A large-scale research project involving current and former heavy users of cocaine, conducted by by Dan Waldorf and colleagues, reveals important insights into how people use cocaine and how they stop using the drug. (3,715 words)
In March 2005, I was delighted when Craig Reinarmann, a Sociology Professor from the University of California Santa Cruz, USA, visited me and gave a talk in our university. Craig, who had been studying various aspects of drugs and drugs policy since the 1970s, pointed out that drug policy in the US was the most repressive and ineffective in the industrialised world. Today, I noted the following quote of Craig’s which appeared on a university Original Thinkers web page:
I’ve spent a lot of my career debunking the lies perpetrated by drug warriors and bureaucrats in this country, and I have consistently pushed for a more humane, effective way of dealing with the problem of drug abuse…. Our drug policy isn’t about safety or public health. It’s about whose morality is going to be dominant. One hundred years from now, people will look back at our drug policies the way we look at witch burning now.
Craig emphasised to me that policy makers and researchers too often focus on the negative effects of illicit drugs, rather than portray a more balanced and objective view. He explained how cocaine became the scourge of America in the 1980s. As President Ronald Reagan put it in a nationally televised address, cocaine is ‘killing a whole generation of our children’ and ‘tearing our country apart.’ In addition to thousands of newspaper articles, Time and Newsweek each devoted five cover stories in 1986 to the cocaine ‘crisis’.
One consequences that arises from vilifying cocaine and cocaine users, is that people who do develop a problem with the drug are less likely to believe that they can overcome their problem themselves. Treatment programmes focused on cocaine misuse began to proliferate in the 1980s, and ‘the clinician entrepreneurs who founded them began to warn all who would listen of the terrible powers of cocaine, claiming that its use led to myriad problems and eventual addiction.’ [1]
Craig told me how Dan Waldorf, Sheigla Murphy and he had conducted, in the mid-1980s in northern California, the most comprehensive ethnographic study of heavy cocaine users. [1]
They interviewed 267 current and former heavy users of cocaine. They deliberately avoided going into treatment programmes and jails to find respondents, focusing on interviewing cocaine users in the more natural settings of their homes and communities. Most of the respondents were ‘solidly working- or middle-class, fairly well-educated, and steadily employed.’
Initially, the investigators were going to focus on the process of cessation from heavy cocaine use, but early on they realised that ‘in order to understand how people stopped, we had to look at how they started and at all the processes of use and abuse.’ Here is a summary of those findings.
1. Using cocaine (powder)
Nearly all the respondents first tried cocaine when it was offered by a trusted friend. Many of the sample reported that they did not get high the first time they snorted cocaine. They had to learn both to experience and then to appreciate the subtle euphoric effects of the drug.
The majority of respondents increased their use gradually—there was no uniform progression or pattern. The slow escalation was likely due in part to a general increase in the availability of cocaine in Northern California at the time. Two other factors were often cited as contributing to escalating use: a slow increase in tolerance for the drug, and the seductive and insidious nature of the drug itself.
The tolerance reported with cocaine appeared to be somewhat different to that observed with opiates. Whilst some users reported increasing their doses of drug, they did not generally report decreased effects of the same dose. Rather than needing more of the drug to get the same effect, they reported wanting the same effect again and again.
Many participants ‘agreed that cocaine’s euphoric effects offered not only a sense of well-being, but a feeling of mastery or power that was so reinforcing it often led them to use more frequently than they planned or expected.’
The researchers described four relatively discrete patterns of use. Hogs showed a consistent, very heavy daily use. This pattern of use caused more dramatic effects, greater compulsion, as well as marked painful ‘comedowns’ and depression.
Nippers used regularly, often every day, but only in relatively small amounts. These users kept their drug use subordinated to work and family responsibilities, and often avoided the negative effects associated with heavy use.
Bingers used cocaine heavily and then lay off the drug for days or weeks. Use was often constrained by personal finances or by prolonged negative effects. Some bingers found their binges getting longer and longer.
Ceremonial or occasional users used the drug on special social occasions.
The researchers reported a considerable movement by individuals from one form of use to another. Although some users followed a downward spiral from experimental use to addiction, as many others nipped and then binged and then nipped again. Others moved from heavy binge use or sustained abuse to ceremonial use.
2. Problems following cocaine use
Long-term daily use of cocaine or regular heavy binges often led to problems. The most frequently mentioned were nasal irritations, paranoia, insomnia, strained relationships with their wife or husband, depleted savings, hangover days at work, and periodic sexual difficulties.
