This is one of the "site reports" from a WHO Cocaine Study that was completed in 1995 but never published because of intervention by the US government (See article in this section entitled "The suppressed 1995 WHO Cocaine Study). It was submitted in this form from the Vancouver Site, one of 21 or 22 sites in the study, and accepted as part of the Final Report, which was never released. I was Principal Investigator at the Vancouver Site. The Authors of the site report are the four paid interviewers and myself. This material has never appeared in print.
The British Columbia Key Informant Study
Lisa C.B. Matthews, Gary A. Dawes, B.G. Nadeau, Linda S. Wong, B.K. Alexander
Simon Fraser University, Burnaby, B.C., Canada, V5A 1S6
1. Introduction: Background of the British Columbia Key Informant Study 3
I. The Site 3
II. Methodology 5
2. Consultant Details 6
3. Patterns of Cocaine and Other Drug Use 7
I. General Population of Users in B.C. 7
II. Users Best Known to Consultants 8
4. Availability of Cocaine 16
I. Cocaine Compared to Other Drugs 16
II. Distribution/Underground Scene 16
III. Cocaine Production or Manufacturing 18
5. Consequences of Cocaine Use 18
I. Acute Effects of Cocaine on Users 19
II. Longterm and Indirect Effects on Users 27
III. Lifestyles of Cocaine Addicts in B.C. 30
IV. Cost-benefit Analyses.. 30
V. Consequences for the Community.. 31
6. Current Responses to the Use of Cocaine.. 31
I. Treatment 31
II. Law Enforcement 36
III. Prevention and Education 40
7. Changes in Cocaine Use 44
I. Over the Last 5 Years 44
II. Over the Next 5 Years 45
III. Need for Intervention 46
8. Future Issues 47
I. Assessing the Harm Reduction Philosophy 47
II. Revising the Urban Focus 47
III. Choosing New Directions for Research 48
9. Assessment of Key Informant Interview Instrument 48
I. Positive Features 48
II. Negative Features 49
10. Description of Attachments 50
11. References Cited 51
I. The Site:
The site of this Key Informant Study was the province of British Columbia, Canada. The largest number of interviews took place in the coastal city of Vancouver and the surrounding metropolis. Half of the province's population of about 3,000,000 people reside in this area. Additional interviews were undertaken in small cities and towns in the interior of the province, in rural areas, and on Vancouver Island, a large offshore island close to Vancouver. A few interviews took place in Victoria, the province's capital and second largest city, which is located on Vancouver Island.
The province of British Columbia is located in the southwestern corner of Canada. It is bounded on the west by the Pacific Ocean, on the south by the continental United States, on the north by Alaska (U.S.), the Yukon Territory (Canada), and the Northwest Territories (Canada), and on the east by the province of Alberta (Canada). Although British Columbia lies roughly between 49o and 60o north latitude, the climate is relatively mild, moderated by weather systems from the Pacific Ocean. British Columbia is very large, comprising almost 1,000,000 square kilometres. The northern two-thirds of the province are sparsely populated. Almost all the remote, sparsely-populated areas of B.C. are linked to Vancouver by paved highways, local airlines, and coastal ferries, and to mainstream urban culture by television, radio, printed media, and omnipresent provincial bureaucracy. Virtually every small town has electricity and telephone service. There is a steady movement of people to and fro between rural areas and the cities in search of work, schooling, recreation, and shopping. Thus, the population is not sharply divided between urban and rural cultures.
In fact, British Co lumbia is culturally homogeneous relative to some other parts of the world. Despite a significant Native population (2.4% of the provincial total) and a mixed-ethnic immigration that has not ceased since the 19th century, the predominant language throughout the province is English and the predominant culture is Western-English-Canadian. The greatest cultural distinctiveness within the province is probably found on the various Native reserves. The indigenous "Indian" population of British Columbia was supplanted by settlers of European and Asian descent only recently, the major influx coming with a series of "gold rushes" beginning in 1858 and the completion of the first Canadian transcontinental railway in 1885. British Columbia retains some frontier mystique to this day. This includes a politically active Native population; a reputation for flamboyant, unsophisticated politics; and, in comparison to the rest of Canada, a prodigious appetite for alcohol and drugs. British Columbia consumes more alcohol per capita than any other province, although less than Canada's two arctic territories. Vancouver has been the centre for Canadian heroin consumption throughout the 20th century, and was one of the Canadian centres of marijuana-oriented "hippie" culture in the 1960s (LeDain, 1973; Single, Williams, and McKenzie, 1994).
In recent decades, control of the province has fluctuated between two political parties that characterize themselves respectively as "free enterprise" and "social democratic". Although the province has a history of class antagonism, political observers have suggested that both political parties might currently be described as "populist", rather than as representing a business and a labouring class respectively (Elkins, 1993). Thus, under governments from either party, the province maintains large "crown corporations" which provide certain basic services at reasonable prices (e.g., electricity, auto insurance, coastal ferries) and, in concert with the federal government, provides a "social safety net" to protect citizens from the worst calamities. The social safety net includes comprehensive tax-supported medical insurance, available to all and completely subsidized for the poorest citizens, free public education through grade 12, and good roads, even in remote northern regions. The political culture is egalitarian--notwithstanding obvious differences in wealth, the great majority of the population maintains a middle class standard of living. Traditional Anglo-American rights and freedoms are usually respected.
In Canada, British Columbia is often envied for its mild climate, relative wealth, mountainous beauty, and a certain insouciance of its residents. The provincial economy is sustained traditionally through forestry, mining, fishing, and agriculture, and recently through thrusts towards "service" industries (particularly tourism), manufacturing, and advanced technology (Dyck, 1986, chap. 10). British Columbia is frequently referred to in Canadian media as "Lotusland", although the Key Informant interviews confirmed the presence of a full range of serious social problems as well, including crime, family violence, and drug addiction.
Drug laws are enacted on a federal level in Canada, although enforcement is carried out by provincial and municipal police in many areas. In most of British Columbia, drug law enforcement is in the hands of the federal police force, the Royal Canadian Mounted Police, which is universally known as the "RCMP". However, Vancouver and Victoria and a couple of smaller cities maintain municipal police forces, which are also heavily involved in drug law enforcement.
Federal laws outlawing the sale and possession of cocaine, opium, and heroin, were passed shortly before the first world war; marijuana was outlawed in 1923. By the late 1920s, Canadian drug laws had assumed their modern form, although there has been a succession of minor revisions (Giffen, Endicott, & Lambert, 1991). Currently, the two chief laws regulating drugs are the Narcotic Control Act and the Food and Drugs Act. The first of these laws contains the provisions which apply to cocaine, which it defines as a "narcotic". Canadian law provides harsh penalties for the production, distribution, and possession of cocaine and a large number of other drugs, and accord fully with United Nations conventions on drugs. In fact, Canada has been widely regarded as having one of the harshest sets of drug laws among the developed countries (Smart, 1983, chap. 8; Solomon & Usprich, 1991). Although Canadian drug laws are not enforced with the same fury and relish as in the neighbouring United States, Canada has a high rate of drug prosecution by international standards (Erickson, 1992).
Long-standing laws banning production, distribution, and possession of drugs have been augmented in recent years with new legislation outlawing the sale of drug paraphernalia and drug literature and providing for the seizure of assets of those accused of drug trafficking. A new federal drug law (Bill C-18) currently before parliament shows no inclination to liberalization but, rather, consolidates and strengthens existing laws and modernizes some archaic language in the older statutes (Fischer, 1994)
Interviewers. Funds provided by the British Columbia Ministry of Health supplemented the WHO research grant, enabling the Chief Investigator to hire four interviewers to recruit and interview informants, and enter the data into computer files. One of these interviewers was hired to provide technical computer support also. All four interviewers were known to the Chief Investigator through their work at Simon Fraser University; all had completed at least a B.A. degree. They were chosen on the basis of their diversity as well as their abilities: There were two males, two females; two with little or no past use of illicit drugs, two with some experience; two who expect to continue academic training in psychology and two with other interests. Each interviewer contributed at least 13 usable interviews; each had other interviews that were not included in the study because the interview could not be completed to their satisfaction or the informant's knowledge of cocaine use in B.C. proved too limited.
Timeframe. Training sessions involving the four interviewers and the Chief Investigator began in the summer of 1993 with a series of interviews conducted in observation rooms. Interviewers observed each other's interviews through one-way glass. In the subsequent data collection phase, arrangements were made so that the Chief Investigator was able to observe or hear at least one "keeper" interview by three of the four interviewers. All interviews were completed in the late summer and fall of 1993 and all data were entered in the computer by the end of January, 1994. Data analysis began immediately thereafter.
"Consultants". Sixty consultants, the larger number of whom were cocaine users, were recruited through personal and professional contacts, through advertisements placed in local newspapers and radio, and through notices posted in public places. A few consultants were located by "snowball" methods, but the largest "snowball" yielded only 3 consultants. Some users and intermediaries were paid for their time (generally $15), but most participated gratis, or were treated to a beverage or snack while being interviewed.
Throughout the study, the emphasis was on finding the greatest diversity of consultants. By the end of the study, when there was a surplus of consultants available to be interviewed, choices were aimed at maximizing diversity with respect to type of cocaine use, location in the province, and socioeconomic status. The emphasis on diversity enabled the collection of a data set that should provide maximum information about the range of cocaine experiences in British Columbia.
Questionnaire. The original order of questions on the WHO questionnaire was modified after pilot testing. The questions concerning the users the consultant knew best were moved to the front of the questionnaire and some questions were combined to minimize redundancy. The consultants felt most comfortable and knowledgeable discussing the cocaine users about whom they had direct knowledge, so these sections produced a wealth of detailed information. Subsequent discussions with other sites in the Western Hemisphere revealed that many had modified the order of questions for similar reasons. Although all questions in the original form of the interview were retained in the modified form, the questions concerning the larger population of cocaine users were sometimes answered hastily or omitted when interviews became excessively long.
Interviews. The setting in which interviews were conducted varied, depending on the desires of the informant and the available facilities. Interviews occurred in offices, parks, cocktail bars, and consultants' homes. No interviews were conducted by telephone. Only one interviewer, and usually only one consultant, were present at each interview. Consultants were generally relaxed and interested, although a number of consultants stressed their concerns about confidentiality. Most consultants were not particularly concerned about being paid, but viewed their participation as an opportunity to contribute information on a topic that was important to them. Interviews ranged in length from 90 to 200 minutes, with the larger number of interviews being towards the longer end of this dimension. Some interviews required more than one meeting between interviewer and consultant. Nearly a third of the interviews were tape recorded.
Data. Each interview was entered into a computer file by the interviewer who conducted it. The tape recorded interviews were entered as transcripts of the conversation, others as the interviewers' paraphrasing of the consultants' responses.
Analysis. The interviews were subjected to qualitative analysis. For the most part this entailed scanning and re-scanning the computer files, gradually developing generalizations, and illustrating generalizations with short quotations from the interviews. In later stages of the writing, it became possible to rely on the NUDIST software. The NUDIST software made it possible to have immediate access at the computer to all the responses to any single questionnaire probe, or all the answers to any question that included a particular key word or phrase. This capability proved to be extremely useful because of the sheer bulk of information contained in the 60 interviews, and may become more useful still as the analysis proceeds from this generalized report into smaller summaries written for publication.
Authors. The authors of this report are the four interviewers and the Chief Investigator.
2. Consultant Details:
The breakdown of the consultants, according to gender and their type of experience with cocaine users (users, ex-users, intermediaries, and professionals) appears in Table 1. As Table 1 shows, it was impossible to unambiguously assign 10 of the 60 consultants to only one of the four basic consultant types.
Table 1. Types of Consultants.
60 Consultants total
24 current cocaine users
14 recent cocaine users, currently abstinent
The age range of the consultants was 17-73. (The 73-year-old was a professional; the oldest user was 60). All consultants spoke English well, and all interviews were conducted in English. Beyond this, generalizations about consultants are difficult. They covered the full range of possibilities with respect to experience with cocaine, socioeconomic status, and other demographic variables. A sense of the diversity can be found in Attachment 2, which summarizes some characteristics of each consultant, including the number of days during which cocaine was used during the last 12 months and during his or her lifetime. For those consultants who were users or ex-users, cocaine use extended from 2 persons who had used only once in their lives to several persons, on the other extreme, who had used almost daily for several years, and were continuing to do so at the time of the interview. Attachment 2 also summarizes some characteristics of the group of users that each consultant knew best.
