Cocaine. In the case of cocaine, as with heroin, the evidence is consistently against both the strong and the cautious form of Claim A. In the case of cocaine less clinical research is available, since cocaine has less application in modern medicine, but there is more epidemiological research thanks to the great surge of recreational cocaine use in North America in the 1980s. I will discuss cocaine in general first and conclude by discussing the special case of "crack" cocaine.
Contemporary Clinical Research. Cocaine is administered in medical practice in the United States and Canada primarily as a local anaesthetic, although there are a variety of other uses described in the contemporary medical literature as well. Although reports of iatrogenic addiction to cocaine were common in the 19th century and early 20th century (Erickson, Adlaf, Murray, and Smart, 1987), none of the contemporary clinical reports has produced any indications of iatrogenic addiction.
Probably the most common contemporary medical use of cocaine is as a local anaesthetic in nasal surgery (Haddad, 1983; Moore et al., 1986; Gordon, 1987). Nasal surgeons apply cocaine to exactly the same area—the nasal mucosa—that cocaine "snorters" do. Although the textbook maximum doses are around 200mg of cocaine hydrochloride, the dosages that have actually been used in nasal surgery (Johns & Henderson, 1977) are comparable or higher than those that are actually taken by Canadian recreational users (Erickson et al., 1987). Moreover, the peak blood levels of cocaine following the medical doses are comparable to those found following administration of doses that produce a "high" in experienced users (Javaid et al., 1978). All anaesthetics are dangerous, so patients that receive cocaine in this manner closely monitored for side effects. The levels of side effects compare favourably with other anesthetics—this is part of the reason that cocaine is the anesthetic of choice for many doctors. A survey of plastic surgeons revealed five deaths and 34 severe but non-fatal reactions in 108,032 medical applications of cocaine (Feenan and Mancusi-Ungaro, 1976)—but not a single case of iatrogenic addiction has been reported.
Cocaine also appears to be a valuable treatment for older people who suffer from chronic rheumatoid arthritis. A small group of doctors in California in the 1970s reported good success in relieving the pain and depression of this disease with "Esterene" which is simply "free-base" cocaine prepared for nasal application. In this form, cocaine is released slowly into the blood stream. The arthritis sufferers recovered some strength and showed some reduction of inflammation. In the most successful cases, bedridden patients were sometimes able to resume normal activities that they had given up years before. Every one of the two hundred or more patients used the drug only as directed, even though they did experience a mild euphoria from it (see Arthritis News Today, 1980). Ronald Siegel (1989, p. 308-312), who reviewed the effects on the entire patient population, reported that Esterene seemed to have the same effect as chewing coca leaves.
When the Esterene story hit the newspapers, the government shut down the California clinic where Esterene was being administered and disciplined the doctors prescribing it, without investigating its efficacy. As well, sufferers from rheumatoid arthritis began to experiment with intranasal free base cocaine outside of the medical setting. Siegel (1989) was able to track down 175 illegal arthritic users in the Los Angeles area:
Surprisingly most were not experiencing problems. They reported antifatigue effects, as well as suppression of chronic pain and discomfort, but they failed to experience the rapid and reinforcing euphoria that gives cocaine its addictive potential. Unlike daily cocaine hydrochloride users who repeatedly dose themselves throughout the day, people sniffing cocaine free base administered the drug infrequently and did not show signs of dependency. Some had financial or legal problems associated with their use; several also experienced loss of appetite or sleep. Yet their ability to maintain daily doses as high as 1,000 milligrams without severe dysfunction suggested that safe use was possible even in nonmedical settings (pp. 310-311).
Epidemiological Research. Numerous surveys in the U.S. and Canada indicate that cocaine use peaked in the 1980s at levels that had not been seen since early in the 20th century. However, in spite of widespread availability and moderate prices, a majority of North Americans never used cocaine; of those who did, most used it only once or a few times; of those who became more regular users, most did not become addicted; and of those whose addiction became serious enough to require treatment, most had lives that were marked by severe alienation or misfortune before they first used cocaine, suggesting that their addiction had causes other than mere exposure to the drug. These facts come from field studies from various countries.
An American national survey, conducted annually since 1975, involves random sampling of two groups: high school seniors and high school graduates up to age 32. In 1990, for example, 8.6% of high school seniors reported having used cocaine (other than "crack") at some time in their life, 1.7% reported using it once or more in the month that they were interviewed, and 0.1% reported using it at least 20 days in the month that they were interviewed. Thus, in contradiction to the strong form of Claim A, less than 1 student in 80 who admitted to having used cocaine could be considered a current addict, if addiction is assumed to require use on at least 20 days out of a month (Johnston, O'Malley, and Bachman, 1991). Moreover, data reported below indicates that only a fraction of those who use regularly can be considered addicted if a fuller definition of the term is applied.
