History of Cocaine and Crack Use (in the US)
Chapter 3 - Approaches to Treatment (member's section)
Appendix A ~ Bibliography (member's section)
Chapter 4 ~ Practical Application of Treatment Strategies (member's section)
Appendix B ~ Worksheets (member's section)
Chapter 5 ~ Medical Aspects of Stimulant Use Disorders (member's section)
Appendix C ~ Screening Tests (member's section)
Chapter 6 ~ Treatment Issues for Special Groups (member's section)
Appendix D ~ Glossary (member's section)
From Cocaine to Crack
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In the early 1980s, thousands of people began to seek treatment to help them with their struggle to stop using cocaine. The U.S. health care system was rapidly overwhelmed. To many treatment experts who had spent their careers treating heroin addicts and alcoholics, the idea that someone would require “treatment” to discontinue cocaine use was a novelty. Among the first questions asked of the individuals seeking treatment were, “What do you need treatment for?” and “Why don't you just stop using?”
Today, much more is known about addiction to cocaine and other stimulants. Although researchers, clinicians, and treatment providers have gained insights into why it is so difficult for stimulant users to stop using and why they need treatment, it is only recently that the substance use disorder treatment field has determined the most appropriate treatment approaches for these individuals.
When the U.S. cocaine epidemic was just beginning, there was a generally held assumption, even among addiction experts, that cocaine was not “truly addicting.” A popular joke during this period was that “cocaine is God's way of telling you that you have too much money.”
The cocaine epidemic that began in the 1970s peaked in the 1980s and slowly declined in the mid 1990s (Golub and Johnson, 1997). The pattern was similar to the first epidemic that occurred 30 years after cocaine hydrochloride was first isolated from coca leaves in 1885. During the first epidemic, physicians mistook cocaine's powerful stimulant properties as a cure for depression, morphine addiction, chronic tuberculosis, and a long list of other disorders. Physicians and other “healers” prescribed the drug for a range of maladies, and cocaine soon became the major active ingredient in many popular medicines, tonics, and elixirs (including the original formulation of Coca-Cola®).
Early Legal Responses
Eventually, however, the adverse effects of high-dose and consistent use were recognized. This recognition soon led to legislative responses. First, the Pure Food and Drug Act of 1906 required the proper labeling of cocaine “and other narcotics” on proprietary medicines. Second, the Harrison Narcotic Control Act of 1914 virtually eliminated the use of cocaine-containing patent medicines by forbidding their manufacture and sale. But cocaine did not simply go away, and sometime after 1970, a complex set of social and economic circumstances conspired to prompt its return. Increased demand for the drug initially drove supply, and subsequently, its widespread availability and reduced cost fostered greater demand and abuse.
The cocaine epidemic of the 1980s and early 1990s affected a broad spectrum of American society, with the advent of crack cocaine hitting major cities the hardest. A less publicized and more geographically circumscribed stimulant epidemic is the rise of methamphetamine (MA) in the West and Midwest. The spread of MA has brought many of the health, legal, and social problems like those associated with cocaine to smaller and more rural communities.
These stimulant epidemics have had a devastating impact on American society. The impact of illicit stimulant abuse has affected international politics, the U.S. legal system, and the U.S. health care system. “Freebasing”, “crack houses,” and “coke fiend” have all entered the American lexicon to describe elements of the stimulant epidemic.
Current level of public awareness
As the end of the 20th century nears, the powerful psychostimulants cocaine and MA and their derivatives have joined opiates and alcohol as primary targets in the efforts to combat substance abuse and dependence. But on the positive side, the pressing need to effectively deal with stimulant epidemics and treat people with stimulant use disorders has produced a tremendous amount of scientific and clinical research. The results of this research have broadened our knowledge of the human brain and expanded our understanding of substance use disorders.
The slow response of major U.S. (and Canadian) institutions to the dangers of cocaine and MA was partly due to an ignorance of the basic biological and psychological effects of these powerful psychostimulants. The knowledge gained over the past two decades on the properties of these substances can help treatment providers and other health professionals to understand, prevent, and treat the problems created by the use and abuse of cocaine and MA. This Treatment Improvement Protocol (TIP) summarizes the latest research as well as first-hand clinical experience of substance use disorder treatment professionals.
Purpose of the TIP:
Since the mid-1980s, there has been an explosion of knowledge about the effects of cocaine and MA. Because these psychostimulants alter the functioning of the body and the brain so profoundly, physicians, nurses, psychologists, social workers, marriage and family counselors, and substance abuse counselors must understand the profound biological aspects of stimulant addiction. New areas of expertise include the relevant pharmacology, neurobiology, psychiatric and psychological manifestations, and appropriate treatment approaches for stimulant abuse and dependence. The new findings suggest that neurological impairments may last up to 2 years after cessation of stimulant use (Hoff et al., 1996; Melega et al., 1997a).
