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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Repeating Cycles of Cocaine Use and Abuse Ronald K. Siegel On October 12, 1860, Abraham Lincoln walked into the Corneau & Diller drug store in Springfield, Illinois, where he regularly purchased such items as bay rum, brandy, and cough candy laced with opium. On that day, Lincoln bought 50 cents worth of a product that a few historians claim contained coca or cocaine,1 thus becoming possibly the first American to buy this newly available substance (Pratt, 1943:153). Little else is known about Lincoln's pattern of "cocaine" use or its consequences, but the following week he started growing his famous beard and shortly thereafter became president of the United States. Although Lincoln may not have pursued the use of cocaine, the time of his purchase—five years after the alkaloid was isolated from coca by Gaedecke and one year after Albert Nieman named it "cocaine"—signaled the beginning of a new cycle of coca and cocaine abuse. This cycle was marked by new preparations, doses, and routes of administration. Prior to this time, only coca products had been available, and the patterns of their use had not changed substantially in more than 4,800 years. THE FIRST CYCLE: USE (3000 B.C.-1860 A.D.) Historically, South American natives administered coca orally and topically and ingested it by smoking in low, albeit effective, dosages. When used orally, the leaves were chewed, sucked, and swallowed. Studies involving contemporary coca chewers suggest that this pattern of administration results in an average daily ingestion of 200 to 500 milligrams (mg) of cocaine with plasma cocaine levels similar to those achieved from intranasal administration (Holmstedt et al., 1979; Paly et al., 1980). Quids of Ronald K. Siegel is affiliated with the Department of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California, Los Angeles.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment partially chewed leaves were used as topical 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 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 in magico-religious practices, as well as for the relief of upper respiratory problems, probably delivered less than 25 mg of cocaine (Siegel, 1982). There is little evidence that these patterns and dosages were associated with abuse or toxicity. However, because coca use was considered a habit connected with idolatrous Indians of poor health, it was continually condemned starting in 1567 (Mortimer, 1901). This view of coca as "wicked" and with "no true virtue" was expressed throughout the first cycle and set the stage for future treatment of the habit to include religious and moral education. THE SECOND CYCLE: ABUSE (1860-1914) Coca was introduced to Europe by the reports of sixteenth-century explorers, seventeenth-century chroniclers, eighteenth-century naturalists, and nineteenth-century botanists (Mortimer, 1901). After Mantegazza's 1857 and 1859 essays on the virtues of coca, medical and nonmedical coca products appeared, and European 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 support, encouraged frequent use of escalating doses, a pattern that inevitably led to a new cycle of cocaine abuse. Recent analysis of these preparations reveals that changing dose regimens were inextricably tied to this abuse (Siegel, 1985a). An analysis of representative pharmaceutical bottles and formulas in the author's collection reveals that these tonics and extracts contained approximately 3 to 160 mg of cocaine per dosage unit. The coca wines and related alcoholic beverages contained approximately 35 to 70 mg of cocaine per dosage unit (glass). Some, like Vin Mariani, were concentrations of 2 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 0.01 percent to 1.5 percent cocaine (Hanna, 1970; Novak et al., 1984; Plowman and Rivier, 1983; Rivier, 1981). The leaves used in manufacturing wines and tonics averaged 0.65 percent, a concentration remarkably similar to assays of contemporary cultivated coca leaves (Coca
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 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 ounces, or 20 mg) to a full wine glass (4 ounces, 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.2 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,3 Chevrier (1868) claimed a wide variety of therapeutic applications for coca preparations that 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 the 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) that expanded on the therapeutic applications of his commercial line of coca products. The fourth book, published by New York physician W.S. Searle (1881), endorsed the medical use of coca for all problems of life and as an alternative to tobacco, tea, coffee, and wine. The coca dosage regimens recommended by Tibbles, Searle, and their colleagues would have resulted in daily ingestion of no more than 65 to 160 mg of cocaine. Coca-Cola, promoted as a "Brain Tonic" for exhaustion, went through several changes in its formula (Louis and Yazijian, 1980) and from the 1890s to 1903 contained approximately 60 mg of cocaine per 8-ounce serving.4 By the time the fifth book on coca was published (Thudichum, 1885), it was an accepted medical fact that coca, and its alkaloid cocaine, had the power to relieve suffering. Concomitant with the growing number of new coca products on the market, advertisements promoted their use for a wide variety of nonmedical purposes. However, cocaine itself was widely available at this time, and the dosage regimens recommended for use of cocaine products by Tibbles, Merck (1885), and Martindale (1886) would have resulted in
