Drugs as a Social Construct

Preface

I approached Prof. Harm ‘t Hart a year ago with the question of whether he would be willing to act as my promotor. I expected him to react as he he always does: with a great amount of caution. And indeed, he quite prudently said he would have to look into what I presented him with.

He then kindly invited me to write a short introduction showing the connections between all the different parts of my work. I am glad he insisted. This introduction has known more versions than any other part of my dissertation. Keeping it short was much more difficult than I had foreseen. Writing it convinced me that sometime I will have to take time, a year or more, to submerge myself in all the theories behind what is now called drug science, and to write something longer.

I thank Prof. ‘t Hart for his patience, and for playing the invaluable role of “methodological encyclopedia” behind the work that went into the study of cocaine use in Amsterdam.

Prof. Hans van Amersfoort, my second promotor, deserves gratitude for his wise criticism. He also gave me all the time and workspace I needed as a new member of the Vakgroep Social Geography, University of Amsterdam, to do what I wanted to do.

I thank the other members of the “Promotiecommissie”, Professors Grinspoon, Hess, Hulsman and Polak and dr. Musterd for taking the time to evaluate the material that was assembled for this publication. They have all been important, years before this dissertation, in shaping my views on and my relation to the field of drugs. Some of them influenced me through their writing, some through long discussions and some by both.

My study of cocaine users could not have become what it is without the assistance, professional zeal and curiosity of both drs. Dirk Korf and drs. Paul Sandwijk. I hope to continue my cooperation with them in other non conventional studies in this field.

Peter Cohen
September 1990

I. Introduction into the author’s bias

• Introduction into the author’s bias
• References chapter I

Introduction into the author’s bias

The four sections, assembled for this dissertation, have been published earlier in 1983 (Heroin dependence pathological?), 1985, (Cocaine and Cannabis), 1986 (On Rehabilitation), and 1988 (Cocaine use in Amsterdam)[*]. In this introduction some of the principles that helped me in writing these publications are presented.

An important background of my work is an opinion about the competency of much medical and social science when applied to drugs. These sciences seem to be unable to describe and explain the phenomenon of drug use without an unusually strong bias. This bias is produced by a cultural dependency on concepts of much larger significance than drug use itself. As a result the object is almost completely blurred from view.

Note that I do not claim to be right. Of course, I construct my own view on both science and drugs. An important bias here is my own political distaste for discriminatory forms of control. Furthermore, I have been assisted by an epistemology offered by the many varieties of sociology, political economy and psychology. I could not help but seeing much of what happened around me in the drug arena as “social constructions”; realities created by a myriad of relationships between persons who used concepts to understand a reality that would adapt them for their survival within these relationships[*]. And since the inequality of power is one of the structural characteristics of interpersonal (or for that matter, inter-organisational) relationships, much of the so called scientific analysis of drug use would tend to be most instrumental to the survival of the most powerful. Power, of course, is not only connected to wealth or decision making, but also to the construction of morality and ideology.

Long before I started writing about drug use I realized the validity of the general concept that science is one of the fundamental instruments of political and ideological conflicts. The determination of which branches and concepts of science will be developed or applied is, apart from chance and some interdisciplinary logic, dependent upon economic and political power. Because power cannot be evenly distributed in a community (the university included) those in power will develop science according to their interests and taste. One should not look upon this as dishonesty or exploitation per se, but in most cases, as honourable and quite inescapable.

The concepts I initially used to attain a detailed understanding of the relation between concepts and power were the “I”, the “Ego”, and the “individual” (Cohen, 1980[1]). Educated as a social psychologist, I critically investigated many psychological and sociological theories in order to come to grips with the use of social science for the conceptual construction of the “ego” and “the individual”.

To summarize, I learned that in present Western society, dominated as it is by entrepreneurial activity, persons have to very often find their way against or without others. Therefore, generally a person will learn to “experience himself alone, in the centre of things for whom everything else exists outside himself, separated by an invisible wall from him, assuming as self evident that other individuals experience the same”. (Elias, 1969, p. 125[2]) I followed Norbert Elias in the theory that this “Homo Clausus” concept of the individual is a specific historical construction. Of course, this construction is not the intentional product of some office or ideologue, but a by-product of people in their mutual and socially structured relationships. It goes unnoticed, like breathing. It follows that naïve science will explain the individual as a Homo Clausus. In this way psychiatry, psychology and sociology are tools of a class of people who interpret, influence and try to shape others and society from this dominant perspective on the individual.

In the short essay “On Rehabilitation” one will easily recognize my constructionist point of view. I simply do not take seriously the reasons for the use of drugs that are often mentioned in scientific literature. My psychological bias tells me to look for motives behind the words, and my sociological bias compels me to search for these motives in the field of power inequalities. One discovers that the so called ‘reasons’ why people take drugs are convenient conceptual constructions that are fitted to a predetermined, mostly psychopathological model of explanation of drug use and ‘dependence’.

However, as observed by Musto[3], it might very well have been the emergence of a new class of professional medical men at the end of the last century that helped to socially define illegal (often so called ‘non-medical’) drug use. Professionals related to the maintenance of physical or mental health and the management of pain have throughout history been very powerful people.

The tools and concepts of these professionals may change in history. The modern power to mediate between (a large majority of) drugs and the use of drugs is a new and tremendously important instrument. In contemporary Western society drug use is not left to the individual responsibility of the consumer. It is assumed that the consumer is not able to exercise this responsibility. Every consumer of drugs is therefore forced to first consult a ‘drug broker’, which produces in turn an almost total monopoly of the drug broker class. Total prohibition of certain drugs is the focal point of the assumption that drugs should be excluded from the realm of consumer freedom. In this sense the existence of ‘illegal’ or ‘non medical’ drug use is a vital concept for present day legitimizations of medical power. This particular concept has been internalized by all categories of the public, although it has been attacked by theoreticians such as Szasz[*],[4] And as long as the definition of “illegal drug use” helps medical professionals to retain their power, a large majority of them can be expected to hold to it.

Power also plays a role in the management of minorities. How tHe management of minorities is related to our history of drug prohibition is illustrated in “Cocaine and Cannabis”. Management of minorities does not only relate to the opportunities of economic exploitation, but also applies to the warding off of fear. If mainstream groups develop fear of minorities for whatever reason, there is a small likelihood that scientists belonging to these mainstream groups will not share these fears. Science can then be used to translate popular and crude verbalisations into an ‘objective’ scientific discourse of warding off policies that legitimate the use of physical force against the feared minorities. One of the most common legitimizations of the use of physical force is the redefinition of drug use as crime or “crime generating”. Once this has been accomplished the social institutions that will care for drug users can be defined as the police, prison personnel or, in extreme cases, the army.

The article on the assumed psychopathology of heroin dependence focuses on the use of psychological theory for the essential construction of drug dependence as illness. The redefinition of illegal drug use as pathology is on first view completely different from its redefinition as crime. The difference, however, is mainly in the selection of control institutions. The violence of health institutions towards the users of illegal drugs is often less outspoken than the violence of criminal justice institutions. This is a difference that can be very important for individuals that are subject to this violence. But both medicalization and criminalization are techniques to control defined deviant groups and in this sense they are identical.

The article on the psychopathology of heroin addiction evaluates the empirical evidence we have for just one of the medicalization techniques commonly applied to illegal drug use[*]. Following Zinberg I conclude that the conventional combinations of behaviour we define as heroin dependence are mainly a product of society’s reactions toward a frequent heroin user, not of the effects of heroin itself. We are so conditioned by medicine to think in terms of the pharmacological effects of a substance that drug-use related behaviours are automatically associated with the substance. But the effects of a substance are almost always mediated by the user and the social context in which use takes place. A failure to understand this interaction gives rise to an invalid emphasis on the pharmacological dimension. This distorted emphasis is often connected to narrowly conceived psychiatric models of explanation.

If, apart from a few cases, regular drug use in general and heroin use in particular would be no longer defined in terms of pharmacology and pathology a conceptual cornerstone of 20th century prohibitionism would seriously erode.

Investigation of the concept of addiction itself, as an expression of “central cultural conceptions about motivation and behaviour” (Peele, 1985, XII)[5] would have been a logical extension of my bias. But until this dissertation I never attempted to venture into this trickiest and most fundamental of labyrinths in the field of drug use.

Conceptually shifting away from the incorrigible association between frequent use of illegal drugs and pathology, a drug use career with all its secondary social effects can be researched in a completely different way.

Once on this road (coupled with the view of the instrumental function of science for drug political status quo) one quickly recognizes “realities” that have been excluded as an object of scientific inquiry. A good example is the pleasure that drugs provide. Drug-related pleasure or other non-negative functions of drug use cannot be easily investigated within a political structure that is committed to the prohibition of drugs as a defense against evil. Imagine a high officer of the Inquisition in the late Middle Ages allowing for the possibility that a large proportion of heretics were “non evil”! This would have been impossible. (Is this principally different from the current ban on the use of the expression “recreational drug use” from the publications written with grants from the National Institute on Drug Abuse — NIDA — in the USA, because drug use should not be even conceived as “non sick”?[*])

The pleasure of drug use is a topic of empirical description appearing inconspicuously in both publications on cocaine reprinted in this dissertation. Cocaine use has not been portrayed as a reinforcer of compulsive behaviour as it is often presented from the perspective of pathology. In contrast, I have made room for the perspective of the majority of users in which it often appears as one of the hedonistic entities of everyday life. The importance of taking drug related pleasure as a research topic can be illustrated by the serious attempt to understand controlled drug use. One of the conclusions of my cocaine user study was that most cocaine users do not lose control. Apparently some “control mechanisms” exist and they are not restricted to cocaine. This conclusion has been reached by a growing number of drug researchers[*]. A full understanding of control mechanisms is still lacking as well as a a thorough theoretical investigation of this concept itself. But, assuming the validity of such a concept, one of the regulators of drug use might very well be a relative change in drug related pleasure when drug use exceeds certain limits. My cocaine study showed that when a level of use of 2.5 grams of cocaine per week is exceeded, the number of reported unpleasant negative effects rises steeply. This could very well be one of the explanations of why levels above 2.5 gram per week are so rarely maintained over longer periods in my sample of experienced cocaine users, even though many respondents are very well able to financially support such levels of use.

In many psychological and sociological views on drug use both the concepts of drug related pleasure and controlled use are of little or no importance. Heroin and cocaine allegedly cannot be used in a controlled and pleasurable manner because the concepts of control and pleasure conflict with ruling notions. Loss of control and extreme misery is what the use of these drugs will yield. Empirical verification from an epidemiological point of view of such ex cathedra notions is still rare. The purpose of my study “Cocaine Use in Amsterdam” was indeed to empirically verify through epidemiological research the prevailing notions of cocaine use.

If one realizes that much of our knowledge about the use of cocaine has come from studies done by clinicians, one also comes to realize that there is a sampling bias with the data that clinicians use use in their generalisations. This problem is similar to the problem one would have if our knowledge about the use of alcohol would be derived solely by the knowledge gathered by clinicians working in alcohol treatment. Alcohol users not seen by these medical professionals of course do exist and are indeed the great majority of the users of alcohol. My aim in the cocaine user study was to verify whether long term cocaine users not seen by clinicians would show the same problems as the ones that do present themselves for treatment. Or, in contrast, are the “invisible” users of cocaine comparable to alcohol users who are not seen by clinicians? And if so, is self control and possibly self management of eventual drug related malfunctioning an exception or the rule?[*]

Another aim of the cocaine user study was to explore what could be scientifically determined about the regular use of cocaine from a perspective that does not assume a priori that regular cocaine use is related to (mental) pathology. I simply wanted to know how experienced cocaine users report about their consumption, what pro’s and con’s they would define, how they eventually handle unwanted side effects and if they develop certain rules of use. For someone who does not automatically associate regular use of cocaine with loss of control and all kinds of dramatic dysfunctioning, the results of the study are hardly surprising.

The selection of the publications that comprise this dissertation is grounded upon their illustrative significance for some of the issues that I have mentioned. Each of them deals with a certain mix of conventional wisdom, conventional ‘fact’ or conventional application of concepts in social sciences. Together they can serve as an integrative perspective on drugs and drug use as research objects and behaviours that need not be so heavily fetishized or charged with emotions and mores.

These publications also try to demonstrate that psychology and sociology can be productive in distancing a researcher from what has become mainstream “drug abuse” science. The emphasis is on changing perspectives.

Nevertheless, some factual statements would be different if written now. For instance, I would no longer say, as I do in “Cocaine and Cannabis” that cannabis or cocaine do not produce tolerance. Instead, I would now dissect the general concept of tolerance into specific tolerance for each different main effect of the drug used in its social and recreational patterns. I would then, in turn, attempt to list as far as possible dose related tolerance for some specific effects. And if I would find that no valid research about differential tolerance for cocaine or cannabis effects exists, I would leave this aspect of comparative risk analysis open.

Thus, in conclusion I have observed that the specific ways in which psychology and sociology have looked upon drug use and selected topics for research are often purely instrumental in not endangering the existence of the a priori’s of the present “drug problem”. On the other hand, both disciplines yield notions that enable us to clarify and identify this instrumentalism. Where an individual scientist will stand might be a matter of chance, but most probably it is a result of his attachment to conventional perspectives and prejudice on drug use or drug dependence. And the chances for developing a non-conventional scientific outlook on illegal drugs become slimmer as financial support for drug research is regulated by drug policy institutions whose aim is to support conventional drug politics. This works also the other way round. No doubt my way to look upon matters of drugs has been very much influenced by the simple circumstance of living in the Netherlands where drug policy is deviant when seen from a global perspective. Both psychological and sociological concepts have been used and are used by official policy bodies in this country to defend and legitimize this deviance. Here at least some research can be funded precisely because its main questions fit non-conventional drug politics. In this sense my work is also instrumental, creating its own constructions more or less in line with recent work of others in the Netherlands (Leuw, 1981[6], Jansen and Swierstra, 1982[7], Van de Wijngaart, 1990[8]).

Finally, a neutral view on drugs is highly improbable in a world that translates the drug issue in war metaphors. I am convinced that only the abolition of drug prohibition might ultimately create the conditions for a maximum of independent scientific involvement in the issue.

