Drug Abuse

THE NESTING OF COCAINE IN HEROIN RITUALS

 

Introduction

The history of cocaine use in The Netherlands can be traced to the end of the nineteenth century. As in many other countries at that time, cocaine was an important ingredient of many of the, so called, patent medicines or specialités used for self medication in traditional folk medicine of the lower classes. However, cocaine was also used in higher social classes and by practitioners of medical and para-medical professions. By the year 1912 the number of cocainists was estimated to be higher than the number of morphine users (1). Besides being a consumer country, The Netherlands played a major role in the production and distribution of cocaine. The coca leaf grown in the Dutch Indies was of higher quality than those from South America. In 1911 The Netherlands were, with a world market share of 22%, the most important cocaine producer in the world (2). During the First World War the production of coca-leaf in the Dutch Indies decreased but soon after the war the production increased again very rapidly. In this period, a strong increase in the number of cocainists in Europe occurred (3). Although officially all the cocaine manufactured in The Netherlands was solely for medical purposes, in 1922 the Dutch production alone was sufficient for the world demand for medical purposes as was the combined export of Bolivia and Peru. However, cocaine for recreational use was in these days distributed through medical channels by which the medical demand seemed much larger than it in reality was (1).

Apart from the use of alcohol, the recreational use of (illegal) drugs in The Netherlands became popular in the late 1960s and early 1970s. At this time the availability of cocaine was still very limited. In the early 1980s cocaine became more readily available in The Netherlands and it became very popular in some discotheque- and nightclub-circuits of the big cities in the Randstad (the large urban complex of Amsterdam, The Hague, Rotterdam and Utrecht). In the media, cocaine had the image of a safe drug and among some drug treatment professionals it was also viewed much less problematic than heroin (4). As it was very expensive (± ¦250.- a gram), it was seen as a jet set drug. In the course of the 1980s, cocaine use spread throughout larger segments of Dutch society. A 1988 E.C. pilot epidemiological study reveals some distinctive cocaine using groups with little overlap. 29% were actors and artists, 21% blue collar workers, 18% students, 18% unemployed, 7% white collar, 4% pimps and prostitutes and 4% were people with restaurant, bar and cafe occupations (5).

In the early 1980s cocaine use grew rapidly in the heroin scene. Already in 1981 in many places on the Kop van de Zeedijk in Amsterdam (at that time a main heroin copping area in Amsterdam) heroin and cocaine were sold together. However, a considerable number of users had prior experience with cocaine. 41% of client intakes of the Amsterdam methadone bus in 1979 used cocaine. In 1987/1988 this had increased to 77%, while in 1989 this was 73.2% (6). Unfortunately, frequencies and (daily) doses are unknown. It is therefore unclear whether this early cocaine use was incidental or part of a regular pattern. As a consequence of their dominant position in the lower levels of heroin dealing, the Surinamese heroin users were the first group in the heroin scene that became heavily involved in the use and dealing of cocaine. Indicators of arrest statistics from the Amsterdam police and of intake data from a Rotterdam low threshold methadone program for ethnic minorities, suggest a steady rise of cocaine use and dealing in this group through the years 1983-1985 (e.g. in 1984, of 612 cocaine-related arrests, 41 % concerned Surinamese, 33 % were Dutch, 4 % Moroccans, 9 % Germans, 2 % Americans and 11 % others) (7).

A number of snowball sampling studies conducted in Dutch cities support the hypothesis of an increasing prevalence and preference of cocaine among heroin users in The Netherlands. Studies conducted in Amsterdam (8, 9) and in Rotterdam and Utrecht (10) on selected subpopulations of heroin users (foreign origin, prostitutes) showed about a 60 % prevalence of cocaine use. A further study of cocaine use in Rotterdam confirmed a coprevalence of cocaine and heroin in various milieus, suggesting a high prevalence of cocaine use among heroin users in general (5). In the present study 96% of the research participants were using both heroin and cocaine. Cocaine seems to have become a drug of choice for many heroin users in The Netherlands. This is in contrast with the situation before 1982, when it was more or less seen as a frill, or a matter of secondary importance.

Like many other drugs, cocaine can be taken into the body in a number of ways. Via the mucous membranes of the stomach (swallowing), the nose (sniffing), or genitals (rubbing), by smoking or inhaling the fumes when heated and by injecting. Oral use of cocaine has a very mild effect and is for that reason hardly practiced. For that matter, during the first half of the 1980s, Peruvian mate de coca, or coca tea was sold over the counter in the U.S.A.. Each tea bag contained about five milligrams of cocaine. After publications in the scientific press, the tea was outlawed (11). Sniffing, absorbing cocaine hydrochloride through the nasal mucous membranes, seems to be the most common mode of administration in so called non deviant users (12).

To understand cocaine use among heroin users, one has to start off with a basic understanding of the ritualized patterns of heroin use. In The Netherlands, these patterns were subject to a subcultural development of 20 years, starting around 1972. Cocaine use may be conceived as being nested in these heroin taking rituals. These heroin rituals were, however, developed for heroin use and, as will be demonstrated in the following pages, were less appropriate for cocaine consumption. In the succeeding sections the effects of the nesting of cocaine in heroin self-administration rituals will be presented.

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Cocaine Smoking

Preparing Cocaine Base

As crack (commercially fabricated cocaine base) is almost not available on the illegal drug markets in The Netherlands, cocaine smoking heroin users normally prepare the product themselves. In order to smoke cocaine, the Dutch user must first process the cocaine- hydrochloride he bought at a house address to its precursor base form. This seems preferable to the users as then they have more control over the product they will smoke. In order to prepare this home-made crack, one needs some additional tools and home chemicals, such as a spoon, some tissue or toilet paper and a base like aqueous ammonia or baking soda (sodium bicarbonate) and a little water. At many dealing places spoons, ammonia, tissue or toilet paper and water are supplied by the dealer as is aluminum foil to chase. The spoon is usually a teaspoon, often bent, so that when put down on a flat surface it stays steady and level. The ammonia or bicarbonate is used to separate the hydrochloride group from the cocaine base. The tissue or toilet paper is used to dry the cocaine base when processed. The knife is used to extract the base from the solution in the spoon.

