Drug Abuse

CHAPTER V DRUG DEPENDENCE COCAINE CHLORHYDRATE (CRYSTAL) USAGE

A habitual chronic user can consume between 500 and 1000 milligrams in 24 hours. An occasional user: will not be able to finish that quantity in weeks or months. After a long period of use, to obtain the original results, a double dosage increase or little more emerges. Few modifications are necessary from this average to reach the expected results. If the drug quantity is increased abruptly, unpleasant symptoms may appear, such as nausea, vomiting, muscular tension, severe anguish or states of panic. One gram, directly injected into the bloodstream produces respiratory or cardiac arrest.

On the other hand, when the average dose is not increased by much and the period of consumption is not prolonged more than what has been mentioned, once the drug has been metabolized completely, the delayed reactions can return with double the strength. There is fatigue, hunger and deep sleep. The need for drugs, if any, does not necessarily produce the compulsive behavior to search for drugs. In some cases a strong rejection to the drug may occur, similar, to what happens with alcohol. If the usage is limited to one day, for example, the following day, barely perceptible symptoms of depression or anxiety may appear or simply an uncommon fatigue may occur. In other cases, there are no post-intoxicating symptoms. But as the dosage increases and it is repeated daily, the deprivation will be followed by proportional depression and anxiety that will tend to perpetuate the use. Nervous irritability and bad humor are frequent manifestations of this mode.

If the doses do not surpass the 60 to 100 mg. (aprox.) daily, and in between are many days of abstinence, generally there are no observable physical nor emotional consequences. The same relationship exists between a person that drinks alcohol daily and the social or occasional drinker. The former will suffer a general progressive deterioration, while the latter will be considered a well adopted individual in a society where alcohol consumption is not only allowed but expected.

And just as it happens with alcohol or any other drug, there is another mode characterized by larger quantities of drug and periods of usage. This mode deals with true intoxication marathons, the type that lasts many days or cycles.

In reference to this point I let Lucifer speak. He is a 37 year old, married, white male, who comes from a traditional family from La Paz. He has studied two years of psychology and received medical treatment under my supervision since 1985. He does not have prior medical-psychiatric or psychological treatment.

TRIP EXPERIENCES

...I tried cocaine for the first time in 1972 in Mexico, when I was 23 years old. I did not notice any effect. Later, already in La Paz, in 1975, because my relationship with a group of artists and the great availability that there is in our country, 1 began to use cocaine in greater quantities. Before 1970, 1 also consumed marihuana only sporadically, and mostly on weekends. At that time 1 had my first LSD (lysergic acid) experience. Later, I took Benzedrine for about a three month period. At present 1 do not take any amphetamines, because 1 consider them a lousy drug.

I have used cocaine (hydrochloride) for 11 or 12 years. When 1 am in Bolivia I use it daily. I have two ways of using it. If I have a enough quantities, 1 use it for four days without sleep. One can reach different levels in this manner than, for example, when one snorts for only one night. The quantity as well as the effect varies every 20 hours that pass. This means that 1 have three cycles of 20 to 24 hours each. Daybreak of the first cycle is the most critical of all, especially if I started early at night. Tension is very high.

Night, that is all tranquillity and absent of ticking time, ends. The sun with its light, brings movement, noise, and schedules. The latter is felt even if 1 have nothing to do during the day. This tension brought upon by the daylight, expresses itself generally with the difficulty to talk fluently, due to a hoarseness or a hardening of the vocal cords. The speed of thought does not correspond with the ability to speak, so one arrives at "amuquismo" or "mouth shut" which is quite common and usually starts around three o'clock in the morning. Sunlight hurts the eyes. Hearing becomes very sensitive; the street noises seem stronger than usual. This sensation is quite intense. If 1 feel tired, I use a higher dose than normal every ten minutes. When the tiredness fades, around eleven o'clock in the morning, in that state of mind there is little desire to go out. You are left with a serious facial expression due to the poor mental coordination; thoughts are quicker than normal and the body is adopting to that speed. It could be said that the "po" (coke) is massaging the encephalic mass for it to accept the speed and coordinate the functions between the body and the senses. By four o'clock in the afternoon, tiredness arrives. It is counteracted by absorbing enough "po", some three to four lines, of the same quantity used at eleven o'clock.

Up until this moment I have had no desire to eat, but am extremely thirsty and have an equal desire to smoke. I am quite sparing in words and wish to be alone. Reading is one of my pastimes for these moments. Sometimes 1 have the tendency to be accelerated at morning and at the beginning of the afternoon. There is a tremor in my hands or internally. It is rare that before the first cycle that I leave the house, since one is in a complete mental state. There is the idea that one may not be able to act normally once out of known territory, or home. If one does go out, overcoming this idea, the moment you and close the door behind you, one adjusts to the outside hustle with little difficulty and does whatever must be done. This requires little practice and, of course, only if it is necessary.

Entering the second cycle, tiredness has been surpassed and one goes from one moment to another, into a very different state of mind. It can be said that the "po" has already finished massaging the encephalic mass and the coordination of mind, body and senses begins to occur. A state of alertness and quickness coordinated in the whole being is expressed quite free and extroverted. To go out and socialize is no longer inconvenient. The mental state is at a very fast pace, concrete and continuous. Because of this, it is easier to achieve objectives, to define and to plan. You must only remember that you are going quicker that any logic or analysis.

By the 30th to 35th hour one can eat. Only the amount necessary should be eaten, without going beyond that point. The quantity of cocaine used drops a little in relation to the day before and the laps are longer between dosages. If in the first cycle one snorted a line every ten minutes, in the second cycle it should be every 20 to 25 minutes.

Between the 45th and 50th hour, another moment of tiredness arrives, which also goes away with an extra dosage of 4 to 5 of lines in about 20 minutes. The third stage is far more speedy. Once in it, one has the tendency to talk about abstract matters, philosophy or politics. Because the mind or the intellect acts too fast, it is difficult to hold any conversation with people that are not in the same state of mind. Because of that, one becomes sarcastic.

It is not negative, but rather mocking.   Sharp but not hurting. Jokes are made for everything. Near the 60th hour there is a great necessity for rhythm, and dancing becomes imperative. Even the voice itself acquires melodic tones and the body becomes very elastic.   It is imperative to have fun. The consumption clearly diminishes, it is only necessary to take a line every 30 to 40 minutes and sometimes even up to an hour or more.

The fourth cycle can be reached, but it is more satisfactory to finish it on the third. In the second and third cycle appetite is normal and there is no indication of paranoia, instead the opposite happens, there is a lot of security. Oral expressions as well as manifestations are intense. This fact is perceived by people around you. By the end of the third cycle, speech is faster and one must pay attention, otherwise one runs the risk of not being understood. In respect to sex, on the first day there isn't a great physical response. Erection is not complete and only if one is lucky, they will arrive at an orgasm. On the other hand, on the third day, sexual activity is intense. There is a long, hard and continuous erection, eroticism is more intense and freer.

Reading comprehension improves as the cycles pass. On the third day there is a better grasp than on the first day. The recollection of the reading is permanent and much more clearer than without the effect of "po". Conversation has higher levels than on the other levels. It can be said that thought is linear, it starts on A and finishes on A; clear and definite conclusions can be arrived at. Of course, to enjoy all this, the environment is very important. More than three people together under the same effect would find it difficult to experience harmony. Music and rhythm have a lot of importance. To do it between two persons or as a couple is ideal. Above all it must not be combined with other drugs, such as alcohol, marihuana or any others. After eating., it is imperative to take a strong dosage, if not, sleepiness and fatigue dominate the body. Of course there is no better moment to inhale than after a meal. For these cycles one has to eat well and sleep long but no longer than 14 hours, or a strong feeling of heaviness will occur when waken up. (La Paz - August 1985)".

Lucifer's report has neologisms that are not his exclusively. They belong to a kind of subculture that is conformed by psychoactive users. The term "jalar" means to inhale cocaine through the nostrils. Po is a word derived from Portuguese and means powder (cocaine). Lines are some 80 to 100 mg., of cocaine crystal arranged in lineal form, usually over a mirror or glass.

The observation of these "cocaine crystal marathon runners" allowed me to verify the absence of the withdrawal syndrome, the physical addiction and tolerance, that in these cases, due to the quantity and time of prolonged usage, should have presented itself. To my surprise, I have been, able to see that the withdrawal of the drug, whether by being forced to be away from it, by own will or any other reasons, was not followed by symptoms that indicate physical necessity of the drug. Hours after the intoxication has terminated, deep sleep occurs, which is only interrupted by biological, basic needs, above all the need to eat voraciously. At the moments of vigil, the following may be observed: disorientation in regard to time,

difficulties in evoking recent memory, and difficulties in concentration and in all high mental functions. The emotional state is unstable with generally unjustifiable fleeting bursts of fury. The anxiety and depression levels are variable and increase later on. Nevertheless, at least in the cases I have observed, these states can be more or less manageable and do not prevent the social and familiar development of the habitual user.

According to the previous personality, the psychological equilibrium, the physical state and the environmental conditions, can present themselves, during the course of excessive intoxication, typical cases of paranoid states or panic fits. Which we will see in depth with the study of cocaine sulfate, because it is there and not here that the phenomena is the rule.