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment daily ingestion of as much as 810 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, 1 grain of cocaine being the equivalent of 200 grains of coca leaves (Hammond, 1887). Yet little adjustment was made for this dose consideration. In fact, the convenience of cocaine prompted even the most conservative of physicians to apply its use to virtually all medical and 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" for all remaining problems of life. 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 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 through 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 the 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 more than 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 free base in the 1970s. As the nonmedical use of cocaine and other narcotics escalated, state legislatures and Congress increased restrictions and penalties. The significant federal legislation included the Food and Drug Act (1906), the Harrison Narcotics Act (1914), the Narcotic Drug Import and Export Act (1922), the Uniform Narcotic Act (1932), and the Narcotics Drug Control Act (1956). Consequently, the growth in use and abuse was slowed significantly but persisted in underground populations supplied by a new black market. Indeed, by the middle of the 1920s, the underground traffic in narcotics equaled the legitimate medical traffic, and "dope peddlers"
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment appeared to have established national as well as international organizations for smuggling the drugs by land and sea. Concomitantly, the behavior and health problems of users, already changing for the worse before restrictive legislation was enacted, were exacerbated by the new laws (Courtwright, 1982). These legislative acts, coupled with the Depression and the subsequent introduction of amphetamines in 1932, contributed to the low plateau of cocaine use until the late 1960s. Amphetamines initially were legal, abundantly available, and cheap. The cycle of widespread cocaine use would not resurface until changes in medical practices (e.g., the Drug Abuse Control Amendments of 1965), legislation (e.g., the Controlled Substances Act of 1970), and a strong educational campaign (e.g., "Speed Kills") effectively stopped the widespread use of amphetamines. Soon after, the subsequent third cycle of cocaine use was born. Treatment in the Second Cycle The initial paucity of adverse reactions to coca and cocaine prompted early clinicians to deny the existence of genuine medical problems. They suggested that people decide for themselves if they must abstain or not (cf. Beard, 1871). An 1897 survey of 396 physicians uncovered only 14 cases of a coca habit per se (Mortimer, 1901:491-516). Once cocaine dependence was recognized, physicians began treatment of the withdrawal symptoms with alcohol and morphine (Erlenmeyer, 1889). As the number of abusers seeking medical help grew, so did the list of treatments. Many treatments emphasized religious and moral lectures to ensure abstinence (e.g., Bunting, 1888). But most cocaine users treated themselves with "home cures"—patent medicines taken at home. These "home cures" were gradually replaced by "sanitarium cures," which employed long periods of hospitalization. By the end of the second cycle, clinics, cures, and sanitaria were blossoming throughout the United States. Only a few clinicians really understood the addicting nature of cocaine and attempted to teach patients how to avoid conditions conducive to cocaine use (e.g., Crothers, 1902). Most treatment programs simply demanded longer and longer periods of hospitalization (e.g., Lewin, 1924). Despite the growth of all such treatment services, however, there was no appreciable change in recovery rates.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment THE THIRD CYCLE: USE (1970-1978) The first contemporary book on cocaine appeared in 1972 (Chasin, 1972) and marked a resurgence in nonmedical cocaine use. The book noted that 90 percent of users preferred intranasal administration, a pattern of use illustrated in several motion pictures released that same year (Go Ask Alice, Dealing, Super Fly, and The Discreet Charm of the Bourgeoisie). In those movies, cocaine use was portrayed as discreet, involving small intranasal 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 models of use (Starks, 1982). The cocaine paraphernalia industry was also developing (Wynne, et al. 1980), and spoons and straws for intranasal cocaine use became popular. Siegel (1977) determined that the average cocaine spoon available at that time delivered 5 to 10 mg of pure cocaine. The average amount of cocaine delivered through a straw from a "line" was 25 mg. Because two cocaine spoons or two lines (one for each nostril) were used, each administration consisted of 20 to 50 mg. Various patterns of use ranging from experimental use of a few "lines" or "hits" of cocaine to daily compulsive use of 4 grams appeared during the period 1970-1978 (Siegel, 1984a). Five patterns of nonmedical cocaine use have been defined by Siegel (1977), and these will be used for discussion here. Experimental Use--Siegel's article defined experimental use 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 for a multitude 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 Siegel found was a social-recreational one in which use generally occurred in social settings among friends or acquaintances who wished to share an experience perceived by them as 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