3. Patterns of Cocaine and Other Drug Use:
I. General Population of Users in British Columbia:
The consultants typically found it difficult to answer questions about the general population of users in British Columbia. Some preferred not to respond to this part of the interview at all, because they felt their knowledge was inadequate. This seemed reasonable to the interviewers, because extrapolation of official estimates would suggest that over 300,000 British Columbians, spread over almost 1,000,000 square kilometers, have used cocaine at least once in their lives (Co-ordinated Law Enforcement Unit, 1987).
According to those consultants who were willing to comment on the cocaine-using population of British Columbia as a whole, cocaine use occurs in all parts of the province, and cocaine users are found in all age groups (except the very young), both sexes, all socioeconomic classes, all occupations, all education levels, all ethnic backgrounds, all sexual preferences, all marital statuses and all religious affiliations. The data from the users known best to the consultants, described in the next section, supported these generalizations. The consultants who were willing to comment on the cocaine-using population as a whole offered little information on the early history of users in general, again from lack of knowledge. These consultants offered differing views on future trends, some seeing cocaine use as a growing practice and others seeing it as stable or in decline now that it is no longer fashionable. Although these consultants generally agreed that cocaine is used by people in every demographic category, they differed on the number of people that were involved, some describing cocaine use as widespread, and others describing it as relatively rare.
II. Users Best Known to Consultants:
The bulk of this report focuses on the description by the consultants of the small number of users whom they felt they "knew best". A reasonable estimate would be that the users whom the consultants knew best comprised at least 600 current users, or an average of about 10 per consultant. In addition, 47 of the 60 consultants had used cocaine at some time in their lives and 28[i] were current users. Most of those consultants who had used cocaine spoke at length about their own cocaine use as well as that of the users they knew best. In almost all cases, the interviewers felt that the information about cocaine use was richly-detailed and credible. In this section, some generalizations are offered about the natural history of cocaine use as it was reported.
Demographics. The demographic data for the cocaine users whom the consultants knew best, including the 47 consultants who themselves used or had used cocaine, are included in Attachment 2, which comprises a brief summary of each interview. The users covered the full range of demographic possibilities with respect to age (the youngest having been introduced to "crack" by her father at age 14), gender, socioeconomic status, education, occupation, geographical location, ethnicity (native white, native Indian, native Chinese, Asian immigrant, European immigrant, South American immigrant, etc.), sexual preference, treatment experience, and criminal history. The financial status of cocaine users ranged from destitution to a comfortable upper middle class status.
Contrary to the prevalent image of cocaine use as a big-city phenomenon*, cocaine users appear to be about equally represented in the city, suburban, rural, and small town areas of British Columbia. Although the geographic spread cannot be proven with the data from the Key Informant study, since the consultants were deliberately selected to maximize variability, a large-scale survey study based on a random selection from voters lists of people from all sections of British Columbia reached the same conclusion. This important survey study, which will be referred to in this document as the "random sample survey", showed that cocaine use, on a per-capita basis, is quite homogeneous from North to South and between urban, suburban, and rural areas (Co-ordinated Law Enforcement Unit, 1987).
There was a discernible overrepresentation among the cocaine users of males and of people of both genders with criminal records. For consultants with criminal records, the common charges included: shoplifting, theft, prostitution, or drug offenses. Practicing members of organized religions were substantially under-represented, but not completely missing, among the consultants. Few of the users were actively involved in treatment or had been involved in treatment to a significant extent in the past.
Levels of Involvement with Cocaine. Because there was enormous diversity in the types of cocaine use described by the consultants in the Key Informant study, users were categorized according to "level of involvement", following a simple classificatory scheme developed by Jaffe (1990). The classificatory scheme enabled users to be classified as either experimental, circumstantial, recreational, dependent or addictive users, although many users had changed from one category to another at various times in their lives and many users belonged to different involvement categories with respect to various other drugs that they used. Jaffe's definitions, which were used in assigning users to these categories, are summarized in Attachment 3. Readers unfamiliar with this system of categories are urged to read Attachment 3 carefully, for it provides a basic set of definitions that will be followed consistently throughout this document.
All of Jaffe's involvement categories were represented among the consultants in this study*. Because the Key Informant study is not based on random sampling of cocaine users, it provides no indication of the relative prevalence of these involvement categories or of the relative frequency of change from one pattern to another. However, data from the random sample survey, described above, strongly indicate that experimental use is by far the most frequent mode of use in British Columbia, followed by recreational use. Among the approximately 11.2% of British Columbians who have used cocaine at least once, 56% had used it less than 10 times in their lives by the time of the interview, 36% had used it 10-99 times, and 8% had used it 100 times or more (Co-ordinated Law Enforcement Unit, 1987)[ii]. Dependent and addictive use would appear to be relatively rare among those who use or have used cocaine, since it is hard to conceive of a person being classified as a dependent or addictive user if they have used cocaine less than 100 times in their lives.
Although experimental use is very probably the most common form of use in British Columbia, this document is primarily focussed upon recreational and addictive users. This is in part because of the composition of the group of consultants that participated in the study, and in part because the experience of these two types of users can be used to illustrate the extremes of the spectrum of experience that can be found among people who would normally be considered "users" of cocaine.
Three patterns of change between levels of involvement were commonly reported by the consultants, and are referred to in this study as follows:
Pattern 1: Experimentation followed by consistent recreational use up to the time of the interview. In some cases that pattern had persisted for decades. In pattern one, there is a tendency to slight decreases in cocaine use over time, but not to abstinence.
Pattern 2: Experimentation followed by recreational use for a period of a few months or a year followed by dependent or addictive use that remained consistent until the time of the interview. The drug intake of people in pattern 2 was occasionally interrupted by sickness, shortage of money, or jail, but the addictive lifestyle remained constant.
Pattern 3: Experimentation followed by recreational use for a period of a few months or a year followed by dependent or addictive use for a year or two followed by reversion to recreational use or abstinence.
Regardless of their level of involvement, or their pattern of change of involvement, a person who uses a significant amount of cocaine may be classified either as a "regular" or a "binge" user. Binge use implies periods of relatively concentrated use interspersed with periods of abstinence. It does not necessarily imply consumption of huge amounts of cocaine--Some binge users consume relatively moderate amounts. Binge users differ from regular circumstantial, recreational, dependent, and addicted users in terms of the duality of their lifestyle. Addicted binge users, for example, alternate between being apparently "average" citizens, with jobs and traditional responsibilities, and being overwhelmingly involved with cocaine-using rituals and the values of drug-using groups (Matthews, 1992)
The "level-of-involvement" and "regular/binge" classificatory schemes provided a basis for analysis of other aspects of the data throughout this document. For example, whereas several very different forms of cocaine administration are described in the following section, the array is rendered more comprehensible by the fact that some forms of administration were typical of experimental and recreational users, whereas other forms of administration were typical of dependent and addictive users. Likewise, some forms of administration were also more likely to be undertaken by binge users than by regular cocaine users.
Forms of Cocaine. Powdered cocaine hydrochloride (Cocaine HCl) was by far the most common form of cocaine available in British Columbia. It was sometimes "snorted" and sometimes rolled up with marijuana or tobacco to be smoked. Cocaine HCl was also sometimes dissolved in water and injected. Cocaine HCl was sometimes converted by users into uot;freebase" or "crack" cocaine and smoked, in a pipe or a pop can. Cocaine was rarely purchased in the form of crack in British Columbia.
Although there were numerous exceptions, experimental and recreational users generally snorted cocaine HCl or smoked it in a cigarette with marijuana and tobacco; dependent and addicted users generally smoked cocaine as freebase or crack, or injected it. The addicts who were the most intensely involved with cocaine generally injected it. Binge users were more likely to smoke cocaine as crack or freebase than to use other modes of administration.
Use of other Drugs. Virtually every cocaine user described by the consultants used one or more other drugs as well as cocaine. Often they used substantially greater quantities of another drug, and/or had a higher level of involvement with another drug, according to Jaffe's classification system. Although cocaine was the preferred drug for many of the users, a somewhat larger number of cocaine users described a different drug as their "drug of choice"*. The majority of recreational cocaine users also used alcohol, marijuana and tobacco. LSD use was confined almost exclusively to recreational cocaine users.
As well as alcohol, marijuana, and tobacco, most dependent and addicted cocaine users also consumed heroin, tranquilizers (e.g., Valium) and other drugs. Heroin and Valium were often used to aid in "coming down" following cocaine use or as an alternate, often preferred, drug of addiction. Many of the people who could validly be labelled as addicted to cocaine, could just as readily be labelled alcoholics, heroin addicts, or Valium addicts.
Group Aspects of Cocaine Use. The consultants described both solitary cocaine users and people who normally used cocaine with others. Among people who used cocaine with others, there were at least 4 types of groups: 1) stable friendship groups, where cocaine use was a central component of their interactions, 2) loose networks, which were centered on cocaine use and had no other apparent function, 3) stable friendship groups, where cocaine use was incidental to other more important activities, and 4) loose social networks, in which cocaine use occurred at times, but did not figure prominently.
Recreational cocaine use was most often a social activity, which occurred both within stable social groups and loose networks of acquaintances in which cocaine did not play a central role. Recreational users came together primarily for the group interaction, not for the cocaine itself. Sometimes cocaine use was described as an occasional activity of a group that got together for more serious consumption of other drugs, such as alcohol or marijuana. From two recreational snorters:
From a 41-year old recreational user:
"[The consultant] used to do it alone but now does it with a few select friends. He has changed because he realizes that cocaine serves a social function. It facilitates discussions and make a person more at ease, somewhat like how alcohol is used--but better." (Linda08)
"Their friendships extend beyond the use of cocaine. Very little of the interaction between these people was based on the use of cocaine." (Bryan11)
"[Cocaine is] always done with other people who were good friends.... Approximately 1% of the contact amongst these people would have involved cocaine use." (Bryan12)
"Recreational use of cocaine and the socializing that goes along with it are very positive." (Gary03)
From a casual recreational user, describing other recreational users, who comprise a loose network:
"Cocaine is most often consumed in social settings.... They are acquaintances, but not friends.... New users replace those who quit. The new ones do not differ in significant ways from those who quit." (Bryan13)
From a recreational user:
"It is used with friends, just other people who use, or alone. For example, if you're in a social situation with friends, then you do it with friends. If you're at a nightclub or something, where lots of people are doing it, you could do it in the bathroom with them in there, as well. Or, if you come home after a hard day at work, you might want to do it by yourself." (Linda02)
Addictive cocaine use, particularly when it involved injection, was most likely to be undertaken in solitude. Several addicted consultants reported that their use became gradually more solitary as their level of involvement with cocaine increased.
From a professional describing intravenous addicts:
"Originally, their cocaine use was a social activity. Now they use alone.... These users are, for the most part, loners." (Gary02)
From a former intravenous cocaine and heroin addict:
"At first its a social thing. But as you get further down the line, you move to being alone when you use. You seem to be in your own world." (Lisa04)
From a 40-year-old former addict, describing addicts he knows currently:
"...they used to do cocaine only with others in a social setting but now it has progressed to more of an isolated activity." (Linda09)
On the other hand, there are some stable groups of addicted users, generally smokers of freebase or crack. An intensive study of a cocaine-centered friendship group of addicts in British Columbia has been reported previously (Matthews and Alexander, 1993).