During these marathons of intoxication it is easy for the daily usage to surpass the four grams (I have seldom found dosages of 6 to 8 grs.). Following the withdraw phase, that may last days, weeks or

months, the usage can be reduced to a gram a day, every other day or even weekly, with variable difficulties to overcome the need to increase the dosage. The habitual user that can achieve this control, can develop nonnally in their daily activities. The abstinence intervals from this chronic modality, are invariably followed by a depressive rebound effect, that it is manifested by bad humor, irritability, permanent tiredness and prolonged dreaming.

The post-cocaine depression and exhaustion states may be due to the psychological need to remain in levels of extra stimulation, such as the one the drug offers, or to an exhaustion of the norepinephrine and its precursors and of the organism energetic reserves. This, in return, forces the subject to search for a quick equilibrium, using the drug even more frequently which in turn deepens the exhaustion, closing the circle and establishing the psychological drug dependency.

In almost all cases where there is this type of abuse of cocaine chlorhydrate, I have been able to find within the habitual user's previous history, depressive states of the most varied origins: exogenous and endogenous, losses in life, defic ient social-economical adaptation, dependent personalities, low tolerance for frustration, etc.. These states in turn, create conditions for easy dependency if this kind of individual get into contact with the drug. Really, it is a desperate and intuitive search of treatment. An empiric, defective and uncontrolled self medication, which only results in the worsening of the previous depression. The absence of help or medical control and the poor quality of the drug, both a result of the drug being illegal, worsen the outcome.

Nevertheless, this phenomena is not privative of the leaf's alkaloids. The same happens with tranquilizers, barbiturates, amphetamines and especially alcohol, which is consumed by a majority of the population. And just as not everybody that drinks occasionally becomes an alcoholic, neither does everybody that occasionally consumes cocaine crystal become cocaine addicts. For a dependency to exist, a potentially dependent subject is necessary. The drug, or object of dependency, is chosen because of its availability or easiness to obtain it, more than by the patient's free choice. That is why the incidence of alcoholism is much higher, not only in Bolivia, but in the whole world.

I had the opportunity to verify these facts through the study of cocaine crystal "social" users (moderates or occasional ones). The majority are people relatively equilibrated and socio-economically well adapted. Eighty percent belongs to the upper or upper middle class. More than 70% are between the ages of 20 and 40; the rest are older. Almost all are professionals, artists, businessmen or successful politicians. The majority use hydrochloride with the same frequency that they use alcohol, as an antidote against drunkenness or to prolong the entertainment. A minimal percentage uses pure cocaine chlorhydrate to increase their physical or intellectual output, without mixing it with alcohol, as students do, to prolong their night working hours. Few young women use it to lose weight, meanwhile others like its aphrodisiac powers. We must mention the central role that cocaine plays in orgies that the inhabitants of the metropolis like to engage in. It is also difficult to imagine, for example, the long and exhausting days of dancing and continuous sex in the carnivals of Rio de Janeiro without the extra energy provided by stimulants.

Generally, between the "social" users of cocaine crystal, the quantity does not go over a couple of grams a month (30 to 50 mg. per dose). Its use is usually limited to weekends. Daily use is extremely rare; it is generally used only at night. In almost all the cases that are within this parameter, the use of cocaine does not represent a problem in the life of the subject. Some consulted me for other problems than for the use of drugs, generally for crisis or existential emergencies that they ought to overcome with my help. I learned of their habit casually during the analysis. In many cases, at the request of the family or family doctors that refer them to my care, the patients searched for information due to feelings of guilt or fear for their habit.

Aside from this occasional use, that is considered just as normal or common as the use of alcohol, there exists another group with emotional problems that we discussed and that characterizes the

campaigns against the cocaine plague. In any case, it would rather be about a plague of psychic unbalance, in many cases depression, that lashes out at the civilized world. Or can we refer to the elevated needs for quinine caused by a surge of malaria as a quinine epidemic?

COCAINE CHLORHYDRATE: General Conclusions

Cocaine chlorhydrate besides it's quality as a local anesthetic is a potent stimulant with possibilities for a quick action anti-depressive use far less toxic than amphetamines that at present are legal, aside

from their proven toxicity. If we talk about an anti-depressive drug, we are talking about a medicine that, when administered, must be done carefully and under medical control. In any case, as I will discuss later on. If cocaine's anti-depressive qualities are going to be dealt with, it seems to me that the use of extracts from the whole leave are more effective and safe.

Researchers, such as Van Dyck and Robert Byck, state: "...deaths occurred by cocaine crystal use are very rare; there is little evidence of physical harm due to coca chewing; that its chemical derivative,

cocaine, is a safe drug, provided that it does not get in hands of unbalanced people that can use it with self destructive aims".

SOME SOCIAL ASPECTS ON COCAINE CRYSTAL USE

Even though Bolivia was one of the mayor coca leave producers, (today Peru is in front, and there are enough signs indicating Brazil as other mayor leave producer), the usage of its chemical derivative, cocaine crystal, has very little social significance. The cocaine crystal marathon runners form a small group of habitual users, that only due to legal or emergency reasons felt forced to visit me. Almost all of

them, belong to socio-economic upper levels, and because of this they have enough time and money to dedicate themselves to such a dangerous occupation. Even if we take into account occasional users, the incidence is quite low in relation to other medical problems, such as alcohol, barbiturates and tranquilizers.

This phenomena can be explained by the kind of trade that Bolivia has. There are thousands of rudimentary factories of cocaine paste in Chapare and Yungas that allow for access to this product for countless people of low socio-economic level. Cocaine crystals are available only from a few cocaine chemists, makers of a more expensive product, that does not have an economic incentive in the domestic market and is therefore exported almost immediately after leaving the laboratory. Thus establishing the so called "cocaine crystal ant traffic", represented by a few kilos that the trafficker takes out of the country hidden in their luggage or body.

COCAINE SULFATE (PASTA)

This is the first step in the extraction of the alkaloid. From the chemical point of view, the impure sulfate, is in fact a coca concentrate. The radical sulfate is due to the use of sulfuric acid as the principal reagent, in this first stage and it is also responsible for the anhydride sulfurous that is made when pasta is smoked. Lime, sodium carbonate and kerosene are also necessary components of the pasta, as well as many impurities that result from this rudimentary production, such as: plastic containers, gum boots (not always acid resistant) and, in the majority of the cases, the bare feet of the pisa coca (a coca leave presser). The protein, vitamin and mineralogical components, generate countless numbers of chemical compounds whose influence in human physiology is totally unknown yet.

In the best of cases, cocaine represents only a 30% of sulfate. This chemical diversity of the pasta is enough to explain the serious toxic effects of this phase, a prior state of cocaine. But I believe that it is also the way of administration that is responsible for this substance's devastating effects on the, organism.

FORMS OF ADMINISTRATION

The cocaine pasta is consumed through the pulmonary passage. The drug mixed with tobacco is burned as a common cigarette. It contains approximately 30% pasta and 70% tobacco. This loaded cigarette is manufactured by the user and it is known as pitillo o bazuco in the Bolivian oriental region. Another frequent way of trade within the high land (altiplano) people is a little pipe, made from tin paper called toco, adding another toxic element to the already venomous pasta. The burned tin-plated paper, along with the smoke coming from the burning pasta, is absorbed and retained in the lungs for a few seconds.

EFFECTS OF PASTA IN LOW DOSES

A 80 to 100 mg dose, is what we can call a low dosage. It produces the same effects of cocaine crystal in the organism: general acceleration or increment of basal energy and of the emotional tone.

Nevertheless, the effect is much faster and briefer. Just as the dosage and time increases, the pasta effects differ radically from the effects of cocaine crystal. In just a few minutes, the effects start to disappear, and one has the desire for a new dose to maintain the level.

EFFECTS OF PASTA IN HIGH DOSES

On the other hand, if the initial dose is around 200 mg. or more, depending on the user, the famous flash or high of pasta is reached: a broadening of the forehead and basically, a pleasant state similar to a sexual orgasm, although not genital, is felt. The sensation localized mainly in the chest is one of plenitude, satisfaction or peace. There seems to be a closer unity or contact with life, a greater perception of oneself, that lives and perceives that exact moment. "A sweet taste of sex impregnates the immediate atmosphere, but not a normal sex, a prohibited sex, sinful, as the thousand promises of the exotic Babylonian prostitute" (Lucifer).

Nevertheless, that association to the sexually prohibited, appears to remain as just that, because in the majority of the cases of high doses of pasta, contrary to the cocaine crystal effect, difficulties for erections and inclusively a manifested rejection to sexual activity occur. This constitutes one of the facets which I have called the pasta's great paradox.

The flash or high of pasta, known as such most likely because of the fugacity with which it happens, disappears in a matter of seconds. All the sensations that it created deflate, leaving in its place a unpleasant sensation of emptiness, the void of dissatisfaction that vividly contrasts the previous semi orgasm. The sensation of having come close to a very pleasant effect with the need to finish, to fill the voi, are more than urgent. It is easy to believe that the next dose will definitely be the one that will reach the ecstasy, rushing to take it.