Given the necessary equipment, the user is ready to start preparations. First the pakkie (wrapper) will be opened and with the tip of the knife an amount of the cocaine will be put into the spoon. Then the processing can start:

She cleans a tea spoon that lies in front of her, puts in the cocaine and adds a little ammonia. She heats the spoon with a lighter, but doesn't boil the content. Then she puts the spoon back on the table and picks up her knife, cleans it on her skirt and sticks it carefully into the cocaine and ammonia solution several times, meanwhile turning the knife so the depositing cocaine forms a lump around the top of the blade. Then she dries the lump, still on the blade, in a tissue and breaks it from the blade.

Most users prefer to use ammonia as this is the easiest and fastest mode. The ammonia comes in commercial household bottles containing 0.5 liter. A small hole is made in the cap to secure a careful dosing when dripping it in the spoon, preventing overfloating and wasting the substance. Other users prefer to use bicarbonate, mainly because they regard it as a safer means than ammonia, as the preference for bicarbonate is generally explained in terms of the health consequences of inhaling ammonia vapors:

"Ammonia bites, salt cleanses."

"No never, it's too dangerous. You never know how much ammonia stays behind and how much you get in while smoking. That's why I always use maagzout (=bicarbonate)."

While bicarbonate is safer it requires a more skilled hand as it must be carefully dosed and takes slightly more time. Furthermore, not at all deal places (e.g. in some squatted houses) water is readily available. Some users have developed an idiosyncratic preparation ritual, like Henry, who likes to use both ammonia and bicarbonate:

With a knife Henry took out ± 1 stripe (0.10 g) of Cocaine and put it in a teaspoon. He then poured a little ammonia in the spoon and then he added a little salt. "Adding a little salt to the ammonia gives the best results, I think." ... He then boiled the solution firmly and it looked as if there was no base left over but when he took his knife and tipped the surface of the liquid the base cluttered to the knife-tip and formed a 'good' lump.

When ammonia is used, it is carefully dripped into the spoon. If bicarbonate is used, first a small amount (± 1/3 of the cocaine powder) of the powder is put in and next the spoon is filled with some water, often by dripping it off a finger.

Next the spoon is heated so the chemical reaction between the hydrochloride group and the base can take place. This is mostly done with a cigarette lighter. Sometimes a candle or a turpentine burner is used as the lighter can get very hot because it is on for a longer time than is necessary to light a cigarette. If these are used, it is by the dealer or the owner of the dealing place, as users do not carry these bulky paraphernalia around. Some users heat the solution until the base clusters into an oily drop, floating in the liquid, while others cook the solution firmly until the drop seemingly disappears. Then the user takes his knife and tips the drop or the surface of the solution carefully, often turning the blade of the knife each time. The cocaine base then deposits on the tip of the blade, forming a lump. A small pocket knife is preferred, but any metal tool will suffice. By looking at the solution against the light some users check if any base is left in the spoon. When the lump has congealed most users dry it with a piece of tissue or toilet paper. At this point some users perform an extra action meant as a health precaution:

After the lump has formed on the knife ... he takes the knife with the lump and holds it close to the ground. Then he pours water from the lemonade bottle over the lump to rinse out the ammonia rests.

Other users rinse the base in a glass, while it is still on the knife tip or put the lump in a spoon with clean water and boil it again. Finally the lump is broken off the knife and ready to smoke.

Cocaine Smoking: Varieties of Vapor Inhalation

Cocaine can be smoked in various ways; in cigarettes or coke joints, from aluminum foil and based in specially designed or customized base pipes. As with heroin, the drug is not burned, but melted and vaporized. The vapors are inhaled.

A coke joint can be made in several ways. Often an ordinary cigarette is used. Some of the tobacco is taken out and the powdered cocaine is put in and shaken through the tobacco. In a hand rolled cigarette the cocaine is spread over the tobacco and then the cigarette is rolled. In this case it is sometimes mixed with marihuana or hashish. Sometimes cocaine hydrochloride is used. This is however, a very inefficient and expensive way of taking the drug, mostly done occasionally by sniffers, who are often not aware of the technique of preparing cocaine base. The effect does not differ very much from sniffing besides a little defeaning of the tongue and the, by many users appreciated, sweet caramel-like taste of the fumes (which may result from diluents). In fact, most of the cocaine decomposes into inactive components. This method is considered a waste by experienced cocaine smokers, such as heroin users. Although much more effective than smoking cocaine hydrochloride, smoking the base form in cigarettes still is a relatively moderate, inefficient and expensive way of ingestion. Within the heroin scene, this relatively rare cocaine smoking mode is more prevalent among novice cocaine smokers and among dealers who have a steady access to large quantities of the drug; among the sample of heroin users this was not observed. During the fieldwork a cocaine smoking middle-level heroin and cocaine dealer was contacted who did not use heroin. He claimed that the coke joints he smoked contained up to 2 grams of cocaine. When smoking a coke joint, the cocaine base melts and tends to stick to the inside of the cigarette paper. Therefore, most users constantly moisten the cigarette paper to prevent the loss of fumes when not inhaling. This is also done when smoking heroin in cigarettes.

Chasing was the dominant route of ingestion for heroin in the research group and this was also the case for cocaine. Chasing heroin was practiced before cocaine entered the heroin scene and acted as a model for non injecting heroin users, who started using cocaine. Heroin users chase cocaine in a number of ways; pure, often alternated with heroin and mixed with heroin. There appears to be a functional relationship between cocaine and heroin for both smokers and IDUs that will be discussed in chapter seven. However, cocaine and heroin are also smoked together for directly observable instrumental reasons. It requires more skills to chase pure cocaine than heroin. In the following example from a fieldnote, both users smoke pure cocaine from aluminum foil:

The Surinamese man puts (the cocaine) on the foil and after heating it first to filter out the ammonia vapors he starts chasing. He says he does not need een kleurtje (a little color) to follow the liquid but he misses a lot of the cocaine base fumes. Boris (the dealer) also smokes the cocaine without heroin but he is doing better.