From an ex-addict who is now a drug counsellor:
"There was a group of people I really liked using with--I thought they were absolutely perfect human beings. More getting close to God again, for all of us. Great discussions--we were all very close to our 'Master's degrees in [drug and life] Philosophy,' and if we didn't know, it would come to use. One more line, and we'll have the answer to the meaning of life." (Lisa13)
From a 21-year-old bartender who is part of a group in which cocaine use is a requirement for membership:
"They have been a group for seven years... there is a core of about 10-12.... [They party together and] have two semi-annual camping trips.... [They look at themselves as] anti-establishment and anarchists." (Lisa08)
From a former cocaine addict and hoodlum:
"They would consider themselves a family, a very tight family. Probably because of the amount that's being moved and there's always big quantities of cash. Why I say a family, is because everyone knew everything about each other. If I'd started using too much or started using downers, they'd walk right in and kick the hell out of me and sober me up and put me back to work. There would be nothing I could say or do about it. Just accept it, take the beating, whatever. There are a lot of rules. If you get popped for a bunch of stuff, you take the bust regardless of how much is there. They would take care of you on the inside [in jail], slide you money, whatever. They were very, very tight. You just couldn't walk in; if they don't know you, you'd get your head kicked in." (Lisa18)
Other groups of addicted users comprised loose networks, in which people used with various other people sporadically. Their interactions centered on cocaine use and had no other apparent function. In some of these cocaine-centered networks, it was common for people to deny being "friends" with the other group members. A drug counsellor, describing users in a correctional facility reported:
"[They had] superficial friendships (no intimacy) based on drug use.... Some kept their same circle over time; others either dropped out or hooked up with other users." (Bryan09)
From a cocaine dealer, describing her clients:
"Rarely will a baser use alone. Cocaine is usually used with users who are acquaintances, but not friends, in groups of 2-4 people. They rarely talk to each other during the session. They want to have other users around them for a sense of security if something should go wrong.... He doesn't think the basers can form friendships." (Gary06)
From a drug counsellor and former user:
"They have their own little subculture where they may have nothing in common other than cocaine. When they actively seek out cocaine they are also seeking out other users." (Linda03)
From an addicted IV user:
"It's like a group. With coke, everybody knows everybody. It's related to who you get your cocaine from.... People come and go." (Lisa01)
From a binge addict, describing other binge addicts:
"Their association is based solely on the abuse of alcohol and cocaine. It is the abuse of these drugs that is the common bond among the group members." (Bryan08)
From an addicted freebase user:
"They are acquainted. Most people who are into drugs don't consider other druggies friends.... People come and go." (Lisa05)
From a former addict:
"I would never call them friends--they are acquaintances. They are people that you would use to get what you want and they're using you for the same thing." (Lisa15)
Motivations for Initial Use of Cocaine. Cocaine users were always introduced to cocaine by someone they knew, usually at a party or other social gathering. Snorting was the typical mode of first administration. Consultants generally offered little by way of explanation for their own initial use or the initial use of others they knew well. The authors were left with the impression that initial use of cocaine does not require any special explanation beyond the fact that people often experiment with activities that seem to promise pleasure, and that for many people such experiments are not strictly limited by legality--indeed illegality may provide a bit of extra spice for the adventure for some people, especially when the risk of arrest appears to be negligible. For such people, experimental use of cocaine probably belongs in the same category with experiments in unorthodox sexuality, fast driving, acrobatic skiing, or reckless spending.
Motivations for Continued Use. The "involvement categories" that are listed in Attachment 3 implicitly identify a range of motivations for continued use, each of which is identified with a pattern of use. All of these motivations and the associated pattern of use were found among some users in the Key Informant study. Some of the users, of course, fit more than one of the involvement categories. For example, one heavy recreational user reported using cocaine recreationally at night to enhance his "partying" and on the following morning to be able to meet the demands of his job in spite of somewhat his somewhat weakened condition. In general, circumstantial use was motivated by a intermittent need to perform up to a satisfactory level at work or school. Recreational use served to enhance the users' social relationships and enjoyment of life, although a few recreational users also mentioned social pressure as a reason for their continued use. Dependent use served to help people to "keep going" on a regular basis. Addictive use was described by users and professionals primarily as a way of coping with despair, boredom, guilt, and depression. A few professionals described continuing use as the involuntary result of "addiction" produced by previous exposure to cocaine. (Some statements by both addicts and professionals were ambiguous, and might have been interpreted either way).
Some of the statements that identified despair, boredom, guilt, and depression as the primary motivation for addictive use appear below, followed by some professionals' identification of addiction as an involuntary result of previous exposure to cocaine:
From a professional working in a shelter for destitute addicts and other street people:
"The main reason this informant believes these people use cocaine is an all-encompassing sense of hopelessness. They have no direction or plans for the future, and feel that they have no other options." (Gary02)
From a former regular user, associated with a group of 80% addicts:
"It made you believe that you were important. It gave you a life. It gave you something to do everyday." (Lisa15)
From a female cocaine dealer and intravenous cocaine addict:
"She felt that at least part of the motivation to first use cocaine had, from the beginning, been motivated by depression." (Bryan15)
From a casual recreational user:
"Only people with a dysfunctional life will get into trouble. They use cocaine to make themselves feel better and may come to rely on it to do this." (Bryan13)
From an intravenous addict from a poor area of Vancouver:
"For a lawyer working in an office, he might use it to enhance himself, to make himself a little sharper, whereas, the person on the street, who doesn't have a whole lot, he's on welfare, and while he's doing this nothing really matters. It makes him feel happy for a while." (Lisa01)
From an ex-user who has friend who are recreational users and friends who are addicts:
"Occasional users use cocaine for the pleasurable effects. Cocaine makes you happy , care free, and is enhancing socially. Heavy users have an inability to think clearly about emotional issues and fear dealing with guilt. They have problems connecting up emotionally with others and lack a sense of belonging. They use cocaine to relieve psychological pain." (Gary08)
From a professional therapist:
"The consultant says they continue [addictive use] because it becomes a habit. They let it become a distraction in their lives. The consultant does not acknowledge other problems in the users life which contribute to continued cocaine use. They use the cocaine first, then the problems occur. Even if there are other problems in life that are not cocaine related, they cannot be addressed without getting rid of the cocaine. He never thinks that dealing with other problems may be the solution." (Linda03)
From a professional who worked with female prostitutes in Vancouver:
"...the informant felt that a "profoundly" low sense of self image resulting from physical or psychological abuse was a common denominator among the users he was describing. He did not however feel that the low self image led to drug abuse. Rather, in his view the low self image led only to the circumstances in which drug use was initiated. Specifically he saw these abused children as leaving their families in their teens and ending up in the downtown area congregating with a group of teens and young adults with similar life experience. One aspect of this new environment is drugs and because they are their these teens are initiated into use and continue on into addiction. Hence the key to addiction is in preventing abuse because it propels individuals into circumstances which encourages initiation into drug use which leads inevitably to addiction." (Bryan03)
Changes in Use over Time. Recreational users generally did not experience escalating involvement with cocaine use over time. Both of the following descriptions of changes in use over time come from observations of recreational users:
[Cocaine use was] "an insignificant part of his life which had become even less significant in recent times." (Bryan04)
"It is the minority case that goes onto heavier use... Most people keep it to causal recreational use. They won't turn it down if it is available at a party but they don't go looking for it either." (Bryan11)
A professional who is part of a group of professionals who use cocaine recreationally:
"This group has used less frequently over time." (Gary04)
Addicted users, by contrast, began with occasional use and increased the frequency and quantity of their cocaine consumption dramatically over time. This was almost invariably a gradual process--There was little support in the British Columbia data for the contention that cocaine, in any form, including crack, was "instantly addicting"*. For example, from a childcare worker familiar with IV cocaine-addicted prostitutes:
"Their frequency and amount of use increased over time. However, it doesn't happen overnight. Took approximately 6 months." (Bryan07)
From a 25-year-old recreational user, describing a group of polydrug addicts:
"Use was occasional at first. Then it increased in use until their current levels. The female in the group was the exception, she started using heavy right away." (Gary12)
The following was one of the rare exceptions, in which the consultant, a former addict, suggested something like "instant addiction":
"That old saying that 'one hit and you're done, that's true--you're addicted from your first hit [of freebase cocaine]." (Lisa02)
Increasing use of cocaine is often accompanied by a progression in mode of administration from snorting, to freebasing and, sometimes, to injecting. For example, from a formerly addicted drug counsellor:
"They started off snorting or smoking the cocaine, then there was a shift to injecting the coke." (Gary09)
From an addicted post-secondary student:
"They started out doing lines and smoking it in cigarettes and then moved to freebasing." (Linda10)
From a recreational users describing a group of polydrug addicts:
"They all started out snorting cocaine. After awhile they began freebasing. Two users eventually became IV users." (Gary12)
From a ex-addict treatment professional, working in corrections:
"Generally move from snorting to basing to (for some) booting.... [although] It doesn't always happen that way." (Lisa13)
Several consultants who discussed increasing use of cocaine, reported a heavy involvement of limited duration, followed by a return to recreational use*. For example:
"The informant used cocaine twice a year at a party for the first 5 years of cocaine use. He said that he was quite comfortable with life and where he was going during this time period. The informant then started using cocaine on a regular basis, twice a week. He used cocaine heavily for about a year, and then went back to being an occasional user." (Gary03)
A 28-year-old female recreational user:
"For awhile use increased. Then she got in with a new group of friends who didn't use and she drifted out of use." (Bryan13)
From a recreational user and mother of a teenage son:
"People start off using infrequently, then they become frequent users, and then periodically alternate between the two." (Gary07)
From a regular, binge user of cocaine, who is part of a group that uses marijuana and alcohol heavily:
"These users used larger amounts [of cocaine] in the past... Some people grew out of it... Some use more of other drugs." (Gary10)
From a 42-year-old former user:
"...he has gone through a dramatic change in pattern of use from casual use, to heavy use, to casual, to abstinence." (Linda06)
From an intermediary, describing a group of men who had been dependently or addictively involved with cocaine:
"They used to use daily but had decreased to at most once a month." (Linda07)
From a judge, describing a group of addicts and recreational users with whom he socializes:
"There has been an overall decrease in cocaine use by all of the people [that the consultant] refers to." (Linda12)
4. Availability of Cocaine:
I. Cocaine Compared to other Drugs:
All the users reported that cocaine was easy to obtain in British Columbia. For the majority of users, a phone call or visit to a dealer's home was all that was required. Some users had the cocaine delivered to their home by the dealer. Cocaine was generally viewed as neither easier nor more difficult to get than other illegal drugs. Cocaine was generally purchased as powdered Cocaine hydrochloride, rarely as crack or freebase. Only a few users saw the process of obtaining cocaine as dangerous. The two risks mentioned occasionally were being "ripped off" and being arrested.