It is the same as an incomplete orgasm that immediately impulses the search to reach one. The desire flash never arrives, despite the effort and certainty that the user has of reaching it. The repeated doses, one after another, aggravate the need for pleasure that it is searched for with the new dose. The void grows more each time, like a snow ball effect, that drags the user like a puppet without will. He has put himself in a pendulum that oscillates between reaching pleasure and reaching pain. The journey is the pasta and the return is absence.

The well known fascination that the abyss exerts on the diver, to the point of totally absorbing him, is a good illustration for these strange phenomena of the world of pasta. In both cases, the drug user, such as the diver, travels fascinated in search for the extraordinary promise of pleasure beyond what already is experienced. But they only find destruction, a fact that becomes quite evident for the drug user. At least the divers are adverted from this danger, which they leam to overcome. The pasta user, most of the time, before he realizes it, is caught by the fascinating song of the Great Prostitute of Babylon, as defined by Lucifer.

The new dose leads to the next one and days, weeks and inclusively months of continuous use can go by, in which among few people, some kilos can be consumed. They become unaware of themselves in search of the ultimate unknown pleasure: the lost paradise.

The activity of compulsively repeating the dosage, so appealing of the pasta, acquires grotesque or caricature characteristics within a short time of commencing the use. The ritual of preparing-lighting-smoking monopolizes the user's activity to an incapacitating level. All other activity becomes second rank. In best of cases, it is replaced by other equally compulsive acts such as the searching for the drug in their pockets, on the floor, or to revise the body meticulously in search of irregularities, scabs, pimples, etc. At times it can even reach tactile hallucinations.

In the beginning, the drug may well cause loquacity, but it finishes on sterile verbiage. When the dose is increased, a tendency of non-communication overcomes the user. Isolation is the rule. The shut mouth of the pitillero (pasta smoker), may have its origin not only in the high indexes of anxiety that go along with high doses, as we will see later, but also in a contraction of the chewing muscles, to an anesthetic level of the buccal cavity, specifically on the tongue, and certainly in an acceleration of the train of thought, that does not correspond with the larynx.

The increased state of vigilance and alertness due to the low doses of pasta quickly degenerates, as the dose increases, into an in crescendo anxiety which characterizes the symptomatology and monopolizes it in advanced stages. With this, the habit becomes a painful and masochistic act. This is why both terms are often utilized by the users in reference to their habit. If the doses continue to be administered the psychomotor agitation, expression of the highest anxiety and effect in itself of the adrenergic increase of power, becomes more evident, trembling and widespread perspiration occur. The face is characterized by the following: pale appearance, eyes wide open and certain muscular contractions that give the user an appearance of extreme seriousness and fear. Tension and excess of energy, force the user to walk senseless from one place to another, or to do any activity compulsively. There is the permanent desire to go or to escape. If a conversation occurs, the voice is insecure, whispered, low enough to avoid being heard. Insecurity and mistrust gain terrain: anything strange is feared and "one looks through the windows moving the curtains slightly". There is a state of hyper-vigilance, an expectation of some undefined but catastrophic event. That is why, any event out of the norm impacts strongly. Common noises, normal not long ago, acquire different meaning and are intensely felt, as it was in Michael's case. In addition to pasta, he loved a set of music tapes from which he almost never depart from. Some neighbors that knew "Michael's Achilles heel", patiently waited for the afternoon hours, in which he used to put himself in the arms of the pasta. Once this occurred, they would enter his room precipitately and making as much noise as possible. Of course, they took more time entering the refuge of our sensitive and selfish pitillero than getting out of it, and not only with the appreciated musical tapes but also with any other thing that these astute and opportunistic friends could get their hands on.

The hyper-stimulated user of pasta will sacrifice anything to escape from the excessive sensorial stimulus, and above all, from strangers to his world. For this reason, the long hours of the night are taken advantage of, because the possibility of noisy and foreign interruptions are few. The preferred hour to start using pasta is at sunset and, if he has to sleep, he usually will prefer doing it during the day.

When the use is prolonged for several consecutive days, the characteristic hyperactivity of the beginning can reverse itself. Although the tension is higher, movements become slow and difficult. The user can remain seated or lay down for a long time and it seems as if his few movements were made in slow motion, as in Parkinson disease.

The fertile terrain, where paranoia will settle and grow, is given. Final and always present outcome through the prolonged self-administration of cocaine pasta.

THE PASTA'S PARANOID SYNDROME

Slowly, as the consumption of pasta continues, anxiety, hyper-vigilance, fear of being discovered, guilt suspicion and mistrust dominate the individual's psychic until it completely separates him from reality.

Before he realizes, simple suppositions and fears become certain. He believes that he is being pursued to be hurt; the shadows of the night hide fantastic threats. The neighbor, until this moment affable, turns into a super agent of the law who is able to listen through walls or read his mind. That is why, you must listen attentively before lighting a match, the scratch seems to be amplified by the shadows. The passers by that come back home very late at night are objects of a very attentive watch through crevices on doors or windows. Any out of the ordinary action, such as the tying of shoelaces or the lighting of a cigarette exactly in that area, are reason enough for paranoia. These are signs or warnings of danger, that should be counteracted by escapades or long minutes of a total and tense immovability. Fantastic voices are heard that threaten or insult. Some times, terror dramas become real, quite elaborated, fantastic stories of blackmail and persecution. The pitillero believes that he is the center of attention, everybody worries about him and his problems. People have made devices to control him at a distance and he is capable of magical powers on others.

The paranoid state, by pasta intoxication, is almost no different from serious mental affections. Contact with reality is seriously affected. The disorganized conduct, contrary to the paranoiac desire, draws people's attention. Because of this, a great number of people detected by narcotics police owe their success to this mental disorder.

Because friends or relatives' logical reasoning does not succeed in changing the frenzied (unreal) ideas of persecution or harm, the intoxicated individual tries to protect himself by escaping or isolating himself. The jungle of the Eastern part of Bolivia has turned into a pitillero's dramatic resource for an intuitive and desperate treatment. Flung by the anxiety of paranoia, he escapes into the forest, from where, sometimes, he returns days later shaken up from his craziness. In the eastern towns of Bolivia I have seen real zombies. They escape to the jungle, without any means of protection, the siege of insects and beasts of prey ravages the already debilitated bodies, which surely have some days of fasting. The refusal to eat, effect of the pasta, can be reinforced by their fear of being poisoned and thus aggravating the prognostic.

COLLECTIVE PARANOIA

The use of paste is full of absurd, improbable and caricatural stories. Because the use of pasta among some people is frequent, the paranoia due to prolonged use can happen collectively. This was the case of five individuals that dedicated themselves to smoke for several hours. Within many of the susceptibilities that began to appear, there was the one related to the pitillo's penetrating smell and the possibilities of having it noticed by neighbors. Soon, the simple supposition became a certainty; panic dominated the atmosphere and after the last and precious grams of paste ended in the drainage, theyended up hiding in the most improbable of places: under the beds, in the attic and, wherever each of them could find security. Some hours of tense and anguished expectation passed by. The report was never made, the police never came. Surely, the absence of the drug, allows the user to return to a disconcerting reality.

CONTROLLED PARANOIA

Among chronic users, it is common to hear about controlled paranoia to denote a previous state to the one described above, which is characterized by certain control that an individual, quite skilled on smoking, can exert over his ideas of harm and persecution. Certain protective measures, such as buying a limited quantity of pasta, forced feeding, sleep at least some hours during the day and above all not to loose social contact, are taken for this effect. Of course, it is assumed that such things can be done only by an expert, someone that knows pasta and its effects very well, who also possesses intellectual capacities, and more specifically a certain emotional balance. The controlled paranoia is a very deceptive state and can, due to an unforeseen event, degenerate into a typical out of control paranoia.

Generally, pasta produced psychotic paranoid states can disappear naturally, hours or days after having discontinued the use, provided that there is not a previous history of mental unbalance. In such cases, the psychotic states can establish themselves definitely, the pasta being just one more of the unleashing factors. The same can happen with other drugs, such as alcohol, hallucinogenics or serious problems to adapt to his environment However, in individuals considered normal, if intoxication and subsequent paranoid states last during long periods of time, permanent personality paranoid or very deep psychosis traits can develop, all rebellious to medical treatment.

Jose's case is quite illustrative, a school teacher, born in Beni, (a Department of Bolivia), 24 years old, married. Known, in his town, for his extroverted and agreeable character. He started to experiment with pitillos (cigarettes made of tobacco and pasta) on weekends, when he was having a good time with friends around the ever present bottles of beer. Later, problems caused by a premature marriage and financial demands that were impossible to satisfy with his reduced salary, motivated him to increase the use of pitillos to every day of the week trying to draw the sorrows. Weeks and months of continuous use went by. The paranoid state started to take root, with briefer and briefer remission periods until it installed itself into a permanent psychotic state that continued even through a forced abstinence provoked by alarmed relatives. In this state, he was brought to La Paz, where, under my supervision, he was treated at the Social Security Psychiatric Hospital. The psychotic state was deep. Jose was convinced that the government was chasing him to kill him because he knew too much about drug traffickers. To him, his confinement at the hospital was an scheme to eliminate him; his roommate was a government agent in charge of killing him.