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment was viewed as a social drug that facilitated social behavior; (2) cocaine was viewed as ''ideal'' and "safe" in terms of convenience of use and its minimal bulk, rapid onset, minimal duration, and few side and after effects; and (3) cocaine was seen as appealing in terms of sociocultural images. Circumstantial-Situational Use--Circumstantial-situational use was defined as a task-specific, self-limited use that was variably patterned and 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 in coping with a specific condition or situation. Use tended to occur in four or five episodes per week. Motivations cited by users included the enhancement of performance or mood at work and play. 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 does not discontinue such use without experiencing physiological discomfort or psychological disruption. 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 withdrawal-like effects. The Social-Recreational User: 1970-1978 The most common pattern of cocaine use during the contemporary period 1970-1978 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 two to seven days. During days of use, users averaged daily intakes of 150 mg. In 1974, a group of 99 such social-recreational users were recruited for a longitudinal study (Siegel 1977, 1980b, 1984a). These users were selected through advertisements distributed to several million households by Los Angeles newspapers. Although the sample represented a specific geographical population, the users appeared highly similar to those sampled by smaller studies elsewhere (Grinspoon and Bakalar, 1976;
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Resnick and Schuyten-Resnick, 1976). In addition, although only 50 of these users (50 percent) continued through the 9 years of the study (and only 16 were found for a 14-year follow-up interview in 1988), their changing patterns and effects were similar to those found during this period in both short-term and longitudinal studies involving other users (Ashley, 1975; Erickson et al., 1987; 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 more than a decade, a decade that marked significant changes in patterns of cocaine use in America (Adams et al., 1986). Although patterns of use changed considerably over the 14 years of the study, initial use during its first 4 years (1975-1978) appeared relatively stable. During that period all of the subjects remained social-recreational users, but 75 percent 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 that can be called "binge" use. Binge use, also known as "runs," refers to continuous periods 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. Although hinging can be found within all groups of cocaine users, social-recreational users did not tend to binge during the period 1975-1978. When engaged in episodes of intensified use, 17 users reported binges that involved intake of an average of 0.5 grams (range, 0.25-1.25 grams) in runs averaging four hours (range, 1-18 hours). Nonetheless, for a proportion of users the social-recreational patterns appeared relatively stable. Several variables, including the following, contributed to this stability. First, the purity of street cocaine remained relatively the same during this period with an average of 53 percent (range, 43.2-60.8 percent). Second, these users continued to purchase cocaine in half-gram or gram quantities for prices that averaged $75 to $100 per gram. Third, the size and nature of cocaine spoons and other paraphernalia remained relatively the same. Fourth, the intranasal 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. Fifth, the misperception of intranasal cocaine as a "relatively safe
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment and ideal social-recreational drug" was common among users (Siegel, 1977). Finally, physical and 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 percent of these users. Treatment in the Third Cycle Because the social-recreational patterns of cocaine use during this cycle resulted in relatively few users seeking clinical attention, researchers and clinicians alike minimized the dangers of cocaine. Most efforts focused on treatment of acute toxic reactions in emergency rooms (Siegel, 1985b). However, by the end of this cycle the long-term effects were emerging, thus prompting more users to seek clinical attention. The treatment services that were available were generally unfamiliar with cocaine problems and, not surprisingly, reported little success. THE FOURTH CYCLE: ABUSE 1978-1988 The patterns of use among continuing users began to change between 1978 and 1988 (Siegel 1982, 1984a, 1985a). As dosages increased, a new cycle of abuse became inevitable. 1978-1982 The users in Siegel's longitudinal study averaged between 1 and 3 grams per week from 1978 through 1982 (Siegel, 1984a). Fifty percent (N = 25) of the users still in the study (N = 50) in 1983 remained social-recreational (with continuing episodes of increased use) whereas 32 percent (N = 16) of the users became primarily circumstantial-situational users, 8 percent (N = 4) became intensified users, and 10 percent (N = 5) became compulsive users. Dosages varied with the pattern of use. The social-recreational users averaged approximately 1 gram per week, circumstantial-situational 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 1975-1978. Perhaps the most dramatic change was seen in the compulsive pattern