Some of these problems were reported as serious, but many were not. The most serious cocaine-related health problem reported was seizures and convulsions. Most of the respondents appeared to find most of the problems manageable most of the time. They seemed to get pleasure from cocaine, and accepted the problems as part of the territory.
Most of the sample agreed that moderate use of cocaine can be an exceedingly enjoyable experience—it produced euphoria, more energy, a certain intellectual focus, enhanced sensations, an increased sociability and social intimacy.
However, daily use or regular binges transformed the experience of the cocaine high. The initial euphoria slowly and subtly became dysphoria, whilst feelings of well-being turned into feelings of being unwell and unhappy. Feeling energetic was replaced with feeling apathetic.
For some heavy users, the world that had once been good to live in became a place that was far less hospitable—paranoia increased, and depression sometimes developed. These changes in psychological experience were accompanied by transformations in social experience. The person used the drug in isolation, rather than in social groups as was done initially.
The shift in balance to the negative effects of cocaine often resulted in considerable psychological pain, and a questioning of the rationality and desirability of continuing to use the drug. At this time, those people with conventional stakes in families, homes, jobs, communities and identities tended to find the resources and resolve to abstain or reduce their drug use.
3. Giving up cocaine use
Waldorf and colleagues interviewed 106 people who gave up using cocaine (quitters) in their study. Thirty of these had received some form of treatment, whilst 76 stopped using cocaine without treatment.
When respondents were given a list of personal reasons for quitting, the most common (47% of sample) was given as health problems. The next most cited reasons were financial problems (41%), work problems (36%) and pressure from spouse and/or lover (36%). Only 7% cited actual arrest, although 28% cited fear of arrest as a reason for quitting.
Respondents were also given an open-ended summary question on the most important reason or reasons to quit. A total of 61% mentioned some form of psychological problem or stressful state caused by cocaine as the most important reason to quit. The next most common reasons were financial problems (23%), and severe or recurrent health problems or concerns (19%).
There was great diversity in actions that respondents took to quit using cocaine. Some made a number of attempts to stop before they actually succeeded. They despaired over the hold the drug had over them and had great difficulty in maintaining a resolve to stop using.
However, over a half of the sample stopped using on their first try, although this was not always easy. Two-thirds of the untreated cases stopped on their first attempt, whilst only 20% of treated cases did so.
The most frequently used strategies for stopping to use cocaine were social avoidance strategies. More than 40% of all quitters reported making some sort of geographic move as part of their successful attempt to quit. Two-thirds of these people said they moved to another city or state, at least in part to help them stay away from cocaine. Nearly two-thirds of the quitters said they had stopped going to places where cocaine was being used, or had made conscious efforts to avoid seeing cocaine-using friends. Over 40% had also sought out new friends who did not use cocaine.
More than 75% of the sample became more concerned about their physical health whilst quitting and acted upon these concerns. Two-thirds improved their eating habits, and a half undertook new programmes of physical conditioning. Over half of the quitters sought out new interests, with 39% participating in sports to help them avoid using cocaine. Similarly, 55% of the sample used informal help, such as family or friends, to stop using cocaine.
Only 17% of the sample started using other drugs after quitting cocaine. Of those that did, the majority used only marijuana, which almost all had used before and during their cocaine use. Whilst 21% drank more alcohol, most drank less after giving up cocaine.
Whilst most of this diverse sample had used cocaine heavily for a good number of years, their use had not led them to becoming stigmatised. The majority worked regularly, maintained homes, and were responsible citizens—‘… a commitment to their everyday lives gave them a stake in normalcy and bonded them to the conventional world.’ The sample were different to heroin addicts in other studies, many of whom came from disadvantaged backgrounds, had been criminalised and stigmatised, and had few private resources (e.g. education, jobs).
For many of the present sample, prolonged use of cocaine stopped being fun and starting disrupting rather than enhancing everyday lives. Since these lives had meaning and value, the difficulties caused by cocaine became powerful spurs for cessation.
The researchers were ‘pleasantly surprised’ by the relative ease with which so many cocaine users managed to quit. Their strategies were in general fairly commonsensical social avoidance strategies designed simply to put distance between themselves and the drug.
Most of the quitters were able to manage the cravings they experienced after stopping cocaine use. They realised that cravings were only transitory—distractions caused them to subside. New interests and activities provided such distractions. Many quitters found cravings ‘… little different from yearnings one might feel for an old lover—one feels the desire, but with time it subsides and one thinks of him or her less and less.’
These findings emphasise the importance of one’s personal and social identity in influencing drug use. A commitment to a conventional identity and everyday life helps form the social-psychological and social-organisational context within which control and cessation of drug use is possible.