High doses of neuroleptics were needed during several weeks to put an end the paranoid ideation and to equilibrate a little of Jose's damaged psychological state. When he resumed contact with reality, the florid paranoid ideation was replaced by an abulic anhedonia depressive state, a live without colors. This state is characterized by a serious face, inexpressiveness, uncontrollable susceptibility and irritability. High doses of antidepressants imipramine type drugs were administered until Jose was out of danger. Nevertheless, he surprised me with a request: he wanted to remain for some time at the Hospital. The countless times that he had attempted to leave the pasta in vain, had taught him something: that it was impossible to trust his own will. He recognized that it would be impossible to control himself if he had pasta near him. He also knew that at home, pasta would be within hands' reach. Fortunately, relatives that lived in La Paz accepted to take him in for some months, thus prolonging the withdrawal from the drug. I saw him again three years later, quite improved. He had partially recovered his cheerfulness and sense of humor. He told me that he had recesses, and because of that he decided to accept a job in a faraway hacienda which could only be reached by plane. This was the only way, until today, to get away from the drug.

While the pasta induced resolution of paranoid states, can abate spontaneously once the toxic administration is interrupted or, as we have just seen, through the use of medication and isolation, this is just one of the many problems encountered because of this substance. As was revealed in the cocaine crystal marathon runners' study, a real abstinence syndrome is non existent. These states can be interrupted abruptly, without having the habitual user going through the painful hunger for drugs state that characterizes the physical dependency. It is replaced by an automatic or compulsive behavior that can, if the drug is at hands reach, eternalize the usage. In the last few years, when I was working at the Health Ministry's Drug Addicts Treatment Center, I was able to ascertain the lack of the abstinence syndrome, typical of the physical dependency as in the opiates. There, we evaluated the people detained by the anti narcotics police. These users, once detained, were brought in for a medical evaluation, many in full and prolonged states of intoxication. Nevertheless, they could manage relatively well and did not show desperation to find the drug, even though they wanted it.

Whoever has been a pasta lover and has enjoyed its voluptuous pleasures, even if it was for a short time, becomes like Odysseus' fascinated crew, incapable of resisting the sirens song even at the cost of their lives. That is why, whoever has lost control, even if only once, to pasta's arms, must do the same as Odysseus and his men: tie themselves to the ship's mast, so that even if they desire, they will not be able to answer the irresistible call of the undine. In this case is useless to trust in will power, because the phenomena is independent of it, due to a mechanism that we will analyze later. At this level, the user is divided in two. On side that desperately fights against the habit and recognizes it as something absurd, painful and destructive at the same time and as a last resort, the sought after pleasure dilutes itself in the intent, leaving only frustration. It is the weak guardian angel that wears himself out in promises, despair, reproaches and guilt. And there, at the bottom, behind the scenes, in the darkness of the unconscious, is the other automatic mechanism: a true mischievous little devil that casually steers the car's wheel to the corner where pitillos are sold.

I have heard it been said from more than one pasta lover, that they sometimes find themselves walking and looking for the drug almost not realizing what they are doing. This is just minutes after making the greatest abstinence promises. The longer the habit lasts, the stronger and more rebellious will the little devil lover of pasta is, and more certain the relapse. In this manner, an internal fight is established between both sides, of which it is very difficult to escape with out the help of another person that can tie them to the ship's mast as the seducing pasta smoke passes by.

Maria N., a young 27 year old, refers her experience. She had used pasta, routinely for a year. After she noticed that it was impossible to get out on her own will power, (of which she had always felt sure, until the out of control relapses demonstrated the opposite), she searched for medical help and was confined for treatment at the Hospital:

"...today something strange happened to me. After lunch, as always, I took a nap. I woke up at two o'clock and I automatically got dressed very quickly. The only idea in my mind was to go out and buy another "sobre" stash (with pasta); it did not even cross my mind where I was. After I got dressed, and as 1 was going out of the room, 1 realized that 1 was confined in this clinic. My anxiety was so strong, that I even thought of making an excuse so they could give permission to go out. I think my good part won, because I started to analyze my situation and realized that it was ridicule and absurd to go out, and above all, to ruin the effort that I was making and to lose the trust of the doctors that have been supporting me".

The Automatic Drug-Search Behavior manifests itself in varied ways, but it always shows itself in a dissociate state. In the most severe cases it can be expressed by an absence of oneself or by a perturbation, an almost non-perceptible by the conscious, a kind of confusion or lack of mental clarity, like when awakening from a dream, in a state of drunkenness or in an state of rage that characterizes a fight. In general, it seems that while the habit is more consciously opposed, the more indirect resources it will find to satisfy itself or, it will provoke more intense interruptions of the consciousness. That is why, a person trapped by the pasta and who wishes to get out of it, must save their energy. He should better concentrate in establishing the Odysseus' strategy instead of fighting the habit, and waste his efforts. This should be done with the help of an honest relationship of a relative, friend or doctor that understands the problem and can serve as loaned willpower while the danger lasts. This of course, is one more of the measures that must be taken in this respect.

For all that has been mentioned, it does not surprise me that in different places, in an independent manner, the tern satuquearse (satuco means the devil, so the term means to drench one self with the devil) is used in reference to the consume of pasta. Is a direct allusion to the Devil or Satan. The pitillero :suffers a progressive disorganization of his life, abandons his routine obligations, work, social contact and especially personal cleanliness. There is a noticeable rejection to bathe. The atmosphere around him is dirty, from the handling of the drug, which must be previously mixed with tobacco, to the countless burned matches. The long hours of night vigil, added to the expression of fear and seriousness, give the face a cadaverous and wan aspect. Their also exists a sulfuric and penetrating pasta smell, and excessive transpiration and unkemptness, to the point that they are confused with beggars.. All of this added to paranoia, perfectly conform a diabolical picture, in the common sense of the word.

Lastly, many users accept to find in pasta a real perverse pleasure that is painful at the same time. "Truly,- said a pitillos dealer-what we sell is paranoia in smoke. When my clients do not find paranoia in my merchandise, they think that 1 have cheated them".

I have seen this association to go beyond a simple comparison. A patient, quite deteriorated, reported to me his relapses as evil possessed states and, in his deliriums, he saw me as a dangerous exorcist.

TRIP EXPERIENCES

From the many trip tales that I have heard, I past on to you Lucifer's experience, whom we already know as a marathon runner of cocaine crystal. I do so, because he best resumes the multiple aspects of the phenomena, thanks to his capacity of innate introspectiveness and especially for his accessibility and cultural level. This report, as the first one, has many terms that should be made clear: Toco: a small pipe to smoke the drug from, usually made of tin-plated paper arranged into a pipe-like form, they are also made of wood, stone or ceramic. This term has been extended to the act of smoking the dose itself. Po, as we already mentioned, means cocaine crystal. Many times he refers to pasta as base, even though later on he himself recognizes that base is a more refined product, previous to the cocaine crystal state. It is from this term that the term baserolo is derived, meaning: "he who smokes base". High (same meaning as in English) to be stoned or drugged; equivalent to the flash that we have described. He refers sometimes to paranoia as paras and to the effects as mambo. The little paper envelopes or other objects to store the drug, are known as enguilles (stashes). The lumps or pieces of the drug that have agglutinated and hardened are the "rocas" (rocks) or roquitas (little rocks).

"1 started to smoke pasta after two years of using Po, at the middle of `77. Initially it was just one night. The first "toco" gave me quite a different physical sensation in comparison to the one 1 feel from "Po". That was enough to call my attention. I could describe it as (as 1 always have a vivid recollection of it) physical and very sensorial, semi-orgasmic, but shorter. The first thing that goes through the mind is to smoke another toco, in order to reach an end (a climax ?), but it never comes. The intensity of the first toco was not repeated through out the rest of the night. That first night, there was no special symptom, just to smoke one toco after another plus a light tremor in the hands.   At sunrise, I felt an emptiness as result of all these hours. The effect is quite different from Po, which also kept me up until morning. In the latter case, the night always is advantageous in some way, reading or doing something of the sort. The question "why did I do it?" was clear when I decided to stop smoking.

Ten months later I started to smoke again. At the beginning, I used the excuse that I smoked marihuana with base (that takes hunger away), so that 1 would not be hungry when the weed wore off I say excuse because from the beginning I had some feeling of guilt. Before I started to smoke base, I used to criticize the "baserolos", as something that I could never become. Consequently, when 1 began smoking, it was something like cheating on myself, so as to not recognize my liking for the base. Social pressure against its use is strong, it is hard to accept that one likes to smoke it. At the same time, one realizes that a dependence exists from the very beginn ing Of course, in the first few weeks it is possible to smoke whenever wanted and not compulsively, as it will become in a short while. Dependency starts with the first "toco" and at night, when it is generally smoked, you only want to smoke one toco after another. It can be said that it takes about 8 to 10 weeks to accept that one wants to smoke daily. At this stage, the. usage is small and, to certain point, the possibility to control it still exists. It also can be said that the effects are mild or different maybe, of what is felt after this first period. At this stage, if there is no exaggeration, the high of the base can be felt.   On the other hand, the "amuquismo"( amuqui or shut mouth symptom of not being able or of wanting to speak), the paranoia and the hallucinations do not appear and if they do, they are superficial. At the same time , one is curious of the novelty of the effect. It has no comparison with the effect of hydrochloride or crystal.