References chapter I

• I am highly indebted to Jason Ditton, Richard Hartnoll, Charles Kaplan, and Russell Newcomb who helped me translating these publications into English.
• I use the term ‘social construction’ in a common sense way, with only a very vague notion of the existence of a large school of thought in sociology that has social constructions as its object.
• Szasz also discussed this item extensively in Rome, March 1989, at the founding conference in the Italian Parliament of the International League against Drug Prohibitionism.
• Another medicalization technique is to generalize rare somatic risks, or medical risks of extreme drug use patterns for all drug use; this technique is not discussed here.
• Of O’Hare, P.: Ideology, Research and Policy. In The Intl Journal on Drug Policy.Vol 1/3.p.24-26
• See e.g. Zinberg, N.: Drug, Set and Setting: the basis for controlled intoxicant use. Yale University Press, 1984. Zinberg studied the use of marihuana, LSD and heroin. Cf also Rosenbaum, M. et al: Exploring Ecstacy: A descriptive study of MDMA users. Final report to the National Institute of Drug Abuse, Rockville 1989.
• The concepts of “self control” and “self management” of problems are used here in such a way that they include mechanisms that are dependent on the existence of small and private social control systems made up of several people or small groups.

1. Cohen, P.: Het groeps-ego concept en de verhouding psychologie-sociologie. IWA 1980. (The group ego concept and the relation between psychology and sociology).
2. Elias, N.: Sociology and Psychiatry. In: Foulkes, S. H and Stewart Prince, G. (Ed): Psychiatry in a changing society. London 1969.
3. Musto, D.: The American Disease. Origins of narcotic control. Yale-University, 1973.
4. Szasz, Th.: A plea for the cessation of the longest war of the 20th century: the war on drugs in CORA (Eds): The cost of prohibition, proceedings of the congress, organized by the Coordinamento Radicale Antiprohibizionista, European Parliament, Bruxelles, Oct 1988.
5. Peele, S.: The meaning of addiction. Compulsive experience and its interpretation. Lexington, 1985.
6. Leuw, E.: Een criminologische visie op deviant druggebruik. in: Goos, C. en van der Wal, H. (Eds) Druggebruiken, verslaving en hulpverlening. Alphen 1981 p 77-106.
7. Janssen, O. en Swierstra, K.: Heroïnegebruikers in Nederland. Groningen 1982.
8. Van de Wijngaart, G.: Competing perspectives on drug use. The Dutch experience. Dissertation, Utrecht 1990.

II. Some critical remarks on the concept of “social rehabilitation”of drug addicts[1]

• II.1 – Introduction
• II.2 – Magical ideologies
• II.3 – Consequences of drug policy
• II.4 – A historical analysis of our drug policy
• II.5 – Poverty
• II.6 – Economic power and world market
• II.7 – Medical power groups
• References chapter II

Table of contents

II.1 Introduction

One of the popular subjects in the field of the so called drug problem is the “social background” of illegal drug use, “social background” perceived as a complex of causal factors.

Since social scientific reflections have entered daily life we can no longer circumvent the notion that particular social backgrounds exist for those who start the use of illegal drugs. Furthermore, these “backgrounds” are claimed to be causes of this drug use and play a role in all kinds of arguments, e.g. about prevention.

Often, so we are taught, drug users or addicts have had a particularly difficult time when young because of alcohol-abusing parents, divorced parents, uncaring or over-caring parents, or because of having no parents (when raised in institutions). When investigating addicts concerning these “backgrounds” one indeed finds them, but unsystematically distributed among a small minority of them.¹

An almost insurmountable problem of these studies is that comparison with control groups of similar persons who have not become addicted to some drug is usually absent, or impossible because of lack of data. How to constitute a control group is moreover not at all so clear as one would assume at first sight, even in circumstances when many data would be available.

In short, although (family) backgrounds are at the moment very fashionable in aetiological thinking about drug use and addiction, they have little practical relevance from a scientific point of view.[2]

II.2 Magical ideologies

One can find many more “backgrounds” associated with drug use apart from the family related ones. During the sixties the social backgrounds of then emerging deviancies (like drug use, political rebelliousness, greater sexual freedom) were allegedly to be found in sociopolitical changes like greater affluence among youths, absence of real challenges, the cold war, etc.

At the moment we find present day culture-pessimistic backgrounds associated with the use of illegal drugs, like no future for youth, unemployment, racism etc. Even in Lasch’s theories we find very elaborate postulates about the aetiology of drug use, as published by Faccioli and Simoni.³ For them, the increasing pluriformity of society, and the difficulties of finding one’s identity which arise from it, shape todays background to illegal drug use. The experience of having “an empty identity” is countered by taking drugs. Faccioli and Simoni state very emphatically that these conditions actually exist for every one of us. But why then elaborate so much on their being the present day background for drug addiction? Clearly, not all of us belong in this category. Don’t they see their work is quite irrelevant if the conditions for drug use are general and all encompassing?

This rhetorical question leads me to the assumption that often the search for the causes of drug use is not a proper scientific inquiry but more a magical activity of ideological control.

We look for backgrounds and causes of illegal drug use because finding them exerts a soothing action. But we confuse looking for causes with expressing specific and historical preoccupations, valid during a certain period. These preoccupations are projected onto things considered threatening, like drug use. Is one’s major preoccupation our overdeveloped welfare state, then drugs are taken because of too much welfare state. Is one’s preoccupation unemployment, then drugs are taken because of unemployment. And when one’s preoccupation is pluriformity of culture, or uncertainty of about where to go in the world, the backgrounds or causes of illegal drug use and addiction are there. It is a ritual providing us with an ever new deus ex machina, one which is every time as impotent as any other.

This last remark is added because I can not conceive of how such knowledge about social backgrounds could be of any political relevance. Just assume that affluence among youth was a cause of drug use, would economic measures be taken to curb wages? Or assume that poverty among youth was a cause, would wages be made higher? And what if both were true for different groups? And continuing this argument, let us assume identity problems are a cause, will we facilitate identity searching? And what about family conditions? Will we be able to improve them in such a way that severe problems will no longer or less often occur?

So, thinking about social backgrounds has, apart from the enormous scientific problems involved, the disadvantage of being totally irrelevant to social policies. It seems there is more than enough justification to start looking at the problem of social rehabilitation of drug addicts in a completely different way. But there is more to it than the reasons I just stated. It is not only a counter reaction.

II.3 Consequences of drug policy

The issue of social backgrounds of drug use and their possible relevance for rehabilitating drug addicts can also be approached from a complete different perspective on background factors. To illustrate this I would like to present here a few results of an analysis of drug problems, made by the Joint Commission on Alcohol and Drugpolicy in its recent report Drugpolicy on the move.⁴

In this report the Joint Commission uses a distinction taken from criminological and sociological theory about primary and secondary deviance. The Joint Commission does not use exactly the same concepts, but speaks about primary and secondary problems of drug use. The similarity is clear however. Primary problems are defined as those that are strictly related to toxicological aspects of a particular drug. Secondary drug problems are caused by drug policies that determine to a large degree the conditions under which drugs are consumed.

This distinction makes sense because it contributes to a more objective picture of the risks of using a particular drug. The fact that experts do not always agree about the category to which a “problem” belongs is interesting, but is not the subject here.

The Joint Commission states that the secondary (drug policy related) drug problems consist of:

• problems of public order
• health problems with users, like infections
• marginalization of drug users
• criminality and prostitution
• blocking the institutions of Justice.

I do not disagree with this rather dramatic summing up. All these problems are not drug related but drug policy related. And what is the core of our drug policies? The maintenance of the illegality of a number of drugs for any purposes other than medical or scientific ones.

The topic I have been asked to address here is the rehabilitation of drug addicts. We seem to believe that such a rehabilitation is something the addict has to do himself, in some cases with the help of state financed institutions who use our knowledge about “social backgrounds” of illegal drug use. But when state officials who coordinate drug policies in this country indicate that the larger problems of illegal drug use are mainly caused by drug policy, we may find much more potential for the rehabilitation of drug addicts by changing this policy. And this is something we should do.

So, we would no longer use our resources to find out about the “social background” of drug addiction, but would direct some attention to the question of what social backgrounds maintain illegality for a number of socially used drugs. We change our perspective away from drug addicts in order to direct it towards drug policy.

Why do we keep some drugs illegal?

II.4 A historical analysis of our drug policy

Because eminent social scientists have preceded me on the road of this analysis I am able to present some of their findings.

It should be clear from the beginning that our present way of prohibiting some drugs is relatively new, although none of us have ever known anything else. Our present drug policy was conceived in the latter half of the last century and first implemented in the first decade of this century in the U.S.A.

The goals of this new policy can only be understood in the context of the social and global relations of those days. Of these goals I want to focus on the three most important ones.

II.5 Poverty

The first and most prominent goal was to counter poverty and cultural backwardness, conditions in which drugs were seen as contributing factors. The miserable paupers that emigrated to the U.S.A. from China, Eastern Europe and Russia took with them patterns of drug use that were incompatible with adaptation to the then existing American way of life. Above all, drinking patterns of Irish and Polish immigrants were far removed from the behavioural discipline that the anglo-saxon elite associated with the American Dream.

In short, the first goal of the new drug policies — including a rigourous ban on alcohol — can be seen as a direct and progressive confrontation with social misery.

II.6 Economic power and world market

At the end of the last century the U.S.A. started to present itself as an emerging economic power looking for spheres of influence and markets outside its own territory. Although the U.S.A. clearly had a huge potential, its world position was minor to colonial empires like England, The Low Countries or France. But by a strong anti-opium policy the U.S.A. hoped to win for itself, to the detriment of England, one of the most promising markets in the world: China. Most of the scarce foreign exchange the Chinese had available was used for the import of very expensive opium the English provided on a completely monopolistic basis. The import of English opium[3] prevented the import of many other commodities into China, a state of affairs clear to both the Americans and the Chinese.

From those days stems one of the the most resistant myths about opium: that it caused famine and poverty in China. This is a myth that is still one of the cornerstones of the orthodoxy that says opium should be illegal.[4]

The very aggressive opium policy of the U.S.A. was led by a bishop, but both Musto⁶ and Scheerer⁷ cite the possibility that economic policy was the most influential motive for the federal American government to support a foreign anti-opium policy.

In short, at the turn of the century the U.S.A. used both an external and an internal anti-opium policy, with motives of conquering foreign markets and influencing the home labour market (cf Helmer8, 9).

II.7 Medical power groups

A third and, for this paper, last goal of the new drug policy which emerged in this century can be found in a completely different field again. This is the field of medical organisation, or the monopolistic role emerging medical power groups demanded for themselves in the mass public health institutions of the 20th century.

Until far into the 19th century the practical possibilities of medicine were rather restricted. Skin burning, bleeding and amputation were not the most appropriate methods to fight the many diseases that plagued humankind. But little else was available. All kinds of incurable disease were accompanied till death by pain and anxiety. Many hundreds of drug store “medicines” had become available in the last century, almost all containing some opium which was indispensable for the treatment of pain and anxiety.

After the introduction of modern scientific medical method based on the discoveries brought about by the microscope, the practical possibilities of medicine began to grow. Drug store “medicine” was more and more associated with backwardness and embezzlement.

In spite of the fact that opium was then used by about 0,2% of the American population (one tenth of the prevalence it had among medical personnel. cf Musto, 1975 p. 42), the leading medical organisations participated rigourously in outlawing the use of opiates in non medical settings⁶.

They claimed that “medicines” should only be available via licensed doctors within types of treatments agreed by them. The success of this claim is at the same time one of the most fantastic success stories of one particular social group in this century.

In short, the historical roots of our present day drug policy can be found in the U.S.A. at the beginning of this century when the new drug policy served three main functions:

1. adapting the 19th century immigrant to the image of the non-catholic anglo-saxon elite;
2. acquiring economic power in the markets of the Far East and
3. helping the monopoly of medication by the modern doctor, by outlawing “self-medication”.

To analyse the historical roots and functions of the present oppressive drug policy is a fascinating activity that merits a far better treatment than given to it in the few lines above. Our drug policy comes from a long-gone historical period and is therefore no more than an anachronism.

But such a historical view on drug policy does still not answer the question why the basics of drug policy have not changed during the last eighty years, although the conditions that gave birth to it have already long passed away. Unfortunately I do not have the answer, although one aspect of a full answer would have to deal with the potential of this policy to legitimize itself continuously.

By making some drug inaccessible via legal prohibition, in spite of many people finding these drugs important for their own well being, a clear class of violators of the law is created. As a result, a minority of these will show conspicuous forms of criminal or otherwise immoral behaviour.

Pointing to these phenomena, one can then legitimize the illegality of these drugs by saying “look what happens to their users”. The public supports this policy out of fear. They will then have a continuous need to be protected from “the consequences” of illegal drug use. Moreover, the prejudices lay people have against drugs are perfectly mirrored by the prejudices of many of our professional drug experts, thereby reinforcing each other. All of these circular processes look surprisingly like the circles within a dependence as outlined by van Dijk¹². Would our eighty year old drug policy remain unchanged because it produces an attachment to it, which if it were towards a drug we would define as dependence?

References chapter II

1. Gimpel, M. and de Jong, R.: De voorgeschiedenis van problematisch druggebruik. Unpublished Manuscript. Psychologisch Lab. Universiteit van Amsterdam, 1981
2. Fazey, C.: The aetiology of psychoactive substance use. Unesco, Paris, 1977
3. Faccioli, P. and Simoni, S.: Identità e droga nella società complessa. Dei deliti e delle pene, 2. 1984, p. 577-594
4. Interdepartementale Stuurgroep Alcohol en drugbeleid: Drugbeleid in beweging. Staatsuitgeverij, Den Haag, 1985
5. Kramer, J.: Speculations on the nature and pattern of opium smoking. In: Zinberg, N. and Harding, W. eds.: Control over intoxicant use. New York, 1982
6. Musto, D.: The American Disease. Origins of narcotic control. Yale-University, 1973. Cf in particular chapter 2.
7. Scheerer, S.: Die Genese der Betäubungsmittelgesetze in der BRD und in der Niederlände. Göttingen, 1982
8. Helmer, J. and Vietorisc, Th.: Drug use, the labor market and class conflict. Drug Abuse Council, SS-2, 1974
9. Helmer, J.: Drugs and minority oppression. New York 1975
10. Morgan, Wayne H.: Drugs in America. A social history 1800-1980. New York 1981
11. Van Dijk, W.: Alcoholisme, een veelzijdig verschijnsel. Tijdschrift voor Drugs, Alcohol en andere psychotrope stoffen, 1976. p. 26-32

III. Cocaine and Cannabis. An identical policy for different drugs?

• III.1 – Introduction
• III.2 – A short history of cocaine use
• III.3 – Subjective and societal effects of cocaine use
• III.3.1 – Subjective effects
• III.3.2 – Societal effects of cocaine use
• III.3.3 – Societal reactions to the use of cannabis type drugs
• III.4 – Cannabis and cocaine
• III.5 – A closer comparison of cannabis and cocaine
• III.6 – Recommendations
• References chapter III

Table of contents

III.1 Introduction

Many policy makers are continuously influenced by incidental drug observations and haphazard media coverage relating to drugs. But, in order to reflect about possible guide-lines for the development of a governmental policy which is specially directed towards the use of illegal drugs, some background information is necessary.

