In the propaganda of the drug war, cocaine is an unmitigated evil, perhaps symbolized most vividly by one of those none-too-subtle images from the Partnership for a Drug-Free America: a revolver with its barrel aimed up the user's nostril. At other times and in other places, however, the drug has been known as a benign stimulant and a marvelous tonic for a variety of major and minor ills.
The modern controversy over cocaine is neatly framed by the writings of two bold young doctors: Sigmund Freud and the American addiction specialist Mark Gold. Working a century apart, Freud and Gold both established their reputations by investigating the effects of cocaine. Both were skilled physiologists who undertook the study of cocaine soon after they left medical school. But their conclusions about the drug are diametrically opposed. Indeed, it is at first difficult to believe that they are describing the same substance.
Gold, a former member of the psychiatry department at Yale Medical School who now directs private hospitals in Florida and New Jersey, considers cocaine terribly addicting for experimental and recreational users. Freud, on the other hand, believed that cocaine addiction is rare and confined largely to people already addicted to other drugs. Gold maintains that nonaddictive use of cocaine is useless and dangerous, but Freud thought it medically harmless and beneficial. While Gold calls for warlike drug-control measures to combat the cocaine menace, Freud eagerly explored the drug as a potential blessing to humanity.
Although current conventional wisdom supports Gold's position, the bulk of modern clinical, experimental, and historical evidence indicates that Freud was closer to the truth on the first two issues. On the third issue, both Freud and Gold are wrong. It turns out that cocaine is neither a terrible scourge nor a great boon. Simply put, it's not nearly as important as it's made out to be.
The data on cocaine use tend to support Freud's view of the drug's addictive potential rather than Gold's. In spite of widespread availability and declining prices, most people never use cocaine; of those who do, most use it only once or a few times; of those who become casual or regular users, most do not become dependent or addicted; of those who become dependent or addicted, most return to moderate use or voluntarily abstain without treatment; and of those whose addiction becomes serious enough to require treatment, most had lives that were marked by severe alienation or misfortune before they first used cocaine. None of this is intended to deny the horrors of severe addiction to cocaine, but rather to challenge the view that these horrors prove cocaine is a highly addictive drug.
Whatever the drug's power, the vast majority of Americans have managed to resist it. Cocaine use appears to have peaked by 1979, leveling off in the early 1980s. The National Household Survey on Drug Abuse indicates that at the peak, less than 10 percent of Americans had ever used cocaine and less than 2 percent had used it even once in the year in which they were surveyed.
The "addictive liability" of a drug is not a precisely defined term, but it should be reflected in the difficulty that people have in terminating use. When the National Institute on Drug Abuse questioned high-school seniors who were considered recent users of cocaine in 1983, 3.8 percent reported that they had tried to stop using cocaine and found they could not. By comparison, 18 percent of cigarette smokers reported that they were unable to give up tobacco. Other American surveys of more geographically limited populations have produced similar results.
Taken together, the survey data indicate that cocaine is used by a minority of Americans and that only a small fraction of this minority uses very much. Of course, general population data like these tell little about special populations, such as school dropouts, in which more people may use cocaine and a higher proportion may become addicted.
In addition to the surveys, there have been a few studies of cocaine users who were located through advertising or personal networks. Since these samples were not randomly selected, they do not represent all cocaine users. They do, however, tend to provide more in-depth information on users than do random surveys because the participants, as volunteers, are unlikely to conceal information from the interviewers. Subjects in these studies generally report considerable control over their patterns of use. They often use the drug casually for years without progressing to heavy use, and when use does get out of hand, they are able to cut back or stop.
(There is a recognizable sequence of reactions after a binge of heavy use, including a dramatic "crash." However, cocaine does not produce physical withdrawal symptoms comparable to those that follow heavy use of alcohol, barbiturates, or opiates. Indeed, authorities differ on whether the aftermath of heavy cocaine use should be called "withdrawal symptoms" at all.)
The number of clients seeking help for cocaine problems in the United States and Canada increased substantially during the late '70s and '80s. But this does not necessarily indicate that cocaine is an especially addictive drug. It is just as likely that some of the disturbed people who were previously apt to receive treatment for alcoholism or other types of deviance started using cocaine as the drug became popular and relatively abundant.
