,

may be denied. Cocaine use was reported to be present in almost

all social and professional levels of society, including the

health professions. At the same time, little in-depth knowledge

exists about cocaine users outside of the treatment population, a

group that may be entirely unrepresentative of all cocaine users.

It was pointed out by clinicians that cocaine users tend to do

well in treatment. However, this observation is qualified by the

fact that treatment success rates are based on a select population composed largely of middle- and upper-class professionals who

enter private treatment programs. The fact that they can afford

private treatment expense is itself an economic screen, and

possibly an achievement screen, which may bias outcome results.

Success rates raise further questions in the absence of long-term

followup data, especially in light of the chronic relapsing disorder which is associated with cocaine use. Despite the selectivity of patients in treatment, certain conclusions can be drawn

describing the current population. They tend to be compliant and,

at least while in treatment, they tend not to have high relapse

rates. However, comparison must be made with more traditional

treatment populations to determine if certain factors, such as

motivation, may be impacting more forcefully on cocaine treatment

success. Carefully designed long-term followup studies with control groups are needed since data from some studies, such as Anker

and Crowley (1982) and Siegel (1982), provide reason to question

the optimistic clinical impression that cocaine abusers have high

treatment completion and abstinence rates. At the same time, the

point was made that we currently have many treatment strategies

which can be employed in the treatment of cocaine use. Cognitive

behavioral and cognitive restructuring approaches, when coupled

with urine screening, have demonstrated efficacy, at least in the

225
short term. It was asserted that the lack of controlled studies

cannot be allowed to interfere with the attempt to effectively

treat people at present.

Perhaps one of the clearest messages to emerge from the technical

review discussions involved seemingly conflicting reports resulting from epidemiologic analysis and clinical observation. At the

treatment level, an epidemic of cocaine use was being noted. From

the clinical point of view, a significant increase of patients

reporting problems associated with cocaine use was occurring. At

the same time, surveys indicated a plateauing of cocaine use in

the general household population during recent years. This

apparent contradiction was resolved during the course of the

technical review. Dramatic increases in cocaine use had occurred

during the mid to late 197Os, at which time large numbers of

people initiated cocaine use. Many of these people eventually

developed pathologic patterns of use which necessitated treatment

several years later. During the last few years, treatment programs have been deluged with the casualties of that epidemic

period. Thus, we do not currently appear to have epidemic levels

of use so much as epidemic levels of destructive use.

As pointed out earlier and confirmed by the chapters that appear

in this as well as earlier manuscripts, much is known about the

epidemiology, pharmacology, effects, and treatment of cocaine.

Still, much more knowledge is needed. Scientists who attended the

technical review were asked throughout the meeting to identify

areas of specific research concern and need. In addition to the

those cited above, a number of other issues were identified,

including:

More detailed information is needed regarding patterns of

use, such as dosages, frequencies, routes of administration, drugs used in combination and runs, and how different patterns of use change over time. In addition,

research is needed regarding risk factors associated with

cocaine use in the general population and adverse health

consequences related to pattern of use.

Pharmacokinetics and basic behavioral pharmacology data

are needed and these might be obtained through animal

models which look at the toxic effects associated with

intravenous, intranasal, smoking, and oral ingestion of

cocaine as well as dose effect.

A survey of ear, nose, and throat specialists should be

conducted to determine incidence of perforated septums

and other sequellae associated with insufflation of

cocaine.

Closer collaboration between epidemiologists and clinicians should be encouraged, specifically in developing a

standardized questionnaire that could be used during

clinical intake and which also could be used in general

226
0

and special population surveys. This standardized set of

questions could be used to obtain data on patterns of

cocaine use as well as demographic data and subjective

drug effect information regarding cocaine use.

Medical examiners should be encouraged to do bronchial

swabs with suspected cocaine-related cases to determine

if cocaine smoking has been the route of administration

prior to death. At this point, there appears to be no

other technique being used to associate cocaine smoking

with death other than the presence of freebase paraphernalia near the body.

A technical review should be held regarding the legal

consequences of cocaine use and the impact of the law on

use patterns.