This text focuses on the use of cocaine but does not contain all the possible background information about this psychotropic substance. It does however discuss the question of which attitude a government should have toward the use of cocaine within the present legal constraints, both from pharmacological and social scientific perspectives. I will eventually plead for a highly restrained government involvement in this area.

The text has four parts. First some brief remarks are made about the history of cocaine use and some methods of ingestion. The second part is dedicated to user descriptions of subjective experiences after the use of cocaine. In this part also some attention will be given to social reactions to cocaine use in the United States of America at the beginning of this century. These reactions are compared to some of the most important social reactions in the U.S. to the use of cannabis products. The purpose of this part is to show how crucial the constructed association between drugs and identified user groups is for judging the effects of a drug, both by the general public and by so called drug experts.

The third part continues the comparison between cannabis and cocaine, introducing at various points a comparison with alcohol. The final fourth part contains some general recommendations for a government policy in the field of cocaine.

III.2 A short history of cocaine use

Most material in this part is taken from the fine study Ashley¹ published in 1975.

The use of cocaine was unknown in Europe until the Spaniards conquered the South American continent. Indians living in and around the Andes mountains have chewed the coca leaf since time immemorial. Spanish church authorities initially banned the use of coca leaf because they were convinced the effects of the leaf resulted from a pact between the devil and the Indians. However, the low quality of labour Indians presented in the many mines where they were put to work without coca chewing led the Church to stop forbidding the old custom. She then initiated a tax of 10% on the price of coca leaf.

A 19th century visitor to Peru gave witness of having used coca leaf himself, stating it gave him a pleasant soothing experience. It enabled him to “endure long abstinence from food with less inconvenience than I should otherwise have felt, and it enabled me to ascend precipitous mountain sides with a feeling of lightness and elasticity and without loosing breath”. He recommended its use to members of alpine clubs.²

In the second half of the nineteenth century the prime alkaloid from the coca leaf, cocaine, was isolated in chemically pure form. An Italian, Mariani, applied the alkaloid immediately in a drink, Vin Mariani. This drink would become famous and remain so into the early 20th century.

Scientific circles started to show some interest after Freuds study “Über Coca” (1884) and after the application of cocaine as a local anaesthetic in eye surgery (1884). Confusion about the effects of cocaine — is it a narcotic (cf Kollers way of using it) or a stimulant (cf Freuds way of using it) — has raised considerable attention.

Cocaine may be ingested in several ways. Indians chew the leaf together with a small amount of calcium. The calcium serves to make the cocaine more available to the saliva of the chewer. An Indian will chew during one day several small bundles of leaf, ingesting the cocaine via the mucous membranes of mouth and throat. Typical use of an Indian chewer is estimated to be around 60 grams of leaf or ca 400 milligrams of cocaine per day.

Chemically produced cocaine hydrochloride from the coca leaf was used in Vin Mariani, but also in many other popular drinks, of which Coca Cola is the most well known. At the beginning of the 20th century these so called coca tonics were forbidden.

Presently cocaine is mostly used as a powder, snorted intranasally in dosages of 10 to 30 mg (so called lines) or injected intravenously by some users in dosages between 50 and 500 mg.³

Modern use of cocaine occurs most frequently by snorting. By snorting, cocaine hydrochloride is being conveyed into the blood stream via the mucous membranes of the nose and throat in which it dissolves. Several patterns of snorting are known. One can snort a few times a year in certain social groups, one can use every weekend and some use cocaine daily, sometimes repeatedly. Which frequency of use is chosen depends on taste, availability, financial means, fashions in ones social circles, etc. An individual use pattern is a complicated mixture of frequency and social rules of use. Use patterns are not static. A person may be abstinent for a couple of months then turn to frequent daily use until a certain work or task is finished, be abstinent again until the next occasion, and so on.

Also, with i.v. users several patterns are known. Persons who mainly inject can have sudden periods of very frequent injecting (so called binge use). Cocaine injections may be mixed with heroin to make “speedballs” although in the U.S. the injection of cocaine only is reported to be most frequent among injectors.⁴ It is assumed that in the Netherlands this is not different.

It will be clear that a completely reliable report on the quantity a user uses per week or month is not possible. This is not only due to the large differences a user may show in use patterns, but also to the unknown purity of cocaine on the illegal market.

A relatively rare way of ingesting cocaine is by smoking it free based. Cocaine hydrochloride, the substance available on the black market, is made basic in order to recreate the original free base alkaloid of cocaine. Cocaine free base is volatile which makes it fit for smoking. Untreated street cocaine (hydrochloride) would simply burn, for instance when smoked with tobacco. The effect of cocaine free base smoking is reported to be immediate and strong, comparable to the ‘flash’ effect of an injection. The mild and subtle effects of cocaine, which can only be learned through experience, are said to be not comparable to the effects of smoking free base.

III.3 Subjective and societal effects of cocaine use

III.3.1 Subjective effects

In a survey Ashley performed among eighty American cocaine users the most praised effects of cocaine are described as marked mood improvements, increase of energy for performing ongoing tasks, disappearance of feelings of tiredness and appetite for food and an increase in sexual stimulation.⁵

Large quantity use is experienced as unpleasant, but defining a large quantity is difficult. “Some persons can consume several grams a day and experience no notable ill effects, while others experience them when they exceed a quarter of a gram”.⁶

Somebody taking more than the dosage level appropriate to him will experience a kind of ‘hangover’ feeling. Other effects of an overdose of cocaine can be: anxiety, a level of aggressiveness not proportionate to the actual situation, sleeplessness, sweating, impotence and a heavy feeling in the limbs. Very heavy users of cocaine may report strong feelings of paranoia “as if the police were on the point of breaking into the house”.7,8,[2] The learning period of recognizing the unpleasant effects of too much cocaine is relatively long.

Lethal dosages of cocaine are said to be around 1200 mg, but according to several researchers such high dosages do not occur in the social use of cocaine.[3]

III.3.2 Societal effects of cocaine use

In the more than hundred years that cocaine has been used in the Western world a vast and broadly dispersed knowledge about this drug has been generated. This knowledge can be found in encyclopedias, medical handbooks, stories and media coverage. Most of this knowledge however is partial, unprecise and sometimes downright wrong. This concerns especially the dangerous characteristics ascribed to cocaine. This drug allegedly is heavily addictive, a source of violent and criminal behaviour, induces severe depression in its users and may even lead to permanent moral degeneration.9,10

Understanding this description of cocaine as an extremely dangerous drug is impossible if the role ascribed to cocaine as a cause of all sorts of social disturbance and deviance is not taken into account. The following examples will illustrate this role.

Cocaine has become popular since the end of the last century, at a time when in England11,12 as well as in the United States of America13,14,15 much concern had developed about alcohol and opiate use, especially in the lower classes of society. Both countries showed the emergence of a powerful popular movement against the use of drugs. In America this movement even succeeded in conquering a total ban on alcohol (Volstead Act 1919).

Because the image of cocaine as a very dangerous drug has its roots in the U.S.A. I will use mostly American material for the social history of cocaine.

Between 1880 and 1900 relatively little concern had been generated about cocaine. For as far as it was recognized at all, the drug was considered as “attractive to sensitive and intelligent people seeking to maintain energy in order to work harder at socially acceptable tasks”.¹⁶

In medical circles the social use of cocaine seems to have been propagated. Cocaine was then still used as a substance in the famous coca tonics and many other “therapeutic” drug store products of the time.

But after 1900 cocaine started to become extremely well known. The media started to report the use of cocaine by the black population in the southern states of the U.S.A. The end of the century had seen many lynchings of black persons, and many apartheid laws were made including the curbing of voting rights. The white majority thus had many reasons to expect black opposition. Although white violence against the black population will have been many times larger than vice versa, black violence against white Americans (mainly manslaughter and rape) has received enormous attention in the media. All black violence was said to have its cause in the use of cocaine.

“The drug produces several other conditions that make the ‘fiend’ a peculiarly dangerous criminal. One of these conditions is a temporary immunity to shock – a resistance to the ‘knock down’ effects of fatal wounds. Bullets, fired into vital parts, that would drop a sane man in his tracks, fail to check the ‘fiend’ – fail to stop his rush or weaken his attack.” “A recent experience of Chief of Police Lyerly of Asheville N. C., illustrates this particular phase of cocainism. The Chief was informed that a hitherto inoffensive negro was ‘running amuck’ in a cocaine frenz… Knowing that he must kill the man or be killed himself, the Chief drew his revolver [a heavy army model… large enough to kill any game in America], placed the muzzle over the negroe’s heart and fired – ‘intending to kill him right quick’- but the shot did not even stagger the man. And a second shot that pierced the arm and entered he chest had just as little effect in stopping the negroe or checking his attack.”

In the Report International Opium, written by Hamilton Wright M.D. for the American Congress, cocaine was mentioned as a drug about which “it has been authoritatively stated that cocaine is often the direct incentive to the crime of rape by the Negroes of the South and other sections of the country”.¹⁹

A certain Colonel Watson from Georgia reported already in 1903 in the New York Tribune that “many of the horrible crimes committed in the Southern States by the coloured people can be traced directly to the cocaine habit”.²⁰

At the beginning of this century emerging organizations of pharmacists participated in creating the cocaine myths. In the same year Colonel Watson made his report, the American Pharmaceutical Association made it known that cocaine was attractive to “negroes, the lower and immoral classes”.²¹

The Philadelphia Pharmaceutical Board explained in 1910, that “a great many of the southern rape cases have been traced to cocaine”.²²

We see cocaine depicted as a drug that not only causes sexual assault and murder, but also as one that enables its user superhuman energy. Or, like Everybody’s Magazine wrote in 1914 about cocaine using Blacks: “Ordinary shootin’ don’t kill him.”.²³>/a>

The fear that was raised in those times about cocaine has found its way to both national and international legislation. In the U.S.A. cocaine was seen as by far the most dangerous drug.²⁴ This point of view, that was shared by medical and pharmacological authorities, has recreated itself via a long chain of citations (of cited citations) until the present times. The Dutch pharmacologist van Rossum writes in 1979:

“Logically regular use of cocaine creates a moral decay in the addict who intends nothing else but acquiring his euphoric stimulus and who becomes insensitive for social interactions. This causes a lack of duty and will power, egocentrism, wild associations and sometimes psychotic states. His extreme obsession with action, coupled to paranoia can make the addict under the influence of cocaine into a dangerous individual; homicidal behaviour occurs. The cocainist under influence of cocaine is more dangerous than the morfinist under influence of heroin. Moral decay with chronic use however is with both cases identical.”²⁵

It is reasonable to assume that the very negative connotation of cocaine in the U.S.A. emerged as a side effect or a side function of a much larger complex of social change and upheaval. But because of the creation of international Drug Treaties, in the process of which the U.S.A. were a strong and dominating force²⁶, cocaine has remained petrified as a dangerous drug since the first Convention of The Hague in 1911.

III.3.3 Societal reactions to the use of cannabis type drugs

The early history of cannabis has many similarities to the history of cocaine. Use of cannabis was known, but the Harrison Act of 1914 had no rules about cannabis use. In view of the very strong attitudes against all drugs during this period the omission of cannabis from the Harrison Act may be seen as a proof of the lack of concern cannabis use created. The first Convention of The Hague (1911) advised about cannabis that its use be studied statistically and scientifically.²⁷

This peaceful attitude would make way for a similar mythology as we have seen emerge for cocaine. Since the early Twenties Mexican immigration into the U.S.A. had increased considerably, above all to the States bordering on Mexico.

Although Mexicans already had the reputation to be violent people their cheap labour was sought in order to develop large agriculture in the South. The discussions in this era about curbing immigration also concerned the Mexicans.

Under pressure of both the Mexican government and the large farmers Mexicans were not included in quota regulations.²⁸ Opposition against on-going Mexican immigration was increasing however, lead by patriotic organizations (like the American Legion) small farmers and labour Unions.²⁹ A passionate and racist campaign started against Mexicans in the U.S.A.. Early reports about violence of Mexicans under the influence of marijuana can be found in a 1917 document of the Department of Agriculture. In this respect a 1925 American document about problems with the Panama Canal has also been influential. This document described countless conflicts between police and violent marijuana using Mexicans.³⁰

In the Thirties reports about extremely violent crimes committed by marijuana using Mexicans increased so much that political pressure emerged to outlaw cannabis type drugs on the federal level in the U.S.A.. The orthodoxy in relation to drugs, the Federal Bureau of Narcotics under Harry Anslinger opposed such legislation initially. Later it supported and co authored the necessary Tax Act.³¹

In 1929 the Michigan Municipal Review reported: “Marahuana, the Mexican dope known as Indian hemp or Loco, is being sold in large quantities around high schools in many localities.” “This affords a peculiar thrill and is followed up until another addict to drugs is made and the helpless chap joins this gruesome procession that has only one end. This social drug is known as the murder weed”.³²

The Police Chief in Los Angeles reported in the early thirties that “marihuana is probably the most dangerous of all our narcotic drugs.” “In the past we have had officers of this department shot and killed by marihuana addicts and have traced the act of murder directly to the influence of marihuana,with no other motive”.³³

During the hearings about the Marijuana Tax Act the physician Treadway maintained that marijuana produces “a delirium with a frenzy which might result in violence: but this is also true of alcohol.”³⁴

Such a delirium has also been documented in a 1931 report about Crime and Foreigners. After showing that marijuana use is quite frequent among Mexicans the document states that “if continued, the drug develops a delirious rage, causing smokers to commit atrocious crimes.”³⁵

The objective level of violence between Mexicans among themselves or towards other groups is quite irrelevant, although Helmer has tried to give some quantitative data.³⁶ What is important is that a causality is constructed between the use of marijuana and a consequent committing of the most hideous crimes. This is why marijuana got a name it would keep until into the Sixties, i.e. Killer Weed.