It is commonly stated that drugs come to dominate identities and lives. This was true in the most problematic cases in the Waldorf study. However, for the bulk of the sample, identities and lives usually dominated drug use. This is a critical fact that must be remembered when we try to help people overcome problems caused by drugs and alcohol.
4. Controlled use of cocaine
One striking aspect of the study was the proportion of people who used the drug on a controlled basis (approximately 50%), some of them for even up to a decade. According to Waldorf and colleagues, controlled use can be defined as either:
- ‘regular ingestion without escalation to abuse or addiction, and without disruption of daily social functioning’, or
- ‘a pattern in which users do not ingest more than they want to and which does not result in any dysfunction in the roles and responsibilities of daily life.’
Based on their observations, the researchers described the ideal type of controlled users:
- ‘Controlled users tended to be people who did not use cocaine to help them manage pre-existing psychological problems, and did not also abuse other drugs, especially alcohol.
- Controlled users generally had a multiplicity of meaningful roles which gave them a positive identity and a stake in conventional life (e.g., secure employment, homes, families). Both of these anchored them against drifting toward a drug-centered life.
- Controlled users, perhaps because they are more anchored in meaningful lives and identities, were more often able to develop, and stick to, rules, routines, and rituals that helped them limit their cocaine use to specific times, places, occasions, amounts, or spheres of activity.’
This research suggests that a stake in conventional life and identity are central for understanding continued controlled use. Such stakes seem to keep a person’s drug use from overtaking their life and identity. They also facilitate an individual reasserting control after a period of problematic use.
The fact that these social and social psychological factors mitigate against cocaine misuse and related problems suggests that not everyone need develop a problem with cocaine, even when using heavily as this population was. At the same time, it follows that those people with the least stake in conventional life may be at the highest risk for problematic cocaine use. Cocaine, and in particular crack, have had a marked impact in poor neighbourhoods, causing problems to many individuals and communities.
Obviously, these forms of social control are not foolproof for maintaining controlled use. Some people with a large investment in conventional life did lose control of their cocaine use and develop serious problems. Waldorf and colleagues reported that, ‘after scouring our other interview transcripts, we could not put our fingers on any one magical ‘factor X’ that explained why some people get into trouble and others did not.’
The researchers recognised that some well-intentioned parents and policy makers might not want to broadcast findings about controlled use for fear of facilitating the denial of some misusers or increasing the risks for some new users. However, they contend that the ‘considerable possibilities for exercising control over cocaine use can be seen as cultural resources that can facilitate personal capacities for control and social capabilities for harm reduction.’
Waldorf and colleagues made the very good point that if the only frameworks in society for interpreting one’s drug-using behaviour are addiction and abstinence, then the idea that one can and should exercise control can atrophy. The interviews revealed that one important reason that control was possible for so many of the participants was that they believed that it was possible. They believed that cocaine was ‘not necessarily addicting, that it could and should be used in a controlled fashion.’
Whilst cocaine is often portrayed as a powerful reinforcing psychoactive drug, we sadly do not often hear that its powers are also mediated by users’ norms, values, practices, and circumstances. We underestimate the powers of social, social psychological and cultural aspects, whilst overestimating the pharmacological power of the drug. Waldorf and colleagues point out that heavy cocaine users have taught us:
… that beyond the drug itself, how users think about and behave towards drugs matters a great deal. Cultural norms matter. Subcultural practices matter. How closely we look out for each other matters. The uses to which we put consciousness-altering substances matters. The personal and social resources of users matter. The values placed on productive daily lives matters. And, of course, the social distribution of opportunities for productive lives matters…
5. Crack use
Crack is derived from the processing of cocaine hydrochloride to extract a purer, more solid form of cocaine (freebase), which provides a powerful high when smoked. Crack initially appeared in impoverished minority neighbourhoods in the USA and was claimed to be ‘instantly addicting’ and associated with high levels of crime.
Fifty-three of the sample interviewed by Waldorf and colleagues had been freebasers or crack users for a substantial portion of the peak period of their cocaine careers. Most had snorted cocaine for years before using crack and some went back to snorting after stopping using crack. This meant that the change in mode of ingestion was a small step down a well-worn path, rather than a large one down a road never taken before.
Most of the sample believed that the idea that crack was ‘instantly addicting’ is overly simple. Many experimented with the drug for months before getting in to a pattern that might be described as compulsive, whilst others freebased or smoked crack on a periodic basis without the drug taking over their lives. Others quickly realised the allure of this form of ingestion and walked away from the drug, without experiencing physical withdrawal.