II. Distribution/Underground Scene:
For recreational users, cocaine was almost exclusively purchased from friends, using money earned from working, or was shared, without cost, among friends or at a party. Some recreational users never paid for cocaine, but always had it provided by friends:
From a recreational user's description of a recreational cocaine-using group:
"Within the group one person on a given occasion would have cocaine and that would be their contribution to the activity of the day or evening. To that extent it was a gift to the other people present. That person would have paid cash to get it." (Bryan12)
From another recreational user:
"The informant said that the cocaine was never directly acquired by himself or many of the users he was familiar with. It was not sold to himself or these users. Rather it was given. Someone at a social event would say they had some and a group would share. Use would usually be initiated in a washroom or bedroom. Not all individuals present at these gatherings used any cocaine."(Bryan04)
Addicted users who maintained a degree of social integration usually purchased cocaine from dealers whom they knew well. They were often "fronted" cocaine, on credit. It was only the destitute, socially-excluded addicts who regularly bought cocaine from anonymous dealers on the street or in "shooting galleries": From a drug counsellor working in a male correctional institution:
"These users were not out on the street "hustling" to find cocaine. They generally get their cocaine from friends or from dealers who are well-known to them. He described the process of cocaine distribution as an informal network among people who know each other." (Bryan09)
From a social services worker, familiar with street prostitutes:
"Cocaine is almost always bought with cash. If they are known to the dealer, they may get some credit." (Bryan07)
From a former freebase addict:
[Cocaine is] bought with money. I lived in a small town and it was fronted to me many times." (Lisa15)
A former heroin and cocaine intravenous addict, describing a "shooting gallery" he ran with a friend:
"We had a place with three rooms; my partner stayed on one side and I stayed on the other. One room was strictly for buying, the other was for going and shooting. I would hand out the dope. I had a system where I pushed a button and they would send over three or four [flaps]--I had a little shoot right through the wall. The money would go right back through. You would come in and you would buy your drugs and if you wanted to shoot there you would pay five dollars to go in the other room and do your thing. It was 24 hours a day. You see all kinds of people coming in. It was strange; it was wild. We went through a lot of bullshit setting up a security system. We had cameras and an intercom system set at maximum so that I could hear if someone came in our back gate." (Lisa04)
Like recreational users, addicts generally paid for cocaine with cash, but the money was as likely to come from selling stolen goods or from prostitution as from employment. Property and sex were rarely traded directly for cocaine, although some female users, usually addicts, provided sex to men who provided them with cocaine, generally without the transaction being explicitly recognized as an exchange of cocaine for sex. A female addict described two rare instances of direct exchange of sex for cocaine:
"Cocaine is mainly exchanged for money. When [the consultant] was using she would get it for free. Cocaine may occasionally be exchanged for stolen goods or personal goods. In some instances a person would give their car up, a leather coat or expensive jacket just for 1 gram of cocaine. The 33 year old gay man may perform oral sex in exchange for cocaine. The consultant knew of a female who is not mentioned in the interview until now who would perform oral sex to get her cocaine." (Linda10)
From a formerly-addicted freebase user, who was part of the cocaine "glamour" crowd:
With the dealers, if the dealer wants somebody [sexually] and you're getting high, it just sort of happens. It's not like a trade, you're just partying and you end up staying there. Everyone leaves and what happens, happens." (Lisa02)
From a 22-year-old ex-recreational user:
"Usually it is strictly financial, [but] there are a couple of girls who will get involved with the dealers physically for [the cocaine]." (Lisa12)
From a freebase addict, living on the street:
"The group buys with money, no sex involved. But I know it happens.... The money comes from jobs, from scamming, or from dealing the drug." (Lisa03)
From an ex-dealer, describing his addicted freebase clients:
"Cocaine is always bought with money. Many in the group make good money and are able to afford it. Others get their money from theft." (Gary06)
From a former street addict and sometimes hoodlum:
"When I was low on funds I would steal tools. I was not above violence when I was using. My favourite was to hang around and grab the little spics, shake 'em up and make them empty their pockets [take their drugs], and they would. I don't do that any more... We used to buy [and sell] ID. I was always good for [stolen] pagers and cellular phones." (Lisa18)
From a physician who has contact with street people:
"Most of the cocaine would have been bought with the proceeds of prostitution or shop lifting." (Bryan03)
From a regular user who freebases 3-4 times per week:
"Bought with money, exchanged. Most dealers have closets full of stereos." (Lisa05)
III. Cocaine Production or Manufacturing:
None of the informants from Vancouver offered any information on cocaine being produced or manufactured in B.C. In fact, the absence of direct knowledge about where cocaine came from (apart from a friend or local dealer) was almost unanimous. The one exception was a Vancouver user who had worked for a time with a group of wholesale level dealers that was run by people from Montreal (Lisa18). This lack of knowledge about the source of cocaine may of course reflect an unwillingness of the consultants to give away secrets to the interviewers, but it was the interviewers' feeling that the consultants simply didn't know where their cocaine came from, and were not particularly interested in speculating about that topic.
Users outside of Vancouver often had a clearer idea about where cocaine came from--Vancouver. The continual movement of people from the interior of the province to and from the Vancouver metropolitan area not only serves to spread urban Western-English-Canadian culture throughout the sparsely settled areas of the province, it also serves as a natural base for distributing cocaine. Some of this cocaine traffic is incidental to the normal flow of people going about their business and visiting their friends and families, but some trips to the Vancouver area are specifically arranged to maintain or replenish the cocaine supply in an interior town or city.
5. Consequences of Cocaine Use:
The consequences of cocaine use are difficult to describe in a compact way because they varied greatly between users, because they sometimes changed dramatically over time, and because many aspects of cocaine addict's life style may or may not be considered consequences of cocaine use, depending on the reader's implicit theory of cocaine addiction. Some readers may presume that the use of cocaine eventually causes people to become addicted and that addiction requires a deviant and violent lifestyle. Other, like the authors of this document, are more inclined to assume that people who are addicted to cocaine choose cocaine voluntarily and may also choose from a variety of lifestyles that are open to cocaine users. If this is so, lifestyle is not a "consequence" of cocaine use (see Alexander, 1990, chap 5; Alexander, 1994). To maintain neutrality on this theoretical issue, some lifestyles of cocaine addicts will be described in this section without speculation on whether or not they are a "consequence" of cocaine use.
Thus, this section on consequences of cocaine use is organized into 4 subsections:
I. Acute effects of cocaine on users
II. Long term and indirect effects of cocaine on users
III. The life-styles of cocaine addicts in British Columbia
IV. Key Informant's cost-benefit analyses of cocaine use.
Some of the extreme diversity of consequences that were reported can be understood with reference to a rough correspondence between the kind of consequences that were described and the user's level of involvement. Experimental and casual recreational users generally, but not invariably, described the consequences of cocaine use as positive. This appeared to be true of recreational users who fit Patterns 1, 2, and 3 (see above). Addicts, and ex-addicts who were currently abstaining generally, but not invariably, described the consequences of cocaine use in extremely negative terms, although they often described more positive consequences that they had experienced earlier in their cocaine using careers. In the following sections, some of the most frequently-mentioned consequences are discussed.
I. Acute Effects of Cocaine on Users:
Acute effects are those that immediately follow the ingestion of a drug, regardless of whether the user is a short-term or a long-term user. This section will list some frequently mentioned acute affects, some ways in which acute effects differ in various types of users, and some of the changes in acute effects as types of use change.
Euphoria and Dysphoria. Some users of all types experienced a powerful euphoria after using cocaine. In some cases this euphoria was described in mundane terms, but in other cases it was described in extravagantly positive terms as enhanced clarity of vision, a sense of heightened self esteem, and an exalted sense of personal power. The following descriptions of euphoria came from recreational users:
"Hyperactivity, exhilaration, talkativeness, stimulates dopamines, new ideas and enhances IQ." (Lisa05)
"The consultant continues to use cocaine because the effects are extremely "seductive". It is an easy way to relax inhibitions, and to feel closer to other people. It also produces a euphoric effect which is very appealing." (Linda08)
There was no consistent tendency for the euphoria reported by continuing (Pattern 1) recreational users to decrease or increase over time, although some recreational users found themselves losing interest and using less over time. Some recreational users moved into patterns of dependent or addictive use. It was less common for addicted users (Patterns 2, and 3) to speak of euphoria as an effect of cocaine use, but several of them did. The following comparison comes from a 44-year-old male who had given up wife, family, savings, and a settled middle class existence for a lifestyle of cocaine addiction that he had shared with a young woman until his money was gone. When the money and the young woman did eventually run out, the man continued to be an occasional cocaine user, supporting himself as a day labourer. In retrospect, he still described the cocaine euphoria of his addicted days in compelling terms:
"He loved the experience of using cocaine. Got into it because coke was so good; even better than the girl." (Bryan14).
From a binge addict:
"Cocaine made you feel like nothing could harm you.... Cocaine made you feel good in a way you couldn't get from any other drug or experience any other way." (Bryan08)
More commonly, addicts and ex-addicts spoke of a past euphoria that had grown increasingly difficult or impossible to re-create.
"It's expensive because you're always chasing that first one [toke/fix], but you can't ever reach it." (Lisa01)
From a current addict, describing other addicts that he associates with:
"I think they're always looking for the first rush, but they never get it." (Lisa03)
From a professional describing a group of male and female prostitutes and drug addicts:
"These users often reminisce about the "rushes" they got when they first started using." (Bryan07)
From a former addict and current treatment professional, working in a prison:
"A lot of chronic users reach a point where they are not ever able to achieve what they achieved early on in their use and they're always working towards trying to achieve it. Chronic users, those using every day, are never able to achieve that ultimate high." (Lisa13)
Some addicts and ex-addicts describe the effects of cocaine in terms of clear-cut dysphoria bordering on disgust. The following quote comes from a freebase addict:
"...the high is pathetic--it sucks. You can't relax because your ears are really sensitive and you hear every noise." (Lisa03)
For several addicted users, it was the ritualized nature of their cocaine use, rather than the direct psychopharmacological effects of cocaine, which imparted the most euphoric aspects of the experience. For example, from a binge, dependent user:
[The ritual was] "the most pleasurable part about using cocaine. He called it "ritual excitement" and it involved: wondering if he could get some, how much he could get, seeing it being weighed, knowing he had it, getting in the car, driving and pulling over, indulging, etc." (Bryan05)
From an ex-freebase addict:
"Obtaining and using cocaine was a ritual which enhanced the effect of the cocaine. Ritual: the cutting, cooking and toking cycle. Watching the smoke curl in the pipe is very erotic. Just taking the toke is exciting. You take it, hold it, always trying to get the perfect toke.... He continued to use cocaine because "freebase coke was magic" and it filled a need in his life."(Bryan14)
Ambivalence. More common than clear-cut descriptions of euphoria or dysphoria were statements of ambivalence. The following comes from a casual recreational user attempting to list the effects of snorting cocaine at parties, among good friends:
"Sneezing, runny nose.
Heart rate picks up. Like what happens when you have MSG, your heart races.
Felt giddy, happy for awhile. But because you were in a great mood before you did the cocaine the cocaine could be said only to be enhancing your mood a little.
A short term euphoria but nothing profound. A free sense of euphoria, you hadn't worked for it.
Was like a flying dream, wonderful but not real.
Kept you awake and alert to 3 AM and beyond.
Like getting a really good bottle of champagne on sale. You really enjoy it and get on with your life.
Actually found it disappointing.
No more wonderful than a cold beer on a hot day.
Didn't like the act of putting something up your nose. Was akin to burping in public." (Bryan12).
From a recreational user of many years:
"There is peer pressure to continue use for [the consultant] and he doesn't particularly like the effects. He may happen to be with friends who initiate it and he doesn't want to not go along with the group if he uses." (Linda11).
Loss of Control and Enhanced Control. Descriptions of the acute effects of cocaine on the experience of "control" were inconsistent in every way. Yet, the vividness of many of the descriptions suggests that, once it is fully understood, the experience of gaining or losing control may prove to be of central importance in understanding the dynamics of cocaine use.
Many British Columbia users experienced a profound experience of "loss of control" that occurred after an episode of cocaine use began. Many used the phrase "loss of control", to describe the lifestyle of addiction to cocaine. Paradoxically, other users, although a smaller number, spoke of enhanced control*. The first description comes from a dependent binge user, describing a sense of losing control:
"What he dislikes most about it was a powerful sense that he was "out of control". Despite professing not to like the effects of the drug, he continued to use it. He sensed that none of what he was doing was really enjoyable and that because he was unable to control his behaviour in this context, the rest of his mature, adult, responsible behaviour was just a facade covering his real immaturity." (Bryan05)
From a social services worker, describing intravenous addicts:
"These users have gradually lost control over their cocaine use.... They are unable to control their intake of cocaine or other substances. This lack of control is related to a lack of meaning in their lives; they can't do what they feel they need to and use cocaine heavily..." (Gary02)
By contrast, from another social services worker, describing a group of male and female prostitutes:
"The popular perspective on these users' cocaine use is that it is "out of control". The informant did not share this perspective. These users were not in the informant's view using as much of the drug as they could. Rather, they were employing a good knowledge of themselves and the drug to construct an informal schedule of use, sleep, eating, and working that they could maintain without getting sick. From this perspective the informant felt that their drug use was "managed" rather than out of control." (Bryan07)
From a male recreational user describing a sense of enhanced control:
It makes you feel in total control of your own body/ability. The peak of experience is a feeling of invincibility and control of faculties mental and physical (Linda14).