The habit of Mexicans to smoke marijuana was quickly forgotten after the Marijuana Tax Act had passed Congress in 1937. The plant emerged again in the Sixties when a fast growing cultural youth movement more or less adopted the plant as its symbol. The original association of cannabis with violence, reached by coupling the behaviour of a deviant subgroup with marijuana, could not be used in this new period. But another behaviour of the mostly well to do cannabis users struck the onlookers, their ‘dropping out’. This was the root of the then constructed most prominent ‘effect’ of marijuana, the so called amotivational syndrome.

In 1967 a Superior Court Judge in the U.S.A. wrote: “Many succumb to the drug as a handy means of withdrawing from the inevitable stresses and legitimate demands of society. The evasion of problems and escape from reality seem to be among the desired effects of the use of marijuana.”³⁷

And a member of the New York State Council on Drug Addiction witnessed during Congress hearings in 1968, comparing LSD to marijuana, that “even marijuana in heavy doses can, after repeated use, produce the same loss of ambition, rejection of previously established goals, and retreat into a solipsistic, drug oriented cocoon.”³⁸

And during the hearings one year later a Harvard expert said: “But I am very much concerned about what has come to be called the ‘ amotivational syndrome’. I am certain as can be ….. that when an individual becomes dependent on marijuana …. he becomes preoccupied with it. His attitude changes toward endorsement of values which he had not before”.³⁹

The essence of this short excursion into the social histories of cocaine and cannabis is to show that the effects of a drug are to a high degree constructed by associating a drug with conspicuous behaviours of deviance in the drug using group. It is not really clear if such constructions emerge as popular images, to be shared later by so called experts who in their turn will reinforce the original images. It is clear however, that so called experts will in the cases of illegal drugs judge the effects of these drugs in a way that fits the above mentioned association and that these experts will only rarely rely on balanced empirical research.

This process of associating drugs with subgroups is not only used in a negative way. This becomes apparent when looking at the costly advertisement campaigns of producers of drugs like tobacco or alcohol, in which their products are strongly associated with certain behaviours of certain (high) status groups.

III.4 Cannabis and cocaine

In the Netherlands the association of cannabis type drugs with large groups of young people who did not or rarely distinguish themselves by dangerous forms of deviance, and the complete lack of a history of negative associations probably explains much of the sceptical attitude of a number of (mostly self appointed) Dutch drug experts when confronted with reports about the ‘effects’ of cannabis. This had a lot of influence on the report of the Baan Commission on Narcotic Drugs, presented in 1972 to the Dutch Government who had not only created the Commission but also asked it to write a report on future drug policies.

The recommendations from this report led to the present de facto undisturbed access to cannabis type drugs for every Dutch person who feels the need. Contrary to the recommendations of the Baan Commission no research has ever been done into the effects of this state of affairs on public health. But, just as valid is the remark that the need for this research has never arisen. Politicians in the Netherlands have never been pressed into researching this subject. Taking into account the large variety of political ideologies represented in Parliament, which include intolerance against the use of alcohol and other drugs, one can expect that bad experiences with the easy access to cannabis type drugs would have resulted in at least strong requests for investigations. Hospitals, individual physicians or Drug Treatment Institutions show a conspicuous lack of reports on the use of cannabis type drugs resulting in problems of one kind or another.

Although all this is not enough to definitively conclude that cannabis use never results in any form of problem behaviour, the absence of concern about the use of this drug is in itself an interesting and important phenomenon. The factors that cause this lack of concern may be the relative inoccuousness of cannabis when used socially, the lack of criminalisation of individual users, etc. Research into this matter would be of international relevance.

But, after more than 20 years of cannabis use by a small minority of the Dutch population we can certainly make two important observations:

1. In the Netherlands the prevalence of cannabis use is very probably not higher than in countries where this use is still vehemently prosecuted and punished ⁴⁰. The prevalence of cannabis use in the Netherlands even seems to decline, in spite of the absence of any form of public pressure or policies that intend such a decline.
2. Apparently cannabis has found its place in the Dutch variety of socially integrated drugs. We can assume that rules and techniques have been generated in relatively easy going atmospheres that help regulate and control use.

Use of cannabis that could be associated with problem behaviour of any quantitative importance has remained outside the attention of the public and as far as we know, even outside the attention of professional drug treatment institutions. Marginalisation of users is unknown. Although all of these remarks require assessment by research, such research is simply not available. For the time being however we may legitimately observe that Dutch cannabis policy, characterized by a lack of state involvement in individual cannabis use, has been succesful.

Could we draw from this the conclusion that a possible cocaine policy in the Netherlands should use the cannabis policy as its model? Let us see.

III.5 A closer comparison of cannabis and cocaine

Just like cannabis cocaine does not result in physical dependence. For those who do not want to be without the effects of cocaine and proceed to daily use this does not result in tolerance for the desired effects. This means stable doses can be taken for long periods without loss of effects.41,42 Long term use of very high doses results both with cannabis and with cocaine in unpleasant and undesired mental reactions for some users (cf 2.1.).

Because of the price of illegal cocaine frequent use can cause financial problems, but this is not an effect of the drug itself.

A very important difference between cocaine and cannabis is that the former can be lethal.[4]In this respect cocaine is similar to alcohol and other legally available psychotropic substances. But in integrated social use of cocaine the doses that are necessary for lethal intoxication do not occur. A snorter will very rarely ingest more than 150 mg per session, an intravenous user rarely more than 500 mg per injection. In daily practice the probability of taking a lethal dose of cocaine is negligible, although more so than with cannabis.

A similarity between between cannabis and cocaine in the present situation of illegality for both is the unclarity of the purity of street market substances. Cocaine and cannabis (e.g. marijuana) can both be cut, although it is far easier with cocaine. A user never really knows how strong the product is he takes after purchasing it. Fortunately, both drugs are most often taken in ways that allow fast adjustment of dosage to perceived purity: cocaine is snorted and cannabis usually smoked. Only when eating a cannabis product or injecting cocaine is adjustment not possible if the substance is unusually strong (pure).

Apart from a pharmacological comparison of cocaine and cannabis both drugs should also be compared on their social characteristics. Cocaine is comparable with cannabis in the sixties as far as the association with dangerous deviance is concerned. Like cannabis in those years cocaine is now taken by a very polymorphous public. An association of cocaine with dangerous deviant groups has not yet appeared, in spite of the fact that it is known that ‘junky-type’ opiate users have reported highly adverse reactions to free base cocaine during its introduction in 1983.⁴³ This means that cocaine use by some heroin junkies has not at all damaged the slightly elitist image of cocaine. This is why no association exists between ‘dangerous’ groups and cocaine, so that depicting cocaine as dangerous is not seen as legitimate at the moment. This creates the chance for a more objective judgement about cocaine. I would like to present such a judgement, along the lines of an idea the Baan Commission published in 1972: “Usually a distinction is made when discussing drugs and drug use between so called hard and soft drugs. One actually designs a kind of danger scale for e.g. heroin,morphine, codeine, etc. By drawing a line somewhere along this scale a categorization of hard and soft drugs may be reached. In some cases the rank a substance takes in the order of the scale is open for dispute.”⁴⁴

We now know that the rank order in such a scale is more or less historically determined. The present number 1 (heroin) has taken its place from earlier numbers 1, cocaine and cannabis. But a discussion on rank order in a danger scale of drugs is not impossible and I repeat that we can reasonably search for a place for cocaine on the “Scale of Baan”.

When I say ‘reasonably’ I mean a way of reasoning in which one does not focus on ways of using a drug that are either very rare or depicted in an extremely ugly way.

Ashley very aptly wrote: “Where illicit drugs are concerned the prevailing practice is to accept the most adverse reports and then to elevate them to generalities applicable to all users.”⁴⁵

Examples of this are described in 2.2 and 2.3. “Just saying no” to the above-mentioned illegitimate generalizations is an enormously important step toward a reasonable searching process for the position of a drug on the Scale of Baan. And for this process we could use another recommendation of the Baan Commission, which is that the risks of a drug, and not only the pharmacological risks, should be the fundament of a drug policy.⁴⁶

So, in my attempt to give cocaine a position in the Scale of Baan I will use evaluations of both pharmacological and social risks of this drug.

In order to really make an objective scale construction one would first have to find agreement among experts how to define or operationalise the different social and pharmacological risks. Also agreement would have to be reached about which drugs belong on such a scale. And what patterns of use will be taken as reference? Are we making a scale for drugs only for patterns where they are consumed very sparingly in well integrated social situations, or do we allow forms of excessive use? All these questions can not be answered, even assuming that agreement among experts could be reached. To be able to proceed with the building of the Scale of Baan I have chosen to use our relation to a widely known drug as a model. This drug is alcohol. This drug is mostly used quite modestly in socially integrated ways[5]. Regular excessive use in a person is the border of what is usually accepted socially. Strong negative reaction occurs from the moment where excessive use becomes the rule and where the capacity of the user to maintain an adequate level of social and economic contacts is clearly damaged. My reference pattern will therefore be: daily low dosage use, once in a while excessive use, always within socially accepted frameworks.

I will try to compare similar cocaine and cannabis use patterns with this reference  pattern for alcohol use. To find a place for cocaine on a scale which includes all known psychotropic substances or even all known socially used drugs would be far beyond the boundaries of this article.

Table III.1 Some medical/pharmacological risk factors of alcohol, cannabis and cocaine when used daily in social situations with occasional high level use.

Comparing the above mentioned medical/pharmacological risks we see that cocaine and cannabis both score “no” 2 times, compared with zero for alcohol. If we just take the safest ways of ingesting the three drugs (drinking a known dosage of alcohol, eating a known dosage of cannabis and snorting a known dosage of cocaine) the scores change slightly. Cannabis and cocaine would score “no” 4 times. Alcohol would score 1 “no” because in daily practice the purity of alcohol is almost always known and extreme lethal dosages do not or very rarely occur.

We see on this selection of severe medical/pharmacological risks that cannabis and cocaine score about the same, but better than alcohol.[6]

For an evaluation of the risk factors involved in taking a certain drug it is not sufficient to look at the medical/pharmacological ones. Social risks are vital for a complete comparison.

At least two kinds of social risks of a drug exist. The first and foremost is the risk of social marginalization. This may occur because use of a drug is so little accepted socially that the knowledge about somebody using the drug will cause panic and later expulsion from the micro-environments of the user. Marginalisation may also occur via strong criminalization of the drug user. Here police and prosecution procedures will be the roots of marginalisation. Often, however, one will find the two kinds of marginalisation combined.

A second social risk of the use of a drug is that its use does not result in socially integrated forms of control or self-regulation. The risk here is not that one uses a drug, but the way one consumes it is not compatible with broader rules of behaviour between persons who take part in a social situation.

Self-regulation of drug use emerges within the circles the drug is used, if rules are learned about which effects and which methods of consumption are tolerated in different situations and which behaviours apply when these rules are not followed.

Self-regulation is in this sense a collective product. This is why the exact form of self-regulation may vary from group to group.

The most important advantages of self-regulation are that users among themselves are able to deal with unexpected effects and that a user is so familiar with the effects that he can choose the dosage (or way of ingestion) that suits the occasion. An example will clarify this. Everybody knows how somebody behaves when intoxicated with alcohol. Somebody may behave disturbingly but the doctor will not be called in. But somebody using a high dosage of heroin outside his usual circle, quietly nodding off in a corner and barely reacting to questions or remarks, will easily elicit panic reactions. In the latter case bad self-regulation is evident. Neither the user nor his social environment are able to adjust their behaviour to the demands of the situation.

What can we say about the social risks of cannabis, cocaine and alcohol? The big problem is that social risks are not independent of each other. Strong criminalization will endanger or even block the emergence of broadly applicable forms of self-regulation and thereby increase the probability of marginalisation. The opposite process is also possible. Strong marginalisation may force public authority to criminalize users. In both cases the two social risks will reinforce each other.

Table III.2 Some social risk factors of alcohol, cannabis and cocaine when used daily in social situations with occasional high level use.

My impression is that the striking absence of problem-inducing forms of cannabis use in the Netherlands has to be associated with the Dutch policy of non-intervention. Social risks of cannabis use are not reported, at least not in the metropolitan areas where prevalence is highest.⁴⁸

For cocaine the evaluation of potential social risks is extremely difficult. We know almost nothing about users or patterns of use. The only thing I am quite certain of is that the image of cocaine at the moment is such that public institutions may still influence the emergence, or not, of social risks.

The contribution of the State could be to not criminalize cocaine use and to supply information about it as objectively as possible. The latter would above all be the task of conspicuous politicians and state servants.

“Government affects behaviour chiefly by shaping the cognitions of large numbers of people in ambiguous situations. It helps create their beliefs about what is proper;their perceptions of what is fact;and their expectations of what is to be done”⁴⁹

If the state would choose not to criminalize cocaine use and to give balanced information about cocaine as was done earlier for cannabis by the publication of the Baan report, a similar drug policy for cocaine is possible. Because of the similarity between user-groups of cannabis then and cocaine now, such a policy would not produce great political confrontation. Beyond this, it is official drug policy to “diminish risks”.50>,51 Thus, a normalization/harm-reduction policy toward cocaine-use is a feasible option.

III.6 Recommendations

1 On the basis of observed similarities in the medical/pharmacological risk-levels of cannabis and cocaine, as well as in the social status of the dominant user groups, the Dutch cannabis policy may serve as a model for a future cocaine policy.