At the same time, however, a clear majority of the sample offered ‘compelling testimony on the extraordinary hold this form of cocaine use can have over those who indulge in it more than a few times. For many, relationships were ruined, families neglected, jobs lost, savings accounts emptied and health imperiled because they found freebasing simply overpowering.’ The potential consequences for young socially and financially impoverished members of an ‘underclass’—who contrast with this population—are clear to see.
Why does crack or freebase cocaine exert such a powerful effect? The respondents’ described a roller coaster ride, in which three interacting elements help explain the power of the pipe. Firstly, the smoker is rapidly brought up to an intense euphoric high (‘orgasmic rush’). Secondly, this euphoria begins to ebb almost immediately. Thirdly, one proceeds downwards almost as quickly as going ‘up’, down to a level that is much lower than one was at before smoking.
This low feeling appears even lower given how high one has been. It is only by rapidly repeating the high that one is able to avoid the painful low. Binging maximises the highs whilst warding off the painful lows, although it is inevitable that the person will eventually plunge into a low state.
The roller-coaster rides described above led most of the freebasers and crack users to ingest in a pattern that was described as obsessive or compulsive. When they had a supply of freebase or crack, most users could not stop smoking until all drug had gone, even when sessions might last days and/or large amounts of money were spent. The compulsive quality was taken for granted; obsession was an intrinsic feature of freebasing and crack use.
6. Problems with crack use
All of the ill-effects experienced by many of the heavy cocaine snorters—problems with physical and mental health, family and friend relationships, finances and functioning in daily life—were amplified and accelerated for freebasers and crack users.
Whilst drug-taking sessions tended to be social in the early stages of freebase and crack users’ careers, these social activities fell by the wayside. The person began to forget about everyone else, becoming totally focused on the pipe. The pleasure of the high and the intense desire to repeat it were so strong that a narcissistic greed took over from the ethic of sharing within social groups that often occurs with other drugs, including cocaine powder.
When under the influence, many crack and freebase users cannot believe their supply has finished and they cannot have another hit. They might crawl around on the floor desperately looking for nonexistent crumbs, or accuse spouses/friends of taking more than their share. Isolation is preferable because the person does not have to share or deal with anyone else.
When smoking the pipe, freebasers and crack users often acted in ways that would be totally unacceptable to them when in a drug-free state. They often lied to, neglected and even stole from spouses and friends. They sometimes neglected their children.
Waldorf and colleagues pointed out that perhaps the clearest indicator of the obsessive form of this type of drug use is the extent to which people continued to use in the face of overwhelming evidence of harm, which could take the form of physical harm (e.g. cocaine-induced seizures, heart pains) or a disintegration of the person’s social relationships and daily lives.
However, whilst many crack users and freebasers did things they were ashamed of, they did not resort to the street crime, violence and prostitution that media reports link to this form of cocaine use. Those who did commit crimes did ones they knew how to do (e.g. lawyer who embezzled, insurance clerk who filed a false insurance claim), rather than resort to an activity (e.g., burglary) for which they had no experience.
Thus, whilst freebase and crack may have led to a person breaking their usual norms (and sometimes laws), it did so within bounds that were set by ‘socialization, by subculture, and by the self.’ On the other hand, the drug can produce a different sort of crime in people who have little other means of supporting themselves, few normative bonds to conventional society, and little to lose by throwing off the remaining restraints.
This is another clear indication that the effects of drugs are not just determined by the drug, but by social context as well. The fact that more pronounced behavioural disruption is caused by freebasing and crack than cocaine powder is another clear example that not all can be explained by the simple effects of a drug in the brain.
Finally, this research revealed that whilst freebasers and crack users seemed powerless to stop using during a session, most would often go days and even weeks at a time without using in this way. Therefore, the obsession with cocaine appeared to be episodic rather than chronic; whilst showing a compulsive pattern during a session, users did not remould their lives into one session.
7. Stopping use of crack and freebase cocaine
Many of the crack and freebase users began to recognise an accumulation of negative consequences (defined as ‘trouble’) and/or a downward spiral in their lives caused by their obsession with freebase or crack. This led to some interviewees to cut down on their freebasing and others to quit entirely. Waldorf and colleagues do not go into details about the quitting process amongst this population, but do report that over 40% had stopped using cocaine.
Endnote:
[1] Dan Waldorf, Craig Reinarman, and Sheigla Murphy, Cocaine Changes: The Experience of Using and Quitting, Temple University Press, USA, 1991.