Sociological studies should be initiated regarding patterns of cocaine use among traffickers.

Studies of medical consequences are needed both in terms

of acute and chronic consequences, as well as treatment

outcome studies which control for patterns of use

variables, such as route of administration.

In-depth analysis should be conducted regarding the

effectiveness and reliability of various urine toxicology

techniques. Research is needed on the effect of neurotransmitter precursors in terms of short-term treatment

or withdrawal from cocaine. Also, the effect of antidepressants on long-term treatment regimens should be

explored.

Research is vitally needed in the area of cocaine use

among women, including the effect of cocaine on conception, on fetal development, and on neo-natal and further

development of the child. In this regard, a survey of

obstetricians should be conducted regarding the number of

pregnant women being seen who report cocaine use in their

medical history.

Research concerning the relationship of cocaine use of

parents to subsequent use by children and the efficacy of

family treatment therapies also should be investigated.

More research data are needed on risk factors associated

with the progression to intensive cocaine use. Ideally

this would take the form of a long-term prospective study.

Interaction effects of cocaine with the benzodiazepines

and othe depressants, alcohol and narcotics should be

studied including the effect of these interactions on

simple and complex performance.

227
The efficacy of chemical interventions such as L

trytophan, L dopa, and desimpramine on cocaine

detoxification and relapse rates should be investigated.

Using a panel design, the impact of school based drug

prevention programs on subsequent cocaine use should be

studied, especially broad-based comprehensive health promotion programs.

The interaction of cocaine with common cutting agents

used on the street, such as procaine and lidocaine should

be investigated.

Cocaine is without doubt a powerfully reinforcing substance with

clearly identifiable negative health consequences. These findings

have been documented in this manuscript as well as in earlier

research papers. What has become particularly clear from this

technical review is that we must continue to build upon the basic

knowledge already established. Research is needed in a variety of

fields of science, ranging from animal models to neurochemical

experimentation, from clinical studies to large-scale epidemiologic investigations. These research findings are vital if we are

to avert future epidemics of cocaine use.

REFERENCES

Anker, A.L., and Crowley, T.J. Use of contingency contracts in

specialty clinics for cocaine abuse. In: Harris, L.S., ed.

Problems of Drug Dependence 1981.

Abuse Research Monograph 41. (NTIS PB #82-190760). Committee

on Problems of Drug Dependence Inc., 1982. pp. 452-459.

Siegel, R.K. Cocaine smoking.

1982.

J Psychoactive Drugs 14(4):271-359,

AUTHORS

Nicholas J. Kozel, M.S.

Division of Epidemiology and

Statistical Analysis

National Institute on Drug Abuse

Rockville, Maryland 20857

Edgar H. Adams, M.S.

Division of Epidemiology and

Statistical Analysis

National Institute on Drug Abuse

Rockville, Maryland 20857

228
monograph series

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1 FINDINGS OF DRUG ABUSE RESEARCH. NCDAI out of stock

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2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH

1975. Jack Elinson, Ph.D., and David Nurco, Ph.D., eds.

NCDAI out of stock

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3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE? Bruce J.

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4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette, Ph.D., ed. NCDAI out of stock

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6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. Jay R.

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7 CANNABINOID ASSAYS IN HUMANS. Robert Willette. Ph.D., ed.

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9 NARCOTIC ANTAGONISTS: NALTREXONE PROGRESS REPORT. Demetrios

Julius, M.D., and Pierre Renault, M.D., eds.

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10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

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11 DRUGS AND DRIVING. Robert Willette, Ph.D., ed.

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12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

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13 COCAINE: 1977. Robert C. Petersen, Ph.D., and Richard C.

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14 MARIHUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

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15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm. Sharp,

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16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne

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17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D., et

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18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D., ed. NCDAI out of stock

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19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen,

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20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FOR STUDY.

Norman A. Krasnegor, Ph.D., ed. NCDAI out of stock

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21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

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22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF

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Ph.D.; Milan Trsic, Ph.D.; and Robert Willette, Ph.D.; eds.