From an intermediary's description of computer "hackers" who are dependent users of cocaine:
"Cocaine use gives them a self-styled romance and helps them to create their own mythology. cocaine use is part of a large lifestyle--video games, hacking and cocaine use give them a sense of individual power--you become the hero and save the universe. It gives them a feeling of being in control." (Gary04)
From an ex-addict (by Jaffe's definition), now living a stable lifestyle as a day labourer and recreational user:
"The informant stated he was not an addict and that his drug use was not out of control. He was adamant that his cocaine use was a choice that he had made--a "choice to live differently." (Bryan14)
From a former dealer, describing his free-base using, addicted clients:
"People are structured, controlled, users in the beginning. Gradually, they become out of control and spend all their money on the cocaine. Then they become controlled users again." (Gary06)
Work and Creativity. A number of users, primarily recreational users, indicated that the short-term effects of cocaine were useful in sustaining their energy for work or study, or for enhancing their creativity. For example:
From an intermediary/user describing a group of heavy cocaine users that work in the food service industry:
Most of the people in this group hold jobs. They will snort some cocaine to get themselves up from a party hangover in order to function on the job...They got more energy when they get to work. It actually helps. (Lisa08)
From a binge cocaine user, addicted to alcohol and marijuana:
"Cocaine use makes you more creative; you see things in a different light." (Gary10)
On the other hand, many users, particularly addicted and formerly addicted users, found that excessive use of cocaine impaired their ability to do their job properly, and led to their getting fired or reprimanded. This was particularly common in the descriptions of people who used heavily or addictively.
From a former user and dealer:
Destroys your interactiveness with other employees that don't do any drugs. Even the other employees who smoke dope you start segregating them because they are not doing coke. (Lisa 14).
From a description of an addict:
His use would keep him from holding down one job. He would loose his job in construction, use cocaine heavily until he ran out of money, find another job in construction, use cocaine heavily to the point where he would loose his job again because of his bad attendance or he would just quit. Eventually he sold all his tools so this took his livelihood away. (Linda06)
In addition to those reporting positive and negative effects of using cocaine at work, there were a considerable number of users who described cocaine use as having no appreciable effect on work or creativity. The best generalization that we can presently offer to encompass this pattern of contradictory results is that cocaine can be used to ameliorate difficult situations or it can be overused in a way that makes difficult situations worse.
Violence. An association between cocaine use and violence was strongly asserted by some of the British Columbia consultants and as strongly denied by others. In fact, when violence was described, some consultants indicated that the perpetrators were characteristically violent people, or that they were aggravated before the cocaine was ingested, and that placid people became more docile when they used cocaine. The following two conflicting statements both come from heavy users of cocaine, describing other heavy, addictive users:
"I've never seen people get violent as a result of using cocaine. It's exactly the opposite." (Lisa01)
It can bring out total aggression. When people are using it in a party situation, I have seen people being mad or getting into a fight outside of that, and because of it just be ballistic, far more than on anything else. Just ballistic. I've never seen anybody, you know how drunks will have a fight, I've never seen anybody [on alcohol] get into a fight like that. (Lisa02)
In the case of violence, as in many other consequences of cocaine use, there is a relationship between level of involvement and likelihood of the consequence. Although reports of cocaine induced violence primarily came from addicts and former addicts, there were other addicts and former addicts who did not see such a connection. It might well be the case that violence is set off in some people who are predisposed to it by cocaine, but that it is not induced in normally peaceable people. It would also appear to be the case that people whose violence is triggered by cocaine tend to blame the drug rather than their predisposing nature.
Paranoia. Reports of paranoia were relatively uncommon for British Columbia recreational users, although not completely unknown. Conversely, reports of paranoia were common for addicts and binge users, and seemed to constitute one of the major problems that cocaine created for them. For example, from a drug counsellor, working in a male correctional facility:
"Paranoia was often described as an effect of use. In some cases (generally heavier users) it was extreme (i.e., walking around the house with a loaded shotgun)." (Bryan09)
From a former freebase binge addict:
"If you've gotten into it long enough and hard enough you can have the narcosis. My friend, she would get to the point where you could see her eyes go, she would sit there with a knife or a baseball bat. My fear was that she wouldn't recognize me, because she would see things. I couldn't see them, but she could see them coming out of the floor. I would keep all the knives locked in the trunk of my car when she was there. I took everything out, even the peeler, the tweezers. There was nothing sharper than a spoon in the house and I had to sneak them out to the car because she was glued to me. I couldn't sleep until she went to sleep. You could see it on her face." (Lisa02)
From a casual, recreational snorter:
"Some mild paranoia. Just an uncomfortable feeling, disturbing but not overpowering." (Bryan12)
From a student, familiar with both recreational and addicted users:
"Using cocaine on a regular basis, or in sufficient quantities, makes you paranoid, confused." (Gary08)
Sexuality. Recreational use of cocaine was often associated with enhanced sexual experiences, both within stable relationships and more promiscuous lifestyles. Group sex was alluded to in some interviews. Addictive cocaine use, on the other hand, was very frequently associated with a lack of sexual ideation and behaviour.
From a description of a group of 35-45 year-old professionals, who use cocaine recreationally:
"...many say that cocaine use heightens their [sexual] experience." (Gary05)
From a recreational user:
"Yes, it makes you more sexually stimulated. It makes you feel more bold to pursue sexual activity." (Linda01)
From a male recreational user:
"It enhances. Get a hard-on forever." (Lisa14)
A bartender, familiar with regular cocaine binge addicts:
"[I] Occasionally explore homosexual aspects while under the influence of cocaine." (Lisa08)
From a former freebase addict:
"Some people say coke is an aphrodisiac, forget it. I hated it, don't touch me." (Lisa15)
From a drug counsellor, working in a male correctional facility:
"If anything, cocaine use decreased their sexual drive." (Bryan09)
From an intravenous addict:
"People who are using intravenously don't even think about sex while they're using... It can act as a stimulant for people who do it in lines." (Lisa01)
From a ex-operator of a Vancouver "shooting gallery":
"I know people who can't have sex unless they're high on cocaine." (Lisa04)
A number of recreational and addicted users reported that cocaine had no particular effect on their sexual experiences. For example, from a woman who snorted cocaine with good friends:
"Heard that it made you horny, but it didn't work as well as flowers." (Bryan12)
From a recreational user:
"One person used it as an aphrodisiac.... for the others, the consultant didn't think the use of cocaine altered their sexual practices." (Bryan11)
Among those Pattern 1 recreational users who found cocaine to be sexually stimulating, there was no indication that the effect either increased or decreased over the years. Pattern 2 and 3 users who became addicts, however, most often reported that cocaine ceased to be sexually stimulating or that it impaired sexual performance.
Insomnia. Both recreational users and addicts frequently mentioned difficulty sleeping after cocaine use. This sometimes was reported after relatively low doses. The addicted users often took Valium, alcohol, or smoked a marijuana "joint", nearing the conclusion of a cocaine-using session, to aid them in falling asleep.
From an occasional recreational user, who commonly shares one gram of cocaine with another person:
"The informant has problems sleeping after taking cocaine throughout the night." (Gary03)
From an occasional user:
"You don't really sleep, and if you do get to sleep, any little thing wakes you up." (Lisa14)
From a former freebase binge addict:
"You can't sleep, you yawn, but you really can't yawn. You have this horrible, empty kind of yawn.... Just before the last rock is done, you grab a few Valium and knock'em back before your last hit, because that way you're kind of coasting off. If you can't coast off, you just might try and figure out a way to get more." (Lisa02)
From an addicted freebase user:
"Harder to sleep when you've been basing than when you've been snorting.... Use Valium to take the edge off. Smoke marijuana." (Lisa03)
Nasal Damage. Sore sinuses were widely reported the day after snorting a moderate or large amount of cocaine. However there were no reports of serious damage to the nasal tissues.
From a recreational user:
"See some sniffing, bloody noses in a few people." (Bryan11)
"Craving"/"Coming down". "Cravings" for more cocaine were the exception among occasional recreational users who consumed small quantities. Cravings for other drugs sometimes figured more prominently in their experience. From an occasional user, describing a group of professionals who may consume 4-9 lines in an evening:
"The effects beginning to wane was not associated with any craving. You might choose to reuse then or you might not. May, therefore, be minutes or hours between applications. It is like deciding to go to the fridge to get another beer or not. Nothing more." (Bryan12)
From another recreational snorter:
"Within a 1/2 hour you start to notice the high is cycling down. Take more cocaine about an hour after last dose if more cocaine was available. If it wasn't available, no big deal. Never went out looking for more. Did on some occasions go out looking for more pot or booze." (Bryan13).
A social services worker, describing recreational users:
"When cocaine is wearing off, there is a mild depression, physical fatigue and lowered self-esteem. These effects are primarily prevalent when cocaine use is combined with other drugs in the same session." (Linda05)
By contrast, most people who used cocaine for extended episodes reported a strong dysphoria at the end of the session, accompanied by a powerful motivation to continue using cocaine. The first example comes from a binge addict:
"The major effect of cocaine for him was anticipating the drugs' wearing off and guarding against it. He felt panicky about the drug wearing off before he could inject more, even if there was a pile of it sitting right in front of him. He would eye the pile and felt that the less cocaine that was in the pile, the more he needed." (Bryan05)
From a childcare worker familiar with IV prostitutes:
"They actively avoid having the high wear off. Avoidance of this is important and is planned for. For example, syringes are pre-loaded in anticipation of need. Will use a dirty syringe, even if a clean one is available nearby, if going to get that syringe means a possible loss of the high." (Bryan07)
A former heroin and cocaine IV addict:
"What I think gives you the heart attacks is the Jonesin', the crawling around [looking for more cocaine], stressing yourself out. You see them--they're sweating like pigs." (Lisa04)
From another IV addict:
"Craving. Craving that comes on in waves. As soon as you started to come down you felt the craving for more cocaine." (Gary01)
From an ex-user drug therapist:
"The effects of wearing off are physical and mental fatigue, and depression. It leaves a general bad feeling as the cocaine effects wear out." (Linda03)
Overdose. Although unknown among experimental or recreational users described by the Key Informant consultants, overdose was a danger for heavy users of cocaine. When it occurred, it was described matter-of-factly. Sometimes cocaine-induced seizures and convulsions were referred to as "doing the chicken". IV users rarely did test injections to test the purity of the cocaine, which could have helped them avoid to avoid overdose. A former heroin and cocaine IV addict:
From an ex-addict who ran shooting gallery:
"They do not do a test injection." (Lisa04)
"Do the chicken from shooting, yeah. Once a buddy of mine, we were doing big boulders of about half a gram, he starts shaking. He was humming for about an hour. Scared himself." (Lisa03)
A professional talking about a jail population of addicted men:
"They described cocaine as making them stupid. They defined this as doing 'the chicken' and continuing to use." (Bryan09) "
From an ex-freebase binge addict:
"This one girl took a whack and they call it the chicken, she went into spasms right there... Over one summer I went to so many funerals, it seemed like one a week. It was terrible..." (Lisa02)
From an ex-addict, first introduced to crack cocaine as a teenager by her father:
"I was DOA [dead on arrival at the hospital] and they were putting on my 'toe tag' when I came to." (Lisa 15).
II. Long-term and Indirect Consequences of Cocaine Use:
Long-term consequences are those that have a delayed onset, and cannot be attributed to a particular dose of cocaine or episode of cocaine use. Thus, there could be long term consequences of cocaine use in an experimental user who had used only once, or in an addict who had used regularly over a period of years.
Virtually no long-term negative consequences of cocaine use were reported by experimental or recreational users, apart from the burden of expense produced by occasional reports of weight loss following relatively frequent recreational use. However, many long-term negative effects were associated with addictive and binge use. Some of these, like weight loss, were probably direct effects of cocaine itself. Others, like HIV infection, were effects of the mode of administration.
Weight loss. Some consultants reported significant weight loss among users at all levels of involvement apart from experimentation, but this was not particularly occurrence. Some recreational users saw the weight loss as a benefit.