In reference to normal quantities, 1 could say that normally anywhere from one to two grams (maximum) are used, each doses of some 150 to 2000 mg. and within a period of 5 to 10 minutes in between "tocos".

There were different intents to give a reason to smoke, for example to play chess, draw, read. This way one would not be concentrated in the toco only. Little by little the excuses begin to end. One for example, is when the marihuana is finished (with which 1 used to smoke). Then, one takes tobacco and find another excuse, as much as for other people as for oneself, and the resources to entertain oneself become boring and the anxiety to smoke the next toco starts to take more and more priority, in which the excuses become weaker. At this point, we arrive at the second cycle: the acceptance of the pasta. Now something different begins to occur . The usage becomes accepted and normal. The smoke of the night before brings bad temper and certain aggression, not physical but quite verbal. If one has smoked until early hours of the morning, having slept enough, some times all morning and afternoon once awake, one is quite hungry and craves greasy food. With other people that smoke, there is the tendency to joke about what happened the night before and to take everything as a joke. It is a kind of "expiation" of the experiences in base, especially if one is within an environment where there is a lot of smoking between gathered people. If the opposite occurs, the bad mood worsens and aggression increases.   This lasts for a few hours and later there in no desire to smoke. At the beginning of the second cycle, there is not much thought as to how one will find money or how to go about buying the pasta. But soon, the whole afternoon is spent worrying about this . It is evening that brings the desire to smoke. Between 6 and 7 in the evening the little worm starts to bother.

Unlike the po, base has the smell of the smoke, which is quite noticeable and specific, and the feeling of paranoia (or "para") is based on this. While the toco as much as the base are easy to have it disappeared or hide, its smell due to an oily nature, is heavy and dense, and its aroma impregnates and remains in the environment for a long time. Among the "baserolos" it is said that the "para" is contagious from another smoker that already knows it. Because to the beginner, and this is true, even if he has felt it, he does not realize that it is paranoia. Only when he sees other people feeling the same, does he accept it and recognize it as paranoia. This necessity to feel and be the center of attention is due to the great energy that one has. For example, and even though it is not a general rule, while one is in company of two or three people that use pasta for a long time, the paranoia can be felt in group. The paranoia is contagious through the constant contact to the point where they feel it together, in a very similar way. But normally, paranoia is not expressed, even if it is strongly felt. Instead, once it has past the conversation is on to some thing else. This maybe so because paranoia in solitude is very strong. 1 suppose that it must be the need to feel part of something else, since the only thing that can be done is to smoke one toco after another. The over-stimulated brain searches for an escape, and it finds one by means of distortions, especially of sight and hearing. Lights, shadows and sounds increase, webbed into perfect plans, sometimes related with real people that casually are near by or somebody on the other side of the door is felt or that people are coming near. Usually the "static" reaction is to stay in a vigilant pose of watchfulness or motionless for many minutes and to leave the mind to act out that dominant fear. But, as strange as it may seem, if this paranoia would not happen, there would be no fun in smoking pasta. I can affirm that the reason for smoking is the search for paranoia.   When base or oxidized, a kind of refined pasta that is more pure is smoked, paranoia does not exist and people that smokes pasta do not like it. Maybe this the reason that the pasta has such a strong addiction, because in my experience, it is not as the publicity shows it. There is a strong desire or anxiety to smoke it, and in order to stop it, a lot of willpower is necessary and, above all to keep in mind what one was before arriving to the disgust of smoking pasta . 1 believe that if it is smoked from a young age, especially before the age of twenty, it will be very difficult to recognize who they were before the pasta. I say this because pasta has a preponderant factor, the flourishing of the personality's negative aspects. One becomes a liar and selfish person. It is the prostitution of the being, especially when, I think do not have it, and scorn him the next day, when he no longer has Pasta and one does. One has it and the other does not. This takes you to unsuspected levels, such as stealing, to the complete irresponsibility. ,Somebody else's things are pawned or sold, honor and pride are no longer important. One sees the negative part come to the surface and is conscious of it. One knows that it is wrong, but the necessity to obtain pasta is a good enough excuse to not accept the responsibility of one's acts. This, plus the factor that one can not openly smoke, helps the paranoia to become acute in time.

I think it is natural that all pasta smokers wish to stop smoking and when he learns that someone who didn't smoke has started to. This originates opposite feelings of sadness and rage at the same time, but there is also a association of complicity. There is a lot of ambivalence during the habit. Only when they have left the habit do they consciously notice the doubt and cowardice. Additionally, if one wants to stop it, one reaches the point of hiding it from oneself. But at the same time one is waiting for help to be able to quit. One does not like what he is, this feeling is discharged on the next dory's bad temper. To be defensive is a normal state and the idea that one will smoke later on is comforting. The funny part of it, is that if one has not smoked yet there is the wish to do so and the image, the expectation that one has, is of pleasure, of well being, of something tasty. This is a quite dominant idea of the first toco and it is related with pleasure. But as soon the first toco is taken, the opposite happens: the possession of the pasta begins, there is no pleasure and the only thing that one wants is to smoke and to finish the quantity, minimum usually, of past a that one has. When one has it in excess, this anxiety to have more diminishes evidently. But if one has matches, pipe, tobacco, and of course pasta of cocaine, there is some pleasure that is missing from effect of pasta. This part of the mambo is called buscadora (the finder) and it is something that affects the majority of smokers. The search ) for an enguille (stash) or some roquitas (little rocks), when we have finished our provision, revising meticulously our surroundings, becomes urgent but it serves to distract the growing anxiety. At high levels of usage, one can reach an exaggerated level and the buscadora can start from the first toco, even if one has more than enough of pasta. Even when walking, you are constantly searching for minuscule pasta particles on the floor. I believe if all these tics are they are acted upon and accepted within an already known frame of action, a way is found not to suffer with the ever growing fear specially if the dosage is increased. For example, I used to smoke on top of a white sheep skin to not have to get up and look for dropped "roquitas" of pasta in the whole area where 1 was. 1 just used my fingers to search within the white hairs of the skin and my need to search was satisfied. In the same way, and even in an unconscious manner, I would buy the utensils, that is: matches, tobacco and pasta, in smaller quantities than other smokers would. For me this is the key to not getting lost in paranoia. 1 would also occupy myself with something to prolong the time in between toco's. The longer this lapse would be, the more the sought after effect will be felt: "the physical sensation". The activity had to be related in some way to smoking. Therefore, between toco's, I would clean the pipe, something that is very personal, or 1 would make mixtures in different proportions of tobacco and base, searching for the "perfect mix", or dry the pasta if I thought that it was humid or any other activity related with the vice. Reading, writing or any other occupation or amusement, is impossible. Sometimes 1 would have a book or magazine open, but it is just to pretend in front of other people. The ears never stop hearing strange noises, but never paying attention to them and only listening without analyzing would keep me away from the paranoiac state. This is more effective if there is another person present, but the moment that I would find myself alone, the paranoia would dominate completely, believing that someone, whether a policeman or any other person, was listening. In early hours of the morning, the sound of a striking match can become the center of paranoia. This happens to the extent that, that even with the toco in hand to be smoked, we take quite a few minutes to light it. All the acts that a person knows as characteristic of smoking base are, on their own, the centers of paranoia. 1 want to emphasize that, at least in what 1 believe and in what 1 have experienced smoking with other people, fear is what one is after. One is not aware of this while feeling the effects of pasta, as one enters needy of this game and accepts it as real, while it lasts.

The way that 1 have left the pasta is wanting to do it because I became ashamed in front of myself of what 1 had become. Second, not to cut it immediately, but to substitute it with hydrochloride and after a few days of snorting Po, to smoke a little of pasta if it is desired (one must stop smoking during many days), by then the effect will be felt in its real dimension. ugly and repelling. It is very important not to fight that desire to smoke a toquito (small toco) of pasta; because the idea' that one has of that first toco must be destroyed once the true effect is felt. Otherwise, the illusion will grow more and more. This is the dependency that exists with pasta and one must come out of it by the repugnance to it. This is arrived at by smoking tocos sporadically in between many days using of cocaine crystal. The idea, the illusion that the first toco is tasty, that you will feel good   and once the opposite of this is proved in practice, the pasta spell starts to dissolve little by little. (La Paz, August 1985).

PEDRO'S EXPERIENCE

I transcribe Pedro's experience, first of all because. he is a foreigner and he gives us a comparison point with our Bolivian psychology. Peter uses the term sulfate referring to pasta. He studied 5 years of Economics. He consumed marihuana, Mandrax, amphetamines, LSD, mushrooms, Artane, alcohol, hashish, Romilar, Sosegon, besides cocaine crystal and cocaine sulfate.

"... I started to use sulfate daily about a year ago, from January `86, since 1 have been in jail. Before, I tried it three times in a year. The first time was in Yungas (June `85). That time was totally different and 1 don't believe this was because of the place or different circumstances in which 1 found myself then and the one 1 am in now. 1 believe that smoking every day sulfate creates an addiction and is very difficult to get out of it, Besides, 1 believe that pasta affects some part of the brain.