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23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A. Krasnegor,

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24 SYNTHETIC ESTIMATES FOR SMALL AREAS: STATISTICAL WORKSHOP PAPERS

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25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman A.

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26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

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Health.)

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27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. L.S. Harris, Ph.D., ed. NCDAI out of stock

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28 NARCOTIC ANTAGONISTS: NALTREXONE PHARMACOCHEMISTRY AND

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Gene Barnett, Ph.D., eds. NCDAI out of stock

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29 DRUG ABUSE DEATHS IN NINE CITIES: A SURVEY REPORT. Louis A.

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30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES. Dan

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31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed.

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32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz.

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33 BENZODIAZEPINES: A REVIEW OF RESEARCH RESULTS, 1980. Stephen I.

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34 PROBLEMS OF DRUG DEPENDENCE, 1980: PROCEEDINGS OF THE 42ND

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

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35 DEMOGRAPHIC TRENDS AND DRUG ABUSE, 1980-1995. Louise G.

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36 NEW APPROACHES TO TREATMENT OF CHRONIC PAIN: A REVIEW OF

MULTIDISCIPLINARY PAIN CLINICS AND PAIN CENTERS. Lorenz K.Y.

Ng, M.D., ed.

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37 BEHAVIORAL PHARMACOLOGY OF HUMAN DRUG DEPENDENCE. Travis

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38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan J. Lettieri, Ph.D.,

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39 YOUNG MEN AND DRUGS IN MANHATTAN: A CAUSAL ANALYSIS.

Richard R. Clayton, Ph.D., and Harwin L. Voss, Ph.D.

GPO Stock #017-024-01097-9 $5.50 NCDAI out of stock

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40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

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Arthur Carr, Ph.D. NCDAI out of stock

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41 PROBLEMS OF DRUG DEPENDENCE, 1981: PROCEEDINGS OF THE 43RD

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DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

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42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

Hawks, Ph.D., ed.

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43 PROBLEMS OF DRUG DEPENDENCE, 1982: PROCEEDINGS OF THE 44TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

GPO out of stock NTIS PB #83-252-692/AS $42.95

44 MARIJUANA EFFECTS ON THE ENDOCRINE AND REPRODUCTIVE SYSTEMS.

Monique C. Braude, Ph.D., and Jacqueline P. Ludford, M.S., eds. A

RAUS Review Report. NCDAI out of stock

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45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

Brown, Ph.D.; Theodore M. Pinkert, M.D., J.D.; and Jacqueline P.

Ludford, M.S., eds. A RAUS Review Report. NCDAI out of stock

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46 BEHAVIORAL INTERVENTION TECHNIQUES IN DRUG ABUSE TREATMENT. John

Grabowski, Ph.D.; Maxine L. Stitzer, Ph.D., and Jack E.

Henningfield, Ph.D., eds.

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47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W.; and

Jacqueline P. Ludford, M.S., eds. A RAUS Review Report.

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48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING BEHAVIOR.

John Grabowski, Ph.D., and Catherine S. Bell, M.S., eds.

GPO Stock #017-024-01181-9 $4.50 NCDAI out of stock

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49 PROBLEMS OF DRUG DEPENDENCE, 1983: PROCEEDINGS OF THE 45TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

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50 COCAINE: PHARMACOLOGY, EFFECTS, AND TREATMENT OF ABUSE. John

Grabowski, Ph.D., ed.

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51 DRUG ABUSE TREATMENT EVALUATION: STRATEGIES, PROGRESS, AND

PROSPECTS. Frank M. Tims, Ph.D., ed.

GPO Stock #017-024-01218-1 $4.50 NTIS PB 85-150365/AS $18.95

52 TESTING DRUGS FOR PHYSICAL DEPENDENCE POTENTIAL AND ABUSE

LIABILITY. Joseph V. Brady, Ph.D., and Scott E. Lukas, Ph.D., eds.

