Changing Patterns of Cocaine Use: Longitudinal Observations, Consequences, and Treatment

2016

In 1858 the Austrian frigate Novara was sent to South America on a most unusual mission. The Novara was named after the city in which the Austrians had defeated the Italians, thereby stopping a threatening cultural and political renaissance. On board the Novara was a trade expert, Doctor Scherzer, who was intrigued by another Italian “renaissance” started by Milan neurolgist Paola Mantegazza. Mantegazza had published an 1857 paper proclaiming the medical importance of coca that he had chewed while a resident of Peru (Mantegazza 1857). The paper was the newest curiosity of the European medical community which even awarded Mantegazza a prize for this work in 1859 (Mortimer 1901). The Novara stopped in Peru and Scherzer took a quantity of coca leaves back to the great chemist Wohler at the University of Gottingen in Germany. Wohler’s assistant, Albert Nieman, named the isolated alkaloid “cocaine” in 1859/1860 (). The isolation and naming of the alkaloid signalled the start of 125 years of changing patterns of cocaine use. Prior to that time, only coca products were available, and the patterns of their use had not changed substantially in over 4700 years.

For most of its early history, cocaine remained hidden and unidentified in the protective envelope of the coca leaf. The coca plant (Erthroxylum spp.) produces at least 14 different alkaloids as defensive agents to ward off foraging animals. The bitterness, numbing, and psychoactive properties of these alkaloids perform this defensive function effectively, teaching animals to avoid the plant and thus contributing to its evolutionary survival. Interestingly, compared with other tropical American crops, coca is relatively pest free. Herbivorous insects are rarely observed on plants and damage to the leaves is relatively minor.

Accidental encounters with ingestion of coca exposed early man to the effects of its alkaloids. From 3000 B.C. to the middle of the 16th century, coca was used by the indigenous peoples of South America in religious, magical, medical, and recreational contexts. Little information is available on the psychopharmacological consequences of this use, but patterns changed very little during this period. The leaves were chewed whole or in powdered form, smoked with or without tobacco, or else swallowed in various infusions.

In 1580 coca was introduced to Europe, where it eventually, by the middle of the 19th century, found its way into widespread medical use. Coca products included preparations of leaves, extracts, wines, liquors, cordials, lozenges, cigars, cigarettes, and chewing gum, among many other forms. Patterns of use were largely confined to medical applications, although sane nonmedical uses were also reported.

After the isolation of cocaine in 1859/1860 by Nieman (a crude alkaloid, named “erythroxylon,” was isolated by Gaedecke in 1855), early experimentation revealed stimulant and local anesthetic properties (). The medical community became enthusiastic about this new wonder drug, the patent medicine manufacturers exploited it, and the nonmedical use of cocaine for pleasure began to grow rapidly. Fostered by glowing reports from the patent medicine advertisements, encouraged by the research and writings of Sigmund Freud (who was strongly influenced by Mantegazza), and pushed by the euphoria-enhancing techniques of intranasal and intravenous administration, the pattern of use began to change.

In addition to the numerous coca products, cocaine itself started to appear in flake crystals, tablets/ solutions for inject ion, ointments, and nasal sprays. Both coca and cocaine were also used in a variety of soft drinks and tonics, the most famous being Coca-Cola. Indeed, “during the seventeen years Coca-Cola contained cocaine [until 1903], the drink and drug became so closely identified that ‘dope,’ as in ‘let’s have a dope’ became the established, common term for Coca-Cola” ().

Observations on these patterns of use were made in both the medical and lay press during the early 20th century. Many of these articles suggested that cocaine was associated with uncontrollable addiction, physical and psychological deterioration, demoralization, and criminal violence. Federal legislation, beginning with the Pure Food and Drug Act of 1906 and the Harrison Act of 1914, effectively launched a period of cocaine prohibition by restricting and controlling all aspects of its manufacture, possession, sale, distribution, and use. Both the medical and nonmedical use of cocaine gradually declined, and general interest in the drug all but disappeared between 1930 and the late 1960s.

Cocaine continued to be used, albeit by relatively few users, during this period of prohibition. The primary route of ministration was intranasal, although the intravenous route was also employed. In the early 197Os, cocaine was “rediscovered” as a recreational drug of choice. As with its initial introduction a century before, contemporary users began to experiment with new preparations and patterns of use.

Cocaine: Short-term observations of users (1970-1983)

Long-term observations and changing legal status (1970-1983)

The period 1970 to 1983 was marked by a steady increase in virtually all aspects of cocaine use (). Importation of cocaine, paraphernalia sales, cocaine-related stories in the media, samples of cocaine submitted by users for analysis, hospital and treatment center admissions for cocaine, cocaine-related deaths, seizures of illicit cocaine, cocaine-related crimes and arrests, among many other parameters, increased dramatically.

The changing patterns of cocaine use, as well as changing attitudes, have been reflected in the nature of legal defenses raised in cocaine-related crimes during 1970 to 1983 (). Initially, cocaine was viewed as a “non-addictive” and non-narcotic recreational drug that was not as dangerous as the law maintained. The first evidentiary hearings on the scientific and medical nature of cocaine were held in Commonwealth v. Miller (366 Mass. 387,318 N.E.2d 909[D.Ct.1976]) in 1976. Here the constitutionality of cocaine’s classification as a “narcotic” was successfully challenged and the judge issued 125 findings of fact regarding the state of knowledge about cocaine as a relatively safe drug in typical patterns of social-recreational use. Defenses from 1976 to 1981 attempted to educate the trier of fact about these opinions and thus, hopefully, to temper the judgment and disposition of the cases. These defenses met with considerable success in lower courts, but higher courts have held that it is valid to classify cocaine as a narcotic for purposes of punishment. As cocaine use spread and effects of toxicity and dependency became recognized, defenses based on cocaine- induced diminished capacity or insanity started to emerge in courts. The effects of cocaine on criminal responsibility, on credibility of witnesses, and as a causative factor in accidental deaths or homicides were raised as mitigating factors in guilt or penalty phases of criminal trials. By 1983, cocaine appeared to be replacing phencyclidine as the novel drug defense of the decade.