The first time that I used pasta in Yungas (203 grams) I felt a lot of tranquillity and no worries. I didn't feel paranoia or fear, but the desire to continue smoking. I never thought 1 would feel what I felt later on. It is like a routine, by the time visiting finishes, it is automatic to start smoking, as an entertainment that is necessary. To get the papers (small envelopes with drug), to borrow money with interest, to pawn clothing, blankets, shoes, kitchen utensils, etc., gives a lot of satisfaction and happiness to get the papers(stashes). But these emotions are gone at the moment you start to smoke. Usually I smoke it with tobacco in a pipe and I drink alcohol diluted with water. The months that I smoked the most, (3 to 4 grams daily), 1 would accompany it with 150 ml of alcohol. The effect that the first smoke has on me is of tranquillity. Just a few minutes later all the contrary happens: a lot of nervousness, paranoia, I start to transpire and I become very introverted. I can say that when one uses drugs, they perceive another reality, another vision, that without drugs is very difficult to capture. It is very dangerous to use them if they are not near someone that is familiar with the drug, someone to guide them in difficult moments. I have been scared many times. I have felt extremely desperate due to my acute perceptions. They were at times beautiful and horrible at others. After a smoke 1 become very susceptible. Many times I heard my last name being called, when it actually wasn't. 1 become quite sensible, to the extreme of thinking that people were talking about me, that everybody was looking at me, and that knew when I was smoking. When the effect passed, I would laugh at this paranoia. This started to happen the second month after 1 started to smoke. 1 initiated myself with what is called rebote, some 15 days later 1 smoked daily, about 150 mg. for 10 days and 1 increased to 3 or 5 grams daily, not skipping one day (from March until the end of October).   Through all those months, I had the same daily reactions of susceptibility, paranoia and sensitivity that lasted in me even in my sleep and in my dreams. To get rid of this, 1 drank alcohol to neutralize the effect a little. In general, when I smoke, I totally lose my appetite and if 1 eat something it has no taste whatsoever. In respect to sex, 1 become totally apathetic, without desire (drinking alcohol does the opposite). There is total unwillingness to work and I lose interest in any type of activity. I can't stand anybody, I can't talk to anybody and I feel that everybody is talking about me. I believe that sulfate causes serious problems in the nervous system. One of the symptoms was that I would get scared even from somebody's greeting. I would lose my memory. For example, while I was talking 1 would forget a word that had always been part of my vocabulary, but I did not lose the thread of what 1 was saying. It is more than a month now that 1 do not smoke and I continue having problems. I believe someone that has used drugs and has had extraordinary experiences, would never be the same. It affects many things. I believe that it invalidates the intelligence. The skin deteriorates, the teeth chip or fall out, the senses become acute and tachycardia occurs. I believe that sulfate causes dependency and it is difficult to drop it and more so in this place (jail), where the majority of the people smoke and are that united by it. It is something that is done normally. There is no other conversation: who sells it the cheapest, the purest, who sells more quantity and the group paranoia are daily topics of conversation.

About half an hour after smoking , 1 feel a lot of confusion and repentance. I feel totally hopeless without any possibility to go to somebody if they wish to help me. The next day I feel a psycho physical tiredness, 1 don't want to talk to anybody, everything bothers me and I just want to sleep.   I would advise anybody not to smoke sulfate, I would like to leave it for good. I have stopped smoking sulfate partially. It is two months that I only smoke on rare occasions. In these two months; I must have smoked 15 to 20 grams, before 1 used to smoke 2 to 4 grams a day".

MARTIN'S EXPERIENCE

Martin is a 36 years old peasant, born in a small town in the valley region of Bolivia. At present he resides in Chapare (tropical coca producer area). He learned about pasta while he was dedicated to the hard work as maton or pisa coca (coca leaf presser). When I saw him for the first time, at his home, he had his hands tied with a thick rope. His face and the little clothing that he had on, were totally bloodstained. His brothers explained to me that it was the only way to control him when he gets crazy. Afterwards, the craziness will go away and he would be back at work. Martin had been treated unsuccessfully many times at Hospitals in Cochabamba. One week from his release, he was once again tied, again prisoner of the merca, as cocaine pasta is called in these places:

"... I don't know what happens to me, but because of its smell, or I don't know what, when the work mates invite me bolillo, is difficult to say no. At times, I will look for it myself even though it is horrible. Of course at the beginning, the first time it is not like this, it is OK. One can work better, but after is the curse I don't know what 1 liked from it. One becomes crazy like, I no longer recognize (people) and worst of all is that 1 lose my job and everything. My last wife left me only because of it. Happily, this All Saints Day (a catholic holiday) will be a year that I haven't tasted it. With the piccho (coca chewing) I am better, a little is enough. 1 had no idea, even with my parents and almost all of my family that chewed coca before. 1 had to learn: every morning, before going out, 1 would chew a few leaves with lye and 1 don't have desire to smoke. If I again feel the desire, I chew leaves and that's it".

I chose these three cases because of the importance they have in respect to the knowledge of the phenomena as well as to the possibilities of treatment. Regrettably, in the majority of the cases similar to these, except at the end, the pasta controls the individual's will to such degree, that if there is not death due to a respiratory or cardiac failure, or some other complication derived from the habit, he will become an invalid, incapable of reacting on his own.

The knowledge that these cases and others alike have, allowed me to formulate the bases of the treatment based on the acullico or the chewing of coca leaves.

MECHANISM OF THE ACTION OF PASTA

The reader must have asked himself. To what are the devastating effects of the pasta due? Why it is not the same with cocaine crystal?

Hypothalamus pleasure center

In my opinion, it could be due to the process of administration, what in turn determines the quantity and speed of the drug consumed enough to press the hypothalamus pleasure button.

Let us recall that pasta, due to its sulfate quality can, by means of heat, volatilize itself and be absorbed by the lung passages (when smoked). Which means that we have an absorbent apparatus of approximately 50 to 70 square meters!, that make up the total alveoli surfaces, which are in direct contact with the blood, that is in charge of transporting gases to the organism. The big absorption surface is further reinforced by the positive pressure that is created when the inhaled smoke is retained by holding the breath. Thus the drug is transported violently and massively into the blood stream. Pasta's impure concentration rises in the plasma and manages, for . brief seconds, when it reaches the brain, to press the pleasure bottom, a sort of fleeting non genital orgasm. This is the famous flash or high characteristic of pasta. Unknown phenomena by the cocaine crystal user through the nostrils, this can be explained by the fact that nasal absorption only has some square centimeters of surface, which limits the speed of absorption, the substance enters very slowly into the blood stream.

The pasta flash searches are the ones that created the notorious crack, today quite fashionable in USA. It is a free base version that is obtained by reversing cocaine chlorhydrate or crystal by means of alkalines, enabling it to be smoked in special pipes. The effects of these new pasta versions Made in USA are unknown. The chemical products used give it sui generis properties. For example, does anybody know the effects that burned baking powder, which is frequently used to prepare Crack, may have?

According to other investigators, similar effects to the flash of pasta can also be reached through the intravenous application of cocaine chlorhydrate, which would confirm my hypothesis on the mechanical production of this chemical orgasm. It would be like a punch to the center of the hypothalamus through the massive and sudden administration of stimulants to the adrenergic system.

Let us recall that the hypothalamic center is the center of the Basic Survival Mechanism -SerVos- 28 through which the organism self-gratifies or recompenses itself and directs its behavior in the sense of survival, the search of pleasure as it's goal and synonymous of life. (I have developed this theme extensively in Dialectic Psychiatry).

The relation between the autonomous adrenergic or sympathetic system and it's role as rewarding answers mediator and the potential function of cocaine (chemical messenger of this system) explains how the cocaine pasta user through the lung passages, can stimulate its pleasure botton.

MONKEYS ADDICTED TO ELECTRONS

By the introduction of electrodes in the brain, pleasure and pain or reward and punishment centers have been localized with precision. The electric stimulation of the pleasure pole quieten the animal, while the other produces pain and fear, reactions of defense or escape. The monkeys used in an experiment leamed to self-stimulate their center of pleasure by pulling a lever. Once they leamed how to do it, they did not stop doing it and they would even self-stimulate themselves four thousand times per hour. They lost interest in satisfying their basic needs, such as reproduction and alimentation. 29

Let us compare the gratifying mechanism with the common Ring the Bell game in an amusement park. cocaine crystal amounts to the weak strikes of the mallet that only elevate the state of mind and energy a little but it does not cause pleasure in itself. On the other hand, smoked pasta amounts to strong strikes that make the gratifying bell sound for a few seconds.

Cocaine as it increases the norepinephrine activity, is converted into the instrument by which the adaptive behavior (the strike of the mallet) achieve the stimulation of the hypothalamus pleasure center (the sound of the bell). This way, the pleasure center is stimulated without requiring the surviving behavior. At high doses cocaine allows for the eludment of the basic requirement that the rewarding mechanism demands to achieve pleasure. The surviving mechanism has found the optimum magical behavior in which, the conquest, dispute and possession of the female, for example are no longer necessary. It is enough to buy a charged cigarette and light it to obtain pleasure. The pleasing experience invites to repetitions, according to the law of learning and in turn repetition reinforces the charge even more, increasing the possibilities of this behavior's repetition.