From a physician describing addicted street people:
"The cocaine acts as an appetite suppressant, so many of these users are very thin from lack of eating." (Bryan03)
A description of a 6-member group, addicted to alcohol and marijuana, who are regular binge users of cocaine:
"When using cocaine, you don't eat properly. This could lead to health problems." (Gary10)
A social services worker, talking about male and female prostitutes, described things they liked about cocaine:
The fourth thing they liked was "Weight control. Use interferes with eating and so assists them in maintaining their weight." (Bryan07)
A former heroin and cocaine IV addict, living on the street:
"Weight loss--can be positive. Some people use cocaine to lose weight--more women than men." (Lisa04)
HIV and AIDS. Users were consistently described as fully aware of the dangers of HIV infection that are associated with unsterile needles and with unprotected, promiscuous sex. Generally speaking, experimental and recreational users took appropriate precautions. However, many of the addicted users took such precautions irregularly, or forgot them completely in the frenzy of drug use. Some consultants described how intravenous (IV) users may be careful at the beginning of a run, but not later. From a formerly addicted freebase binger, describing her past life in a drug and party group that centered its activities about an expensive marina:
"No, when you're high you don't give a shit. When you're that high on drugs you're above everything. AIDS happens to other people; I have this wall around me. The condom of life protects me." (Lisa02)
From a long-time addict and needle user:
"The informant used dirty needles in the past, and is now HIV positive." (Gary01)
From a male addict described the way he and his friend used cocaine together:
"We'd buy a box of 10 packs of 10 [needles] so we had lots. I'd mark mine my way, he'd mark his way and we'd put the cap back on them and throw them in this big garbage bin we had out back. Then, at about 2:00 in the morning, we're out digging in the garbage [for needles]. By then we'd even use water out of puddles on the street [to dissolve the cocaine]." (Lisa01)
From a former IV heroin and cocaine addict:
"80% of IV users will be very careful at the beginning, but about half of them will use whatever's available at the end of the session." (Lisa04)
There were some indications that the needle exchange in Vancouver, which provides clean needles, and condoms, was having some effect on decreasing the likelihood that needles would be shared and that unsafe sex would be practiced. For example, from a cocaine dealer who sells to addicts:
"About half these users will practice safe sex by wearing a condom. Most of the IV users are very careful in cleaning their needles before re-using them. They get clean needles from the drug store or a needle exchange." (Gary06)
From a social services worker, familiar with street addicts:
"All the prostitutes get condoms and use them." (Gary02)
However, one professional discussed an economic component to this problem:
"Often get paid more for not using a condom." (Bryan07)
The problem of HIV and cocaine has not been solved in British Columbia. Although the HIV infection rate among people who appear at the needle exchange has been low until recently, new data from Vancouver indicate that the rate of HIV infection amongst needle users has turned sharply upward and is now close to 7%.
Fetal Damage. Most regular users of cocaine, recreational users as well as addicts, had little interest in having children. When women did become pregnant however, many of them did not decrease or eliminate cocaine use. A doctor who specialized in treating pregnant drug users told the interviewer that a large number of babies are exposed to cocaine during pregnancy and that the effects of this exposure are often damaging to the neonate.
"The informant was able to observe some of these children for a number of years after they were born. Some seemed very normal. Others had attention deficits, violent tempers, learning and behavioural problems. These children were not, in the informants' view, diminished in intellectual capacity." (Bryan01)
A male IV street user who was familiar with many cocaine-addicted prostitutes stated:
"I think they try to have fewer children than people who don't use cocaine, because of their use and because they don't want the responsibility while they are carrying and when the child is born." (Lisa01)
"Track marks". Needle users often complain of unsightly "track marks" left in their arms by repeated injections, of collapsed veins, and of chronic skin infections. Even high levels of such damage were sometimes insufficient to deter continued addiction:
"Many [street addicts] had collapsed most of the viable veins for injection. One 15-year-old woman had only her breast veins intact, into which she was currently injecting." (Bryan03)
From a former addict who was introduced to freebase cocaine by her father:
"I haven't used in over a year and I have scars on my arms [from injecting] and all the way down my chest. I have veins that stick out on my chest." (Lisa15)
Lung Damage. Some of the cocaine smokers indicated that chronic use causes lung damage. For example:
"I've had sore lungs after a good session--throw up these black balls. We cooked one up once as a joke. Lung butt it's called. It's sick, but I bet it's pure." (Lisa03)
III. Lifestyles of Cocaine Addicts in British Columbia.
None of the cocaine addicts that were discussed by the consultants in the Key Informant study would be nominated as ideal role models by the larger community in British Columbia. However, their degree of deviance ranged widely from those that hovered at the margin of general social acceptability and legality, to those that were fully as shocking, violent, and criminal as sensational media portrayals. In this section, we will leave aside the important theoretical issue of whether or not an addictive life style can be considered a "consequence" of cocaine use or of something else, and simply describe the lifestyles that were found.
At the normal end of this continuum, there were addicts who confined most of their cocaine use to close-knit, well established groups of friends, and who found legal ways to earn enough money to afford their drugs. In many cases, these appeared to be binge addicts who returned to a seemingly normal lifestyle between episodes of binging.
From a consultant's description of a group that became involved in an addictive lifestyle only a few times per year:
"Sometimes they will binge on cocaine and everything is cocaine, cocaine, and cocaine and then other times (most of the time) cocaine is not an issue.... coke is everything, then it drifts into obscurity..." (Linda15)
If the binge addicts were "out of control" when they were binging (this too is debatable), their periods outside control were episodic and planned during periods when they were clearly "in control". Many binge addicts "put their affairs in order" prior to embarking on a binge, which sometimes lasted for several days, so that their cocaine use did not adversely affect their financial, employment, family and social responsibilities. For example:
"A certain set of things had to be done before use could commence. These included cleaning the house, getting all current affairs in order, and eating. These things were done due to the informant's recognition that once cocaine use was initiated, that would be all that got done until he was out of money, cocaine or time. He never missed work because of drug use; having to return to work marked the end of a run." (Bryan05)
"The binge addicts had like double lives. They would have their straight lives and then, once in a while, would take off their business suits and have a weekend of wildness and then go back." (Lisa02)
An intensive study of a British Columbia "cocaine family" made up of binge users that was undertaken separately from the Key Informant study has appeared separately (Matthews, 1992; Matthews & Alexander, 1993).
At the other extreme of addictive deviance, there were addicts whose live were shockingly self-destructive and socially unacceptable. For example:
From a male addict in response to a question about possible physical harm caused by cocaine use:
Hygiene, people don't tend to keep themselves clean. No time for a shower.
What I think gives you the heart attacks is the Jones'n, the crawling around, stressing yourself out. You see them, they're sweating like pigs.
...Once a buddy of mine, we were doing big boulders of about half a gram, he starts shaking [referring to "doing the chicken", or undergoing convulsions] he was humming for about an hour. Scared himself.
Needle users get marks.
Snorting eats the inside of your nose, throat.
I've had sore lungs after a good session. Throw up these black balls. We cooked one up once as a joke, lung butt it's called. It's sick, but I bet it's pure. (Lisa03)
From a female addict:
"I would think that people who are into drugs are more open to different experiences than people who weren't because when you're high you would be more open to a one night stand, or whatever. Or especially, depending who the drug dealer was, whatever, homosexual or S&M. There used to be a lot of group sex when there were parties going, it would just happen." (Lisa02)
IV. Cost-Benefit Analyses of Cocaine Use by the Key Informants. Consultants were asked to consider all the consequences that they had mentioned in response to interview questions and to assign a single number to indicate the relative magnitudes of costs and benefits associated with cocaine use. Most consultants were willing to do this, and a few offered to provide different numbers for different patterns of use of which they were aware. The question was worded as follows:
Considering all the costs and benefits associated with cocaine use, how harmful or beneficial would you rate the use of cocaine for the cocaine users whom you know best, according to the following scale?
1 = very harmful
2 = moderately harmful
3 = slightly harmful
4 = neutral
5 = slightly beneficial
6 = moderately beneficial
7 = very beneficial
Responses to this question ranged from "very harmful" to "very beneficial". Addicts and ex-addicts generally chose "very harmful", and some were adamant in insisting that cocaine had no benefits whatsoever. The responses of recreational users, however, ranged from "very harmful" to "very beneficial", with several choosing 6 or 7, and a greater number choosing responses around the neutral center of the scale. Rather than discussing cocaine on a moralistic plane, the larger number of consultants in British Columbia, both users and professionals, appeared comfortable evaluating the consequences of cocaine use on individuals with the same sort of utilitarian logic that they use to assess the effects of other commodities. [Should we have a table here?]
V. Consequences for the Community:
The British Columbia consultants were far from unanimous in their view of the consequences of cocaine use on the community. A minority of the consultants saw cocaine as a moral menace and feel that draconian measures were justified to contain it, in the spirit of the "War on Drugs" of the past decade.
The majority of the consultants who answered this question about the consequences of cocaine use for the community did not discuss cocaine use as a moral issue, but as an issue related to problems of health and social order. This majority was divided between those who blamed these health and social problems primarily on irrational prohibition laws and public misunderstanding and those who viewed these health and social problems primarily as a pharmacological effect of the drug itself. Many consultants, while identifying cocaine use with ill-health and crime, nonetheless favoured some form of cocaine legalization. For example:
"Cocaine is a net negative to society but still only on the moderately harmful side. However, if cocaine were legal then it would be neutral in terms of its consequences to society." (Linda08)
There were no consultants who viewed cocaine as a completely positive influence on community life, although various consultants mentioned benefits that cocaine use might bestow on the community. For example:
"The positives to the community include that the drug can be a release for individuals so that they can better work within society. People live stressfully and when they can take a drug like cocaine 4 or 5 times a year to relieve some of that stress they function better than keeping all that stress and frustration in them." (Linda12)
Several informants felt that even addicted users could control their cocaine use in such a way that it would minimize any negative consequences for the community. For example, from a male recreational user:
"The informant was adamant that people with problems--financial, family, stress, boredom--would be more prevalent in the heavy-using group. Use was part of looking for an answer to these problems. When realities are harsh, cocaine is just a way of "ducking out" for a while. Whether or not this ducking out becomes a problem or not is up to the individual." (Bryan04)
From an intravenous cocaine addict:
"I know people who have been addicted and using for 16 years. You can live as an addict long-term. Some addicts take care of themselves and some addicts don't give a damn--all they want to do is do a hit or take a toke... There are two different types of addicts. Some have more control than others. I don't think everyone who uses is on a self-destruct mode. A lot of people use it heavily for a year or two and then quit or cut down, and other people can do it for decades without problems." (Lisa01)
6. Current Social Responses to the Use of Cocaine:
Whereas almost all the British Columbia consultants were clear and detailed in their discussion of the users they knew best, a sizable minority were vague in their descriptions about the way in which British Columbia responds to the issue of cocaine use. This was usually either because of inadequate knowledge or of lack of interest. On the other hand, the consultants who did express opinions on this issue were clearly concerned and often keenly analytical.
What is Available in British Columbia. The consultants described a wide variety of treatment programs. The most frequently mentioned were "12-step" programs, based on the treatment philosophy of Alcoholics Anonymous, with abstinence as the goal of treatment. Other programs that were mentioned were "detox centres", where heavy users could go to "dry out" for a few days, individual counselling, group therapy, prescribed drugs, and client-oriented treatments in which the clients laid out personal goals and the treatment staff tried to help them achieve these goal. Consultants generally perceived these programs as staffed by a mixture of professionals and ex-addicts. Consultants agreed that there was little treatment designed specifically for cocaine users.
A number of consultants suggested that there was little treatment available for down-and-out users. For example, a judge answered his interviewer's inquiry about who was likely to go to treatment as follows:
"The rich family person, the prisoner who needs it for parole, and the union worker (union provides treatment) are all more likely to go to treatment, because these are the people for which treatment services are targeted. The person of wealth and the union worker are somewhat privileged and have easier access to the treatment services. They know how to get in contact with service or know someone who can put them in contact with the service." (Linda12).