Clients who identify cocaine as their primary problem are likely to be abusing a number of other drugs at the same time. Drug addicts, including those addicted to cocaine, tend to suffer from anxiety, depression, hyperactivity, and other serious behavioral problems before becoming addicted. Therefore, it's likely that the people who are treated for cocaine addiction would be in other kinds of trouble if they did not have access to cocaine.
Drug warriors often cite studies of laboratory animals as evidence of cocaine's unique addictive power. When animals are given intermittent opportunities to self-administer cocaine in the laboratory, there is little evidence that cocaine is highly addictive. Many different mammalian species have been tested, and some members of each will press levers to inject themselves with cocaine. The amounts they self-administer are moderate and controlled. If the concentration of the injected solution is raised, the animals generally respond proportionately less, and if it is lowered they respond proportionately more. There are signs of stimulation from the drug, but convulsions from overdoses are rare. It seems that mammals find the drug pleasantly stimulating but naturally maintain the stimulation at a safe level.
Researchers who make cocaine available to animals around the clock, however, report indications that the drug is highly addictive. In one experiment, three monkeys were put in cages where they were allowed to press only one of two levers—one producing an infusion of cocaine, the other producing food pellets—every 15 minutes. During the eight-day experiment, all three monkeys chose cocaine almost exclusively. Even on trials where they did not choose cocaine, the monkeys did not press the food lever. The animals lost weight and displayed strange, stereotyped behaviors. In other experiments, monkeys and rats have self-administered cocaine over periods of several days until they died of convulsions.
Such research is often interpreted as reflecting the fate of human beings if cocaine were freely available. Psychiatrist Sidney Cohen of UCLA has stated: "Under conditions of access to large amounts of cocaine the human response remarkably resembles that of the laboratory animal. Cocaine-dependent humans prefer it to all other activities. They will continue using until they are exhausted or the cocaine is depleted.…All laboratory animals can become compulsive cocaine users. The same might be said of humans."
But generalizing from the results of animal studies is dubious for many reasons. To begin with, monkeys are gregarious, active, curious animals, with a great resistance to being handled or restrained. The same is true of wild rats and, to a lesser extent, of their laboratory-bred descendants. Cocaine self-administration studies isolate such creatures in small cages, where they are surgically implanted with a catheter and tethered 24 hours a day to the injection apparatus. There is virtually nothing for these creatures to do in their solitary confinement but press a lever on the wall that produces temporary euphoric stimulation.
There's little reason to think that these animals would consume as much cocaine in a more natural habitat. In fact, recent data indicate that rats housed in isolation self-inject much more cocaine in daily tests than rats housed more naturally in groups between tests. The observable behavior of both animals and humans in their natural environments runs contrary to the insatiable cocaine consumption of isolated animals in the laboratory. Moreover, the failure of animals to eat in some experiments may simply be due to the fact that cocaine is a potent appetite suppressant.
It's widely reported in the news media and medical literature that smokable cocaine is much more addictive than snorted cocaine hydrochloride. Crack, in particular, is frequently said to be "instantly addictive" or the "most addictive drug on earth." Some eminent scholars take these claims about smokable forms of cocaine seriously. But others note that these claims are suspiciously similar to the unsubstantiated stories that were told about marijuana, glue, heroin, and cocaine hydrochloride when they first became matters of public concern.
Smokable cocaine reaches the bloodstream much faster than does nasally administered cocaine hydrochloride. This in itself does not prove that smokable cocaine is more addictive than other drugs. The speed with which smokable cocaine reaches the bloodstream is no greater than that with which smoked marijuana or nicotine (or intravenously injected cocaine hydrochloride) normally enters the bloodstream.
Pharmacologically, the effects of smoking crack should be similar to those of smoking coca leaves because the active ingredient, the cocaine alkaloid, is the same. Parke, Davis & Company introduced coca-leaf cigars and cigarettes in 1885, and other drug companies offered similar products, primarily as treatments for respiratory infections. Although cocaine in general was gaining a bad reputation in this period, no one claimed that these smokable forms were especially addictive. In fact, some users publicly endorsed them as mild and effective remedies.