2 The myth, created in the beginning of this century in the U.S.A., that cocaine is an extremely dangerous drug has to be debunked. (This myth should not be replaced by a new one, i.e. that cocaine use produces “psychological dependence” because stopping its use creates severe forms of depression.)

3 The State initiates research into use-patterns of illegal drugs and their potential physical and social risks. Further, it should organise weekly analyses of “black market” drugs, conveying the results to public health institutions. Possible risks of adulterations can then be dealt with at the local level.

References chapter III

1. Ashley, R.: Cocaine: Its History, Uses and Effects. N.Y. St. Martin’s Press. 1975
2. Ibid., p. 5
3. Spotts, J. and Shontz, F.: Cocaine users: A representative case approach. N.Y. The Free Press, 1980, p. 461
4. Ibid., p. 459
5. Ashley 1975, p. 155
6. Ibid., p. 165
7. Spotts and Shontz, 1980, p. 329
8. Ashley 1975, p. 164. Cf also Woods, J. and Downs, D: The psychopharmacology of cocaine, in: National Commission on Marihuana and Drug use, Drug use in America: problem in perspective, Washington 1973, Appendix I, p. 124. Cf also Van Dyke, C and Byck, R.: Cocaine: 1884-1974, in Ellinwood, E. and Kilby, M.: Cocaine and other stimulants, New York 1977
9. Ashley 1975, p. 158-159
10. Editorial British Med. Journal (1930) Quoted in Bean, Ph.: The social control of drugs, London 1974
11. Berridge, V. and Edwards, G.: Opium and the people. Opiate use in Nineteenth-Century England. London 1981
12. Johnson, B.: Righteousness before revenue: the forgotten moral crusade against the indo-chinese opium trade. Journal of Drug Issues, 1975, p. 304-326
13. Musto, D. The American Disease. Origins of narcotic control. Yale -University, 1973
14. Helmer, J.: Drugs and minority oppression, New York 1975
15. Morgan, P.: The legislation of drug law: economic crises and social control. Journal of Drug Issues, 1978, p. 53-62
16. Morgan, Wayne H.: Drugs in America. A social history 1800-1980. New York 1981, p 91
17. Musto 1973, p. 7
18. Williams, E. 1914, quoted in Ashley 1975, p. 71
19. Wright 1910. Quoted in Musto 1973, p. 44
20. Musto 1973, p. 254, footnote 15
21. Quoted in Morgan, Wayne H. 1981, p. 92
22. Ibid., p. 93
23. Ibid.
24. McLaughlin,: Cocaine, the history and regulation of a dangerous drug, Cornell Law Review, 1973. p. 568. Quoted in Austin, G.: Perspectives on the history of psychoactive substance use. Rockville, NIDA 1978
25. Rossum, J. van: Cocaïne: psychofarmacologische en psychotoxische effecten. Tijdschrift voor Alcohol en Drugs, 1979. p. 61-66
26. Musto 1973. p. 52
27. Ibid., p. 51
28. Helmer, 1975, p. 57
29. Ibid., p. 58
30. Himmelstein, J.: From killer weed to drop out drug: the changing ideology of marihuana. Contemporary Crises, 1983, p. 13-38
31. Musto 1973, p. 222
32. Morgan, Wayne H. 1981, p. 140
33. Helmer 1975, p. 66
34. Musto 1973, p. 226
35. Himmelstein, 1983, p. 24
36. Helmer 1975, p. 69
37. Himmelstein, 1983, p. 28
38. Ibid.
39. Ibid.
40. Sijlbing, G.: Het gebruik van drugs, alcohol en tabak. Amsterdam, Swoad 1984. cf Introduction
41. Ashley 1975, p. 160. Cf also Spotts and Shontz, 1980.
42. Ashley 1975 claims that cocaine does not create tolerance (p. 160 and p. 172.) Spotts and Shontz who also use subjective reports of long term users claim a diminished effect occurs if repeated doses are taken within one day. This would indicate very short term tolerance.
43. personal communication of Ch. van Brussel, MD
44. Commission on Narcotic Drugs, 1972, p. 64
45. Ashley 1975, p. 154
46. Commission on Narcotic Drugs, 1972, p. 65
47. Ibid., p. 50
48. Sijlbing 1984, p. 24
49. Edelman, M.: Politics as symbolic action. Chicago 1971. Quoted in Gusfield, J.: The culture of public problems. Drinking driving and the symbolic order. Chicago 1981. p. 15
50. Letter of the Secretary of Public Health to Parliament, Subcommission for Drugpolicy, The Hague, April 15th 1983
51. Report on Drug maintenance, Municipality of Amsterdam, December 1984

IV. Is heroin dependence pathological?

• IV.1 – Critique of a psychological a-priori
• IV.2 – Social determinants of addict behaviour
• IV.3 – Subculture
• IV.4 – Conclusion
• References chapter IV

Table of contents

IV.1 Critique of a psychological a-priori

The psychological a-priori in scientific discussions of addiction to heroin, as well as addiction to other substances, consists of two separate assumptions:

1. that becoming addicted is best described as a psychological process within a particular individual, and that such a description can also serve as the basis for its explanation;
2. that addiction is a psychopathological phenomenon within an individual which necessitates change and that the description in psychological terms serves as the basis for a therapeutic intervention.

Logically, 1 and 2 do not go together. But in everyday practice they are inseparable. In this article, which deals mainly with heroin addiction, both are taken as equally important. However, from the addict’s point of view and certainly in our own dealings with the so called heroin problem, the idea that every regular heroin user, let alone every addict, is a pathological case is especially important. Several ‘theories’ are used to label addictions as a pathological aberration. I will indicate four of them, but undoubtedly more could be found in the vast literature on this subject.

A. Addiction is pathological because addictive behaviour reflects a developmental disorder.

Within psychoanalysis this vision is paramount. Addictions are either based on an oral fixation¹ or on an anal one, or even on both.² In this reasoning the actual addiction is a regression which has to be dealt with by removing the regression. This idea has remained almost undisputed within psychoanalysis even though it has long been known that addiction is extremely hard to ‘cure’ by psycho analytical methods.

B. Addiction is pathological “because it is characterized by an abnormally high intensity of craving for satisfaction and by a strikingly low susceptibility for modification of the need for that satisfaction.”³

This way of describing addiction makes quantity rather than quality the basis of the pathology. One might remark here, that this type of description could easily encompass many behaviours which we do not normally consider pathological (for example, ambition, sex or the need for company).

C. Addiction is pathological because of the function it fulfils within some pathological syndrome.

For instance Kuiper says that not only affective problems, but also other illnesses can lead to addiction. Thus for Kuiper emotional inhibitions can provide the motivation underlying addiction to disinhibitors like alcohol or stimulants; depression or dysphoria can give rise to addiction to alcohol or opiates; anxiety can lead to addiction to alcohol, opiates or hypnotics; and tension, depersonalization and derealization can result in addiction to substances that counteract these affects. Chronic depersonalization and emotional emptiness give rise to chronic use of cannabis.5,6 Here the addiction is functional within a pathology, and thereby becomes pathological itself. It is a secondary pathology.⁷

Authors like Mijolla and Shentoub⁸ fall into this category. For them addiction is a symptom of the impossibility of enacting satisfactory object relations. The addictive substance replaces the human object, and the relation to the substance replaces a relation to the human object.

D. Although the following theory of the pathology of addiction is similar to that given by Mijolla and Shentoub, I present it separately because of its rigour. For Kohut, some cases of addiction occur because people do not have sufficient psychological structure “to soothe themselves or to go to sleep”.⁹ Later he states, in a generalizing context, that “the addict craves the drug because the drug seems to be capable of curing the central defect in his self”.¹⁰

This looks like pathology in extremis. Kohut’s view could also have been considered under the first heading, in which addiction is seen as a developmental disorder.

This short and certainly incomplete excursion through the theories which define addiction as pathological behaviour on the basis of a psychological understanding of the phenomenon, leaves us with a strong sense of disquiet. If we are to believe the quoted authors, there is a lot wrong with addicted people.

But strangely enough, authors can be found who describe addiction as pathological without linking it to specific qualitative or quantitative characteristics. I should mention Van Dijk, who concludes with regard to alcohol addiction, that “for the person who gets addicted there is no indication whatsoever of specific personality characteristics”.11,12 The American investigator Craig has enriched the literature with a thorough review of all empirical studies of personality characteristics of heroin dependents.13,14,15 He concludes that there is pathology, but not a specific one, and that particular personality characteristics of heroin dependents cannot be found. We might be tempted to react to all this with a very modern conclusion. In the current climate, with its preference for multi-causality, multi-functionality and even for multi-disciplinary research we have to accept that different psychological theories may apply when analysing or treating a case of addiction. I do not support this conclusion, because it leaves veiled the a-priori I mentioned at the beginning of this article.

At this point I would like to turn for a moment to a completely different so-called problem area, homosexuality. In the Netherlands we have almost completely passed out a period when we considered homosexuality to be a mental disorder, a psychopathological state. A great variety of theories and scientists were preoccupied during this period with the ‘problem’ of homosexuality, without ever being able to reach a more or less homogeneous view of its causes or its treatment. But nevertheless, homosexuality was by common consent seen as a pathological disorder, either moral or mental, and mostly as both.

This point of view has changed considerably. In fact, as homosexuality has reached a level of social acceptance and integration, so the matter has been dropped. As a result, its earlier problematic content — translated into a scientific problem — has petered out.

During certain periods psychologists and psychiatrists seem to make observations and design theories about assumed pathological phenomena, in which they probably do little more than provide scientific rationalisations for social conventions. What is the plausibility of the hypothesis that our present theorizing in relation to addiction (in particular heroin addiction) takes as point of departure the a-priori which we have seen in the case of homosexuality?

“Impossible,” — a therapist will remark — “in my own work I have seen addicts who are as mad as a hatter. I really cannot see such people as constructions of my phantasies nor myself as promulgating invisible social prejudices. These people cry for help. So I need adequate psychological theory on which to base my therapies”.

Our imagined therapist is right. Some addicts show incontestable pathology. I want to ask two questions here.

1. How often does this occur? Or, in other words, how representative are heavily disturbed people (psychotic or prepsychotic) of the total population of drug dependents?
2. Can we find a theory, maybe even for psychotic drug users but certainly for the mass of drug users or misusers, which does not explain drug use or misuse primarily in terms of psychopathological processes?

For an answer to the first question I will refer not only to empirical research, but also to practical experience. At the time of writing (June 1983) the local government of Amsterdam is considering the enabling of the Health Authority to maintain a small group of addicts on prescriptions of morphine. For the members of this group a completely new word has been coined: EPD. This stands for Extra Problematic Drug-user. In a recent unpublished report by the Health Authority the size of this group was estimated to be 120 people. An EPD is characterized by severe psychiatric disorder with concurrent physical and social neglect. We may assume that the other heroin dependents in Amsterdam (about 8000[2]) do not belong to the EPD-group. This assumption is consistent with what is generally accepted in the literature about (the range of) the proportion of heavily disturbed people among drug dependents.¹⁶ But let us for a moment broaden our concept of pathological dependence to include all people we call junkies. They are the more conspicuous of heroin users, and in Amsterdam they are estimated to number 1200. Junkies are defined by their full time involvement in obtaining their prefered drug and if this is not available in finding a substitute.

Not all of them look badly neglected, not least because many shoplifters, chequeforgers, and in particular prostitutes, cannot afford this.

For an answer to the second question I will turn to the work of Norman Zinberg, an American analyst and psychiatrist. Zinberg tries to show how we construct the pathological and individual psychic source of junkie behaviour. He is not soft in his description of junkies who “look a lot alike: they are usually thin, their clothing shabby and their person somewhat unkempt. Initial conversations reveal their almost total preoccupation with heroin or its replacements and the life-style that surrounds its compulsive use”.¹⁷

Furthermore they demonstrate a clear negative identity, they naively believe in all kinds of magical processes, they are paranoic and their deterioration of super-ego functions is dramatic. If something goes wrong, others are guilty. They cannot reason logically and their memory is bad.

This is not minimal. But still Zinberg does not stop. He adds that their “everyday psychological state seems compatible with a diagnosis of borderline schizophrenia or worse”.

According to Zinberg, it follows that for a psychologist or a psychiatrist it is very attractive to use all these observations to construct psychological explanations of drug dependence. That is, explanations in which drug dependence is seen as being grounded in psychic characteristics which are evidently pathological and — this is essential — which were already present in the pre-morbid person before he got drug dependent.

But Zinberg is not convinced. He asks what evidence we have that the personality state in which these drug dependents present themselves to us, has anything to do with the psychic structure of the person before the onset of his drug dependency. According to him no such evidence is available and he finds it unacceptable to ‘explain’ the mental characteristics of heroin dependents by means of postulated unsolved mental problems which predated the addiction. This is a type of explanations he calls “retrospective falsification”.

Let us go back to Craig now. He concludes his review on the literature about personality characteristics of heroin dependents with many research recommendations. Craig’s conclusion, that “it is impossible to ascertain if traits found in heroin addicts, predated addiction or were the result of it” brings him to recommend longitudinal studies that will answer this question.^l0a Elsewhere he states that “we are in desperate need for longitudinal studies concerning changes in personality over time”.^l0c Craig does not move away from the psychological a-priori, although I consider the massive lack of evidence for a psychological explanation of heroin dependence the most essential part of his findings.

Stanley Einstein has worded his doubts about the psychological a-priori in the following way: “What are the implications of relating to a dynamic living person — a drug user — from the theoretical perspective of a closed system stereotype?”

In addition he states that we see the drug user as somebody who “differs significantly from us and others in our life space in a negative sense”, a view he calls the theoretical dehumanization of the drug user.¹⁸

One could justly interpret these words as a combined criticism on both the psychological a-priori and the social conventions behind it. But in this case the argument is not elaborated.

IV.2 Social determinants of addict behaviour

Now we do have a problem. When we agree with Zinberg and Craig, and accept that at least we make a highly unfounded judgement on the pathological content of something within an individual that makes him into a drug addict, how then can we explain the modes of behaviour we so often see in heroin dependent people.

And if it were true that the strikingly uniform ways in which junkies appear to us are not to be connected to a set of definite personality traits, do we have to leave the realm of psychology altogether in our search for explanations?

To deal with these questions I would like to return to Zinberg and in addition introduce some criminological notions as expressed by Leuw.