The likelihood of a cocaine user becoming an addict seemed even lower among the high school graduates. In this group, 41% reported having used cocaine at some time in their life, 3% reported use of cocaine at least once in the month of the interview and less than 0.1 % reported using it at least 20 days in the month of the interview. Thus, less than one student in 400 who reported having used cocaine could be considered a current addict (Johnston, O'Malley, and Bachman, 1991).
Other American surveys have produced similar results and revealed some further patterns. Kandel, Murphy, and Karus (1985) randomly selected a group of people approximately 25 years of age in New York State. Of the 30% of this group who had ever used cocaine, about 60% had used it less than 10 times in their entire lives, 31% had used it 10-99 times, 6% had used it 100-999 times, and about 3% had used it 1000 times or more. Approximately 2% of the respondents had used cocaine daily at some time, but only about 4/10 of 1% continued to do so in the year of the study (based on re-calculation of data from Kandel, Murphy, and Karus, 1985: 80-1). If using cocaine 10-99 times is a reasonable minimum necessary to lead to addiction under the cautious form of Claim A, and if we take daily use at some time in a person's life as a reasonable minimum that would be expected in an addicted person, we can say that no more than 1 in 15 of the respondents who used cocaine enough to be addicted according to the cautious form of Claim A could ever have been addicted and no more than 1 in 77 could have been addicted at the time of the interview.
Some American studies appear more supportive of claim A, but these generally are based on populations of people in treatment, or on a loose definition of addiction. For example, Kilbey, Breslau, and Andreski (1992) found that 124 of 1007 largely middle class people in the Detroit metropolitan area had used cocaine more than 5 times. Of these 124 people almost 10% had fulfilled the definition for cocaine dependence at some time during the year of the interview. Thus, almost 1 in 10 people who used cocaine as often as 5 times were diagnosed as cocaine dependent at some time in the year of the interview. These data support a weak form of Claim A.
The difference between these results and those of other American studies which suggest a much lower addiction rate probably lies in the inclusive definition of "dependence" used by Kilbey et al. In their diagnostic manual--the DSM-III-R (American Psychiatric Association, 1987)--a person is said to be dependent on a drug if they fit any 3 of 9 criteria. This flexibility makes it possible to diagnose as dependent both people who are fully addicted in the traditional sense of the word as well as people who would not be considered addicted in ordinary language. The DSM-III-R is explicit about this, for it describes one form of dependence ("mild dependence") as the case in which ..."the symptoms result in no more than mild impairment in occupational functioning or in usual social activities or relationships with others" (p. 168). This kind of dependence is not addiction in the ordinary sense--unless we are willing to say that people are "addicted" to all the activities that mildly interfere with their work performance or social life. It is not that mild dependence on cocaine is unimportant. It causes some problems but, apart from the risk of arrest on drug charges, these are no greater than those associated with regularly overeating or watching too much television. Addiction, as usually defined, is a much more serious problem than this.
Canadian survey data are usually far less extensive than American data, but the results are similar. The "Ontario Household Surveys" have provided the best trend data available for Canadian adults. The proportion of Ontarians reporting ever using cocaine nearly doubled, from 3.3% to 6.1% of the population between 1984 and 1987 and thereafter remained relatively stable or declined. Of those who had ever used cocaine, 95% reported using it less than once a month in 1987.(Smart and Adlaf, 1988; 1992).
A survey conducted by the Co-ordinated Law Enforcement Unit (1987) in British Columbia revealed higher rates of experimental use in B.C. than in Ontario, but again showed that most of those who use cocaine do not become frequent users. Of a random sample of respondents from throughout the province, 11.2% reported having used cocaine at least once in their lifetime. Of these, 56% had used it less than 10 times in their lives, 36% had used it 10-99 times, and 8% had used it 100 times or more. (These data are recalculated from the original report into a form comparable to data presented above).
The highest report of cocaine use in any single Canadian subpopulation not in treatment comes from my own research at Simon Fraser University, in British Columbia, where my student interviewers took the time to interview each subject at considerable length under conditions of confidence and security about the way in which they used drugs as well as the frequency. Of 107 students interviewed, 40.2% reported using cocaine at some time in their life. However, only 4 of these had used cocaine at all in the previous 30 days and none had used it daily during that period. One student reported having been a regular user of cocaine in the past, but was no longer. No student reported being or having been addicted to cocaine, although reports of addiction to other drugs were not unusual (Alexander, 1985). These data contradict the strong form of Claim A which holds that any exposure to cocaine at all should yield a high rate of addiction.
Taken together, the American and Canadian population surveys indicate that merely having used cocaine is associated with less than a 10% chance of having it as often as 100 times. Virtually all addicts use it far more than 100 times.
There are several studies of cocaine users in various countries who were located through advertising and/or personal networks. Since these respondents are volunteers, they do not represent all cocaine users. They do, however, provide in-depth information on heavier users who are not in treatment, a group of cocaine users who show up only rarely in random surveys and never in studies of addicts in treatment. These studies show that, contrary to Claim A, there are many regular users of cocaine who cannot be considered addicted, and many who have passed into and out of regular use without lasting addiction or outside intervention. These "snowball sample" studied come from Canada (Cheung & Erickson, 1997; Erickson et al., 1994); the United States (Murphy, Reinarman, and Waldorf, 1989; Waldorf, Reinarman, and Murphy, 1991; Reinarman & Levine, 1997); the Netherlands (Cohen, 1989; Cohen & Sas, 1993); and Australia (Mugford & Cohen, 1989). I supervised a study of this type for the World Health Organization in Vancouver (Matthews et al., 1994; WHO/UNICRI, 1995)
In a study conducted in the San Francisco area, a group of cocaine users who were initially interviewed in 1974-1975 was followed up after 11 years (Murphy, Reinarman, and Waldorf, 1989; Waldorf, Reinarman, and Murphy, 1991). Of the original 27 respondents, 21 were re-interviewed. There had been no formal contact with the respondents in the 11 year hiatus between interviews. The original sample was characterized as a "naturally occurring friendship network" in which the age range was 16 to 51, the sex ratio was approximately equal, and most of the respondents were university students or graduates. [how much did they use?] In 1977, the investigators did not consider any of the 27 respondents to be addicted. Most were described as casual users, However 4 used daily.
The follow-up interviews revealed that all 21 respondents were gainfully employed, many in professional and managerial positions. One of the 21 respondents, i.e., 5% of the group, was currently a compulsive cocaine user. Eleven others reported having used cocaine daily at some point, but were no longer doing so. Seven of these eleven had reduced their consumption from as much a 3 grams a week to one quarter gram or less but continued to use in a controlled way. Four had adopted abstinence after periods of heavy uncontrolled use. Seven other subjects were characterized as "continuous controlled users" who maintained moderate use patterns throughout the eleven year period. Two other past users of this continuous controlled type had stopped using entirely for two and five years prior to the follow-up interview.
With respect to claim A, this study shows that 20 of 21 people who had used cocaine for years retained, or lost and then regained, a pattern of controlled use of cocaine. For 4 of the respondents this eventually meant abstinence. Between the beginning and the end of the study a minority of the respondents passed through periods during which they could have been considered addicted.
The fact that people pass into and out of addiction contradicts an implicit supposition that accompanies Claim A. This is the supposition that entry into addiction is an irreversible transition. If this were so, the possibility that cocaine may cause addiction in some users would be extremely serious. However, beyond the San Francisco study reviewed above, many interview studies have now demonstrated that it is common for people to pass through a period of dependence of cocaine addiction and to return to moderate use or abstinence without social intervention or any dramatic discomfort (Cohen, 1989; Erickson, Adlaf, Murray, and Smart, 1987; Matthews et al., 1994). Addiction to cocaine is typically a temporary rather than a permanent condition.
In another study, Erickson, et al. (1994) interviewed 111 Canadian cocaine users who had at least one experience with cocaine in the past three years. Attempts were made to attain a typical sample of users. Two-thirds of the respondents were males, the age range was 21 to 44, and all had been employed in the year prior to the interview.
Nearly all respondents reported favouring the intranasal route of administration, and the average duration of time since first exposure to cocaine was 7 years. While a majority of the respondents (58%) had used less than 10 times in the previous year, only 9% reported using on 100 or more occasions during that period.
Although quantities consumed on any single occasion were generally small, i.e., 6 "lines" or less over several hours, many of the respondents reported occasional binges of intensive use and "runs" lasting 2 days or more at some time. Respondents reported considerable fluctuation in their consumption of cocaine. About half (51%) reported more intensive periods of use in the past, usually of short duration and mainly in response to greater availability. Over half (61%) reported cutting back on their cocaine use at some time and provided a variety of reasons including less availability, concern with physical risks and overuse, loss of interest, and lifestyle changes.
Most of those interviewed by Erickson et al., (1994) were infrequent cocaine users who clearly were able to limit their use of cocaine. Restricting use to party situations or special occasions, buying little or none at all, having a stable employment and/or domestic situation, and appreciating the risks of cocaine were some of the factors that appeared to reinforce the controlled use of cocaine. Between 5% and 10% of these Canadians developed very heavy or compulsive cocaine use at some time. The majority of those who had engaged in more intensive periods of cocaine use cut back on their own initiative. Seven individuals had sought treatment related to cocaine use, mainly for medical complications rather than for addiction. These observations would seem to directly contradict even the cautious form of Claim A.
Crack Cocaine. There was an explosion of publicity in the American and Canadian media a few years ago about crack being the "most addictive drug on earth", and causing "instant addiction" (Trebach, 1987; Reinarman and Levine, 1997, chap. 1). Sufficient time has now passed to evaluate these claims empirically. They are simply false.
The great majority of users of crack and other forms of smokable cocaine are experimenters who smoke cocaine a few times and subsequently lose interest. There are also a number of users who use it intermittently over longer periods without serious difficulty. It is true that some people who smoke cocaine become rapidly and tragically addicted, and others discontinue use because they feel that they are "losing control" over their intake, but these are a small minority of users, comparable in size to the minority of users of alcohol, heroin, credit cards, computers, and sex who either become dangerously obsessed or learn that they must abstain (Inciardi, 1987; Waldorf, Reinarman, and Murphy, 1991; Morgan & Zimmer, 1997a; Peele & DeGrandpre, 1998).
The evidence concerning the addictive potency of crack cocaine is consistent over time. In fact, there never was any empirical data to support the claims of "instant addiction". The picture has remained consistent since the very earliest research on the first "crack epidemic" reported in Miami, Florida.
For example, Inciardi (1987) reported that juvenile delinquents in Miami generally preferred cocaine hydrochloride to alkaloid cocaine, because its effects lasted longer. On the other hand, many of them used crack in addition to cocaine hydrochloride because it was sold in smaller, cheaper doses. Inciardi reported that addiction to crack was rare among the delinquents he interviewed.
The 1990 survey of 19-32 year old American high school graduates cited above reported that 5.1% had used crack at least once in their life, but only 0.4% had used it once or more in the month of the interview, and less than 0.05% had used 20 or more days in the month of the interview. Thus, the "most addictive drug on earth" caused persisting addiction in no more than 1 experimental user in 100 (Johnston, O'Malley, and Bachman, 1991), contrary to Claim A.
Indirect evidence that has been used to argue that smokable cocaine carries an especially high addictive liability is also weak. For example, there are a number of longtime heavy users of cocaine who became addicted only after they switched to smoking cocaine (Siegel, 1985; Waldorf, Reinarman, and Murphy, 1991). Does this necessarily mean that "crack" and "freebase" cocaine have a high "addictive liability", even if cocaine hydrochloride does not? A more parsimonious interpretation of these results would be that the people who exposed themselves to alkaloid cocaine were especially needful of cocaine's stimulation. Waldorf et al. estimate that their original sample of 267 cocaine users came from among the heaviest 1% of cocaine users in the U.S. (p. 2). One-fifth of this group, 53 people, had switched from cocaine to smoking crack. The main reason was that they were seeking a more intense, less expensive experience:
...All that is necessary to explain most freebasers' entry into this method is a relatively common desire to achieve what might be called more bang for the buck...For example, one of my respondent said that he first freebased when a cousin told him he was "wasting coke" by merely snorting it...(110-111).
Thus, the cocaine smokers came from the 1/5 of the top 1% of American cocaine users who had such a strong desire to intensify their experience that they switched from cocaine hydrochloride to smoking crack or freebase, in spite of the incessant media reminders that smoking cocaine carried a high risk of addiction. It is hard to conclude from the addiction of some members of this special group that crack would cause addiction in people in general.
Abundant later evidence has continued to demonstrate the falsity of Claim A for crack cocaine, the drug to which it is almost universally believed to apply (Reinarman & Levine, 1997).
I believe it is of the utmost importance for the Senate to contemplate why a totally false, never-documented belief could have had the universal support of the newsmedia, reputable scientists, the then-government of Canada, and the people. I will take up this question after consideration of the evidence for Claim B, where the situation is logically more complex than in the case of Claim A.