GPO Stock #017-024-01204-1 $4.25 NTIS PB 85-150373/AS $18.95

53 PHARMACOLOGICAL ADJUNCTS IN SMOKING CESSATION. John Grabowski,

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54 MECHANISMS OF TOLERANCE AND DEPENDENCE. Charles Wm. Sharp,

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55 PROBLEMS OF DRUG DEPENDENCE, 1984. PROCEEDINGS OF THE 46TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. NCDAI out of stock

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56 ETIOLOGY OF DRUG ABUSE: IMPLICATIONS FOR PREVENTION. Coryl LaRue

Jones, Ph.D., and Robert J. Battjes, D.S.W., eds.

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57 SELF-REPORT METHODS OF ESTIMATING DRUG USE: MEETING CURRENT

CHALLENGES TO VALIDITY. Beatrice A. Rouse, Ph.D., Nicholas J.

Kozel, M.S., and Louise G. Richards, Ph.D., eds.

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58 PROGRESS IN THE DEVELOPMENT OF COST-EFFECTIVE TREATMENT FOR DRUG

ABUSERS. Rebecca S. Ashery, D.S.W., ed.

GPO Stock #017-024-01247-5 $4.25 NCDAI out of stock

59 CURRENT RESEARCH ON THE CONSEQUENCES OF MATERNAL DRUG ABUSE.

Theodore M. Pinkert, M.D., J.D., ed.

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60 PRENATAL DRUG EXPOSURE:, KINETICS AND DYNAMICS. C. Nora Chiang,

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61 COCAINE USE IN AMERICA: EPIDEMIOLOGIC AND CLINICAL PERSPECTIVES.

Nicholas J. Kozel, M.S., and Edgar H. Adams, M.S., eds.

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62 NEUROSCIENCE METHODS IN DRUG ABUSE RESEARCH. Roger M. Brown,

Ph.D., and David P. Friedman, Ph.D., eds.

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63 PREVENTION RESEARCH: DETERRING DRUG ABUSE AMONG CHILDREN AND

ADOLESCENTS. Catherine S. Bell, M.S., and Robert Battjes,

D.S.W., eds.

GPO Stock #017-024-01263-7 $5.50

64 PHENCYCLIDINE: AN UPDATE. Doris H. Clouet, Ph.D., ed.

GPO Stock #017-024-01281-5 $6.50

65 WOMEN AND DRUGS: A NEW ERA FOR RESEARCH. Barbara A. Ray, Ph.D.,

and Monique C. Braude, Ph.D., eds.

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66 GENETIC AND BIOLOGICAL MARKERS IN DRUG ABUSE AND ALCOHOLISM.

Monique C. Braude, Ph.D., and Helen M. Chao, Ph.D. eds.

GPO Stock #017-024-01291-2 $3.50 NCDAI out of stock

67 PROBLEMS OF DRUG DEPENDENCE, 1985. PROCEEDINGS OF THE 47TH

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68 STRATEGIES FOR RESEARCH ON THE INTERACTIONS OF DRUGS OF ABUSE.

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eds.

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69 OPIOID PEPTIDES: MEDICINAL CHEMISTRY. Rao S. Rapaka, Ph.D.;

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70 OPIOID PEPTIDES: MOLECULAR PHARMACOLOGY, BIOSYNTHESIS, AND

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71 OPIATE RECEPTOR SUBTYPES AND BRAIN FUNCTION. Roger M. Brown,

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.

72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims. Ph.D.. and

Carl G. Leukefeld, D.S.W., eds.

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73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D., and

C. Nora Chiang, Ph.D., eds.

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74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE. Stephen I.

Szara, M.D., D.Sc., ed.

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75 PROGRESS IN OPIOID RESEARCH. PROCEEDINGS OF THE 1986 INTERNATIONAL NARCOTICS RESEARCH CONFERENCE. John W. Holaday, Ph.D.;

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76 PROBLEMS OF DRUG DEPENDENCE, 1986. PROCEEDINGS OF THE 48TH

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77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT RESEARCH.

Elizabeth R. Rahdert, Ph.D. and John Grabowski, Ph.D., eds.

235

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Alcohol, Drug Abuse, and Mental Health Administration

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