COCAINE: WIDESPREAD BUT NOT HARMLESS

The cities of Rotterdam, Barcelona and Turin are studying the nature and extent of cocaine use in the three cities. Bert Bieleman and colleagues report on some results from Rotterdam

INTRODUCTION

Harm reduction has emerged as an approach that has been articulated most for heroin, where the harm to the individual and society is rather obvious. Although cocaine does not have the visible harmful effects of heroin, it is a topic that recently has been much talked about. There is evidence that cocaine has been used increasingly in the Netherlands in the last 10 years (Avicoetal.,1988;Cohen,1989;1ntraval,1989;Bieleman et al.,1990; Korf et al.,1990) . It is not clear, however, if and in what ways cocaine leads to problems or what the connections are to deviant and criminal behaviour. Concern about this prompted the City Council of Rotterdam, together with that of Barcelona, and later Turin, to commission an extensive study on the nature and extent of cocaine use in these three European cities. The study was partly financed by the European Community; the activities in the three cities were geared to one another and the Intraval design (1990) was adopted as the starting point of all three studies.

In Rotterdam information has been collected about 1161 cocaine users, comprising 110 respondents and 1051 nominees users about whom the respondents provided information (Spreen, 1992). A two-part questionnaire was used. The first part - an item list - provided information about the respondents for the analysis of the nature of cocaine use. The second part - questions with pre-coded answer categories about the nominees used to determine the spread and extent of cocaine use (Snijders,1991).

In this paper, we present some of the most important results of the study in Rotterdam (Intraval, 1992). In addition we discuss cocaine and problematic use, and some possibilities for prevention and intervention.

SOME IMPORTANT RESULTS

The use of cocaine occurs in all strata of the population, with the social backgrounds of the users showing wide variations. One-third have received higher education and one-fifth have attended lower technical school. Users are found among the employed and unemployed, school pupils, students and housewives. There is also a great variation in the sectors in which users are employed. The research population is roughly 75 per cent male and 25 per cent female. The average age of the respondents is 29 years. Cocaine use in Rotterdam is spread across various age categories, with concentration in the 20- to 30-year-old category. The average period of consumption is nearly 8 years. One-third of the respondents are using, or have used, opiates in addition to cocaine. At the time of the interview, one third of the respondents declared that they were no longer taking cocaine. The application of the developed estimators gives an estimation of approximately 12 000 cocaine users in Rotterdam. This is about 2 per cent of the total population in Rotterdam. These users have taken cocaine at least 25 times and/or 5 times within the last 6 months.

No other drug shows a greater diversity in the ways in which it is taken. Cocaine is sniffed, smoked, used through 'chasing the dragon', injected, smeared on gums or genitals, or swallowed. Sniffing is the most widespread method. More than half of the respondents use sniffing as their main method, followed by injecting (15 percent),basing (5 percent) and 'chasing the dragon' (3 per cent). A quarter of the respondents use cocaine in more than one way. The way in which the drug is taken largely determines the effect it has. Sniffing often appears to take place in a socially integrated setting, without too much personal or social inconvenience. Basing, injecting and 'chasing the dragon' are more risky methods of use. It often (quickly) leads to compulsive use and the problems associated with this. The chance of a user becoming addicted through using this method is quite high. Also sniffing is not wholly without danger - a small number of such users have developed a compulsive pattern of use. o

Eight categories of cocaine lifestyles have been identified in our study. They can generally be divided into three groups, according to the role of cocaine in the different lifestyles. In the first group (Burgundian, experience and situational type ), cocaine is of only limited significance. Cocaine does not play a dominant role in the lives of these people; there are no problems with the drug and the method used is mainly limited to sniffing. Within the second group (distinctive, hedonist and routine type), cocaine plays a more important role. It is used more often and in greater amounts. Some experiment with methods other than sniffing. The use of cocaine causes problems in different areas. These problems are sometimes solved by using less cocaine for awhile, but there is a return later on. These three types constitute a risk group which needs given attention. The third group (poly drug type and cocainists) has a lifestyle centred around cocaine. Individuals show a high frequency of use (daily) with large amounts being consumed (mostly by way of injecting or basing). In particular the cocainists state that personal problems were the reason for starting to take the drug. The poly drug type also uses heroin; however, when using cocaine, the problems develop a different and more serious character. It was in an effort to limit these negative effects of cocaine that some respondents started taking heroin.

COCAINEAND PROBLEMS

In our study more than half (55 per cent) of the respondents have had problems connected with the use of cocaine. This varies between feelings of hangover on the next morning to abscesses from injecting; the majority report problems of a psychological nature. Opiate users more often have problems caused by using cocaine than non-opiate users - 83 per cent and 40 per cent respectively. One-quarter of the respondents report serious problems connected with cocaine: they say they suffer from both physical, psychological, relational and financial problems, or they call themselves cocaine addicts. Opiate users are more often addicted to cocaine than non-opiate users - 51 per cent versus 11 per cent.

Sniffers have far fewer problems with cocaine use than respondents who base, inject or 'chase the dragon' - 36 per cent versus 92 per cent in the period of heaviest use. All injectors are heroin users, whereas some of the respondents who only use cocaine also base. Sniffers are less often addicted than the other respondents. There is no difference between opiate users and non opiate users who-use the same method as far as the occurrence or the nature of problems is concerned.