Cocaine is harder to chase for a number of reasons. It is colorless when liquid and therefore harder to follow. For that reason users often add a little heroin to the cocaine. This little amount of heroin is called een kleurtje which means a little color. It is meant to color the colorless cocaine base liquid which then becomes transparent light brown and easier to chase:

After he has smoked 2 chineesjes pure base ... he now adds heroin to it. He says he does it for het kleurtje but also to stay relaxed.

When chasing pure cocaine one also needs to dose the flame more carefully:

She heats the foil carefully so that the flame does not touch the foil. This way the cocaine drop slowly runs over the foil.

When heated less cautiously, the liquid cocaine base has a very low cohesion and behaves very capriciously on the foil:

With his fingers he breaks the lump off the knife and puts some pieces on the foil. From his pocket he takes a tube and starts to chase the cocaine base. He follows the drug carefully on the foil. However, the cocaine follows a very whimsical trajectory on the foil. The drop splits up several times and when he stops heating the foil it spreads into a large spot. After exhaling he starts again but he first chases the offshoots of the spot to make it into one drop again.

Heroin is much more cohesive. Therefore it does not only tone the base, but it also produces a more cohesive mixture; it tames the white dragon and makes it easier to chase. The following example depicts that quality of heroin:

He puts some heroin on a foil and starts chasing. The heroin powder melts into a drop and then runs along the foil. In contrast with coke, the heroin drop stays very cohesive and runs smoothly and steady on the foil leaving a light brown track behind.

The rationale of these behaviors is confirmed by laboratory simulations of chasing. Most illicit heroin is much less volatile than cocaine base. Mixing the two substances decreases the volatility of cocaine, while increasing that of heroin (13).

Besides chasing cocaine, many users were observed basing cocaine. Basing is the most direct and efficient smoking mode, producing a rush (impact effect), comparable with, and according to some authors even more rapid and intense than injecting (14, 15, 16). Chasing is also efficient, but a much more moderate way of ingestion. When a certain amount of cocaine base is chased, it may take five to ten runs of the drug along the foil, depending on the (heating) technique. Each run accompanied by inhalation of the vaporized product through the tube. When the same amount of cocaine is based, the vaporized substance is ingested in one or two inhalations.

Compared to chasing, basing does not only produce a more intense impact effect, it is also a very expensive mode of administration and for that reason, often reserved to dealers who have a much higher availability of the drug than the average user. Apparently, when cocaine initially became available in the heroin scene, among the first users that started basing were Surinamese heroin dealers who, through their contacts and financial means, got easy access to cocaine in a time when it was relatively still very expensive. Basing cocaine became a status symbol in their specific scene at the time. After this initial phase, many heroin users, both smokers and IDUs were introduced to basing at Surinamese house addresses. Although in that period the prevalence of cocaine use among heroin users was much lower then nowadays, there was a high prevalence of basing among users who started using cocaine (7, 17). During the 1980s cocaine became more and more available and cheaper in the heroin scene. An increasing number of heroin users added cocaine to their drug taking repertoire. Somewhat simultaneously the prevalence of basing seems to have decreased, not meaning that users stopped basing cocaine altogether, but that they combine it with their preferred administration ritual (18, 19). Thus, IDUs will normally inject cocaine and sometimes they may base the drug. Likewise, chasers will generally smoke cocaine from aluminum foil and now and then base the drug.

However, during the fieldwork the prevalence of basing among chasers seemed to be rising -- a sudden increase in basing was witnessed at house addresses. In that period the prices of both heroin and cocaine were going down. Besides the price level and the stronger impact effect, group dynamics also seemed to play a role in this rapid rise. One user gave the following explanation for the observed wave of basing:

I'm smoking coke from the glass for about three weeks or so. It gives a much better bang than chasing the coke. Now many guys are smoking from the glass. It's a kind of fashion whim. About three weeks ago someone started to smoke from the glass and told others it gave a great kick. Others tried it too and that is how the ball started rolling.

Basing requires the same preparations as chasing. The difference is in the apparatus that is used in smoking; the cocaine base is put in a pipe:

Fred took the cocaine lumps and started smoking the base in a glass water bong. This bong is designed to smoke cannabis. It had a picture of a cannabis shrub on it. ... Fred put a lump in the head of the pipe, put the mouth piece to his mouth and then heated the base, dosing the flame carefully. He first drew the pipe full of smoke and then he released the air hole and inhaled all the smoke. He repeated it until it was finished. He then sat back, closed his eyes and laid his head against the back of the sofa.

All kinds of self-constructed or commercial pipes like hashish pipes, water pipes designed to smoke hashish and freebase pipes (with or without water/liquor) are used to smoke pure cocaine base. Designer pipes, such as in the last example, are not common as they are expensive, bulky and fragile and therefore not easy to carry around. Specially prepared water glasses were most often observed:

Around a little table near the door are sitting two creole Surinamese males, one is smoking cocaine in a base pipe. One of the Dutch men, Fokkie, is smoking cocaine from a glass. The glass is covered with aluminum foil. In the foil are little holes and on the opposite side is a larger hole. First he puts some cigarette ash on the little holes, on the ash he puts some small cocaine base lumps. Jack says that the ash is put on the holes to prevent that the melting cocaine base falls through the holes in the foil. "Now the coke is absorbed by the ash." With his lips Fokkie covers the larger hole, lights the cocaine base and inhales the smoke. On the table stands another smoking glass and also one on the dealing table.

The glass does not necessarily have to be a water glass. Any jar of about the size of a water glass will do. The main requirement is that it must be possible to cover the opening with a piece of aluminum foil:

From the table he takes an empty jar. He fills it half with water from the lemonade bottle and puts aluminum foil over the top. He sets the foil with a rubber. With his knife he carefully makes tiny holes on one side of the foil and a bigger hole on the other side to put his mouth on, to smoke. From the ashtray he takes some ash and puts some of it over the little holes. On top of it he puts the cocaine base, heats it with his lighter and smokes.

Subsequent observations in 1989, 1990 and 1991 have shown that cocaine basing has become increasingly important. Many users have turned to basing cocaine (mostly in little, self- constructed pipes), while maintaining heroin chasing.