As is the case with sex, after the first sensation of pleasure, comes a refractory phase that increases the stimulation threshold; it is almost impossible to repeat the sensation of the first dose in the subsequent ones. The flash each time is weaker and briefer; it limits itself to the few seconds that the smoke is in the lungs. The need to achieve pleasure grows proportionally. This increase of the need for pleasure and the progressive inability to reach it and, of course, the adrenergic c stimulation generate anguish, that rises parallel to the dosage and ends up monopolizing symptomatically in stages not too advanced of the intoxication. We could say, in other words, that the pleasure pole moves away while the organism has tasted the lost paradise. The most powerful instinct in man has been awaken: the search for pleasure. That is why he will try to cling, with all his might, to that magical substance, that resolves the fundamental problem. But as this one, at the same time, removes even further the pleasure pole a very steep difference is created, a pending pleasure, "...at the point of achieving the supreme pleasure". As it is well said by Lucifer: "... pasta is the great Prostitute of Babylon, full of perfume and always inciting more, but it never satisfies".

On the other hand, as pasta only puts the last phase of the cycle into action, imbalance-pain, adaptive behavior-pleasure, it creates mis-information. The cortex does not only believe that everything is all right, but it is also fascinated by the ecstasies. The intoxicated person overflows with energy, does not feel like sleeping or eating, meanwhile his organism, accelerated by the drug, requires more energy and more food to counteract the excessive wearing out. The function of SerVos is inverted: while there is information of pleasure this means that survival or balance assured), there is an state of unbalance, synonymous of destruction. SerVos, damaged as such, is incapable of accomplishing it's coordination work between the two control systems that have separated, isolated and do not have possible communication. The reason being that she is situated in the cortex works without the orientation of her basic compass, that now is magnetized by the cocaine pasta, unable to perceive the degree of destruction that is happening underneath of her. The same happens when the cortex refuses to accept, due to incompatibility, certain contents that arise from the unconscious. They find a passage way short-cirquiting the sensorial information channels, giving the impression to be perceived in the outside environment. This mechanism is known in psychology as the defense mechanism called projection.

If we translate facts into words, more or less it would be as follows:

"..my pleasure indicator says that everything is all right inside of me, that is why the confusing information of danger that 1 receive must be coming from someplace else: not from myself, which means, from the outside.   Surely it is surrounding me, which 1 cannot yet localize, is setting a trap for me". And the extraordinary search for danger in the environment starts. Any element near by, becomes a reason for suspicion, distrust and fear. The extra attentive vigilant of our cortex, accelerated and mis-informed by the drug, converts itself into a very jealous guardian: paranoia has where been itinitiated. Reason searches for destruction outside oneself, to has projected it ignoring ring the one that it has inside. A double fatidical mechanism that arms and secures a closed circuit of mis-information and unbalance, that is very difficult to break, perpetuates itself in self-destruction.   this way, assuring SerVos, when damaged, is so efficient in destroying as f r o m building when normal. It has taken away more than one victim from the deadly ecstasies, to the quietness of the inorganic. Among the pasta users that die in search of happiness, and the rats that drop fulminated by the excess of the self -stimulation of pleasure, I find only one difference: the instrument of destruction. In the former, the instrument of destruction is a chemical, while in the latter it is an electrode implanted in the hypothalamus. The adaptation and survival behavior are reduced to the acquiring of the drug or to pressing the stimulating lever,   g   e "Cocaine pasta's greatest paradox" is the name I have applied to this contradictory phenomena, because we find destruction searching life, and pain searching pleasure. It is a characteristic that we can observe in almost all the phases of the use of pasta.

When the usage stops, usually because the drug is finished, the Postponed functions comeback with renovated vigor. It is possible to sleep through many continuous hours and eat voraciously. The paranoid states generally remit only hours or days after, except in people that has suffered previous unbalances. The use that is prolonged for years can produce more or less permanent harm, for example the loss of short term memory, attention difficulties, deficits in abstraction and in the high mental functions. This, added to depression, which we will analyze later, determine an almost tot mis -adaptation to the environment.   al The individual, at length, is incapable of maintaining a job or occupation, he cannot establish normal emotional relations with family and social nucleus; he suffers a moral and physical degradation; he lies, steals, cheats in order to satisfy his needs. The bad alimentation, the subsequent lowering of defenses, the action of the sulfurous smoke in the lungs and in the whole of the organism  generates a series of infectious diseases such as bronchitis, dermatitis, etc. Promiscuity and the absence of cleanliness leads to venereal diseases and extensive parasitism. The inveterate lovers of pasta are easily confused with common beggars. To get out of it, is not impossible, but it is very difficult. A relapse is inevitable for those who have incursion in pasta beyond 'simple curiosity.

RELAPSE MECHANISM

The image of the night butterfly, unable to dominate its thirst for light and which finally drops carbonized in the middle of the flame, comes frequently to my mind when I think in the problem of: pasta. Why does the user, who is conscious of his elf-destruction and in spite of all his will and effort to get away from the drug, go back to it over and over again? It can be explained by two fundamental facts:

In the first place, pasta represents for SerVos, the undisputed manager of our behavior, the perfect magical element to accomplish its dominant program: the search for pleasure in the most direct way. That is why, the self-administration is incorporated immediately to the repertoire of successful behavior and it is reinforced over and , over again until behavior is completely monopolized. It is same behavior that we will see with rats and monkeys that die of ecstasies, implanted with electrodes in the hypothalamic pleasure center. The survival behaviors limit themselves in some cases to find the drug and consume it, and to press the lever in others. The optimum behavior is incorporated to SerVos in an independent form from the cortex, that is why it can act even against it's logical reasoning. The search and use of pasta can become completely automatic. That is why the pitillero frequently says that he finds himself buying or using the drug, practically, without being aware of it. I have seen incredulous and distrustful faces of parents and doctors of the habitual smoker, when data reveals this fact. It is difficult to believe, but necessary to do so, because it is the first step that we will have to surpass if we want to help our patient or relative.

In second place, is that factor, the one with which this whole story began: the emotional promoters of depressive states and the first ones to get us near stimulants or antidepressants. They may obey to exogenous external causes: damages or loses in life, or to internal causes or endogenous, caused by a reduction of neurotransmitters by causes not determined yet, possibly genetically

The depressive individual that stumbles in his way with pasta, may try smoking the drug to empirically cure himself. But as neither the depression nor the "treatment" are conscious or clear enough to the individual, self-administration is usually chaotic and gets out of control. The overdose is the rule and with it comes one of the most dreaded phenomena within the psycho-pharmacology: the rebound. As dialectics says it: when one pole is developed up to it's maximum expression, it converts itself into it's opposite; too much stimulation generates depression. It is nature's balance factor, everything that goes up must come down. In biochemical terms, it could be a relative reduction of norepinephrine or its precursors, due (as we have already seen) to an excess of self-destruction, by the monoaminooxidaza or, it may be to an excess of this enzyme activity, conditioned by the chronic use of the pasta that demands a greater activity of this enzyme. The adrenergic deficit is manifested as depression, secondary in this case to cocaine intoxication. Thus a first exogenous or endogenous depression, is aggravated with a second depression caused iatrogenically, that is to say by a badly carried out empirical treatment. Closing the circuit: depression originates greater necessity of stimulants and these on themselves, originate mayor depression.

The automatic drug-search behavior and these rebound depressions would be enough to explain the relapses. However, there are other factors, that even though they are secondary, is important to taken them into account. For example, within them there are the self-destructive impulses, quite increased in some, due to different causes. Maybe as a self-punishing medium to expiate sins, in this case the pasta is doubly reinforced. As it's illegality transforms it into the forbidding fruit, its use is a sin that can start out those self punishing mechanisms. Let's not forget the frequent use of the term masochist in reference to the habit. Pasta is the double edge ominous instrument, as on one side promotes punishment and later on the other one acts as an executor off the same. Self-punishment is also a way to alleviate depression, Intoxication would be a slow and pleasurable suicide.

Some adolescents may use the drug as a badly interpreted self-affirmation. Is the same mechanism that induces us to smoke tobacco or to drink alcohol, is the challenge to authority to prove courage and independence. Typical machismo of a child that wants to be man. This is the reason why I have repeatedly criticized the publicity campaigns against drugs, they are not only ineffective, but promote and encourage that which emphatically forbids.

Anybody can use pasta with manipulative ends, for example to awake feelings of guilt or to harm their relatives. It is impossible to generalize more, as each individual is a complete universe and the reasons to start using are specific. Only a deep psychological analysis can help to understand the problem and find a solution.

To finish, we can say although pasta does not produce a physical dependency, it conditions a psychological dependency as harmful as the first one. The absence of an abstinence syndrome, characteristic of morphine and of physical addiction, would be explained as cocaine does not replace any normal element of the organism, it only increases something already existing: the norepinephrine.