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment of use. Compulsive intranasal use has been described in other studies (Ashley, 1975; Resnick and Schuyten-Resnick, 1976); however, compulsive users here were all smokers of cocaine free base. It should be noted that in other studies the proportion of cocaine smokers doubled between 1983 and 1986 (Johnston et al., 1987). Siegel's cocaine smokers averaged 1.5 grams per day (range, 1-30 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 intakes of 1.5 grams (range, 0.25-30.0 grams) in a 24-hour period (range, 1-96 hours). Taken together, 1978 through 1982 marked an escalation in dosages and dose regimens for these social-recreational users. Changes in several variables were associated with this change in pattern of use. First, the purity of street cocaine declined during this period to an average of 29.2 percent (range, 13.9-48.7 percent). Second, users tended to purchase cocaine in full gram or one-eighth ounce (3.5-gram) quantities, and the half-gram unit became increasing scarce. Third, the paraphernalia industry introduced a variety of cocaine-dispensing devices, known collectively as "bullets," which delivered an average hit of 25 mg (range, 15-50 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, 5.0-24.1 mg). The paraphernalia industry also introduced a wide variety of cocaine smoking kits and accessories (Siegel, 1982). Fourth, the smoking route became a preferred route of administration for many new users. Fifth, the perception of intranasal cocaine as a relatively safe pattern of drug use continued in the face of increasing negative publicity concerning cocaine smoking (Siegel, 1982). And finally, users increased multiple drug use in their self-treatment of cocaine-related problems. Fully 30 percent of Siegel's respondents were using methaqualone, and 13 percent were using diazepam. 1982-1984 During the period 1982 to 1984 there were dramatic increases in physical and psychological problems associated with cocaine dependency and toxicity (see Siegel, 1984a). Several studies noted that both intranasal users and cocaine smokers tended to binge more often. Lower street prices and ubiquitous supplies allowed some users to consume an entire week's supply of cocaine during a single episode of use ranging from several hours to several days. 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 and 7.0 grams during binges.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment In addition to more concentrated dose regimens, dosages themselves became more concentrated. The average purity of street cocaine during 1982-1984 for these users was determined to be 73.3 percent (range, 58-87 percent). This change was undoubtedly influenced by worldwide increases in coca and cocaine production coupled with decreased availability of cocaine substitutes, adulterants, and diluents owing to paraphernalia legislation (Drug paraphernalia litigation, 1984; Smith, 1982). Concomitantly, the street 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 toxic overdoses. Many users reported purchasing quantities of cocaine 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 S25. The decline of the paraphernalia industry during this period resulted in a shortage of cocaine smoking accessories. Thus, the most common method of preparing cocaine free base became the baking soda method (Siegel, 1982) whereby the need for special chemicals and glassware was eliminated. The reduced supply of cocaine pipes resulted in an increase in smoking cocaine free base in combination with tobacco. By the end of 1984 users reported experimenting with a wide variety of new routes and patterns of cocaine use. These included use of cocaine hydrochloride vaginally, rectally, and sublingually. A few users employed the intranasal route of administration for cocaine free base, and some experimented with smoking coca paste (Siegel, 1985a). An important caveat is that these methods appeared in only a few communities along the cocaine trafficking corridors, and the number of users was relatively small. However, it is also important to note that more widespread practices, like the smoking of cocaine free base, were initially introduced by a small number of users in these same communities. 1985-1988 Crack The year 1985 began with the introduction of the word "crack" into the vocabulary of American drug use (Washton et al., 1986a,b). The word first appeared in New York City where it referred to tiny smokable pellets
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment interview studies. Most reported compulsive binge use with an average weekly intake of approximately 1 to 5 grams when supplies were available. All satisfied the diagnostic criteria for cocaine abuse. The severity of their cocaine dependence varied: 14 had symptoms that could be diagnosed as mild, 9 were classified as moderate, and 4 had symptoms of severe cocaine dependency. The average RIAH level seen in the mild and moderate users was 18 ng/10 mg (range, 3-122 ng/10 mg). The average RIAH level in the severe cases was 33 ng/10 mg (range, 3-147 ng/10 mg). Intranasal Cocaine Users (N = 51) This group consisted of individuals being evaluated for court proceedings in California, Colorado, Florida, Illinois, Massachusetts, and New York. In general they reported varying patterns of use ranging from social-recreational to compulsive with weekly intakes of 1 to 21 grams. All satisfied the criteria for cocaine abuse and dependence (mild, N = 31; moderate, N = 14; and severe, N = 6). The average RIAH level was 12 ng/10 mg (range, 2-218 ng/10 mg). The higher values in this range tended to be