Zinberg’s response to the problem he himself helped to create is worded in both psychoanalytic and sociological terms. His opinion is that the social situation in which heroin users find themselves after a period of regular use creates a condition which he defines as stimulus-deprivation.

Because of severe disapproval and in many cases rejection by parents, wider family and long standing social contacts, heroin addicts increasingly lose essential sources of stimuli. It is precisely these stimuli which enable a person to maintain a measure of continuity and structure as a person. Referring to Rapaport, Zinberg assumes that the relative ego autonomy in relation to the Id and the environment is harmed or disturbed by this deprivation of social stimuli. Out of that condition emerges the process of ‘junkieization’ of heroin users. Junkie behaviour is not seen as arising from pathological traits within a pre-morbid person but from strong environmental forces which exclude people from standard forms of social relations by labeling them as extremely deviant or even dangerous. This might be compared to banishment to a public Siberia. Few could remain “normal” under such circumstances. I could even add here that a high degree of “normality” has to be assumed in order to account for sensitivity to stimulus deprivation.

Zinberg’s reasoning does not leave the domain of psychology at all, but it does end the primacy of psychological theory when trying to explain junkie behaviour.

And now Leuw. He published a clear and outstanding analysis of the social construction of the so-called heroin problem, but it is outside the scope of this article to summarize it adequately. I will draw only on a few details that supplement Zinberg’s view.

Leuw adopts much of the criminological theory of stigmatization, in which a distinction is made between primary and secondary deviance.

In the case of heroin use primary deviance consists of consuming a substance that is socially seen as devilishly dangerous. Although it is quite possible to use heroin inconspicuously in a perfectly integrated life style, primary deviance almost always develops into a secondary one. For a host of reasons primary deviance creates repressive or rejective social reactions. The expulsion of the heroin user and his concurrent social retreat instigates the process of secondary deviance. In this process deviance becomes the “all defining characteristic of somebody”, “for himself as well as for his surroundings”¹⁹

Also for Leuw it is social rejection that not only diminishes the range of adaptive behaviour but also seems to be a strong determinant of its content.

The difference between Zinberg and Leuw lies in the greater psychological detail which Zinberg uses, but for both it is neither the substance heroin nor the assumed psychological disorder within individuals that explain junkie-behaviour. For both, the explanation has to be found in a complex interaction between a person and several levels of the environment. A completed process of junkieization results in a heroin user who lives at the margIn of society, driven there by his friends, his parents, the police, social assistance or whatever. The heroin-using culture is the only environment where he is allowed to function. “The moral rejection and the (legal) repression did not only ban him from ‘normal’ society, they also convicted him to live in a psychologically very destructive milieu”.¹⁴

In summary, we have seen that psychology or psychiatry offer a great many explanations of addiction. The supply is so large that almost any part of human development, of emotions and the pathology thereof can be causily connected to the emergence of addiction. Little wonder that empirical research cannot support an assumption that specific personality traits can be made to explain heroin addiction any more than was the case with alcohol addiction.⁸

We may quietly consider it plausible that in a great many cases of addiction, psychology by itself lacks the competence to explain them. Denial of this involves what I have called a psychological a priori. The means by which this a-priori is usually maintained was given the name of “retrospective falsification” by Zinberg. Of course psychology must play a role in a theory of addiction and addict behaviour, and so must psychopathology. But neither can play more than an auxiliary role within the broader social scientific theory of the addictions.

What conclusions should psychiatrists and psychologists draw from these arguments?

I hold the view that both groups of professionals are functional in preserving some of the important social factors that together cause the extreme rejection of heroin dependence. Note that I do not say that these professionals create this reality or the dependents by their strong labeling actions. This would be a naive and even nonsensical view because the social factors that uphold the rejection of heroin use are many. The view that regular heroin use or heroin dependence is pathological is one of these factors and may have the function of creating an ideological foundation of quasi-scientific status. However, even without this foundation social rejection would occur, probably because it has very important societal functions. I have discussed these elsewhere.²⁰

I do see, however, a role for the psychotherapeutically busy in the political process of changing the present misery of heroin use. I will discuss this later on in this article. Now I want to go back to the authors and their definitions of the pathology of heroin dependence to which I referred in the beginning. How can we fit their observations into a broader social scientific view of addict behaviour?

Those who see substance dependence solely as a developmental disorder cannot be very useful for such a theory. But those who look upon addiction as a quantitative aberration are already closer to a contribution.

One might reason that the ‘abnormality’ of the intensity which is hypothesized in the craving for drugs does not necessarily have a disruptive function in the social development of a person. This is valid even for heroin dependency under present conditions of severe illegality. The intensity in itself could be without social (and thus personal) consequences if the drug user could keep his use secret, or contain the secrecy within a circle of trustees and if the user were able to prevent his conscience from fulfilling the role of an external rejecting agent.

But for many heroin users these preconditions do not exist. The financial burden of obtaining the illegal substance gives them away, and the consequences of being socially known as a user of forbidden substance take their inevitable toll. Subsequently, the pharmaceutical and subcultural consequences of substance use become dominant in such a way that substance dependence as a normal adaptation is hidden from view. In Mulder’s words. this dominance becomes the “abnormal intensity” of the need for satisfaction.

An additional problem is that current social judgement of heroin use are in part shared by most heroin users themselves, belonging as they do to the same dominant value system. The pain associated with this self-rejection adds to the intensity which, according to Mulder, is abnormal. This might explain the higher than average suicide rate found amongst heroin users, as was the case with homosexuals at the height of their persecution.²¹

This way of reasoning can also be applied to the evaluation of the psychological theory which looks upon addiction as a defense against very intense affects or the lack of them. Depression, depersonalization, great fury, apathy, emptiness: as adaptations to the many stages of a career into a social outcast they are not so strange. One could even empathize with them. This is also valid for the reported feeling of not being a person or in Kohut’s words, a lack of psychic structure or self. I do not want to be misunderstood to be holding the view that these affects or states always develop after the onset of forbidden substance use. We should be fully aware, however, that what we call “pathological” emotions can have principally different etiologies. When we find them in heroin dependent people, the incidence of these emotional states alone is insufficient to locate their etiology in mental processes dating from before the consequences of illegal heroin use became operational.

The observations of these affect-theoreticians have remained useful. However, the theoretical framework in which they can find a place has changed. Where we should seek the explanation of addict behaviour is not the individual in which some pathological process has taken place, but in a polymorphic social interaction between a rejecting environment and a person who happens to like an illegal substance very much.

For normal people it is this interaction which is pathogenic and which gives rise to the heroin addiction problem as we know it now.

What I am saying, in essence is that the run-of-the-mill junkie has some characteristics which could be described as pathological, but which are better described as enforced emotional adaptations of normal persons. Extraordinary psychic pathology does exist in some heroin dependent people, but to use this picture as a generalization for all heroin users or addicts is very bad science.

However, this way of reasoning does not explain why some people get addicted and some do not. This is indeed a challenge created by rejecting the psychological a priori.

IV.3 Subculture

In their essay on possible causal relationships between psychopathological processes and non-medical drug use, Schuster, Renault, and Blaine argue that there is no reason to assume that the use of opiates cannot be normal human behaviour. Their problem is to explain why in our cultures it is seen as abnormal. They suggest that social factors transform opiate use into an exception, and they recommend research to clarify these factors and their operation.²²

One could ask, agreeing with Schuster et al. how it is possible that the social factors of which they speak are in a great many cases, mitigated or neutralized. Fortunately “becoming deviant” is a research topic in criminology. Matza even looks into the concept of pathology in this context.²³

The concept of subculture is of central importance here. In his study “Drug use and Subculture” Cohen shows how subcultural influences ease the emergence of behaviour which is looked upon as deviant or even criminal by others outside the subculture.²⁴ The drug scene provides participants with a different selfconcept, different ideology, ways of defensive communication, warning systems against invasions of the subcultural sphere, rituals, forms of magic and last but not least, with attractive new personal relations.

Clearly the emergence of subcultures explains much concerning why some people get addicted and others not. Matters like proximity are vital here, and possibly chance plays some role.

More important, the emergence of subcultures is not arbitrary. Subcultures are specific reactions to broad social developments that sensitize either one -or an other social substratum into creating them or being attracted to them.

At the present moment opiate use is clearly bound up with specific youth subcultures, in contrast to the opiate use of some 60 years ago when it was called the illness of the better classes.25,26 The similarity in primary deviance between such completely different groups is in itself a very interesting theme.

But the challenge of explaining why some people get addicted and others not, although all belong to the same social strata, may not be completely met by the concepts of deviance and subculture. It is worthwhile focussing research on this problem, without falling back upon the psychological a-priori.

IV.4 Conclusion

The habit of psychologists and psychiatrists of connecting use and misuse of drugs primarily to psychopathological processes in individuals helps to maintain the present heroin problem. This may be sad, but the consistent failure of the greater part of therapeutic work with drug addicts and the history of our drug policy allow no other conclusion.

The real help that these professional groups could give to heroin dependents is to cease every intervention that confirms the drug addict in his role of social outcast and failure. Therapists have to make a conceptual and ideological ‘volte face’ by accepting the drug dependency of a person.

This actually implies their leaving the field of the drug-issue altogether but for the time being this is not very likely. But as long as they are involved in drug problems, they should help addicts to function in spite of social rejection, by supplying drugs in a pure form, and by encouraging the emergence of better regulated ways to consume them. The goal is not abstinence, but amelioration of the social position of the drug addict as much as possible. A consequence of this might be that a body of generally accepted rules emerges for dealing with opiates, as is already the case regarding the way we deal with alcohol. According to Hunt and Zinberg, these rules play an essential part in the (self) regulation of drug use.²⁷ Maybe it will eventually be possible to make a contribution towards changing the relationship between users and non users of opiates so that the pathogenic interaction between these two groups becomes less oppressive, and thereby less risky for both. I strongly oppose the use of psychotherapy in the bulk of drug dependence cases, even if the addict himself asks for it because of his addiction. For, is psychotherapy here not the quasi-scientific treatment of the suffering from social prejudice, a prejudice the addict himself has not been able to escape, alas?

References chapter IV

1. Fenichel, 0.: Impulse neuroses and addictions, in Fenichel, 0.: The psycho-analytic theory of neurosis. London 1946, page 369
2. Glover, E.: Alcoholism and drug addiction, in Glover, E.:The technique of psychoanalysis, N. Y. 1963, page 215
3. Mulder, W.: Een probleem van lichaam en geest, in: Verslaving, Cahier van de stichting Bio-wetenschappen enMaatschappij, Dec. 1976, page 11
4. Idem, Verslaving, Amsterdam 1969, page 132
5. Kuiper, P.: Hoofdsom der psychiatrie, Utrecht 1979, page 326-330
6. Idem, Neurosenleer, Deventer 1978, page 206-207
7. Wurmser, L.: Mr. Pecksniff’s Horse? Psychodynamics in compulsive drug-abuse. In: Blaine, J. and Demetrios, J. eds.: Psychodynamics of drug-dependence. NIDA research Monograph 12, 1977, page 38 ff
8. De Mijolla, A. et Shentoub, S.: Répères theoriques et place de l’alcoholisme dans l’oeuvre de S. Freud. In:Revue Francaise de Pychoanalyse, 1972 (1), page 43-83
9. Kohut, H.: Introspection, empathy and psychoanalysis (1959) In: Ornstein, P. The search for the self, selected writings of Heinz Kohut: 1950-1978. N. Y. 1978, pages 224-225
10. Idem page 846
11. Dijk, W. van, Alcoholisme, een veelzijdig verschijnsel. In: TADP, maart 1976, page 28
12. Geerlings, P. en Wolters, E.: Verslaving, een handboek voor arts en hulpverlener. Utrecht 1980, page 20-21
13. Craig, R.: Personality Characteristics of Heroin Addicts: A review of the empirical literature with Critique. Part 1. International Journal of the Addictions, 1979, 14 (4), pages 513-532
14. Idem. Part 2. Int. Journal of the Addictions, 1979, 14(5) pages 607-626
15. Idem. Personality Characteristics of heroin Addicts: Review of Empirical Research 1976-1979. In: The international Journal of the Addictions, 1982, 17(2), pages 227-248
16. Cf. the review by Khantzian, E. and Treece, C.: Heroin Addictions — The diagnostic Dilemma for Psychiatry. In: Pickens, R. and Heston, L. eds.: Psychiatric Factors in Drug Abuse, N. Y. 1979, page 28
17. Zinberg, N.: Addiction and Ego-function. In: The p. a. study of the child, 30, 1979
18. Einstein, S.: Editorial, International Journal of the Addictions 1981, 16(4), pages iii/iv
19. Leuw, E.: Een criminologische visie op deviant druggebruik. In: Goos, C. en Wal, H. van der, eds.: Druggebruiken, verslaving en hulpverlening, Alphen 1981, pages 77-106
20. Cohen, P.: Maatschappelijke aspecten van de perceptie van het heroineprobleem en het beleid daarop. In: heroineverstrekking, verslag van de heroineconferentie 13 mei 1982, Amsterdam. Stichting Uitgeverij de Oude Stadt, 1983
21. Lettieri, D. (ed.) Drugs and Suicide. Beverly Hills 1978
22. Schuster, C. Renault, P., Blaine, J.: An Analysis of the relationship of Psychopathology to Non-medical druguse. In: Pickens, R. and Heston, L. eds.: Psychlatric Factors in Drug-abuse. N. Y. 1979, pages 1-19
23. Matza, D.: Becoming Deviant, New Jersey 1969
24. Cohen, H.: Druggebruik en Sub-cultuur. In: Dijk, W. van en Hulsman, L. eds.: Drugs in Nederland, Bussum 1970
25. Bijlsma, U.: Chronische morfinevergiftiging, psychiatrisch gedeelte. In: Bijlsma, U. et al. Opium en Morfine, Leiden 1925
26. Kits van Heyningen, A. van,: Over het opium en het Opiummisbruik. In: Indië en het Opium. Een verzameling opstellen betreffende het opiumvraagstuk, Batavia 1931, Uitg. Kolff
27. Hunt, L. en Zinberg, N.: Heroin Abuse: A new Look. Drugabuse Council IS7 9/76

V. Cocaine use in Amsterdam in non-deviant subcultures

0. Summary and Conclusions

• 0.1 – Introduction
• Summary
• 0.2 – The sample
• 0.3 – Inititation of cocaine use
• 0.5 – Abstinence from cocaine use
• 0.6 – Routes of ingestion
• 0.7 – Combinations of cocaine with other drugs
• 0.8 – Buying cocaine
• 0.9 – Set and setting of cocaine use, some rules of use
• 0.10 – Advantages and disadvantages of cocaine
• 0.11 – Effects of cocaine
• 0.12 – Quality of cocaine
• 0.13 – Opinions, advice and cocaine policies
• 0.14 – Craving
• 0.15 – Work and relations
• 0.16 – Health consequences of cocaine use
• Conclusions

Table of contents

0.1 Introduction

The original goals of this investigation were to gain more insight into patterns of cocaine use among groups not normally associated with problematic drug consumption. The intention was to find out how such patterns developed, what mechanisms for controlling cocaine consumption (if any) could be observed, and if problems with cocaine use could be detected. In the Netherlands until now no systematic data relating to these topics was available.