Aims and efficacy. The consultants differed in their evaluation of the treatment that was available to cocaine users. Treatment professionals as a group were generally positive in their description of treatment services, whereas the users' evaluations ranged from strongly positive to strongly negative to uninterested. The numerous "12-step programs" produced the greatest polarization among the clients. They were perceived by some as an imposition of an unwanted religious philosophy, and by others as sensible, effective treatment. One program that was mentioned favourably a number of times was "Crossroads", in Kelowna. From a social services worker, describing addicted prostitutes:
"These users will take a few days off of using to rest and eat. This might mean showing up at detox because they provide you with a bed and food." (Bryan07)
From a 27-year-old, incarcerated, former IV addict:
"Some use the system to get themselves back into shape. They'll go out and break a window or something, and if they've got a long criminal record they will get time for it. Gives them a place to belong for a while. The women come in, they gain weight, they get rid of all the pock marks on their faces 'cause they pick at their bodies really badly, abscesses. They get their AIDS test and their antibiotics, get healthy, eat lots, exercise, save up some money and get out. And come back all over again." (Lisa16)
Most consultants described treatment as an intervention with limited utility. Even professionals and ex-addicts who had completed treatment successfully tended to feel that treatment did not always succeed and that it was only suitable for addicted users rather than for everybody who used cocaine. From a freebase addict:
"I'd say that 80% that go through programs start using again." (Lisa03)
Outpatient counsellor in Kamloops:
"I would say that fewer than 10% of people who go through detox for cocaine use ever get better." (Lisa10)
Some currently dependent and addicted users considered treatment in a much more favourable light, some considered it a waste of time, and some did not seriously consider participating in treatment. Most of the experimental or recreational users did not even consider the possibility of seeking treatment, while some of the heavier recreational users were obviously worried about what might be happening to them.
Users, ex-users and treatment professionals often had different criteria for good treatment. Several of the addicts and ex-addicts insisted that good treatment must be conducted by ex-addict therapists. Whereas treatment professionals and ex-users saw abstinence as the criterion for successful treatment, many users didn't agree. Many users felt that successful treatment could also include: detoxifying and reducing their drug tolerance, getting themselves healthy by eating properly and exercising, etc., without necessitating that the user commit to abstention. This can also lead to problems while the user is in treatment. If a user does not intend to quit using, they are considered to not be co-operating with the program objectives and staff. Many of the users expressed a fear that compulsory treatment might be imposed and that it would be counterproductive:
"The 12-step programs are like cults. Some people just get absorbed into it and get focussed on its ideas and devote their lives to it. It's just a transference of addiction." (Bryan06)
"Forcing someone into treatment does no good at all." (Lisa04)
Consultants' Recommendations concerning Treatment. A great variety of sometimes conflicting recommendations for improving treatment were made by the consultants. For example:
"Felt the only kind of treatment that could be effective was a mandatory, enforced, live-in program which could be used in lieu of being sent to jail. Felt that jail was not a place in which people could recover their self-image and pride." (Bryan03)
"Do not force it on people and do not expect it to be a cure-all for addiction like going to see a doctor for a sickness" (Linda02).
"Mandatory treatment notifies the employer, family and friends [about the user's condition] and may intensify the user's problems." (Bryan04)
"They should have more programs run by ex-addicts because then you're going to get down to the truth. It can't be run by anybody else really, its okay to be in the field of addiction but if you haven't been an addict you're not going to fully understand what this person is going though" (Lisa18).
"Change in treatment services to include an increase in residential services" (Linda03).
"There should be a half-way house where users can go" (Gary02).
"Should try to teach people to use socially. Treatment should be based on a person's dysfunctions (i.e.. lack of education, family ties), not their drug use. Addiction is a response to social conditions, not drug exposure." (Bryan13)
"People should stop blaming the drug for the problems and deal with the issues of 1) lack of jobs and opportunities and 2) problems with identity." (Gary03)
Authors' Recommendations concerning Treatment. The authors could not form firm conclusions about appropriate directions for future treatment in British Columbia on the basis of the interview data alone. The Chief Investigator and other colleagues have written extensively on treatment issues in British Columbia, and these studies appear in other sources (e.g., Alexander, 1990, chaps. 1 and 9), but these other analyses are primarily based on treatment populations, whereas treatment was not part of the experience of the majority of users who were described in this Key Informant study.
Perhaps the most general conclusion the Key Informant interviews suggest is that, in spite of enormous expenditures on treatment in British Columbia and elsewhere, treatment does not touch the lives of the great majority of cocaine users. It is almost impossible to conceive of levels of funding that would bring treatment services to the majority of users, or even to the majority of dependent and addicted users. Moreover, these interviews suggest that although there are some additional needs for treatment services, there is no obvious reason why they should be greatly increased, since the problems that most users encounter are being engaged in the course of normal personal development and social interaction.
The current need may be to identify the specific types of users that could benefit from treatment and to make sure appropriate treatment is available for these people. Four specific needs were suggested by the interviews. Paradoxically, the first and second of these grow from conflicting interpretations of the nature of the problem of drug addiction, but, this would not necessarily prevent a pragmatic society from responding to both:
1) There appears to be some need for additional tough-minded abstinence-oriented treatment services for long-term addicts who are capable of supporting themselves and maintaining at least marginal social functioning. Such services are the only kind that some of these addicts trust, and they do work for some people. Moreover, these kinds of services can be relatively inexpensive to provide, since a great deal of the actual work can be done by voluntary 12-step groups.
2) There is a need for nonjudgmental, client-centered interventions for recreational or dependent users who are nervous about their growing involvement. In such programs, the user would be expected to set his or her own goals, which may or may not include abstinence. A number of current recreational and dependent users expressed fear that they might lapse into severe dysfunction, but also expressed aversion for abstinence-oriented or 12-step treatment, along with a belief that no alternatives to it are available. In many regions of the province they may be correct in this belief.
3) There are clear indications in the Key Informant data that some people who administer cocaine with needles are willing to use the services of "needle exchange" programs. Whether or not such programs are properly called "treatment", there seems to be little doubt that they save lives and the enormous expense of treating people for AIDS. There were no indications in the Key Informant data that needle exchanges are causing problems of any sort. There were, however, clear indications that needle exchanges are not available, or are not functioning adequately, in many parts of the province. This appears to be particularly true in prisons. For example, a jailed female ex-addict told her interviewer:
"They are sharing needles... They get their needles from the outside." (Lisa16)
From an ex-addict counsellor in a male prison:
"It's very common to share". (Lisa13)
A drug counsellor, who has never used cocaine, described how inmates who freebase or inject cocaine also fail to use condoms:
"As far as the informant knew, none of these users used condoms." (Bryan09)
It would seem that additional needle exchange services would be an inexpensive means whereby the province could save lives and misery from AIDS, at a relatively low cost.
4) Additional services are needed for deteriorated, destitute cocaine users, to prevent premature death from suicide, disease, or violence. There is little for such people now, because they are frequently too intimidated to approach existing institutions for help, or are turned away if their needs are too great. For example, according to two of the consultants, it is common to refuse treatment to people who are labelled as suffering from "dual-diagnoses". This refusal, if it is widespread, would have the effect of keeping the most needy people out of treatment, since the most deteriorated people have the most wrong with them, and can frequently be assigned to two or more diagnostic categories.
Deteriorated, destitute people are often ill-behaved and refractory to treatment, but the interviews suggest that there is at least one current program (Portland Hotel, Vancouver) that can successfully house them, and thus keep alive the possibility that they may later improve. It is clear from some of the Key Informant interviews (e.g., Gary01; Lisa15) that even the most deteriorated people are often keenly aware of their situation and that they can sometimes, eventually, recover a degree of normal functioning.
Since people who use cocaine exclusively are extremely rare and since cocaine users are likely to have problems with drugs other than cocaine that are as severe as their cocaine problems, there is no reason for the services recommended above to be focussed specifically on cocaine (or any other single drug). Treatment that is not built on a premise of pharmacological specificity is likely to find easy public acceptance in British Columbia. These interviews suggest that there is almost a universal recognition amongst the consultants--users and professionals alike--that drug problems are not fundamentally different for different drugs. For example:
"The I.V. users are addicted to heroin. The basers use marijuana everyday." (Gary12)
"The informant felt that he had problems with alcohol and pot, in addition to cocaine." (Bryan08)
The heavy cocaine users also tend to be heavier users of alcohol and pot. "They just have addictive personalities". (Bryan11)
"The users would have heroin problems, alcohol problems and smoking problems." (Linda04)
"[The consultant] says that one of the people uses "speed" heavily. And another person uses various prescription drugs heavily." (Linda10)
"There are those who switch from cocaine to other drugs and get addicted to those other drugs." (Lisa18)
Compulsory treatment for drug addiction is a current reality in British Columbia, inasmuch as prisoners are often essentially required to volunteer for Chemical Dependency Programs in prison (and sometimes after release) as a condition of early release (i.e. parole). For example, from an incarcerated, formerly-addicted female:
"It's not always voluntary (to participate in the transition programs), but the women participate in order to get parole and get out. If you don't agree to go to the program and don't go to NA [Narcotics Anonymous] then there's no way they're going to get out [on early release]." (Lisa16)
There are at least three reasons to view this practice with suspicion. The first is the strong opposition towards compulsory treatment expressed by a number of the user consultants in these interviews; the second is the lack of substantial evidence in the outcome literature that compulsory treatment in prison is beneficial (see Alexander, 1990); the third is the necessary minimum of choice in prison-based compulsory programs (particularly choice between abstinence-oriented and client-oriented programs). In the face of these problems, it might well be that money could be diverted from essentially mandatory prison programs into other, voluntary programs, where a genuine need for treatment services exists, and where treatment, therefore, may have a greater likelihood of success. This would require a revision of the current practice of making participation in treatment programs an important criterion for early release for inmates who have committed drug-related crimes. From the same incarcerated, former addict, quoted above:
"When I'm having to address this stuff in my [upcoming] parole hearing, I think my parole coordinator is really pushing the fact that I'm not attending any [drug] program and my charge was drug-related. It will be three years by the time I go in front of them that I haven't used. I smoke and I drink coffee and that's it. Her fear is that I haven't addressed it on paper. I said "well, it's not an issue," but it's going to be an issue to them. The crime was eight years ago, an awful long time ago... I haven't attended programs for years and that's been totally my choice. So being clean and sober doesn't always have to do with the programming that they have. It was my own personal decision and I've grown out of it. I'm a student now--I don't need this crap." (Lisa16)
A final recommendation that arises from these data is that the expectations for treatment in general be lowered. People with experience in drug treatment--professionals and clients alike--know that the probabilities of dramatic success are always low, but that, properly undertaken, with a good match between client and program, treatment can often ease painful burdens and lay a groundwork for gradual improvement. There are occasional dramatic successes, but these are never the day-to-day outcome of even the best treatment programs. If treatment is approached from this perspective, the burden of overly-large expectations--which sometimes undermines the morale of both client and therapist--can be lightened.
II. Law Enforcement:
A substantial number of the consultants were willing to comment on current law enforcement, and to express opinions about how it might be improved.
Aims of Current Law Enforcement. Many street users expressed the view that the law was used even-handedly to enforce a hard-line "zero-tolerance" policy with respect to cocaine and other drugs. These people often criticized the police for being overly zealous or for foolishly believing that the cocaine problem could be solved by putative measures. They did not, however, accuse the police of corruption or brutality. However, other consultants, particularly professionals or middle class users, expressed the view that the law enforcement system showed favoritism, or was serving a hidden political agenda. Both types of view are illustrated below:
"The aim of the law is to stop use and to stop the existence of cocaine in Canada." (Linda07)
"Zero tolerance. Dealers and users who buy on the streets are more likely to get busted." (Gary01)
"They have quotas to fill. So they only arrest enough to fill their quotas:" (Bryan04)
"How legal or illegal cocaine use is depends on who you are--not zero tolerance. Laws are preferentially being enforced against people at the street level of distribution--low SES dealers. More a matter of public relations posturing (showing the public the authorities are doing something) to show tax dollars are at work." (Bryan07)
"The aim is a sociological one. [The consultant] says the aim of the law is to [impose] a measure of state control over racial groups, and the down and outs in society." (Linda13)
There is a strong reason to believe that the law is not being rigorously applied to middle class users and recreational users, in spite of the belief of some street users and addicts that it is. This is the fact that middle-class users and recreational users rarely expressed any real fear of legal consequences for their own cocaine use.