In spite of many media testimonials about the addictiveness of smokable cocaine, the only experimental evidence that I have found to support them comes from a single study on smoking coca paste in Lima, Peru. The subjects were all described as nondependent, "occasional" users. All subjects (the total number does not appear in the report) became anxious before smoking, all expressed an "extreme desire" for alcohol during the experimental sessions, and two reported "an inability to resist smoking" during the sessions. Nonetheless, all subjects must have resisted smoking enough to stop voluntarily, since no injuries or deaths were reported, even though the subjects were allowed as much coca paste as they wanted during two of the three experimental sessions in which each participated.
There is no statistical evidence of widespread use of crack or any other form of smokable cocaine in North America. In the United States, 5.6 percent of high-school seniors surveyed in 1987 had ever used crack (as compared to 15.2 percent for all forms of cocaine). Only 1.5 percent reported use in the 30 days preceding the interview (as compared to 4.3 percent for cocaine in general). Thus, crack did not cause "instant addiction" in the great majority of people who tried it.
A study in Miami found that juvenile delinquents generally preferred cocaine hydrochloride to crack, because its effects last longer. Many of them used crack in addition to cocaine hydrochloride, however, because it was sold in smaller, cheaper doses. The study also found that addiction to crack was rare among the subjects. Taken together, these data suggest that there is no difference in addictive liability between crack and cocaine hydrochloride.
The data from surveys, self-selected user studies, clinical studies, and animal experiments, together with the limited information available on smokable cocaine, provide no evidence that cocaine in any form has a high addictive liability or that we are experiencing an epidemic of cocaine use. The widespread belief that cocaine is extraordinarily addictive is based largely on subjective reports and anecdotal evidence. Although most people who experiment with cocaine subsequently use it intermittently and moderately, if at all, some report that they "cannot control" or "can't handle" cocaine, and must therefore abstain completely. Patients and hotline callers often describe cocaine as irresistibly addictive. It is unwarranted, however, to say that a drug has a high addictive liability if the great majority of people who have used it are not addicted, even if some of them find abstinence to be the best policy.
People who are inclined to become addicted to drugs tend to prefer cocaine, just as people who are likely to become obese or bulimic are more drawn to junk foods than to Brussels sprouts or turnips. Likewise, people who become compulsively religious are more apt to be involved in an evangelical sect or a trendy cult than in Presbyterianism. If we define addictive liability in terms of the preferences of addictive people among the available options, then cocaine is only one of hundreds of everyday substances and activities that is highly addictive.
Cocaine use is closer to a fad of conspicuous consumption than an epidemic of addiction. To call it a fad is not to trivialize it; fads exert powerful effects on people's motivations. One subgroup that has been caught up in the cocaine fad is adventurous, young, affluent adults. For many such people, "Coke is it." As with other expensive fads and fashions, the consequences for the great majority of participants are not dire, although a small fraction of the participants become addicted or suffer serious side effects.
Perhaps even more than the young and affluent, fads attract socially marginal people who seek magical remedies to their problems. Because their need is greater, they are more likely to use cocaine excessively. People who at other times in history would have become obsessed with marijuana, LSD, alcohol, sex, gambling, or political fanaticism became addicted to cocaine in the 1980s.
The idea that cocaine addicts are socially marginal runs counter to the media portrayal of "normal" people becoming addicted merely because of an ill-advised experiment. Yet some people who appear successful are inwardly disaffected and desperate. Throughout history disaffected and desperate people have fallen into compulsive involvements, chosen from the fashionable indulgences of the day.
On the question of whether moderate use of cocaine is useful and harmless, as Freud believed, or useless and harmful, as Gold maintains, Freud was again closer to the truth.
Heavy cocaine use can produce unwanted side effects, including hallucinations, feelings of paranoia, unpleasant tactile sensations called "coke bugs," repetitive behaviors, and severe depression. In the most extreme cases, the unwanted effects resemble a short-term paranoid psychosis accompanied by convulsions. In addition to these experiences, excessive use of cocaine sometimes damages the nasal tissues and kidneys. The great majority of cocaine users, however, take the drug in moderate amounts and experience positive effects. Some moderate users experience side effects, but they are generally minor.
Experimental and recreational users of cocaine do not feel "stoned"; they feel more competent and confident. It is possible that these perceived benefits are illusory, but many careful observers have reached the conclusion that cocaine helps people do simple tasks, especially when fatigued or hungry, and that it helps performers of various sorts achieve the confidence they need.