associated with individuals who reported histories of compulsive intranasal use and were diagnosed with severe dependence. Several of these intranasal users showed RIAH exposure levels far greater than any found among crack users. Treatment in the Fourth Cycle During the early years of this cycle there were increasing numbers of users seeking treatment. In the absence of specialized programs, users turned to self-help approaches—the modern equivalent of the "home cures" popular during the second cycle (see Siegel, 1985b). More formal cocaine treatment programs eventually appeared and these incorporated behavioral, supportive, psychodynamic, and pharmacological approaches (Kleber and Gawin, 1984). Although registrations in cocaine treatment programs increased steadily from 1984 to 1988, they represented a small fraction of all cocaine users. Several studies (e.g., Erickson et al., 1987) found that the majority of cocaine users did not experience deleterious consequences, a finding undoubtedly related to the continued popularity of social-recreational patterns and the relatively low numbers of compulsive users. However, treatment programs may not have been widely available to innercity crack users who, despite their low doses of cocaine, were engaged in high-risk patterns of use.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment DISCUSSION The history of coca and cocaine has been a history of increasing doses, increasingly effective routes of administration, and increasing incidence of dependency and toxicity. It is clear that cocaine has a high potential for abuse and that the effects are neither predictable nor controllable. It is also clear, however, that by avoiding high doses and risky routes of administration, individuals have engaged in long-term use of cocaine with low incidences of clinical problems. The best example of this is also the oldest: coca. The chewing and smoking of coca leaves marked the first cycle of cocaine use, and these practices continue today among native Andean peoples with little if any abuse. The amount of cocaine ingested from these leaves amounts to less than 500 mg per day, a behaviorally effective dose but one delivered slowly throughout the day. A contemporary example of the relative safety of coca leaf preparations can be found in the coca tea episode of 1983 (Siegel et al., 1986). In order to divert Peru's enormous coca production into legal products, the Peruvian government's National Enterprise of Coca exported mate de coca or coca tea bags, to the United States. Millions of tea bags, labeled in English as either coca tea or decocainized coca tea, were sold and used throughout a three-year period ending in 1986. Analysis revealed that each tea bag contained approximately 5 mg of cocaine, the same dose found in a single, small cokespoon of street cocaine as used in the early 1970s (Siegel, 1977). Examination of representative coca tea drinkers using an average of 5 to 10 mg per day (range, 5-400 mg) confirmed the effects expected from the small amounts of cocaine: mild stimulation, mood elevation, and increased pulse rate. Most importantly, however, the coca tea drinkers did not satisfy the diagnostic criteria for cocaine abuse, and their claims of controlled use seemed to be correct. Indeed, during this three-year period the National Addiction Foundation in San Francisco dispensed coca tea as part of their cocaine treatment program, and their patients reported that it was effective in curbing the craving for cocaine itself. Coca tea was also one of the many coca products in use at the end of the first cycle of use in the nineteenth century. These products delivered relatively low doses through relatively slow-acting routes of administration. Few nonmedical uses or abuses were noted during the subsequent era of coca patent medicines. Starting in 1860, 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 the second cycle of both medical and nonmedical abuses grew.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment After legislative suppression of cocaine in the early 1900s, followed by a period of amphetamine use, abuse, and suppression, cocaine enjoyed a third cycle of use in the 1970s. The cycle began with social-recreational patterns of intranasal cocaine use. This pattern involved the use of 1 to 4 grams per person per month, consumed in several episodes. The cycle ended with these same users consuming 1 to 3 grams per week in far fewer episodes. In addition, many users escalated doses and dose regimens as they changed to patterns of circumstantial-situational, intensified, and compulsive use. The pattern of cocaine smoking also appeared at this time. A fourth cycle of cocaine abuse was clearly visible by 1978. The cycle began with increased availability of cheaper cocaine and a changing pattern of binge use wherein users continued cocaine use until their supplies or their 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 began to emerge including increased cocaine smoking and the use of topical routes of administration. The doses and routes associated with these patterns made controlled use difficult if not impossible and substantially increased the risks of dependency and toxicity. In 1985 the introduction of crack changed the epidemiology of cocaine use in America by allowing individuals to purchase single doses of smokable cocaine free base. These vending practices brought cocaine free base within the budgetary reach of almost anyone; however, studies of crack users in Los Angeles suggested that they used impure preparations and consumed less cocaine than either cocaine free base