As explained above, the smoking of cocaine in The Netherlands is generally limited to smoking home-made crack. Although no extra cuts or fillers will be added during self processing, this product still contains the impurities and cuts that were in the cocaine before processing it into the base (20). In addition it may hold some of the processing chemicals (bicarbonate or ammonia). This product is different from free-base, cocaine base of almost a 100 % purity. This purity is reached by refining the cocaine base of all cuts and processing residues in ether. Due to the superior purity the effect is even more potent. Because of the rather complicated and dangerous process (ether is a highly inflammable liquid) actual free- base is rarely smoked by heroin users in The Netherlands.

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Cocaine Injecting

Cocaine hydrochloride dissolves in water without the necessity of additional chemicals or heating. To inject pure cocaine, one does not have to go through much preparation and the preparation requires the least technique and tools as can be seen in the following fieldnote:

While discussing Alex had peeled out some cotton threats out of the lining of his jacket. Between his fingers he rolled a little ball from it. From his pocket he took a spoon and a little package which contained cocaine. He put the coke in the spoon with a little water and stirred it. Next he put in the little ball which he used as a filter. He drew up the cocaine and took the shot.

Although it dissolves without heating, cocaine is usually prepared in the same cooker as heroin. The cocaine is mostly stirred into solution with the safety cap of the needle, sometimes with the knife that is used to put the drug in the spoon. Often cocaine is combined with heroin in what is called a cocktail:

Doug starts to prepare a cocktail of heroin and cocaine. He puts some heroin in the spoon and adds some lemon juice and water. Then he boils the contents with his disposable lighter. When the heroin has dissolved he puts the spoon back on the table and waits a few moments. Then he carefully puts his fingertip in the solution in the spoon; "it's okay now", he says, referring to the temperature of the solution. He holds the package with cocaine above the spoon and with a knife from the table he pushes the cocaine out of the package into the spoon. When most of it is in the spoon, Doug scratches the package with the knife, so the last cocaine falls in the spoon too. He then stirs the cocaine through the heroin solution with the plastic needle-protector from his syringe.

At first glance, the nesting of cocaine in the self-administration rituals typical for heroin users may not seem to make much difference. However, as will be demonstrated in the next sections, the addition of cocaine did, in fact, have a significant and often negative impact on many aspects of the lives of the research participants.

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Varying Patterns of Cocaine/Heroin Use

A Comparison of the Effects of Heroin and Cocaine

Agar distinguishes four effects of an intravenous injection of heroin: (21)
1) The rush or flash is the initial physiological effect after the drug is injected into the body. It is sometimes compared to a driving force or an orgasm.

"It's a very warm feeling that starts in one place and spreads. Probably that's where the similarity with an orgasm begins and ends".

The intensity of the rush varies with the administered dose and tolerance.
2) The high is a feeling of general well-being and is longer lasting than the rush, the length of time varying with tolerance and dosage.
3) The nod is usually described as a state of unawareness varying from light (dropping eyelids and jaw) to heavy (unconsciousness). A higher dose of heroin relative to the tolerance is necessary to produce the latter state.
4) Feeling straight describes the state of not being sick, that is withdrawal symptoms are absent, without feeling the, as pleasantly described, high.

"I'm not high, I just took the sick off."

Ameliorating the withdrawal symptoms is one of the main goals of the low dose methadone maintenance prescription in The Netherlands. As opiates are dependence forming, a fifth effect, withdrawal --feeling sick, can be distinguished when the drug has worn off. In terms of behavioral pharmacology the first four effects are positive reinforcers, while the fifth is a negative reinforcer (22).

When chasing the rush is much less apparent. The drug effect is, compared to injecting, slowly and moderately built up to the desired level. An IDU administers a certain dose in one injection while a chaser spreads the ingestion of the same dose over a much larger time span. The high and the nod are not different from those experienced when the drug is injected. Although nodding is not unfamiliar to chasers, it occurs much less often than when the drug is injected. When chasers do smoke themselves into a nod, this results from a much more gradual and time consuming process. Because of this gradual build up, fatal overdosing is, apart from inclement circumstances, unlikely when chasing (see chapter ten).

Cocaine and heroin are quite different substances and have rather opposite effects. Heroin is a downer, a suppressant, while cocaine is an upper, a stimulant. So cocaine does not produce a nod. Nevertheless, "[a]lthough many of the subjective effects are different, euphoria is a property that opiates share with cocaine and amphetamine" (23). Just as heroin, cocaine delivers a rush and a high. The rush, the most intense of these, so called, positive reinforcement effects of cocaine is induced by injecting and basing Chasing produces a milder effect. Compared to these modes, sniffing hardly produces a rush. The cocaine rush is often valued higher than that of heroin and qualitatively different. Some users stated that the heroin rush is more physical and the cocaine rush more cognitive. Such explanations may, however, for a large part be idiosyncratic. The cocaine high is also qualitatively different than the heroin high. Heroin produces a feeling of satisfaction, a warm blanket. Cocaine is said to give a feeling of extreme alertness and a perception of increased power and coping skills (24, 25). Again caution must be emphasized, before generalizing such depictions, as the individual experience may vary considerably. While injecting and smoking cocaine produces an intense euphoric rush and a subsequent high, these effects are extremely short in duration (± 5 to 20 minutes.) and, in particular in cases of chronic intoxication, often followed by a rebound or crash, an opposite state of intense dysphoria (26). Even heavy cocaine use does not seem to lead to intense physical dependence, as is established by chronic use of depressants, such as opiates, barbiturates, benzodiazepines and alcohol (23). It has, however, been questioned if the adverse state following discontinuation of (chronic/intense) cocaine use is solely attributable to psychological dependence. This crash may have a negative reinforcement effect (26).

Among the research participants, cocaine's extreme rush potential and the high are the main incentives for its use, but the drug's association with increased and persistent activity is likewise highly valued:

± 15 minutes after he took a shot, Richard pours in the tea, while Chris is busy with dustpan and brush in the hall. "We always clean up right after the coke, then you have the energy and the lust to do it.", says Richard.