Cocaine measurably improves performance on simple physical tasks in North Americans who are fatigued or deprived of sleep. South American Indians working to the point of exhaustion also had slightly better endurance and higher heart rates when chewing coca leaves than on non-coca trials. There is also experimental evidence that chewing coca leaves affords some protection from exposure to the cold.
As in Freud's research, these modern studies suggest that cocaine is of little benefit to people who are well-rested. Contrary to Freud's observations, however, cocaine apparently does not help with complex mental or learning tasks.
The stimulation from a moderate dose of cocaine can be as useful as the lift from a cup of coffee, a short nap, or the satisfaction of a task well done. Of course, legal lifts seem more proper than cocaine highs. But outside the sheltered world of the well-fed and well-adjusted, for whom little naps and tasks well done are a realistic possibility, illegal highs may be a sensible recourse. Andean peasants used cocaine in this way for centuries without provoking alarm, until they fell under the searchlights of the war on drugs.
Negative effects are relatively uncommon among moderate cocaine users. About 17 percent of Ontarians who have used cocaine report that they either rarely or sometimes "become violent or aggressive," and 23 percent report that they rarely or sometimes "feel that someone was out to get you" when they use cocaine. However, the remaining 83 percent and 77 percent of these Ontario cocaine users never have these reactions. These adverse effects are less common among infrequent users than among heavier users.
There is direct evidence that moderate doses of pure cocaine, administered intranasally, are reasonably safe. Cocaine is routinely applied intranasally in doses of 200 milligrams or more in nasal surgery. These doses are comparable to those typically taken by Canadian recreational cocaine users, and the peak blood levels of cocaine following medical administration are comparable to those found following doses that produce a "high" in experienced users. A survey of plastic surgeons revealed five deaths (.005 percent of the patients) and 34 severe, nonfatal reactions (.03 percent of the patients) following 108,032 applications of cocaine in surgery. Moderate injected doses of cocaine have also proved safe in experimental studies with human subjects.
There is no doubt that overdoses of cocaine can cause illness and death. The victims generally become excited and confused shortly after a large dose of cocaine and subsequently undergo convulsions, depression, coma, and, in severe cases, death from respiratory depression or, sometimes, heart failure. Overdose death usually occurs within a few hours. This syndrome has been well-documented in human beings since the 19th century and can be replicated in experimental animals.
There is little evidence, however, that moderate doses are often fatal. After an extensive search of the literature, I have concluded that the widespread conviction that moderate use of cocaine is dangerous is based on horror stories that are accepted uncritically and on medical research that is misinterpreted because of the presuppositions of the war on drugs.
The misinterpretation of medical research entails each of the following errors: (1) exaggerating the amount of sickness and death that is associated with cocaine; (2) gratuitously assuming that people harmed by using cocaine are moderate rather than heavy users; (3) neglecting indications that medical emergencies that befall heavy cocaine users could just as well have resulted from their other drugs, activities, or pathologies; (4) gratuitously assuming that cocaine purchased by users who experience medical emergencies was unadulterated; and (5) ignoring the fact that many legal drugs and activities are just as dangerous as cocaine.
Since 1982, the Drug Abuse Warning Network (DAWN) has reported dramatic annual increases (up to 200 percent) in the frequency of "emergency room mentions" of cocaine relative to other illegal drugs in many of the 27 cities that it surveys. However, these DAWN data do not mean that cocaine has become a substantial health hazard. Cocaine is currently "mentioned" in only 2.6 out of every 1,000 emergency-room visits in the DAWN cities. A mention does not mean that a drug necessarily caused the emergency-room visit, since each report may mention several drugs detected in a patient. Moreover, the fact that a patient has used drugs does not necessarily mean that drugs have caused his or her illness. In addition, the DAWN cities do not represent the United States as a whole, which has a substantial rural and small-town population.
Similarly, although cocaine is currently mentioned in 14.4 of every 1,000 deaths reported by medical examiners in the DAWN cities, this does not mean that cocaine causes that proportion of American deaths. Medical examiners may mention several drugs in connection with a single death, so cocaine is certainly not the cause of them all. Most routine deaths are not reported to medical examiners, so this is hardly a sample of typical American deaths. Most important, there is no information in the DAWN studies to show that any significant proportion of the emergencies and deaths are related to moderate cocaine use, or that the "cocaine" used by any of the decedents was free of common black-market adulterants.