smokers or intravenous cocaine users, and only slightly more than intranasal users. Contrary to perceptions generated by the media, crack users studied here had a lower incidence of severe dependencies than intravenous users or cocaine free base smokers. Nonetheless, the association of crack with violent crime, together with pressures from the government's war on drugs, acted to negate cocaine's image as a safe recreational drug and to reinforce the view, previously held at the end of the second cycle of abuse, that cocaine was an especially dangerous drug and that users were menaces and fiends (Ashley, 1975). The similarity of events in these repeating cycles prompts speculation about where current trends will lead in the future. one source of these trends has been Siegel's study of a small group of social-recreational cocaine users who have been tracked through the third and fourth cycles. The changing patterns of use seen in these Los Angeles users appear to reflect trends eventually manifested in other populations. For example, in
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment 1974 these users first experimented with smoking cocaine, a pattern of use that took many years to surface in other parts of the United States. By 1988 several of Siegel's subjects had stopped using cocaine, a report supported by a new RIAH analysis of cocaine exposures in hair samples. For most of a decade these individuals had been continuing social-recreational users who escalated their dosages and changed their dose regimens while remaining resistant to total abstinence. Why did they stop? The users cited two factors: (1) the changing negative image of cocaine as a street drug and (2) the overall antidrug atmosphere promoted by the war on drugs. Nevertheless, although these factors may have influenced some of Siegel's subjects who were drawn from a population of generally well-educated and employed adults, they did not appear to affect the growing number of young, unemployed crack users appearing in the inner cities of America. The war against cocaine was unsuccessful in stopping cocaine use and only changed the patterns and behaviors of users (Wisotsky, 1983). The second cycle of cocaine abuse had ended with similar changes in cocaine's image, similar antidrug campaigns, and the development of a widespread amphetamine problem. While nothing can be concluded from Siegel's two subjects who switched to methamphetamine, the growing number of methamphetamine labs and abusers surfacing throughout the western part of the United States (Methamphetamine labs, 1988; Methamphetamine on fast track, 1988) points to a potential methamphetamine epidemic that could attract many cocaine users. Indeed, small communities scattered throughout the United States already are experiencing a dramatic escalation in methamphetamine abuse (Isikoff, 1989). Taken together, these forces may bring about the end of the fourth cycle of cocaine abuse. The demand for cocaine, however, a substance far more reinforcing and desirable than methamphetamine (or any other psychoactive drug), will persist among the millions of continuing users. If the domestic coca cultivation industry can develop to the levels achieved by marijuana cultivation, or if domestic synthetic cocaine laboratories can improve their production methods, then a fifth cycle of cocaine may follow. Whether such a future cycle is one of use or abuse will depend entirely on preparations, doses, and patterns of use. The nature of these repeating cycles has important implications for treatment. The most significant finding is that cocaine abuse, and the need for its treatment, is not a necessary concomitant of growth in the number of users. Cocaine use is clearly different from cocaine abuse in terms of the doses and frequencies that constitute the various patterns of self-administration. Although the absolute number of people using cocaine has continually escalated, when low-dose preparations and infrequent patterns of use are the rule, as during the first and third cycles, there has
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment been little need for treatment. Increased dosages and frequent patterns of use, as seen during the second and fourth cycles, have resulted in abuse, and these trends have been paralleled by an increase in the number and diversity of treatment services. Therefore, it is important to recognize that behavior in the current fourth cycle includes several patterns of use associated with low doses and low toxicity, albeit large numbers of users (e.g., coca tea drinkers and some social intranasal users). Consequently, it might be more efficient to focus medical treatment resources on specific types of users who are almost always abusers (e.g., cocaine smokers) rather than targeting all users per se. However, it is equally important to note that even within a particular group such as crack users, individuals may differ substantially in the severity of their dependence. Thus, treatment services must remain adaptive to the needs of clients and flexible in approaches. In cases of cocaine intoxication and acute toxic reactions, treatment can be guided by clear diagnostic criteria including physical and behavioral indices. But diagnosis of cocaine abuse and dependence do not rest on such clear signs as intoxication or even route of administration. Rather, such determinations rely more heavily on an individual's self-reported history of cocaine use. Self-reported histories are not completely trustworthy: they may be lacking in important details, they may be self-serving, or people give confused histories because of intoxication. Therefore, treatment services might benefit by utilizing the RIAH toxicology test as an aid to diagnosis and to monitor treatment itself. Notes 1 Pratt (1943) records the purchase as cocaine. The original entry in the day books of Corneau & Diller records the purchase as "cocaine." This spelling was sometimes used for coca extract products, for a coca wine named "Cocaine," for a cocaine-based local anesthetic preparation, and for a coconut oil hair product named "Cocaine." 2 This statement is based on unpublished raw data and archival information obtained from B. Hester, Khoka Productions, Inc., Jacksonville, Florida. 3 Several 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). 4 Based on information obtained from B. Hester, Khoka Productions, Inc.,