The idea is prevalent that problems with cocaine, especially addiction problems, occur only after a long period of use. The addiction aspect of cocaine should in this respect correspond more to alcohol addiction than to heroin addiction. However, no (significant) connection has been found between duration of use and the occurrence of problems. This lack of associations also holds for the relationship between duration of use and the sort of problems occurring. Significant differences are only noted when a distinction is drawn between opiate and non opiate users. Against expectation, non opiate users who use cocaine for less than 5 years have problems significantly more than non-opiate users with a longer period of use. For non-opiate users, there is also a connection between the occurrence of problems and stopping the use of cocaine: of those who have stopped, 79 per cent report problems connected with the use, for those who were still using cocaine at the time of the interview this was only 27 per cent. This points to the fact that a great part of the non opiate users cease taking cocaine as soon as problems occur. For opiate users such a connection between the occurrence of problems and abstinence has not been recorded.

More than one-third (38 per cent) of the respondents has (had) contacts with drug-assistance agencies (especially in the context of their cocaine use). Of those who said they had problems with using cocaine, almost two-thirds (64 per cent) have visited these agencies. Considering the greater amount of problems they encounter in their cocaine use, it is not surprising that opiate users (86 percent) have contact more often than non-opiate users ( 14 per cent). For opiate users, the main contact is with agencies that distribute methadone (70 per cent). It is important to note that half of the non-opiate users who are addicted and who have or had contacts with drug-assistance agencies have had these contacts only when in prison (CAD or probation service).

PREVENTION AND INTERVENTION

Although cocaine does not have the visible harmful effects of heroin, our study clearly indicates that cocaine is not such a harmless drug as has been claimed in the past. Addiction depends not only on the duration of use but, more particularly, on the method employed. Compulsive use occurs among opiate as well as non opiate users. Cocaine addiction appears to differ from heroin addiction. Popular opinion often refers to the 'psychological' dependence of cocaine, whereas heroin is said to produce a more 'physical' form of dependence . What the studies indicated is that a number of compulsive users stop on their own accord when excessive cocaine use leads to an overload of problems. In these circumstances aspects such as social-economic status and social bonds are important. Thus, the reduction of harm for society and the users of cocaine must be focused on how social bonds of the users which do not depend on cocaine can be reinforced.

It is predicted that, especially when basing and injecting become more and more popular, the number of cocaine users with dependence problems will increase, both among poly drug users and those taking only cocaine. This means that an increasing number of users will be in need of services from the (drug) assistance agencies. Noting the effect of cocaine, it is advisable in the consideration of new treatment methods that are more therapeutic in nature. In the USA, for example, behaviour therapy combined with antidepressants is widely used (Kleber, 1992). Another approach, the 'coping' model, derived from social workers may offer opportunities for targeted intervention. It is important to draw a clear distinction between provisions for the more socially integrated cocaine addicts and those for poly drug users . The former wish to avoid any identification with the latter.

In addition to good intervention programmes, information on the various facets of cocaine should be presented openly and clearly, and related to the different risk groups. We have to note, however, that it will not be easy to draw up an effective prevention policy which will embrace the different ways in which cocaine is used or its diverse effects. One individual may sniff for years without any problem. Another who is basing will often (and very quickly) have dependency problems and may be involved in criminality. It is vitally important that this difference between categories of users is emphasised and clearly understood. An additional risk factor for those who are injecting is the link with AIDS. Not only are dirty syringes a risk, unsafe sex is also one (MacDonald et al., 1988). Examples from the USA and the UK show that use of crack can lead to major social problems, particularly for the socio economically disadvantaged groups. This is linked to the compulsive working of crack and the criminal violence often linked to dealing.

Thus, prevention efforts need to be targeted, i.e. the different social strata need different prevention messages. These special features make it advisable for intervention and prevention to be oriented towards the lifestyles rather than the substance itself. At the same time, the interventions and prevention actions require multiple designs directed specifically towards the different situations that exist and the different risk groups. In any event, the information that is given out concerning cocaine, and the risks that can be involved in its consumption, should be presented clearly, openly and truthfully. It is as important to avoid being alarmist as it is to remove the myths from the substance and differentiate its effects.

CONCLUSIONS

Compared to heroin, cocaine is not by definition an addictive drug, for example it is a far less straight forward drug than heroin. Cocaine appears to be a drug with two different faces, depending on the method of use. Sniffing can apparently be pursued without too many negative, social or personal consequences. Basing, 'chasing the dragon' and injecting are more risky methods. They usually lead (in a short time) to compulsive consumption and the problems associated with this. Basing, in particular, also occurs among non opiate users. It appears, moreover, that cocaine is not such a harmless drug as some people claim.

We may expect that an increasing number of cocaine users, both poly drug users and those who are exclusively on cocaine, will seek help from the (drug) assistance agencies. Prevention efforts need to be targeted, i.e. the different social strata need different prevention messages. Seeing the effect of cocaine, it is advisable to consider new treatment methods that are of a more therapeutic nature, perhaps in conjunction with pharmaco therapies in the form of antidepressants. Furthermore, the provisions for the more socially integrated user must be clearly distinguished from those for the poly drug addict.

In addition, there is the danger of crack. This variation of cocaine has a strongly compulsive effect. Its use and dealing in the ~USA and the UK have already resulted in major personal and social problems. It is therefore vitally important that measures are taken to prevent this variation ( just as basing) from getting a firm foothold in Europe.

Bert Bieleman, Edgar de Bie and Cilia ten Den, Intraval, Bureau for Social-Scientific Research and Consultancy, Groningen-Rotterdam, The Netherlands

Charles Kaplan, IPSER/University of Limburg, Maastricht, The Netherlands

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