Some users rely heavily on this effect; to them cocaine may become the most important source of vitality:

"A Surinam user told me he was sick, really sick as from heroin. If he hadn't been using coke he said to be feeling languid and weary. Taking white would pep him up he said, making him ready for the day."

Various Cocaine/Heroin Combinations within the Ritual of Preference

For both chasers and IDUs a variety of use patterns, involving taking cocaine pure or in different combinations with heroin, have developed. Whereas these patterns --turn taking (alternating doses of cocaine and heroin) or cocktailing (combining the two drugs in one dose)-- cannot be tight to specific individuals or groups, most users have developed a pattern of preference within one of the main administration rituals. Like Karel, who likes to shoot his cocaine pure, followed by an injection of heroin:

Karel is shooting up cocaine. He puts the coke in the spoon, stirs, pulls it up through a piece of cotton and shoots the coke without using a belt. The rush makes him sweat very much. "It's an extreme flash it's very good coke.", he says, "I always first take the coke, cause I want to enjoy the coke-flash first." A little later I take the bruin.

Or this chaser, who likes to combine cocaine with heroin:

The customer first puts some heroin on the foil and on top of it he puts some cocaine. "I like to smoke it this way, it's pleasing me the most if I smoke them together".

However, most users do not have a fixed consumption pattern. One moment they turn take cocaine and heroin and another they use the drugs in a cocktail. It simply is not always possible to stick to preferred pattern. Obviously, the available money is a very important factor:

"When we have enough money we will buy 0.5 g cocaine and 'een kwart bruin' (=0.25 g heroin). That we put into one cocktail, so each has about a 'kwart wit en een streep bruin' (0.25 cocaine & 0.10 g heroin) per shot."

While other, primarily situational variables --such as the type and amount of the drugs already ingested (methadone), gifts, the time of day, available tools and physiological (habit size, withdrawal), psychological (mood or craving) and social factors (the present company and their objectives, motives, drives and expectancies)-- can also be seen to influence the patterns of use, the data suggests that availability (in terms of money and/or drugs) is a main factor.

Two Different Cocaine/Heroin Patterns

Closer examination of the data on the cocaine use patterns identified two cocaine/heroin patterns with an uneven distribution. In the most common, cocaine is used for pleasure and heroin --to curb cocaine's side effects (see chapter seven)-- in similar quantities. In the second, less common, pattern the use of heroin is maintained at a minimum level, while cocaine use is much higher. Both patterns are also evident in the study of Grapendaal and colleagues Although they reported that most of their respondents prefer to use similar quantities of both drugs, they found a monthly mean use of cocaine (14.6 grams) which doubled that of heroin (7.7 grams) and attributed this to a few extreme users with monthly cocaine use maxima up to 140 grams (27).

The observations and conversations with cocaine users strongly suggest that the latter pattern is more prevalent among the minority of users who do better than average in their specific hustle --the successful shoplifter or burglar, the most popular or top-poes (top pussy) sex worker on the stroll, and, most typically, the steady house address dealer. Pat, a 35 - 40 years old dealer using drugs for about 20 years explained the relationship between his occupation and his drug use:

"I use about a gram of 'bruin' now and a gram of 'wit', but when I'm dealing I use much more cocaine."

Doorman Jack explained the relevant reasons for heroin's lagging behind:

"When you're a doorman on an address, you're using more 'wit' (cocaine), I do. I don't have to be sick then (a doorman rarely is, as he's being paid by the dealer to screen visitors). Using more heroin then isn't making sense, more heroin gives more tolerance. It also makes it harder to stay not sick all day when I don't have a job as doorman. And, you don't feel it anyway (more heroin), a doorman has to stay alert.

The higher prevalence of the second cocaine/heroin pattern (much cocaine, little heroin) among dealing users is thus for a large part explained by the different pharmacological properties of the drugs and the relation of this difference to drug dealing. When employed in a dealing team, both heroin and cocaine are readily available --though not unlimited as dealers dislike overindulgent employees--, but Jack restrains from ingesting large amounts of heroin. Well aware of the uncertain nature of his employment, he anticipates periods of unemployment in which drug availability is much lower. Thereby he prevents unpleasant withdrawal experiences or having to resort to money raising activities below his (ethical) standards (27, 28). Cocaine's superior status as a pleasure drug may also add to this choice. But, maybe even more important, the specifics of the dealing setting promote the increase of cocaine use. To prevent loss of control of the dealing process (mistakes in weighing and financial transactions, rip offs, police busts or any other interference of the economic process) those involved in dealing must stay alert, perform their task accurately and constantly monitor the situation at the dealing place. This requires rather careful drug titration. In particular, too much heroin is contra-productive, as it decreases attention and results in reduced control over performance and the setting. In contrast, cocaine elevates alertness and is therefore tailored to the requirement of the job. As a result, cocaine use increases, generally both in quantity and frequency.

Although both patterns may ultimately lead to some degree of cocaine related psycho-social problems, as described in the following section, the second pattern would especially seem to do so, as cocaine use is less compensated with heroin. Oddly enough, while the second pattern is more common among dealers and their total consumption is generally well above the average, they seemed to experience less problems. Cocaine related symptoms were not observed in stable dealers. In itself this seems a paradoxical finding, as it apparently contradicts the commonly held idea that psychological problems due to cocaine use are dose related (12, 29). It is a question, though, if this contradiction is real. Whereas dealing users may use considerably more cocaine, it does not mean that this is without limits or that they are not susceptible to cocaine related problems. This finding may thus merely mean that under the specific conditions of the dealing setting these users can consume more cocaine than their non dealing peers before experiencing these typical problems, and when such problems appear, they are apparently more successful in applying controlling procedures.

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Consequences of Cocaine Use

Problems due to heavy cocaine use are well known among heroin users. Physicians in treatment and methadone maintenance programs are more frequently confronted with cocaine-related symptoms and some of them are prescribing antidepressants and tranquilizers (7). Problems range from loss of control and craving escalation, individual psycho-social complaints to the collective disturbance it has on the structure of social interactions. While the state of intense heroin intoxication (the nod) has positive value for a considerable number of users, this is not always the case with cocaine. Irritability, extreme sensitivity to external stimuli, paranoid and delusional thinking, formication (coke bugs), and other unpleasant effects have all been related with heavy cocaine use (12, 26). At the other hand, discontinuation of use may lead to craving, tremor, muscle pain, eating disturbance, extreme nervousness, sleeplessness and social withdrawal, and rebound depression (26). As 96% of the research participants used both heroin and cocaine, almost all have experience with the negative sides of cocaine and it was a frequently mentioned subject. Many users furthermore report that quality of life has decreased since cocaine has entered the scene --mutual tolerance and support seem to decrease when cocaine is involved.

As explained above, when smoked or injected the desired effects of cocaine are highly intense but very short followed by an unpleasant rebound. To check or prevent this state and maintain the high, the drug is administered repeatedly over short time intervals. As a consequence of this practice, craving for cocaine can easily escalate:

"There I go again with that coke, I just took a shot. Often the needle is still in my arm and I'm in the flash. But already I'm thinking about the next shot. You're so busy with the next one that you ruin the flash you're in."

This can lead to the consumption of enormous quantities of the drug. To maintain the high and prevent the crash, users end up binging (a binge is a prolonged period of heavy use) on the drug in administration schedules of twenty minutes or less, until the cocaine is finished:

"In the period that I was sitting in my kitchen all day shooting cocaine, I found the cocaine high delicious. But, the crash I found horrible and I would experience this crash within 20 minutes. I was not using heroin in that period. Normally after a shot of cocaine, I would inject some heroin to avoid that jittery body feeling. But without the heroin, I just had to keep adding cocaine every, say, 17 minutes. Not so much to keep the high going but to stay one step ahead of the crash."

A binge is often heralded by a sudden rise in financial means, for example the result of some (mostly unplanned) criminal success. Such an event not only interferes with preceding comparably balanced use patterns, it may be the end of it (28) --a turning point in the career, ushering in a period of insatiable craving and resulting (extremely) high use levels of cocaine and heroin. Maintaining such high use levels requires large amounts of money, in the study group normally generated through involvement in the lower echelons of drug dealing or high levels of criminal activities. Billy, one of the research participants, explained that in one of his periods of high cocaine use, he was making money daily by following the mailman, observing where he mailed check books. Subsequently he lifted the check books (each containing 20 checks with a maximum of ¦200.-) out of the mailbox with an ingenious gripper and sold them to his fence for ¦1500.- each. Often he would start the day with ¦4500.-, buy cocaine and inject until it was finished. Although he sometimes is arrested, Billy succeeded in making the large amounts of money he required for his cocaine use on a regular basis. Normally he worked with a partner and than they formed a dyad (see chapter nine).

A little later Billy's partner comes in. He lives at Billy's place and they make money and use together. He is 35 - 40 years old. He tells Billy has just been busted when stealing in into the Shell building. He clearly has respect for Billy's criminal skills. "Billy is a real crack, lots of guts, he just walks into every place. We make a lot of money, regularly we earn 5000 to 6000 guilders a week."

The opportunity to make such large amounts of money on a continual basis is, however, not evenly distributed. When engaged in heavy cocaine use without access to ample financial resources or when a profitable source suddenly dries up, many heroin users, who before exercised some degree of control over their use, lose all grip on their situation and get into problems in many different ways.

During a binge often decisions are made that probably otherwise would not have been taken. In the words of Arie: "Cocaine steals the brains out of your skull, you keep on going" Everything becomes subordinate to the goal of maintaining the cocaine high. A considerable number of users will even neglect their heroin habit. That this is not an unusual occurrence is implicated in the following comment of a dealer:

"Many times I've seen users being sick from withdrawal and having only three 'tientjes' (¦30.-) left. But they still buy 'voor twintig wit en een tientje bruin' (¦20.- cocaine, ¦10.- heroin). That's what they do when they are on coke."

Although they like the drug very much, not all users go that far:

"When ... I'm sick, I would always buy brown first. I just know, I need it not to get sick again later on the day. I'm not in a methadone program, so white is nice but it stays a matter of secondary importance. White is really a delicacy. But getting better in the morning (from withdrawal) is just like having a flash. Really, when I'm sick and take a shot, the flash from the heroin is nicer than a coke flash. One thing is sure to me; morning brown is the nicest shot you can experience on a day."

Not only are (weekly) benefits spent on cocaine before the day of remittance has ended, even the grey market value of methadone, has been affected. This widely dispensed heroin substitute is frequently sold below the price. Paco and Numa provided information on the price dynamics at the drug market at the Central Railway Station and the inflationary effects of cocaine:

Paco tells: "Normally you have to pay ¦2.50 (for one tablet of Rohypnol; a strong, short acting and therefore popular benzodiazepine), but when there is no one else around with ropies the price can go up to ¦3.50 or even ¦5.-. With methadone it's the same, normally it is ¦1.- per cc" Numa adds: "There are a lot of dumb people around here. When you come here on a Friday everybody is selling methadone (the weekend doses). There is so much around then that some of them can't get rid of it, they can't find buyers. So they're lowering the price, some will sell it for 50 cents or even less. They should wait until Sunday, then they can make much more out of it. Sunday is always a special day: dealers are not at home or won't open the door, and a lot of users don't have enough money left to buy dope. And it's hard to get methadone on a Sunday, especially here on the C.S." Paco replies: "you know how they are, they can't wait. Especially when they are on coke, they need money, fast and now."

During the field work users were often followed on their daily rounds. The day the following fieldnote was recorded Richard and Chris, two older IDUs were accompanied. They were contacted at the Central Station, where they were trying to sell their methadone. Their behavior was a strong confirmation of the account of Paco and Numa:

Richard tells: "The methadone program allows us 10 days off in one year. Today we both took 2 days off, Thursday and Friday. And so we could also take the weekend doses with us. I have a daily dose of 20 cc and Chris gets 35 cc. Today we both got for 4 days, which makes a total of 220 cc, we are trying to sell now. We are trying for a half an hour now, but we still haven't found a soul that's interested in it." Chris says: "I Can't find no one either. Only some girl, but she wanted 100 cc for ¦50,=. I first want to look further." Half an hour later Richard finds a customer. He first wants to buy 25 cc for ¦25.-, but Richard offers him 55 cc for ¦35.-. Richard says: "But wait a second, I have to ask my friend, we're together in this you know." He walks towards Chris who is still searching for buyers. Chris agrees. Richard continues: "We make ¦35.-. Than we can buy '2 streep wit en 1 streep bruin'(0.2 gram cocaine and 0.1 gram heroin). The rest we can pay in methadone at the dealer." Chris replies: "Okay with me, but lets go now, this takes so long and I really need a hit now."

When they sold their methadone, they rushed to a house address, bought the drugs, went home and shot a cocktail. The consequence of being without methadone the coming three days did not seem to bother them much.

Impaired judgment may lead to overestimation of criminal skills and indifference over the consequences of ones actions, as long as it generates more cocaine:

"I was sentenced for a burglary, they caught me on the spot. It was because of the coke. The day before I made a lot of money. First, I bought some clothes for ¦700.- and gave my mother ¦300.- to have the television repaired. The rest I gave to her to keep it save for me. But that day I went on going to her, each time asking for ¦100.-. I don't know exactly how many times I went, but the last time was about two a clock in the morning She got very angry at me and told me to take all the money. That night I spent ¦1100.- on dope, mostly cocaine. When I ran out of money I still wanted more and decided to go out to get money. I wasn't sick or so, I just wanted more coke. The people at the place I was tried to stop me from going, but I would not listen. I just wanted more."

In this case, the arrest meant the end of the cocaine binge. Although during the fieldwork only few cases of violent behavior could be established, several violence stories associated with out-of-control cocaine use were recorded.

Jerry tells about a guy who went crazy through his excessive cocaine use. "He started to demolish the room downstairs and also broke a window. He just wanted more cocaine."

Normally these outburst were directed at other community members:

Last week Footy tried to rip me off my money. He first tried to borrow ¦25.- of me. I told him I did not have money. Then he started to threat me, he took the sword I keep as an ornament and put it on my breast. He wanted me to empty my pockets. I did not do it, we went into a struggle and I took the sword from him. I threw this table to him and then he backed off."

Intensive cocaine use can render the user overly sensitive to external stimuli, especially sound:

The Surinamese user ... stands up and says: "My head. My ears are singing" This happens after he's been smoking (cocaine from the glass) for 15 minutes. He says he has to leave and goes out on the street.

This sensitivity can lead to social withdrawal. Some users, particularly IDUs, can not stand others around when taking cocaine and therefore isolate themselves. One IDU told that when shooting cocaine, he retreats himself into the shed behind his parents house, puts wadding in his ears and a towel over his eyes. If not, his rush would be ruined. For an outsider such events may not look pleasurable and even for insiders such behavior can be startling, but as the comment in the next fieldnote indicates, there is clearly some entertainment value in the act:

"Lately we had somebody here who was only shooting coke, about 1 gram a day. When he had taken a shot, he used to lay down and wanted everybody to be quiet. His eyes would turn in his head and his arms and legs would swing wildly in the air, shaking his body. He looked 'para', but he seemed to enjoy his shot. As soon as the shot was worked out he would take another one, over and over."

In a minority of cases, when users involved in intensive cocaine use are disturbed in their rush they may turn aggressive.

Paranoid thinking is often associated with heavy cocaine use. The relation between cocaine and paranoia has been clinically known ever since cocaine became widely used (3). Paranoia and related phenomena like restlessness and anxiety are indeed well known as consequences of heavy cocaine use in the Rotterdam heroin scene. Users talk a lot about paranoia and relate it to the use of cocaine:

Mover [has smoked cocaine and heroin. He]... is very speedy, talks fast and loud, sweat on his face. Nadir bends over to his neighbor saying: "you see how para he is, it's the cocaine".

Prior to the following fieldnote, Ria had just taken an injection of cocaine:

Ria comes down to the first floor and starts searching in a plastic bag which is filled with garbage. Gus (her boyfriend) tells her to stop with what she's doing but she continues searching. She goes on for about 10 minutes and finally comes up with some old stamp bags (which had contained drugs). she shouts at Gus; it seems to have something to do with the bags. "Stop it Ria", Gus shouts back, "you're talking nonsense, it's just paranoia!" A few minutes later upstairs, Ria is having a nervous breakdown, she is crying heavily. "I can't stand it any longer", she's crying, "Can't you see I need rest. Tell them all to go, Gus, I want them out."

As they frequently give dealers the opportunity to sell drugs, it is often very crowded in the house of Ria and Gus and they hardly have any privacy. Moreover, because of the dealing, there is always a risk of police busts, which results in a continuous tension.

Another psychological cocaine-related problem, frequently mentioned in the literature, is depression (14). Both field and clinical observations have shown that after periods of heavy use of cocaine, users may often get depressed (12, 26). Harrie, a 40 year old native Dutch drug user who has been shooting up for about 20 years is a case in point. Over the last years Harrie has used methadone, heroin and primarily amphetamines. During the fieldwork period, Harrie started dealing heroin and cocaine. He left the methadone maintenance program and stopped taking speed. Instead he began shooting cocktails of heroin and cocaine. The first months this went fine; he earned more than enough to support his habit, even to pay a dealing team, and began to live with a woman. But later Harrie started having problems. He was robbed twice, which was stressful, and felt forced to hire bodyguards which were expensive. The begging and wheedling of customers brought additional stress. About a month prior he ran short of money and had to stop dealing. Shortly after that, his girlfriend left. Attempting to feel better he continued binging on large amounts of cocaine but grew more and more depressed. He talked about suicide and feeling down. The following fieldnote documents the cocaine related depression Harrie fell into at the end of his binge:

Harrie is sitting in the corner in a car seat. His face looks very sad and his eyes are wet although he is not crying. He says he called because he doesn't see any perspective anymore. He is not able to make any distinction between his problems and can't say what exactly bothers him. He says everybody has let him down and he would like to commit suicide, but does not dare. When asked what he wants to do about his situation he says he does not know, "what difference does it make. It all seems one black hole." He has not eaten for days but refuses offers of food, saying a shot of cocaine would make him feel better. He asks and almost begs several times for money to get some coke, but does not think that cocaine is a part of his problem. He feels left alone and thinks he's so down because his relation broke up.