This was a serious gap during a period of regular media reports of increased cocaine use, increased cocaine confiscations, and repeated predictions since 1982 of ever increasing national cocaine use following saturation of the U.S. market.

It was decided by the local coordination group for drug policy in Amsterdam that a survey should be undertaken among hitherto invisible cocaine user groups. Funding was requested from the Ministry of Health. It was moreover decided that the health of respondents would simultaneously be researched.

This cocaine research project was designed to clarify the relevance of two contrasting views of the relation between the use of cocaine, behavioural problems and policy options in the Netherlands (cf Cohen, 1987). These views were:

1. Cocaine use will inevitably develop into problematic use patterns because of pharmacological characteristics of the substance, irrespective of the nature of the user groups where cocaine consumption is found. Therefore an increase in efforts to reduce supply is needed, plus an increase in treatment facilities.
2. Cocaine use is seen as acceptable in different social environments. Most users do not experience social or physical problems with the effects of the substance because they either use cocaine sparingly, or they have learned to diminish possible ill effects to an acceptably low level. Special efforts in supply reduction or increase of treatment facilities are not needed. On the contrary, increased law enforcement efforts will lead to increased criminalisation of cocaine users with exactly opposite effects to those which are the goals of present drug policies in the Netherlands. Central in present drug policies is not only prevention of drug use itself, but also reduction of risks inherent to drug use. Since criminalisation is one of the most serious risks of illegal drug use, increased efforts against cocaine would possibly result in greater harm.

An extensive overview of available literature, lent greater support to the second view (Cohen, 1987). The proposed cocaine survey would enable policy makers to discuss both views in the light of recent Dutch empirical data. Even, if data resulting from this survey was insufficient to be conclusive, the research would have to clarify what additional kinds of data would be needed, and how it should be collected.

On top of this, the proposed research would enable policy makers and researchers to discuss problems of generalisability of data from outside the Netherlands to cocaine users within the country. Throughout this report comparisons have been made between research data obtained form cocaine users abroad and in the Netherlands, showing that comparibility is not yet fully possible on a scientific basis.

This introductory chapter will now offer a short summary of our findings in the same order as they are presented in the following chapters. Finally an overview will be given with concluding remarks, in which the results of this survey are discussed in the light of its initial goals for policy discussion. Some comparisons are made between the prevalence of cocaine and cannabis use in Amsterdam and New York City.

Summary

0.2 The sample

In the months February, March and April 1987, 160 persons with a minimum cocaine use of 25 life time instances were interviewed. Users from so called deviant sub cultures (junkies, criminals, prostitutes) were excluded. The sample was selected by means of a snowball method with random selection of the next respondent from a list of nominees made by the interviewed person. Males constituted 60% of the sample, and females 40%. This is very close to the gender distribution of previous 12 months cocaine users in a representative sample from the population of Amsterdam in 1987, drawn from a household survey.

Mean age was 30.4 years. This is younger than mean age in the group of previous 12 months cocaine users in the general household survey (34.5 years). General level of education was relatively high. Economically the respondents do not belong to an elite stratum of the Amsterdam community: 50% of the respondents had a net income of Ÿ 1,500[1] or less, average income is about 10% lower than the income of the same age cohort in the general household sample. Almost one third of our sample was living on income provided by social security institutions. However, compared to a representative sample of previous 12 months cocaine users in the Amsterdam population, the average economic situation of our snowball sample is very similar. The same holds for educational level. Age excepted, our sample was demographically similar to the group of previous 12 months cocaine users in Amsterdam.

A majority of the respondents were living in their own quarters by themselves, even if they have a ‘steady’ partner.

0.3 Inititation of cocaine use

Although a ‘typical’ age of initiation for cocaine use is not a fruitful concept we found that our sample showed a mean age for initiation of 22 years. In comparison with a Miami sample this is almost three years older, but almost equal to mean age of initiation in a Toronto sample. Friends were the main company at initiation, and location of initiation was most frequently own home or friend’s home. Average dose at initiation was 104 mg of black market cocaine, the equivalent of four ‘lines’. Snorting was the typical route of ingestion.

0.4 Level of use through time

One of the conditions for a rational discussion of drug use is that the concept of ‘use’ has to be clearly defined, and where possible quantified. We investigated use through time of our respondents and found this to vary considerably during the cocaine using career. We distinguished four career stages for measuring cocaine use: initiation, first year of regular use, period of heaviest use (top period) and last three months. Average dose taken at these four measuring points were, respectively, 104 mg, 184 mg, 406 mg and 188 mg.

Comparing dose, consumed in Amsterdam (at three months prior to interview) with dose in a Toronto study (average typical dose) and in a Miami study (at three months prior to interview) we found that 53% of the Miami users averaged doses higher than 500 mg vs 8.5% in Amsterdam and 2.7% in Toronto.

By multiplying dose by frequency of use per week for each respondent, we computed their ‘level of use’. For each respondent we computed use level in three periods (excluding initiation). Levels of use were defined as low (less than 0.5 g per week), medium (between 0.5 and 2.5 g per week) and high (more than 2.5 g per week). These levels are approximately two to three times lower than similar definitions by Chitwood for his Miami sample. Reasons for this difference are explained in paragraph 3.5.

We found level of use varied considerably over time, with a maximum of 20.9% of all respondents consuming at a high level during their period of heaviest use. Although Chitwood’s criterion for high level use is three times higher than ours, he found 41% of his sample used at a high level during their top period. We assume that the nature of his sample (more than half of whom recruited through drug treatment programs) is responsible for this difference.

In the Amsterdam sample 48.7% never exceeded a low level of use, period of heaviest use included.

Daily cocaine use occured with 33.7% during their period of heaviest use, but with only 1.2% during three months prior to interview. Looking exclusively at high level users, 93.9% used at a daily rate during their top period. Only 1.3% of the low level users have a daily use pattern during their top period.

There was one surprising similarity between the groups that used at low, medium or high level during their period of heaviest use. In each of these 3 groups, approximately 25% were abstinent at the time of the interview.

The most frequent general description of use pattern development is ‘up-top-down’, meaning that from the onset of cocaine consumption, level steadily rises to a certain top level and then steadily declines to present lower level or abstinence. This overall description was given by 39.4% of the sample. Checking these general descriptions with computations of level of use at three measuring points it was found that 43.7% of all users could be described as following the up-top-down pattern. Of all users, the use pattern of only 3.1% matched a ‘slowly more’ pattern. This pattern, associated with a possible development of dependence, is also found with 3.1% of all users via computations of level of use. This indicates a high level of reliability of use pattern reports.

We conclude from the data presented in this chapter that the dependency producing characteristic of cocaine may have been overstated.

0.5 Abstinence from cocaine use

Periods of cocaine use abstinence of one month or longer were reported by 86.2% of the respondents. Just half of the sample (50.6%) reported 6 or more periods of abstinence. The most often mentioned reasons for abstinence were lack of money, and lack of desire to use.

Respondents were also asked about the length of their longest period of abstinence. For 43.6%, the longest period ranged from 2 to 6 months. For 40%, the longest period ranged from 7 to 24 months. The most often mentioned reasons for having the longest period of abstinence were lack of desire to use, and the absence of friends that use.

To diminish one’s level of use was reported by 69.4% of the sample, with almost a third of these (35 persons) mentioning financial reasons. Negative effects were mentioned by sixteen as their most important reason for cutting back, and ‘no desire’ by thirteen.

0.6 Routes of ingestion

A very large majority used cocaine intranasally. Only 18.1% of the sample had ever tried free base cocaine. Life time prevalence of injecting cocaine was 6.2%.

Our respondents associated free basing and injecting cocaine with negatively valued user groups. About 15% of the respondents saw either free basing or injecting also as disadvantageous because these routes of ingestion were considered to lead to dependence.

0.7 Combinations of cocaine with other drugs

Of all respondents in our study, as many as 36.2% had ever used opiates. Compared with 12.7% of legal plus illegal opiate (life time) use in a representative sample from the age cohort between 20 and 40 years in the city of Amsterdam, this is relatively high.

Life time prevalence of opiate use in combination with cocaine was 9.6%.

Life time prevalence of the use of cannabis was 91.2% in our sample. (vs. 41.5% in the age cohort 20-40 in a representative sample from the Amsterdam population). Cannabis use in combination with cocaine had a life time prevalence of 70.2%.

Drugs reported to be often used in conjunction with cocaine were tobacco (80.5%), alcohol (72.3%) and cannabis (27.2%). Tranquillizers, opiates or hypnotics were used very little in combination with cocaine.

0.8 Buying cocaine

Only 79 persons in our sample knew how much money they had spent on cocaine during the four weeks preceeding the interview. Average value of cocaine used was Ÿ 243. Average value of cocaine respondents paid for turned out to be Ÿ 246. Average price of cocaine turned out to be Ÿ 180 a gram. Friends were the most often mentioned category of persons from whom cocaine was bought. Bars were a purchase location for a minority of our respondents (8.7%) and so are discotheques (12.7%).

0.9 Set and setting of cocaine use, some rules of use

Social gatherings were the situations in which cocaine was most often used. The most mentioned situations in which cocaine is explicitly not used were work or study. In our sample the emotional state that most often generated an appetite for cocaine was the desire to feel joyful. Feeling depressed and not well created an emotional background of not wanting to use cocaine. Partners and members of the family are the most often mentioned persons with whom cocaine is not used.

Often mentioned rules of use related to periods within a week or a day that are ‘fit’ to use. The lack of rules that relate to dose or to effects was surprising.

Half of our respondents reported having upper limits on monthly cocaine purchase, with an average value of Ÿ 233. This is very close to the average expense of Ÿ 246 during the last four weeks preceding the interview reported in chapter 7. Having or not having a financial limit to monthly cocaine purchase does not predict level of use (during top period). However, if a limit was set to monthly purchase of cocaine, the level of this limit related significantly to level of use during top period.

0.10 Advantages and disadvantages of cocaine

When asked to state in their own words advantages and disadvantages of the use of cocaine, our respondents gave a large number of each. Per user, 2.9 advantages were mentioned and 2.5 disadvantages. The most often mentioned advantages were ‘gives more energy’ (110 times) and ‘makes one high, relaxed’ (69 times). The most mentioned disadvantages were ‘expensive’ (64 times) and ‘unpleasant physical effects’ (57 times). In the answers about advantages less differentiation and more agreement between users was found than in the answers about disadvantages.

We asked our respondents if dose and/or circumstances played a role in the probability of occurrence of both advantages and disadvantages. For the occurrence of disadvantages dose clearly plays the most important role. For the occurrence of advantages of cocaine circumstances play a more important role than for the occurrence of disadvantages.

0.11 Effects of cocaine

The extensive interviews with respondents included showing each three separate lists of ‘cocaine effects’, with a total of 91 items. Respondents were asked if they had ever experienced any of these 91 possible symptoms as a result of cocaine use. Only five of these symptoms were not associated with cocaine use by anyone. All the other symptoms were, but rarely by more than 75% of the users. The low and medium level users scored 75% prevalence or more with 9 positive effects, and with 3 negative effects. With high level users, 75% prevalence or more was also shown for 9 positive effects but for 11 negative effects. We infer from these data that above a use level of 2.5 grams of cocaine per week the balance between positive and negative effects of cocaine is changed in a negative direction.

We computed the probability that some effects of cocaine use will occur with increasing dose, with increasing frequency of use, or with increasing level of use. For 70 effects (e.g cotton mouth, restlessness) a correlation could be found between occurrence and one or more of these parameters. This means that a cocaine user can influence the probability of occurrence of these effects by his choice of dose and/or frequency of use. For 21 effects (e.g. mystic experiences, spontaneous orgasm) we could not find any correlation between probability of occurrence and one of these parameters. This could mean that these effects can be expected by any user of cocaine, independently of his use pattern.

Prevalence (or probability of occurrence) of reported effects ranges from 98.2% (energetic feeling) to 1.3% (venereal diseases).

When we compared the influence of parameters of use on the probability of occurrence of certain effects between respondents from Toronto, Miami and Amsterdam similar outcomes for 27 effects (e.g. increased heartbeat) are apparent. But for 14 effects no similarity can be found (e.g. teeth grinding). This means that more research is needed to establish the impact of local conditions and choice of user group samples on the occurrence of some alleged pharmacological effects of cocaine. This applies also when we look at the scores on effect scales. Between certain effects a clear correlation exists, and some groups of intercorrelated effects can be rebatched as scales. But variation in scores on these scales is not explained by the central variables of cocaine use or cocaine career. The scales as they are presented here are only applicable to the Amsterdam sample. For each new sample the scaling procedure will have to be repeated. After many such repeat exercises it might be that some scales seem to have a wider applicability. This investigation, and the international comparisons, suggest that the issue of the subjective effects of cocaine is still a large grey area.

0.12 Quality of cocaine

Most respondents said that cocaine they buy or use was adulterated. Amphetamine was most often mentioned as an adulterant. Negative effects of this adulterant were mentioned by 86.8% of all respondents.

We bought 45 cocaine samples from respondents, of which only 39 contained cocaine. None of the samples contained any amphetamine. Average purity of the samples containing cocaine was 65.1% cocaine hydrochloride. No dangerous adulterants were found.