Nonetheless, cocaine is a heart stimulant. The data indicate that even moderate doses could increase the risk of heart attacks in people who already have high blood pressure or severe heart damage from other causes. But instead of singling out cocaine as uniquely dangerous, these data place it squarely in the company of a broad class of agents that includes caffeine, alcohol, tobacco, sports, gambling, and sex.
It's widely accepted in North America that crack and other forms of smokable cocaine are especially dangerous. Some of the reports on which this impression is based are simply false. For example, USA Today attributed 563 deaths to cocaine and crack in the first six months of 1986. After a careful study of the official government reports and available medical literature, Arnold Trebach, president of the Drug Policy Foundation, found that none of these deaths could be confirmed.
Some articles in medical journals claim that crack, free-base, coca paste, and other forms of smokable cocaine are significantly more harmful than cocaine hydrochloride. However, apart from the well-established fact that smokable cocaine reaches the bloodstream faster than orally or nasally administered cocaine, these articles offer little data to support this assertion. The authors seem to have relied on uncritical assumptions about evidence, including all five of the logical errors mentioned above.
I do not mean to claim that harm never results from moderate use of cocaine. All drugs, including cocaine, can hurt people. However, the existing research does not justify the claim that using cocaine in moderation is an unusually dangerous practice.
When a person dies as a result of jogging, playing squash, driving a car, or engaging in sexual intercourse, the event may lead people who engage in these activities to reassess the costs and benefits. It does not provide the occasion for a War on Jogging, a War on Squash, a War on Cars, or a War on Sex. The kind of research that has been taken as serious proof that cocaine regularly causes heart attacks and other dire consequences in moderate users only proves the existence of an extraordinary, warlike mentality. This kind of thinking forfeits a normally critical perspective to embrace spurious justifications for the war on drugs.
The third difference in the outlooks of Gold and Freud is the tone of their writings on cocaine. Gold discusses cocaine only in the context of pathology and control. Freud, by contrast, was uncharacteristically lyrical in his description of the drug and its effects. In his proposals that cocaine be used to cure most diseases and improve most human activities, Freud appeared to view the drug as a welcome benefactor and a savior from the stress of life.
Upon reflection, it is clear that both views are wrong. Contrary to Gold's view, cocaine cannot hurt us much. It is a drug that can be used in destructive ways, but it is very unlikely to lead to addiction or injury except in people who are already in deep trouble. The great majority of people who try cocaine find it possible to use it in a generally beneficial way or to leave it alone. The percentage of users who are harmed by it is probably comparable to the percentage who are harmed by other stimulating but socially acceptable activities.
Freud was also wrong. Cocaine is not the great chemical savior he thought it was—it is just a stimulant, and stimulants do little more than enable people to borrow from psychic reserves that have to be repaid later. Sometimes such loans are useful, even pleasurable, but they don't represent a net gain.
No drug can make people feel alert, healthy, and alive for very long. The only hope for a persistent sense of well-being is the patient cultivation of courage, honesty, friendship, realism, and hard work. The promises of the ancient homilies are far more valid than the magical promise that cocaine held out to Freud. Cocaine has potential medical applications that might be investigated further if not for the drug-war atmosphere, but there are no signs that it can be the panacea that Freud imagined.
In sum, cocaine neither causes the problems that wrack our times, nor can it rid us of them. Rather, the abundance of refined cocaine is yet another complexity of a technological age. It may improve our lives to a degree if we learn to use it wisely. But using it wisely could turn out to mean not using it at all.
In this century we have overreacted to the dangers of cocaine with a futile attempt to ban it from the world. This campaign stains the earth with blood and corrupts the fragile institutions of democracy. Worst of all, it diverts our attention from the real causes of the misery and conflict that surround us. Cocaine is not a significant source of crime, violence, addiction, heart disease, brain damage, unhealthy babies, student apathy, low productivity, or terrorism in the Third World. The real danger is the destructive illusion that we can relieve these deeply rooted problems by attacking cocaine.
Bruce Alexander is a professor of psychology at Simon Fraser University in Burnaby, British Columbia. This article is adapted from chapter five of his book Peaceful Measures: Canada's Way Out of the "War on Drugs" (University of Toronto Press, 1990).
This article originally appeared in print under the headline "Snow Job".