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Jacksonville, Florida. 5 The RIAH tests were performed by Ianus Foundation and Psychemedics Corporation. 6 Compulsive cocaine smokers also showed significantly more cocaine trapped in the outside cuticle layer of hair (which absorbs ambient smoke) than did compulsive intranasal users. 7 Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. Washington, D.C.: American Psychiatric Association, 1987. References Adams, E.H., J.C. Gfroerer, B.A Rouse, and N.J. Kozel (1986) Trends in prevalence and consequences of cocaine use. Advances in Alcohol and Substance Abuse 6(2):49-71. Allen, D., ed. (1987) The Cocaine Crisis. New York: Plenum Press. Arif, A., ed. (1987) Adverse Health Consequences of Cocaine Abuse. Geneva: World Health Organization. Ashley, R. (1975) Cocaine. Its History, Uses and Effects. New York: St. Martin's Press. Baumgartner, W.A, C.T. Black, P.F. Jones, and W.H. Blahd (1982) Radioimmunoassay of cocaine in hair: concise communication. Journal of Nuclear Medicine 23(9):790-792. Baumgartner, W.A., J.D. Baer, V.A Hill, and W.H. Blahd (1989) Hair analysis for the detection of substance abuse in pretrial/ probation/parole populations. Paper presented at a Workshop on Hair Analysis for Drugs of Abuse, National Institute of Justice, Washington, D.C., January 8. Baumgartner, W.A., V.A. Hill, and W.H. Blahd (1989) Hair analysis for drugs of abuse. Journal of Forensic Sciences 34(6):1433-1453. Beard, G.S. (1871) Stimulants and Narcotics: Medically, Philosophically, and Morally Considered. New York: G.P. Putnam. Bunting, C.A. (1888) Hope for the Victims of Alcohol, Opium, Morphine, Cocaine, and Other Vices. New York: Christian Home Building. Chasin, D. (1972) The Gourmet Cokebook. White Mountain Press. Chevrier (1868) Notice sur les Propriétés et L'Usage du Coca du Pérou. Roanne: Ferlay. Coca wines of the market (1886) The Druggists Circular and Chemical Gazette, February, p. 32. Cocaine labs on the rise (1984) Drug Enforcement Report 1(2):4.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Courtwright, D.T. (1982) Dark Paradise: Opiate Addiction in America Before 1940. Cambridge, Mass.: Harvard University Press. Crothers, T.D. (1902) Morphinism and Narcomanias from Other Drugs. Their Etiology, Treatment, and Medicolegal Relations. Philadelphias: W.B. Saunders. Darth, C. (1977) The Whole Drug Manufacturers Catalog. Manhattan Beach, Calif.: Prophet Press. Drug paraphernalia litigation (1984) Drug Law Report 1(9):105-108. Eddy, P., H. Sabogal, and S. Walden (1988) Cocaine Wars. New York: W.W. Norton. Erickson, P.G., E.M. Adlaf, G.F. Murray, and R.G. Smart (1987) The Steel Drug. Cocaine in Perspective. Lexington, Mass.: D.C. Heath. Erlenmeyer, A. (1889) On the Treatment of the Morphine Habit. Detroit, Mich.: Davis. Feral, R. (1984) How to Rip Off a Drug Dealer. Boulder. Colo.: Paladin Press. Gentile, D.P. (1979) Cocaine: Legal and Technical Defenses. Houston, Tex.: National College of Criminal Defense Lawyers and Public Defenders. Grinspoon, L, and J.B. Bakalar (1976) Cocaine. A Drug and Its Social Evolution. New York: Basic Books. Hammond, W.A. (1887) Coca: its preparations and their therapeutical qualities, with some remarks on the so-called "cocaine habit." Transactions of the Medical Society of Virginia Nov.:212-226. Hanna, J.M. (1970) The effects of coca chewing on exercise in the Quechua of Peru. Human Biology 42(1):1-11. Hisayasu, G.H., J.S. Goodman, J.L Cohen, and R.K. Siegel (1982) Evaluation of cocaine free base extraction kits and procedures . In R.K. Siegel, Cocaine Smoking. Journal of Psychoactive Drugs 14(4):352-354. Holmstedt, B., J.-E. Lindren, L. Rivier, and T. Plowman (1979) Cocaine in blood of coca chewers. Journal of Ethnopharmacology 1(1):69-78. Honer, W.G., G. Gewirtz, and M. Turey (1987) Psychosis and violence in cocaine smokers. Lancet 2(8556):451. Hrdlicka, A. (1939) Trepanation among prehistoric people, especially in America. Ciba Symposia 1(6):170-177, 200. Isikoff, M. (1989) In rural America, crank, not crack is drug plague. Los Angeles Times, February 21, Part V, pp. 1, 4. Jeri, F.R. (1984) Coca-paste smoking in some Latin American countries: a severe and unabated form of addiction. Bulletin on Narcotics 36(2):15-31. Johnston, L.D., P.M. O'Malley, and J.G. Bachman (1987) National Trends in Drug Use and Related Factors Among American High School Students