Clearly Harrie is unable to make sense of his condition or distinguish the ingredients of the process that left him in his present state. Deprivation of food (and obviously sleep) have taken their toll. But, most of all, his complete fixation on cocaine --in his perception the drug was not part of the problem, but the one and only solution-- prevented him from making any rational assessment.

It has also been demonstrated that cocaine has a disturbing effect on sleeping patterns (26). In this context, the use of benzodiazepines and other pills has been reevaluated in the heroin scene. Before the increase in cocaine use, benzodiazepines and other pills were mainly used by a low status minority, nicknamed pill freaks. Nowadays, many users take benzodiazepines to control negative side-effects of cocaine, such as disturbed sleeping patterns:

"I'm having sleeping problems, that's why I use Rohypnol and Valium, so I can sleep."

Besides sleeplessness, these prescription drugs are used to decrease restlessness produced by cocaine. Prior to the next excerpt the user has just injected a cocktail of cocaine and heroin:

"I've got to walk, I'm 'speedy' and by the way I can get some pills somewhere."

In the Central Station survey 59 % of the sample used benzodiazepines. Apart from cocaine related self medication applications, benzodiazepines, e.g. ropies (rohypnols) and other pills are taken to substitute, supplement or potentiate the effect of other drugs. The stereotypical staggering junkie is often the product of the use of large doses of pills. A considerable number of users take pills to ameliorate withdrawal when they cannot get heroin:

Achmed tells he's sick and asks Nadir if he got something for him. He explains: "Friday (today it is saturday) I sold all my weekend methadone to buy heroin. But now I've got nothing I took a Rohypnol, it keeps you easy for a couple of hours. But it doesn't take away the withdrawal symptoms".

The combination of benzodiazepines with other drugs, alcohol in particular, gives a high some users appreciate, but can also produce unexpected effects and subsequent amnesia. Therefore many users feel ambivalent about their use:

Achmed tells that the effect of the rohypnol is waning off. "It helps a little, but I don't like to use it at all, it's bull shit. I always call it 'de vergeetpil' (the forget-pill). I'll tell you what it did to my brother. Once he came home and was totally upset, like a mad man. He had used rohypnol and alcohol. A fight came up. He fought with my father and me. He made a mess. The next morning when he woke up he asked me what had happened. He didn't know anything about it, couldn't remember a thing. He was very ashamed. That's why I call it a vergeetpil."

The combination with opiates may lead, depending on the doses, to an unexpected nod or even overdose, especially when benzodiazepines are not regularly used:

Harrie was very upset about the 'rip-off' and took two 'ropies'. Normally he never does. From the ropies he got relaxed. But some time later he took a shot and through the combination with the pills he went out (into a deep nod).

Transitions between administration rituals --in a considerable number of cases related to cocaine use-- will be addressed in chapter six.

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Conclusions

In contrast with some years ago, when cocaine was incidentally used by a minority of heroin users, cocaine now seems to have become the underlying motor of the former heroin scene. The results presented in this chapter indicate that rituals, developed for the use of heroin, which effects last about four to six hours, are not instantly adaptive for cocaine use, as this substance forces users in administration schedules of twenty minutes or less. Because of the short lasting effects and the subsequent high frequency administration schedules, the perceived availability of the drug is for most users much lower than that of heroin (although the drug may be just as easy to purchase), provoking increased drug craving and thus higher drug use levels.

The cocaine use patterns of the heroin users in this study result in a deep paradox of pleasure and pain. While most users are fully aware of cocaine's paradoxical qualities, only few are able to withstand the seduction of the intense high cocaine delivers. In that respect, binging on cocaine has some points in common with a crusade. Blind for the negative consequences, the binger resembles a food and sleep deprived hallucinating crusader, who is mesmerized by a vision of (artificial) paradise, that, when rushing on coke, is so intense it almost becomes tangible. Intensive use, however, not infrequently entails tremendous sacrifices. It is therefore not surprising that users often describe cocaine in lyrical or religious as well as derogatory terms (27).

However, Grapendaal et al. recently wrote that "users can consciously choose to (temporarily) quit the use of cocaine" (27). Although their respondents displayed a fearful respect for cocaine and refer to the substance in terms as "insatiable appetite", "bottomless pit", "never enough", "forbidden fruit" and "... absolutely no brakes on this stuff", these authors conclude that "any compulsion due to the composition of the substance is ... out of the question. One uses cocaine as long as certain rewards are connected to its use and use is functional in a certain lifestyle. Use ceases as soon as the (figurative) costs outweigh the benefits" (27). While some users indeed seem able to stop the use of cocaine at will, such a bold conclusion does not seem justified by the data they present. As this chapter makes clear, a considerable number of users go to any lengths using cocaine and persist far beyond the point a rational cost benefit analysis allows. Some users renounce cocaine only after having paid a considerable price in terms of economical, social, psychological and legal costs. Not surprisingly, periods of intense cocaine use often end with arrest and incarceration.

For some, such experiences or those of friends are an incentive to (further) abstain from cocaine:

Petra says: "Not for me, I never use coke, I never did and I will never start to do so. I have seen enough of that shit".

However, many users do not succeed to abstain from cocaine use and regularly experience some degree of the in this chapter described problems. In order to prevent or minimize these problems most users have developed cocaine/heroin patterns that, besides satisfying the craving for the high cocaine provides, also aim to control its adverse effects. This is an indication of some degree of adaptation. Chapter seven will discuss these patterns and explore the determinants that moderate their effectiveness.

At this point it can, however, be concluded that in this population control over cocaine is still far from perfect. Rituals and rules developed for heroin use can apparently only slowly be adapted to cocaine. The, compared to heroin, low perceived availability of cocaine complicates this process to a large degree. With the nesting of cocaine in heroin rituals, the homeostasis and normalization of the heroin user has been severely disturbed.

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References

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