The forensic issue that most clearly illustrates the changing patterns of cocaine use is the quantity necessary for charges of possession and sales. Some courts, particularly Federal courts, have permitted an inference of intent to sell to be drawn from the fact that a large quantity of a drug was involved, despite the absence of a statutory presumption. Thus, in the early 1970s possession of more than a gram of cocaine was often viewed as possession for sale. As users escalated their patterns and dosages, particularly with smoking cocaine free base, possession of larger amounts for personal use became more common. It was not unusual to find that intranasal users might possess a week’s supply of several grams or a cocaine smoker might use as much as 1 ounce or more. Consequently, by 1980 many jurisdictions viewed 1 ounce of cocaine or less as simple possession for personal use.

One aspect of a changing pattern in cocaine use was clear: there were more users in general, more intensified and compulsive users in particular, and more cocaine-related psychological, physical, and legal problems. Another aspect of this changing pattern was less clear: did individual long-term users manifest parallel changing patterns of cocaine use? In other words, do the recreational and circumstantial users cited in the above studies escalate use to more intensified and compulsive patterns of use? Does increased use of cocaine increase the incidence of negative and toxic effects? Is long-term use of cocaine inevitably associated with an escalating dependency marked by more frequent use? If not, what factors control and maintain stable patterns of chronic use? A longitudinal study of a small sample of users was begun in 1975 to provide information on these questions as well as the consequences of long-term use dur iry this period. Preliminary findings from the first 4 years of this study have been reported elsewhere (). Only those results relevant to the question of changing patterns of use will be discussed below.

Cocaine: Longitudinal study of users (1975-1983)

Overview

The year 1970 began with an increase in the nonmedical use of cocaine. Most users began as experimental users engaged in short-term, nonpatterned trials of cocaine with varying intensity. These users were primarily motivated by curiosity about cocaine and a desire to experience the anticipated drug effects of euphoria, stimulation, and enhanced sexual desire (). Some users experienced little or no drug effect, which supported their belief that cocaine was a subtle, over-priced drug undeserviry of continued use. Other users who experienced a “kick” or “rush” expressed a desire to continue use.

From 1970 to 1983 these users separated into various patterns of use and abuse. Short-term observations of these users suggested that intensified and compulsive patterns of use resulted in physical and psychological problems. Observations of users seeking clinical attention confirmed the presence of serious dependency, dysfunction, and toxicity. Longitudinal observations confirmed many of these findings but revealed that many users who adopt social-recreational patterns appear to control use with no escalation to more individual-oriented patterns, thus circumventing toxic crises.

Taken together, however, the increased frequency of negative effects and crisis reactions, the escalation of some users to canpulsive smoking of cocaine free base, the rising psychosocial and financial and legal costs, all indicate that the last 13 years of changing patterns of cocaine use have been the most unlucky of its 125 year history. Given the promise of cocaine as a “renaissance” of the 185Os, the “medical miracle” of the 187Os, and the “safe recreational drug” of the 197Os, these 13 years have also been disillusioning. As Mantegazza, who may have started it all, might have commented, as he did upon recovering from a coca intoxication full of blissful and fantastic images only to realize that they were mere hallucinations:

One sighs deeply or laughs madly.

(Mantegazza 1859, p. 39)

Summary

The literature describing contemporary cocaine use from 1970 to 1983 has been reviewed. Short-term studies published on users observed an initial period of social-recreational use supported by the belief that cocaine was safe. By the end of this period, both dosages and chronicity of cocaine use showed an escalation marked by increased adverse reactions. A longitudinal study tracked 99 social-recreational users from 1975 to 1983. By 1983, 41 users had dropped out of the study while eight others had stopped all use. Of the 50 continuing users still in the study in 1983, 25 remained primarily social users with few negative effects and no toxic physical or psychological crises. The remaining 25 users, while engaged in some social use, were more frequently involved in other patterns. Sixteen users frequently escalated to circumstantial-situational patterns marked by some toxic physical effects but no psychological crises. Four users developed intensified (daily) patterns of use with episodes of both physical and psychological crisis reactions. Five users became compulsive users, smoking cocaine free base, and experienced crisis reactions in approximately 10 percent of their intoxications. The majority of users attempted to treat the hyperexcitability and stimulation of excessive cocaine use with multiple drug use or self-initiated strategies of controlled use or short-term abstinence. It is concluded that many of the social users are capable of controlling use with no escalation to more individual-oriented patterns. Others, by escalating patterns of use, increase the risks of dependency and toxicity.

 

Selections from the book: “Cocaine: Pharmacology, Effects, and Treatment of Abuse”. John Grabowski, Ph.D., ed. Content ranges from an introductory overview through neuropharmacology, pharmacology, animal and human behavioral pharmacology, patterns of use in the natural environment of cocaine users, treatment, through commentary on societal perceptions of use. National Institute on Drug Abuse Research Monograph 50, 1984.