Colombia and especially Peru confront pasta's problems for some years before Bolivia did. Their tried treatments have been based of antidepressants. Nor have been missing amphetamines and the whole battery of minor tranquilizers. There have been desperate cures such as "the dream cure", which consists in introducing lethargy for many days. This treatment, of course, had no success, as to be effective it would be necessary to have the patient sleep for years. Electroshock, almost abandon today or reserved for deep or rebellious psychosis, has been revived once more with categorical failures. In Peru doctors' extreme cure of addiction has been the interruption of the pleasure channels, by means of neurosurgery. I know of other therapeutic attempts in specialized clinics of Argentina, Brazil, Chile and United States. In the great majority of cases the results are discouraging, specially in those where use of the drug has been too prolonged. The limits being quite variable, depends on the individual. It can be affirm that the longer time of use the more difficult to abandon it. The chronic patients take longer to be out of the hospital than to get back into the habit. I have seen people that were released from hospital with no depressive clinical symptoms, quite the contrary, they were optimistic, sure and confident to abandon pasta definitely, to see them coming back few days or weeks later, unable to explain what had happened to them, how they had relapsed.

Similar experience were confronted in Bolivia. It was thought that once the original depression or rebound was overcome, the need for anti -depressants (pasta in this case) should have disappeared, 'but in the majority of cases such thing did not happen.

From the biochemical stand point of view the phenomena could be explained because there is an extra wear of neurotransmitters, for which not even the imipramine type drugs work. Under this concept; the administration of L-Dopa, a precursor of norepinephrine or the raw material to manufacture neurotransmitters was tried. I am attending a case who after been treated in USA, comeback with this novelty. Now, on top of antidepressants and L-Dopa; he consumes pasta. Moreover, he tells me that he is in better conditions than before to continue using the drug, because L-Dopa lessens the rigidity and tremors of exaggerated usage. Relapses continue same as at the beginning. I know other individuals that have become habituated to L-Dopa which is yet more dangerous than pasta itself, it quickly causes mental disorders.

It was believed that relapses presented themselves before imipramine type drugs had time to act. But, if that would be the case, it could be resolved with prolonged hospital confinements. In some cases there has been a positive reaction to this scheme (of course with psychotherapy help). But the majority, even those where the antidepressants had acted quite well and removed almost for entire the depression, once released from the clinic they tend relapsed again.

Some habitual users, when unable to find pasta in their countries, they found themselves forced to turn to amphetamines with very confusing results. I know the affects of amphetamines through young women that fell into the, so much advertised today, diet pill trap. This drug further to create strong addiction, causes very serious emotional and mental unbalances. That is why, sometimes I have referred to amphetamines as second class pasta.

On matters of measures taken on the environmental type, the only thing that appears to give results is the isolation from the drug; generally long periods of time in hospitals or a kind of police control from the family's side. But here we incursion into the socio-economical side, as confinement can last as long as nine months or more. That means money, a generally scarce commodity, we have seen already that socio-economic maladjustment is the rule in these cases. The habitual pasta user becomes, from the treatment point of view, a very expensive invalid. The National Budget for treatment and rehabilitation has been relegated to emphasize police and interdiction aspects.

Especial situations that allow a prolonged withdrawal of the drug are not always possible, nor are within everybody's economic means. As Jose's case that resorted to a voluntary isolation in the country side, in an hacienda with no land access. A change of residence supposes not only extra money, but also change of jobs and the stress resulting from it.

The habitual pasta user, when finally recognizes that he has a problem and that he needs help to get out of it, which generally takes a lot of time even years, and gets to see a doctor he finds that very little can be done for him. Desperate measures are then tried on, expensive trips abroad searching for experts, job changes, divorces, seclusion whether voluntary or forced, religious conversions, etc. Meanwhile, pasta is thrown many times into toilet seats, followed by futile withdrawal promises. Callawayas (respected medicine native individuals) sorceress, naturists, miracle workers, fruitlessly parade which finishes with the last hope of salvation. Frustrated doctors, friends and relatives abandon the sick and he abandons himself too. That is how he ends wondering through the city confused with beggars, until in a conscious or involuntary act an overdose paralyzes the respiratory and cardiac center, putting an end to it all.

COCA LEAF CHEWING TREATMENT

At the end of 1982, in the video-film titled THE COCA LEAF LEGEND, I demonstrated the beneficial properties of the coca leaf as an antidepressant and energizer and proposed it's utilization in the treatment of depression. Subsequently, when that proposition became the Pilot Project for the Coca Leaf Industrialization with Pharmaceutical Goals, I was hired as adviser to the Coca Producers Peasants Organization. I spent, since then until today, long periods of time in peasants homes, in the Yungas (a coca producing province) from La Paz, as in the tropic of Cochabamba (another coca producing place). The opportunity allowed me to have a vision from the inside of the coca producer families, and almost all are consumers of the coca leaf. There, besides from continuing my investigations on the coca leaf effects on Andean people, ,l witnessed that other phenomena that we are dealing with, the ravages caused by cocaine. pasta. One particular' fact brought my attention,, the incompatibility between the pasta and the leaf. Many cases of pasta intoxication that I attended to in the coca zones, especially in the 80's, almost all corresponded to people that arrived from the city. The great majority, former peasants that immigrated to the city at a young age or as a child searching for better opportunities. There were brick layers, carpenters, car drivers, blue collar workers, maids, small business men, school teachers, students, etc.. All were coming back to the country side, disillusioned from the city due to the economic crisis, specially to these zones that were doing good thanks to the coca economy.

The states of depression that certainly accompany to the disillusioned immigrants, the change of occupation in unusual climates, the hard agricultural work or the narco-traffick work and the great availability of pasta, made of the pitillo a common thing, with already known results. But meanwhile the merca (word for pasta within people that produces it) was quickly gaining terrain within the floating population, the farmers, show themselves invulnerable to pasta's spell. As my attention was precisely on the habits of the acullico (chewing of coca leaves) it was easy for me to see the differences. The immigrant group for different reasons did not chew coca leaves, but fundamentally, a majority, chew the leave daily. When I delve deeply into this fact I found something else, the old coca chewers that had tried pasta for any reason, specially curiosity, did not like it. From that point onwards I started to prescribe the leaf as a medium to control the desire for pasta, with good results within that population. Later, when I tried to introduce the system in the city, another problem appeared, the difficulty of the chewing technique, the smell and unpleasant taste for many and specifically the green coloration of. the mouth, all these show themselves as serious obstacles. This did not happen with foreigners that I attended to, the majority of them accepted my proposal to chew the leaf as something interesting and they exert themselves in learning the technique. The group of pico verdes (green mouths), as someone has called them, grows slowly with failures and successes that necessarily go along in anything new.

Surely due to the difficulty of the coca chewing technique, a percentage of this group has found in cocaine crystal the easy solution to get out of pasta. For sure potency and easiness of administration has a lot to do with this choice. But, as we already saw, these qualities are precisely the ones that the empiric use does not recommend, as they allow abuse and overdose. It's use could be accepted as a minor evil in circumstances such as the case of Fleischl-Marxow, Freud's friend, where cocaine crystal certainly due to it's potency, is an indispensable element to fight the physical abstinence syndrome of morphine. Nevertheless, that example demonstrate to us the dangers of overdose inherent in that modality. If we should use cocaine crystal at any. time, (only in case that coca leaves may not be available), it must be administered under medical supervision. In Bolivia where the use of the leave is legal and easily available and specifically due to it's quality in regulating the dosage, it would be a mistake not to use it.

Problems concerning the administration of the coca leaf as a quick action antidepressant were already seen in the Industrialization Project of the Coca Leaf with Pharmaceutical Goals. In it, I suggested the manufacturing of full leaf's extracts with a minimum of chemical preparation, with the object to facilitate it's administration.

GENERAL CONCLUSIONS

The coca leaf is a true energizer.   It has a number of vitamins, minerals and proteins. It is a very effective antidepressant or stimulant. Mayor ethnic groups such as the Aymaras and Quechuas have used it by generations through the centuries. It allows a social-economic adaptation beyond what is humanly possible, such was the case of the mita's infra-human work (forced native labor for the Spaniards) during the Spanish colonization and of the present Bolivian miner.

The cocaine chlorhydrate or cocaine crystals is one of the leaf's chemically extracted alkaloids. It is an efficient local anesthetic and a potent stimulant. But is this potency which precisely makes it inadvisable for a pleasurable use or as an empiric self-treatment for depression. The abuse and overdose are the rule with subsequent emotional unbalance. It is little known and used in Bolivia. It can produce socioeconomic maladjustment.

The cocaine sulfate or pasta, is a violent drug and its modality of obligated administration: through smoking conditions compulsivedrug-search behavior, something very difficult to resolve. This in turn, causes overdosing. These abuses destroy the emotional and mental balance. It is known in Bolivia from the beginning of the 80's and it's growing usage threatens to become into a serious medico-social problem. Socioeconomic maladjustment is the norm.

We can conclude that, in the first place, it is urgent to look for a solution for this last problem: the pasta, that can be applied, secondarily, to cocaine crystal abuse. In the second place, we have a century proved element: the coca leaf, whose properties could be taken advantage of as a therapeutic element in the context of the situation.

Especially cases such as Bolivia's, where medical hospitalarian assistance is very difficult because of money and infrastructure shortage. The following statistical analysis are the result of this situation. Forced by the absence of resources I have recommended the chewing of the coca leaf, between 100 to 200 gr of coca leaf per week, as an ambulatory treatment since 1984.

In 1992 I was invited to work in a Therapeutic Community Center for drug dependence, created by Dr. Carlos Jordan. There, we proved the importance and efficiency of the psychological factor in he treatment of drug dependency, when done within a controlled environment.

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