Importance of Science in Building the Treatments Of the Future:
The Consensus Panel believes that scientifically derived knowledge should serve as the foundation of treatment for stimulant use disorders. Findings from basic and clinical research efforts funded by the National Institute on Drug Abuse (NIDA), as well as other government and private institutions, have given treatment providers an entirely new set of strategies and tools to assist those with stimulant-related clinical disorders. The field of stimulant use disorder treatment presents the perfect opportunity to move the role of scientifically based approaches into the forefront of the treatment effort. There is very little in the way of a “traditional treatment system” for stimulant use disorders, and therefore, there should be fewer “turf battles” over the implementation of new treatment approaches.
The Consensus Panel recognizes that most traditional treatment approaches are still viable and highly regarded by providers, and that new treatment techniques may be initially viewed with distrust. Continuing research and clinical experience will ultimately reveal the efficacy of such treatments.
Scope of the TIP:
For purposes of this TIP, the substances included in the category of "stimulants" include the derivatives of the coca plant (cocaine hydrochloride and its derivatives) and the synthetically produced amphetamines, with emphasis on the major illicitly produced and abused drug of this category, MA (in its various forms).
Certainly there are other stimulants that are more widely used (e.g., caffeine) and that produce major health and social problems (e.g., nicotine); however, an extensive discussion of issues associated with these substances is beyond the scope of this document. Although considered drugs of abuse, MA analogs--compounds with similar molecular structures but not necessarily similar effects, sometimes called "designer drugs"--such as MDA (3,4-methylenedioxy-amphetamine) and MDMA (3,4-methylene-dioxymethamphetamine)--have not been studied adequately for inclusion in this document.
A Brief History of Stimulant Use in the United States: Cocaine
Cocaine hydrochloride is extracted from the leaves of the coca plant (erythroxylon coca), which is indigenous to the Andean highlands of South America. In its extracted and purified form, it is one of the most potent stimulants of natural origin (Drug Enforcement Agency [DEA], 1995). For thousands of years, the Native Americans in the Andean region have chewed coca leaves to relieve fatigue, much as present-day Americans chew tobacco. Just as tea and coffee are brewed as refreshments or “pick-me-ups,” the Andean natives brewed coca leaves into a tea. Furthermore, Andean groups have historically burned or smoked various parts of the coca plant as part of their religious and medicinal practices (Siegel, 1982). However, none of these other uses has had the same impact as purified cocaine hydrochloride.
German chemist Albert Niemann recognized the stimulant properties of the cocaine plant, and in the mid-1800s (ca. 1862) extracted the pure chemical, cocaine hydrochloride. In the early 1880s, the drug's anesthetic properties were discovered, and it was soon used in eye, nose, and throat surgery. As physicians and other prescribers became aware of cocaine's psychoactive properties, it was widely dispensed for anxiety, depression, and addiction treatment (primarily for morphine use).
Coca-Cola® ~ Coke adds Life…
Extravagant claims of its curative powers increased cocaine's popularity; by the early 1900s, it was the main active ingredient in a wide range of patent medicines, tonics, elixirs, and fluid extracts. It is believed that the original formula of Coca-Cola® that was developed in 1886 by Georgia pharmacist John Pemberton contained approximately 2.5 mg of cocaine per 100 mL of fluid (Coca-Cola Bottling of Shreveport, Inc., et al., vs. The Coca-Cola Company, a Delaware Corporation, 769 F.Supp.671). This formula was sold as a headache cure and stimulant. Another pharmacist bought the rights and founded the Coca-Cola Company in 1892.
Harrison Narcotic Control Act of 1914
By the early 1900s, public health officials were becoming alarmed by the medical, psychiatric, and social problems associated with excessive cocaine use. These concerns from health officials and legal authorities played a major role in initiating and supporting the effort to pass the Harrison Narcotic Act of 1914. This Federal legislation severely restricted the legal uses for cocaine and, for all practical purposes, ended the extensive use and abuse of cocaine in the early part of the 20th century. Interestingly, cocaine hit a low during the 1930s when the advent of amphetamine almost eradicated demand.
From the time of the Harrison Narcotic Act until the 1970s, cocaine use was generally limited to groups on the periphery of society. Legal prohibitions and severely restricted supplies of the drug helped to maintain its low profile. But microcultures of cocaine snorters, swallowers, and shooters remained, and cultivation of coca plants continued in the South American countries that traditionally grew them--Bolivia, Peru, Colombia, and Ecuador.
As the cultural proscriptions against the use of drugs for recreational purposes weakened during the 1960s, cocaine again became part of the American drug scene. Its use increased along with the use of many other psychoactive substances. Snorting was the initial mode, and most experimenters were occasional consumers. They experienced the cocaine euphoria and generally went back to their “normal” lives. Because of this casual use, the fictitious notion arose that cocaine was harmless.
The advent of recreational use
In the 1960s, limited supplies and high prices combined to restrict the use of cocaine to relatively small amounts used by a small number of individuals. Although serious clinical problems were being connected with the use of hallucinogens, barbiturates, and amphetamines, little attention was given to the problems associated with cocaine use because they were rarely seen.