We have to assume that the reported negative effects of ‘speed’ in cocaine are in many cases cocaine effects, or effects of cocaine in combination with another drug.

0.13 Opinions, advice and cocaine policies

We asked experienced cocaine users if they still remembered the opinion of cocaine they had before the onset of their cocaine use. Mainly negative characteristics of cocaine were remembered. The most mentioned positive aspect was cocaine’s ‘energizing’ action.

School and the media were the only sources of information that were mentioned a great deal more often by those whose old opinions about cocaine were that it was ‘dangerous or scaring’. For the opinion ‘addictive’, books also played an important role. We have to treat these data with a great deal of caution, because they relate to only very few people.

When asked about changes in opinion about cocaine after onset of use, 30% reported changing to a more positive direction, 20% to a more negative one.

As one of the methods of understanding important personal rules on cocaine use, we asked respondents to give advice to novice users on a number of aspects.

The most often advised mode of ingestion is snorting small quantities. Circumstances of use are clearly social (partying, being in good company). Cannabis and opiates are hardly mentioned, both as drugs to use or as drugs not to use in combination with cocaine. Alcohol plays a more central role in advice to novice users, but opinions are rather ambiguous. About one quarter of respondents say cocaine can easily be used with alcohol, and about the same proportion suggest moderate use of alcohol with cocaine. Another quarter of respondents suggest that no drug should be used with cocaine. Respondents add that novice users should buy cocaine with a trusted person, or always from the same dealer. To counter the potential disadvantages of cocaine, moderate use is advised, or abstinence when ill-effects are experienced. Further advice is not to use alone, and to rinse one’s nose.

Asked about a preferred national policy regarding the control of cocaine, a majority of respondents opted for a policy which resembles either complete legalization (as for alcohol) or informal societal tolerance (as for cannabis). The most mentioned arguments for this are: cocaine will be removed from its criminal context; cocaine is just as (non) dangerous as cannabis and/or alcohol. Users themselves are responsible for their drug use, not the State. A majority (61.9%) of those respondents that reported to have stopped using favoured a cocaine policy like the one we have for heroin. Of those respondents who were still using at the time of interview, 34.5% supported a similar policy for cocaine as we have for heroin. The main arguments for the latter were the possible hazards of cocaine and its potential for habit formation.

0.14 Craving

Just over three quarters of all our respondents reported familiarity with craving for cocaine. Although craving is reported less often for cocaine that is not around, and more often for cocaine that is around, the difference was not very large. Craving was significantly more often found among female users than among male users.

Over one third of all respondents reported that cocaine was an ‘obsession’ at some time in their use career. Here there was no difference between men and women.

Criminal activities related to obtaining cocaine were engaged in by 31.9% of our respondents. When we exclude ‘selling cocaine’ from criminal activity, this figure is 15.7%. Reported frequency per person of these activities was low. More than 10 individual criminal activities was rare. There was a significant relation between having ‘ever’ been engaged in criminal activities, (‘selling cocaine’ excluded), and level of use during top period. We found no difference between men and women.

Our data do not allow us to infer a causal relation between the (level of) use of cocaine and engaging in criminal activities. In order to find out what kind of relation exists between these two variables in our sample this topic would have to be tested explicitly in a possible follow-up project.

0.15 Work and relations

Although half of those respondents that had been employed during the three months prior to the interview reported to have been under the influence of a drug during working hours at least once, we consider this as not especially worrying for this type of population. Just over one third had hotel/bar or artistic professions in which drug use during working hours is accepted practice.

When asked about the influence of cocaine on the quality of work or social relations, most respondents report both positive and negative effects. Negative influences are dominant. A striking fact is that 20 persons reported cocaine as the cause of divorce. This should be tested in follow-up research.

0.16 Health consequences of cocaine use

Part of the cocaine research project was an investigation into the possible health consequences of long-term recreational cocaine use. Nine respondents of the 117 who were non-abstinent at the time of interview were willing voluntarily to participate in a physical examination. This took almost a full day and was executed by two neurologists and a neuro-psychologist at the hospital clinic and the psychiatry clinic of the Vrije Universiteit in Amsterdam. The results of this examination are by no means definitive because of the small number of participants. In order to find more respondents to volunteer for this type of examination either substantial financial compensation, or far less time consuming diagnostic tools must be chosen.

Of the nine volunteers, three were women. Their average age was 34 years (range 27-41 years), and their use level was between 0.5 and 3 grams a week during a period of between 3 and 10 years.

The results of the somatic examination were that no clinical or sub-clinical aberrations were found. The neuropsychological part of the investigation showed some ambiguity. No effects were found in memory tests, but six respondents scored high on neuroticism tests. Four of nine respondents scored low on mental concentration tests, and two complained of depressive moods. Two persons reported emotional insensitivity as an effect of cocaine use, and one nervousness. More research is needed with many more persons, where respondents with similar life styles but where non-users of cocaine are contrasted with cocaine users.

Conclusions

The two contrasting views presented at the beginning of this chapter can now be discussed.

When we found that during interviews with 160 very experienced cocaine users (their average period of cocaine use was over five years) 27.8% of these were abstinent, 63.9% used at a level of less than 0.5 gram a week, 6.3% used between 0.5 and 2.5 gram a week, and 1.9% used over 2.5 gram a week, we have to conclude that use levels are very low. This picture changed somewhat when looking at periods of heaviest use. In this period, 20.9% of the sample had been consuming cocaine at a level of 2.5 gram a week or over. At this level, the probability that adverse effects of cocaine will show up is considerably larger than at medium or low levels. This probably explains why so few respondents that ever used at a high level remained at that level. Another explanation might be the cost of cocaine makes a continuous high level use difficult. Both (and more) explanations might work together, possibly in different proportions for different users.

Periodic abstinence of one month or longer is found during the cocaine using career of over 80% of our respondents.

Many indications were found that experienced cocaine users controlled their use by adhering to sniffing as their route of ingestion, by keeping cocaine consumption at a moderate level, and by associating consumption to a limited number of social circumstances and emotional states. The use of free base cocaine, a commercialized version of this type of cocaine is called ‘crack’ in the U.S., is not popular. Life time prevalence of this form of cocaine use is 18.1% in our sample, individual frequency of this use when found is low. It carries a negatively charged emotional connotation, like intra venous drug use.

Support for the hypothesis that the pharmacological characteristics of cocaine make problematic (high) use patterns inevitable was not found. On the contrary, there are no indications that our group of experienced cocaine users lost control and developed into compulsive high level users with a marginalized life style in order to support drug consumption. Clearly users are aware of many adverse effects. Low and medium level users reported an average of 3 adverse effects (vs. 9 positive effects) occurring with a prevalence of 75%, but high level users reported 11 adverse effects with a prevalence of 75%.

It should not be forgotten that we chose our respondents in a particular manner. We started our ‘snowball sampling’ in circles of non-deviant cocaine users, a long distance away from professional criminals, full-time prostitutes or junkie-type drug users. But once a snowball had started, we let it take its own course. Our chains were relatively short, and did not take us into deviant social circles. It cannot be excluded however, that improved methods of snowball sampling (with far longer chains) might eventually lead to deviant user groups, enhancing the probability of finding problematic use patterns. Such results would still make inferences of a causal type between cocaine use and harmful use patterns quite difficult. Which factors cause people to use a drug in a harmful way? Are these factors drug related, drug law related, or related to psychological, social and economic determinants for particular groups in the population?

The data for the group of experienced cocaine users interviewed for this investigation show that cocaine users of the types we found can control their use. It disproves the view that cocaine use does lead inevitably to harmful patterns of use. Criminalisation is more of a threat to these users than cocaine itself.

Policy option 1, which called for increase in drug treatment ‘slots’ (because a high proportion of cocaine users will turn out to be addicts) and stepped-up enforcement activities, can not be supported with data from this investigation.

Policy option 2, which called for very restrained enforcement of the laws against the use of cocaine is not contra indicated by the data from this survey. We found life time prevalence of illegal income generation related to cocaine use true for only a small minority (15.7%) of our respondents. When selling cocaine is included, this figure rises to 31.9%. The generation of illegal income on a regular basis (more than ten times during life time) related to the use of cocaine is only true for 1%. This means that at the time of interview, criminal involvement of this user group is low. The most frequent illegal act related to cocaine consumption is selling cocaine to other users, found with 23.1% of our respondents. If law enforcement proceeds with cocaine selling charges at the private user levels, involuntary contacts with police (and thus criminalisation) would become more frequent for this user group.

In general the quality of cocaine we found in the homes of our respondents was quite high, with an average cocaine hydrochloride content of 65.1%. No dangerous adulterants were found. We have no empirically based explanation for these phenomena. But possible explanations are that: the relative absence of policing related to this user group lowers the risks of obtaining cocaine. This, in turn, might influence competition in this sub-cultural market in such a way that cocaine sellers who handle low quality cocaine cannot maintain a market position. Another important factor might be that under low police pressure the retail market for cocaine will not be dominated or monopolized by established criminals who can handle the risks of high police pressure who pass on the cost of doing so in the form of highly adulterated drugs. This phenomenon of criminalisation of small trading was described by Ashley (1975) for the United States. In Amsterdam we have already seen small retailing of cannabis products moving away from criminal gangs because of a policy of non prosecution of individual use and low level trading. As long as domination by criminal gangs of small scale selling of cocaine can be prevented, we may continue to see the absence of violence and the absence of high levels of possibly dangerous adulteration.

A possible side effect of the high purity of black market cocaine might be, that free basing keeps its low popularity among experienced users. The need to purify low purity black market cocaine by freeing its alkaloïd base remains low in circumstances of relatively good quality supply.

In spite of low law enforcement zeal directed at the level of the individual cocaine user, life time prevalence of cocaine use in the city of Amsterdam was no higher than 6.1% in 1987 although cocaine had been available since the early seventies (Sandwijk, Westerterp, Musterd, 1988)[2] In New York City where policing on the individual user levels is very active, life time prevalence is 13% in 1986 and 7% in 1981 (Frank et al, 1988)[3]

Although we do not know if any causal relation exists between level of policing and level of life time prevalence, these figures illustrate that a low level of policing does not necessarily provoke high levels of life time prevalence. Let us for the sake of argument continue a comparison between NYC and Amsterdam, pushing aside all doubts about the validity of comparing two so dissimilar cities and cultures. (NYC is the only city for which we found detailed and non obsolete data on prevalence of illegal drug use. Figures for European and more comparable cities are unfortunately not available).

For recent cocaine use the difference between New York City and Amsterdam is substantial, although it only covers a small minority of each city’s population. Recent use in Amsterdam, defined as cocaine consumption in the year prior to the interview is 1.7%. In New York City the figure for recent use, defined as cocaine consumption six months prior to interview, is 6%. This figure would probably be higher if cocaine use had been measured for one year prior to interview. In spite of this measuring difference this means that (one year) recent use in Amsterdam is only 28.6% of life time prevalence, versus (6 months) recent use is 46% of life time prevalence in New York City. The relatively low consumer use of cocaine in Amsterdam is in spite of the fact that regular access to cocaine has quite probably been less dangerous than in the gangster dominated retail market of NYC.

Of course we do not know which factors led to almost a doubling of life time prevalence in NYC from 1981 to 1986.[4]

These data support a view that increased law enforcement activity does not necessarily go hand in hand with decreasing prevalence. In Amsterdam it could have a negative and risk provoking influence on the quality of cocaine, could generate more criminalisation of users and small sellers and could hardly have influence on lowering an already extremely low level of recent use (1.7%).

Problematic patterns of cocaine use are reported to exist in Amsterdam, but with a completely different population in quite different sub cultures. Police efforts in relation to this group are more active. We have no means of knowing whether this higher level of policing against this particular group has lowered problematic use patterns. It is quite improbable though, because the dynamics behind the development of problematic use patterns are far more complicated than the absence or presence of strong policing against a substance (although strong policing has influence on the generation of life styles in which very high levels of drug use are instrumental).

Since Amsterdam already has long experience with an informal system of tolerance of distribution of cannabis products which results in an almost complete absence of policing and controlling of individuals’ access to these products, we will now compare cannabis consumption between New York City and Amsterdam. Because in New York City a system of non criminal and commercial cannabis distribution does not exist, one might expect lower prevalence figures there because of greater difficulty and risk involved in finding access to cannabis type drugs.

In reality prevalence figures for Amsterdam are lower again. In spite of considerable differences in law enforcement activities between both cities, prevalence of both cocaine and cannabis use in Amsterdam is lower. It would be very interesting to see the prevalence figures of an American city, about as big as Amsterdam but with a similar level of cultural and metropolitan functions. In fact, an attempt to make a serious comparison between American and Dutch effects of drug policy could not exist without such further analyses.

Table 0.1.a Prevalence of cannabis use in Amsterdam (1987) and NYC (1986) of adults of 18 years and older, in %.

Source: Sandwijk et al 1988;[5] Frank et al 1988

But, looking at these figures from a point of view of drug use prevention, the Amsterdam model in which a (very) low level of policing is dominant is at least not less ‘successful’ than the NYC model in which strong law enforcement is a key policy tool. When we add to these figures the perspective of risk prevention, low or absent criminalisation of cocaine and cannabis use is an advantage that at least under Dutch social-economic conditions may make the local model of restrained drug control in Amsterdam more effective than the NYC model.

Apart from the questionable comparison between NYC and Amsterdam, all data taken together legitimise the conclusion that developing a cocaine policy in Amsterdam that aims at tolerating a similar non criminalized distribution model of cocaine as we already have for cannabis, deserves serious consideration.

Notes

1. $1.00 is approximately Ÿ 2.00.
2. Figure is for population of 18 years and older,computed by Sandwijk and given as personal communication. The figure mentioned in Sandwijk et al 1988 (5.6%) is for the complete sample in the household survey of 12 years and older.
3. Figure is for population of 18 years and older
4. And maybe we could have seen such a doubling in Amsterdam as well had it beenmeasured in 1981.
5. In Sandwijk et al 1988 a figure is given for the population of 16 years and older (lifetime 23.6% and recent use 9.6%). Sandwijk computed the data for 18 years and older and provided these as personal communication.