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Methamphetamine labs in California: enforcement and legislation. (1988) Substance Abuse Report 19(19):1-3. Methamphetamine labs in California: enforcement and legislation (1988) Methamphetamine on fast track in the American West. Street Pharmacologist Summer, pp. 1-8. Meyers, A.C (1902) Eight Years in Cocaine Hell. Chicago: Press of the St. Luke Society. Moodie, R.L (1923) Paleopathology. Urbana, Ill.: University of Illinois. Mortimer, W.G. (1901) Peru. The History of Coca. "The Divine Plant" of the Incas. New York: J.H. Vail. Newcomb, M.D., and P.M. Bentler (1986) Cocaine use among young adults. Advances in Alcohol and Substance Abuse 6(2):73-96. Novak, M., C.A. Salemink, and I. Khan (1984) Biological activity of the alkaloids of Erythroxylum coca and Erythroxylum novogranatense. Journal of Enthnopharmacology 10(3):261-274. Paly, D., P. Jatlow, C. Van Dyke, F. Cabieses, and R. Buck (1980) Plasma levels of cocaine in native Peruvian coca chewers. Pp. 86-89 in F.R. Jeri, ed., Cocaine 1980. Lima: Pacific Press. Parke, Davis & Co. (1885) Coca Erythroxylon and its Derivatives. Detroit, Mich.: Parke, Davis & Co.. Plowman, T., and L. Rivier (1983) Cocaine and cinnamoylcocaine content of Erythroxylum species. Annals of Botany 51:641-659. Pratt, H.E. (1943) The Personal Finances of Abraham Lincoln. Springfield, Ill.: The Abraham Lincoln Association. Resnick, R.B., and E. Schuyten-Resnick (1976) Clinical aspects of cocaine: assessment of cocaine abuse behavior in man. Pp. 219-228 in S.J. Mule, ed., Cocaine: Chemical, Biological, Clinical, Social and Treatment Aspects. Cleveland, Ohio: CRC Press. Rivier, L, ed. (1981) Coca and cocaine 1981. Journal of Ethnopharmacology 3(2&3). Roehrich, H., and M.S. Gold (1988) 800-Cocaine: origin, significance, and findings. Yale Journal of Biology and Medicine 61:149-155. Rusby, H.H. (1888) Coca at home and abroad. Therapeutic Gazette IV:158-165, 303-307. Sabbag, R. (1976) Snowblind. Indianapolis, Ind.: Bobbs-Merrill. Searle, W.S. (1881) A New Form of Nervous Disease Together with an Essay on Erythroxylon Coca. New York: Fords, Howard, & Hulbert. Siegel, R.K. (1977) Cocaine: recreational use and intoxication. Pp. 119-136 in R.C. Petersen and R.C. Stillman, eds., Cocaine: 1977. NIDA Research Monograph 13. DHHS Pub. No. (ADM) 77-741. Rockville, Md.: National Institute on Drug Abuse. Siegel, R.K (1980a) Cocaine substitutes. New England Journal of Medicine 302:817-818.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Siegel, R.K. (1980b) Long-term effects of recreational cocaine use: a four year study. Pp. 11-16 in F.R. Jeri, ed., Cocaine 1980. Lima: Pacific Press. Siegel, R.K. (1982) Cocaine smoking. Journal of Psychoactive Drugs 14(4):277-359. Siegel, R.K. (1983) Cocaine: new issues for defense and prosecution. Drug Law Report 1(5):49-59. Siegel, R.K. (1984a) Changing patterns of cocaine use: longitudinal observations, consequences and treatment. Pp. 92-110 in J. Grabowski, ed., Cocaine: Pharmacology, Effects, and Treatment of Abuse. NIDA Research Monograph 50. DHHS Pub. No. (ADM) 84-1326. Rockville, Md.: National Institute on Drug Abuse. Siegel, R.K. (1984b) Cocaine and the privileged class: a review of historical and contemporary images. Advances in Alcohol & Substance Abuse 4(2):37-49. Siegel, R.K. (1984c) Cocaine smoking disorders: diagnosis and treatment. Psychiatric Annals 14(10):728-732b. Siegel, R.K. (1985a) New patterns of cocaine use: changing doses and routes. Pp. 204-220 in N.J. Kozel and E.H. Adams, eds., Cocaine Use in America: Epidemiologic and Clinical Perspectives. NIDA Research Monograph 61. DHHS Pub. No. (ADM) 85-1414. Rockville, Md.: National Institute on Drug Abuse. Siegel, R.K. (1985b) Treatment of cocaine abuse: historical and contemporary perspectives. Journal of Psychoactive Drugs 17(1):1-9. Siegel, R.K. (1985c) The war on drugs: the natural history of supply and demand and organized crime. Report prepared for the President's Commission on Organized Crime. Washington, D.C. Siegel, R.K., M.A Elsohly, T. Plowman, P.M. Rury, and R.T. Jones (1986) Cocaine found in herbal tea. Journal of the American Medical Association 255(1):40. Smart, R.G. (1982) ''Crack'' cocaine use in Canada: a new epidemic? American Journal of Epidemiology 127(6):1315-1317. Smith, J. (1982) Challenges to drug paraphernalia laws. Drug Law Report 1:1-9. Smith, M.V. (1981) Psychedelic Chemistry. Mason, Mich.: Loompanics. Spotts, J.V., and F.C. Shontz (1976) The Life Styles of Nine American Cocaine Users: Trips to the Land of Cockaigne. NIDA Research Issues 16. DHHS Pub. No. (ADM) 76-392. Rockville, Md.: National Institute on Drug Abuse. Spotts, J.V., and F.C. Shontz (1980) Cocaine Users. New York: Free Press. Sramek, J.J., W.A. Baumgartner, J. Tallos, T.N. Ahrens, J.F. Meiser, and W.H. Blahd (1985) Hair analysis for detection of phencyclidine in
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment newly admitted psychiatric patients. American Journal of Psychiatry 142:950-953. Starks, M. (1982) Cocaine Fiends and Reefer Madness. East Brunswick, NJ.: Cornwall Books. Thudichum, J.L.W. (1885) The Coca of Peru and its Immediate Principles: Their Strengthening and Healing Powers. London: Bailliere, Tindall and Cox. Tibbles, W. (1877) Erythroxylon Coca: A Treatise on Brain Exhaustion as the Cause of Disease . Helmsley, U.K.: W. Allenby. Washton, A.M., M.S. Gold, and A.C. Pottash (1986a) Crack. Journal of the American Medical Association 256(6):711. Washton, A.M., M.S. Gold, and A.C. Pottash (1986b) "Crack." Early report on a new drug epidemic. Postgraduate Medicine 80(5):52-54, 57-58. Wisotsky, S. (1983) Exposing the war on cocaine: the futility and destructiveness of prohibition. Wisconsin Law Review 6:1305-1426. Wynne, R.D., M. Blasinsky, P. Cook, L.A Landry, and S. Murphy (1980) Community and Legal Responses to Drug Paraphernalia National Institute on Drug Abuse Services Research Report. DHHS Pub. No. (ADM) 80-963. Rockville, Md.: National Institute on Drug Abuse.
Representative terms from entire chapter: