Cocaine Use in America: Epidemiologic and Clinical Perspectives DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Cocaine Use in America: Epidemiologic and Clinical Perspectives Editors: Nicholas J. Kozel, M.S. Edgar H. Adams, M.S. Division of Epidemiology and Statistical Analysis National Institute on Drug Abuse NIDA Research Monograph 61 1985 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse 5600 Fishers Lane Rockville, Maryland 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC. 20402 NIDA Research Monographs are prepared by the research divisions of the National Institute on Drug Abuse and published by its Office of Science. The primary objective of the series is to provide critical reviews of research problem areas and techniques, the content of state-of-the-art conferences, and integrative research reviews. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisors MARTIN W. ADLER, Ph.D. SIDNEY COHEN, M.D. Temple University School of Medicine Los Angeles, California Philadelphia, Pennsylvania SYDNEY ARCHER, Ph.D. MARY L. JACOBSON Rensselaer Polytechnic lnstitute National Federation of Parents for Troy, New York Drug-Free Youth RICHARD E. BELLEVILLE, Ph.D. Omaha, Nebraska NB Associates, Health Sciences Rockville, Maryland REESE T. JONES, M.D. KARST J. BESTEMAN Langley Porter Neuropsychiatric lnstitute Alcohol and Drug Problems Association San Francisco, California of North America Washington, D.C. DENISE KANDEL, Ph.D. GILBERT J. BOTVIN, Ph.D. College of Physicians and Surgeons of Cornell University Medical College Columbia University New York, New York New York, New York JOSEPH V. BRADY, Ph.D. The Johns Hopkins University School of HERBERT KLEBER, M.D. Medicine Yale University School of Medicine Baltimore, Maryland New Haven, Connechicut THEODORE J. CICERO, Ph.D. Washington University School of RICHARD RUSSO Medicine New Jersey State Department of Health St. Louis, Missouri Trenton, New Jersey NIDA Research Monograph Series CHARLES R. SCHUSTER, Ph.D. Drector, NIDA JEAN PAUL SMITH, Ph.D. Acting Associate Director for Science, NIDA Acting Editor Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857 Cocaine Use in America: Epidemiologic and Clinical Perspectives ACKNOWLEDGMENT This monograph is based upon papers presented at a technical review of patterns of cocaine use in the United States which took place on July 11-13, 1984, at Bethesda, Maryland. The conference was sponsored by the Division of Epidemiology and Statistical Analysis, National Institute on Drug Abuse. COPYRIGHT STATUS All material in this volume except quoted passages from copy- righted sources is in the public domain and may be used or repro- duced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or commodity. Trade or proprietary names appearing in this publication are used only because they are con- sidered essential in the context of the studies reported herein. DHHS Publication No. (ADM)90-1414 Alcohol, Drug Abuse, and Mental Health Administration Printed 1985, Reprinted 1987, 1990 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, Biosciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. iv Foreword Over the past 10 years, cocaine, which has been characterized as powerfully addictive, has evolved from a relatively minor problem into a major public health threat. In the early 197Os, evidence on the reinforcing potential of cocaine suggested that if the use of the drug became widespread major social and public health problems could ensue. Fortunately, NIDA had epidemiologic surveys and surveillance systems in place which enabled it to monitor the prevalence of drug use, cocaine- related emergency room cases, and treatment admissions. These efforts have documented dramatic increases in the use of cocaine in the general adult and high school populations of the United States. As the use of cocaine increased, parallel increases in emergency room visits, overdose deaths, and clinical problems reflected by increased treatment admissions were noted. Although the prevalence of cocaine use in the general population appears to have leveled off since 1979, the adverse consequences have con- tinued to increase dramatically. Several explanations, including increased combination drug use, a shift to more dangerous routes of administration, and the lag time from first use to entry into treatment have been offered to explain this phenomenon. There is evidence to suggest that each of these explanations may in fact contribute to the increased negative consequences associated with cocaine. Yet, as much as we know about the epidemiology of cocaine use, many questions remain. It is unknown, for example, whether the increasing number of freebase users seen by clinicians reflects an increase in the numbers of people smoking freebase or a reflection of the increased risk of this route of administra- tion. While our surveys have given us good estimates of the number of people who have used cocaine, we still need an estimate of the proportion of the using population who have experienced problems due to their drug use. In contrast, clinicians often see the problem users but may not collect sufficient drug histories so that risk may be assessed and have no contact with users who are not experiencing problems. The dialogue between epidemiologists and clinicians at the technical review on which this monograph is based increased the awareness of these issues and the benefits to be derived from increased interaction between epidemiologists and clinicians. One result of the technical review was the inclusion of a problem measurement section in the 1985 National Household Survey on Drug Use. Another is the publication of this monograph which represents an important contribution to our understanding of cocaine use and abuse. Charles R. Schuster, Ph.D. Director National Institute on Drug Abuse V Contents Foreword Charles R. Schuster . V Cocaine Use in America: Introduction and Overview Edgar H. Adams and Nicholas J. Kozel . 1 Cocaine Use in the United States: In a Blizzard or Just Being Snowed? Richard R. Clayton . 8 A Decade of Trends in Cocaine Use in the Household Popula- tion Herbert I. Abelson and Judith Droitcour Miller . 35 Cocaine Use Among American Adolescents and Young Adults Patrick M. O'Malley, Lloyd D. Johnston and Jerald G. Bachman . 50 Cocaine Use in Young Adulthood: Patterns of Use and Psycho- social Correlates Denise B. Kandel, Debra Murphy and Daniel Karus . 76 Patterns and Consequences of Cocaine Use Dale D. Chitwood . 111 Cocaine Abuse: Neurochemistry, Phenomenology, and Treatment Mark S. Gold, Arnold M. Washton and Charles A. Oackis . 130 Reinforcement and Rapid Delivery Systems: Understanding Adverse Consequences of Cocaine Sidney Cohen . 151 Characteristics of Humans Volunteering for a Cocaine Research Project C. R. Schuster and M. W. Fischman . 158 Characteristics of Cocaine Abusers Presenting for Treatment Sidney H. Schnoll, Judy Karrigan, Sarah B. Kitchen, Amin Daghestani, and Thomas Hansen . 171 vii Cocaine Use in a Treatment Population: Patterns and Diagnostic Distinctions Frank H. Gawin and Herbert D. Kleber . 182 Cocaine: Treatment Perspectives Donald R. Wesson and David E. Smith . 193 New Patterns of Cocaine Use: Changing Doses and Routes Ronald K. Siegel ....................................... 204 Cocaine Use in America: Summary of Discussions and Recommendations Nicholas J. Kozel and Edgar H. Adams . 223 List of NIDA Research Monographs . 229 viii Cocaine Use in America: Introduction and Overview Edgar H. Adams and Nicholas J. Kozel In the mid-1970s, as the reinforcing potential of cocaine was being demonstrated in the laboratory, the prevalence of cocaine abuse in the general household population of the United States was increasing dramatically. The fourfold increase from 5.4 million in 1974 to 21.6 million in 1982 in the number of people who reported having tried cocaine at least once has been well docu- mented (Blanken et al. 1985; Adams and Durell 1984). Based on data from the National Household Survey on Drug Abuse (1974-1984), lifetime prevalence of cocaine use continued to increase into the early 1980s. The number of current users (used in the past 30 days), however, remained stable between 1979 and 1982. Recent reports of increasing emergency room cases associated with cocaine, increasing deaths, and rising treatment admissions for cocaine problems have heightened concern that the incidence (new use) of cocaine use may be increasing once again. On the other hand, it has been suggested that this increase in untoward effects of cocaine use Is the result of changing routes of administration and more intensive patterns of use, including the use of cocaine In combination with other drugs. It has been noted also that the median time from first use of