As recently as the late 1970s, many experts and public health officials believed that cocaine was a relatively benign substance and primarily of interest as a “recreational” drug. It was thought that only those who had access to very large supplies of the drug and/or those who were somewhat mentally unstable were at risk for developing problems with cocaine. A notable exception among these experts was the voice of two San Francisco addiction experts who sounded a prophetic warning about cocaine.
High abuse potential
In summary, cocaine is a central nervous system stimulant of moderately high abuse potential. At the present time the preferred route of administration is intranasal and the dosage patterns are relatively low. The social rituals surrounding the drug endorse primarily recreational use while the high cost and low availability of the drug produce the current low rate of cocaine abuse in the United States...
Most users now use cocaine by the intranasal route at moderately low dosages, while relatively small percentage use cocaine intranasally or intravenously at high dosages. However, if the drug were more readily available at a substantially lower cost, or if certain socio-cultural rituals endorsed and supported the higher dose patterns, more destructive patterns of abuse could develop. (Wesson and Smith, 1977, pp. 149-150)
Within 5 years of the observation by Wesson and Smith, both essential developments they predicted had occurred. The production of coca in South America expanded from a cottage industry of small groups of subsistence farmers into a major agricultural business that was financed by organized families or “cartels.” The manufacture and trafficking of cocaine became a multibillion-dollar industry, with profit margins high enough that governments and entire legal systems became corrupted by the influx of cocaine industry money. Supplies of cocaine into the United States increased exponentially. During the early to mid-1980s, according to DEA reports, the estimated amounts of cocaine entering the United States doubled and tripled year after year. These supplies of cocaine made the drug available in purer form and at a more affordable cost to consumers.
Cocaine and Crack
Cocaine hydrochloride is generally distributed as a white crystalline powder or as an off-white chunky material. The powder form is usually snorted intranasally. As cocaine became plentiful and less expensive in the early 1980s, its users began to experiment with its various forms and with different routes of administration. Some users began to smoke the powder form by mixing it with tobacco or marijuana. However, those who smoked the powder reported little if any intoxication. At the same time, users in South America began to smoke base (coca paste), which is one of the products from which cocaine powder is derived (Siegel, 1987). Coca paste is more concentrated than the powder form. Paste smokers report immediate intoxication, with effects similar to those reported by intravenous users.
The first hospital admissions for adverse effects of coca paste smoking were in Peru in 1972 (Jeri, 1984). The practice of smoking coca paste appears to have traveled to other countries via illicit cocaine trafficking corridors.
Drug traffickers in the United States learned of the effects of smoking base, but they confused its preparation with that of cocaine freebase, in which the cocaine alkaloid in cocaine hydrochloride is "freed" from the other components (Siegel, 1982). So it was quite by accident that this new process of "freebase" cocaine was discovered. However, its properties were quite unlike those of either coca paste or cocaine powder. Freebase cocaine does not dissolve easily in the blood or mucous membranes of the nasal passages, but it is readily volatilized and can be effectively smoked. The phenomenon of smoking this freebase form was first reported in California in 1974, and by 1980, its use was reported throughout the United States (Siegel, 1982). Today, chunks of the freebase form are most often known as “rock” or “crack.”
The next phase in the American cocaine epidemic came when cocaine traffickers saw an opportunity to expand the retail market by delivering to the consumer smaller, more affordable packages of the drug. Chunks of rock cocaine were soon being sold in small glass vials or plastic containers at a cost of $10 to $20. This new retailing effort made a product that was extremely desirable and inexpensive readily available to a much wider user base. The strategy worked extraordinarily well for the cocaine industry.
By late 1985 and early 1986, the retailing of freebase cocaine had swept through most urban centers of the United States. This form was introduced into new markets by highly organized and sophisticated distribution networks. In an effort to make the product distinctive, it was marketed under the new name "crack." There are numerous versions of the origin of the term “crack,” but the most likely is that as the freebase cocaine is being heated and volatilized into its smokable form, it makes a characteristic crackling or popping sound.
The crack epidemic was at its worst from 1985 through the end of the decade, although it still remains a serious health and social problem. The introduction of crack into urban communities produced devastating consequences. Health-related problems, rapidly escalating rates of addiction, and an extraordinary wave of street crime and property crime swept through most major American cities. In many areas, street gangs of young males were central to the distribution and sales of crack. Warfare between street gangs battling over turf resulted in many fatalities among gang members as well as innocent bystanders in the community. As drug-related crime escalated dramatically, legal penalties for sales of cocaine and crack were increased, and U.S. jails and prisons rapidly filled with crack users, dealers, distributors, and those involved in the violence associated with the crack trade.
By the mid 1980s, the use of crack cocaine had replaced heroin use as the main illicit drug problem in the United States. According to the 1997 NHSDA, the number of Americans who used cocaine within the preceding month of the survey numbered about 1.5 million; occasional users (those who used cocaine less often than monthly) numbered approximately 2.6 million, down from 7.1 million in 1985 (SAMHSA, 1998). Only recently have researchers been able to demonstrate a clear decline or stabilization in the use of crack cocaine in U.S. cities (Golub and Johnson, 1997).
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