Efficacy. Almost none of the British Columbia consultants, in any category, felt that law enforcement measures were having any significant impact. For example, in response to the question "How well do you think these [police] approaches work?", a longtime addict replied:
"Law enforcement doesn't seem to do very much. The people who I saw selling on the streets when I first got here are still selling, still on their same corner." (Lisa01)
From a recreational user:
"No, the law as it is now does not work. People use and will continue to use cocaine, whether there is a law prohibiting it or not. Also, the law is...a cause of social and personal problems...blamed on cocaine itself." (Linda06)
From a member of the police:
"Not very well." (Gary13).
From a professional coroner:
"No the law does not work. It is a knee jerk reaction to the rest of the world--especially the United States. They say we need to criminalize drugs, so we do it." (Linda04)
From a judge:
"No, the [police] approaches do not work". (Linda12)
Consultants' Recommendations concerning Law Enforcement. A substantial number of consultants favoured continuation of a hard-hard line approach to enforcement. Of those favouring hard-line enforcement, a number were professionals and ex-addicts, and some were current users and addicts. For example, when asked about possible changes to existing drug law, a physician who works with pregnant addicts replied that:
"Cocaine should be illegal. The current status under the law should be continued." (Bryan03)
From an addict who was currently quitting:
"Should be tougher on dealers. First offence for dealing should be a mandatory jail sentence. The financial gains made from dealing should be taken away. For example bank accounts should be frozen and confiscated. The proceeds should be put towards drug rehab and education. If a dealer is convicted twice they should throw away the key." (Bryan08).
From a long time addict and former dealer:
"The sentences should definitely be longer. That's the only way they can do anything." (Lisa04).
From a current recreational user:
"The goal of abstinence should be encouraged. But the approaches need to be somewhat changed. We should also maintain legal prohibition on cocaine. Punishment process is wrong. The user should not go to jail. The addict needs to be rehabilitated. Using a drug is not a crime. However, trafficking should lead to incarceration." (Linda14)
A majority of informants however, including both users, ex-users, intermediaries, and professionals, favoured some form of mitigation of current legal severity. Consultants whose observations focussed on recreational use of cocaine, often recommended outright decriminalization or legalization of cocaine. They cited the preponderance of casual, responsible cocaine users and the cocaine black market, which can only exist if cocaine is illegal, in their defence. However, people who were primarily concerned with addicts also favoured some form of decriminalization. For example, a professional talking about a jail population of addicted males advocated:
"Some form of decriminalization, similar to alcohol. Sell cocaine in more benign forms and in small doses." (Bryan09)
A professional who worked with deteriorated addicts argued for:
"Legalization. Cocaine use increases crime because its illegality makes it very expensive." (Gary02)
From a non-using intermediary who was in close contact with many cocaine using "computer hackers":
"...legalization of cocaine". (Gary04)
From a judge:
"[The consultant] suggests that cocaine be legalized in medical form with a prescription somewhat like methadone." (Linda12)
From a regular recreational user and intermediary:
"If they want to stop the influx of cocaine they should make it legal. Make coca leaves legal. It takes so much to make a gram of coke, they should make the leaves available for teas and stuff--it would cut down the problem." (Lisa08)
A casual recreational user argued:
"Tax dollars that could be better spent are going into prisons and policing... the health impact is enhanced because of the impurities in the drug supply--again a consequence of its illegality." (Bryan13)
Authors' Recommendations concerning Law Enforcement. Much in this study supports the arguments for modification of the current system of drug law enforcement with respect to cocaine. None of the consultants who are users in remote areas report any real problem in obtaining cocaine. Even the consultants who favour maintenance of hard-line enforcement see it as ineffective. In addition to a number of cocaine users and intermediaries, a high proportion of the professionals in this sample, all respected and well-informed people, argued strongly for some form of legal availability. There is a considerable body of evidence on the effects of drug prohibition, which bolsters the observation that it appears not to be working in British Columbia (e.g., Trebach, 1987). In view of the expense of drug law enforcement and the need for funds for other purposes that could benefit the public, the argument for a major change in drug law enforcement seems strong.
However, it is not within the power of any Canadian province to alter or countermand federal drug law, and indications are that the current federal government has no real modifications in mind (Fischer, 1994). Nonetheless, the province does have the power to modify the priorities of enforcement and prosecution. The province might well attend to indications that the trend of softening such priorities on a local level, without modifying federal laws, seems to be taking hold in a number of European countries. This logic is at the heart of the "Harm Reduction" movement. (See Index of Abstracts and Speakers, Fifth International Conference on the Reduction of Drug Related Harm, Toronto, 1994)
The Key Informant interviews suggest that, to some extent, a de facto softening federal drug laws is already underway, at least in, in British Columbia. There was no expression of any real fear of legal complications among experimental or casual recreational users, suggesting that the current system already implicitly recognizes that there is nothing to be gained by harassing people for harmless indulgences. On the other end of the continuum of involvement, the down-and-out addicts were keenly aware of a risk of arrest, and often aware that they are far more liable to arrest than more wealthy cocaine users, but the tone of their interviews suggest that they did not seem to be greatly resentful about this state of affairs.
It is possible to hope that, over the course of 70 years of evolution, that drug law enforcement has reached the state where legal controls are normally applied only to users who might actually benefit from external restraints on their self-destructive impulses, from occasional sharp reminders of community standards, or from replenishment with decent food and clean clothing provided by jails. Perhaps the wisdom in Canadian drug law lies neither in the harsh rigidity of the written law, nor in the simplistic rhetoric that is used to justify it, but in a sense of proportion that has accumulated within the legal establishment, and in the day-to-day efforts of policemen to exercise good sense in an imperfect world. If such a benign accommodation is indeed part of the current reality, it can be fostered in a quiet way on the provincial level.
The authors are aware that this hopeful analysis may appear embarrassingly naive. Therefore we hasten to add that the police in British Columbia are no less subject to individual corruption and error than police (and other human beings) everywhere and that the obvious inequities in enforcement, with the well-to-do and socially respectable remaining exempt, cannot be justified on any ideological level. On the other hand, it may by that British Columbia and Canada in general has been spared, to this point, from the high levels of institutionalized corruption that have so conspicuously infected other national systems of drug policing (e.g., Morales, 1989; McCoy, 1972). This hopeful view is generally shared by Canadian criminologists and individual police with whom we have consulted and, we believe, by Canadian drug policy experts (e.g., Beauchesne, 1991). The good fortune of being spared a large measure of institutionalized corruption in drug enforcement might have made possible a reasonable evolution of enforcement policy in British Columbia that the constraints of such corruption could prevented elsewhere.
III. Prevention and Education:
Many of the informants were silent on the topic of "prevention". However, among those who did comment on this issue, there was considerable agreement on the appropriate aims of prevention programs, but a diversity of views on means.
Aims. The great majority of consultants accepted the promotion of abstinence as an appropriate goal. Although a few consultants suggested accepting the reality that, inevitably, some people would use cocaine later in their life and might therefore be trained to use it safely, there was no mention of cocaine use as valid part of a culture with which young people might be familiarized. In British Columbia, cocaine is a socially unpalatable drug, even among those who use it and who consider it inevitable that others will use it. The following is from a male ex-user:
"The aim of abstinence is a positive step for drug education but the methods of producing the results only scares people, gives them inadequate information and can encourage drug use with its sensationalization and propaganda. [The consultant] recommends that use be tolerated but not encouraged. Education needs to instill the attitude that if a person is going to use a drug such as cocaine they need to be careful, know the skills to be careful. They need to learn the effects of the illegal drugs in the same context the legal ones are discussed in." (Linda06).
Efficacy. Among the consultants who commented on prevention issues, there was a clear division between those who felt that the current dramatic style of media and educational presentations on cocaine were offensive and counter-productive and those who applauded them:
"They work fine until children are able to think for themselves. Then they realize that the claims are exaggerated or untrue. This leads to the discrediting of authority." (Bryan06)
"They are harmful because they are inaccurate, don't cover all solutions to drug problems, and stigmatize use as socially-unacceptable and labels all users as addicts. They are disrespectful of the individual." (Bryan07)
But, on the other hand:
"...We need to use graphic gruesome details on the hazards of using cocaine. For example in alcohol awareness they use visual images and film to show car accidents of people involved in drunk driving etc." (Linda04)
"Most kids laugh at them (i.e.. commercials) because they are too sugar-coated. The ones in the States are better, because they are scarier. They aren't getting the message across; they need to be scarier." (Bryan08)
"In school, they should educate on what really happens to people who use cocaine... here's people who've got marks all over their faces and they look like they just came out of the Amazon jungle... Show crack houses how they really look--it can be a gorgeous house on South Granville, or it can be a basement hole. It's what goes on inside, not the decorations on the wall." (Lisa02)
However, few of those who applauded scare tactics claimed to have been successfully deterred, by these ads, from trying cocaine or from continuing to use it.
Many informants familiar with addictive patterns of cocaine involvement recognize that the ads are exaggerated, but feel they are representative of the potential for harm which can accompany addictive cocaine use.
Consultants' Recommendations concerning Prevention. There were a variety of recommendations, the most common being a truthful presentation of facts about cocaine and other drugs and conveying a sense that people don't need to use them at all. Several informants advocated sending recovering addicts into the schools to warn kids about the dangers of cocaine and other drugs. For example:
"Education is the right avenue, prevention and abstinence is the right goal. But to attain this you need to have more positive stories such as bringing in respected people as examples of success stories. They may have successfully gotten off of drugs or they may be successful people who do not need drugs. They need to concentrate on more positive aspects of the drugs and abstinence than to scare them away from it." (Linda07)
"The aim of abstinence is a positive step for drug education but the methods of producing the results only scares people, gives them inadequate information and can encourage drug use with its sensationalization and propaganda. [The consultant] recommends that use be tolerated by not encouraged. Education needs to instill the attitude that if a person is going to use a drug such as cocaine they need to be careful, know the skills to be careful. They need to learn the effects of the illegal drugs in the same context the legal ones are discussed in." (Linda06)
"[The consultant] thinks that the aim of staying clean is good but futile. Doing drugs is natural, it is human nature. But there has to be two sides to the issue. You just can't say stay clean although that is part of it. Acknowledge that people do drugs. Drugs are not evil. There are some negative consequences maybe biologically if you take to much but it is not this evil sinister thing. Yes drugs can have bad side effects but if you are going to use them, moderation exists. [The consultant] wants to make certain that this is not construed as encouraging use because he thinks it is not." (Linda15)
"They should have addicts come into the classrooms and talk about drug use to kids (8 to 10 year olds). They can tell a spicier story than a cop, they can really keep the kids' attention. Things sink in because they're minds would be wide open... If a nurse comes in and tells them about drugs they're not going to go out and tell their friends, but if they've got an ex-addict there who's got some really good stories, they're going to be telling their friends about the kind of trouble you can get into if you use drugs." (Lisa01)
"Let them all try it in a controlled situation." (Bryan10)
Two abstinent, female, recovering addicts expressed a desire to get involved in prevention work, from their perspectives as ex-users, but not counsellors, but they found opportunities scarce. This type of non-professional ex-addict involvement could be a helpful component of recovery for the addict and may be uniquely impactful in the education of young people. However, the indications are that schools and youth correctional facilities don't encourage--and sometimes prevent--ex-addicts from doing work of this sort.
"There is nothing out there [for a recovering addict to get involved in]. When I first got it together, I really wanted to volunteer, but there was nothing." (Lisa02)
"I would love to get involved to help people. There aren't enough opportunities..." (Lisa15)
In addition to expressing their views on media and education, many of the consultants expressed support for what is sometimes called "primary prevention", although they did not always volunteer these views in response to the question about prevention, but in other portions of the interview. These consultants advocated ameliorating social conditions as a way of lowering the probability that people will become involved with cocaine. No consultant expressed opposition to the assumptions that underlie primary prevention. The following example is from a social worker who was also an occasional recreational user of cocaine:
"What needs to be done is an examination of the relationship between economics, social oppression, individual and psychological factors. Psychological factors include identity formation, crisis management and communication skills. Examine how the above factors encourage and facilitate drug use and abuse. There needs to be the distinction between use and abuse. Education campaigns must be initiated from the informed and not the fearful or ignorant. Educate about drug usage and abuse as symptomatic of other problems that do not include the drug itself. The education campaign should also acknowledge other cultures, historical uses of drugs which include cocaine." (Linda05).
From a professional coroner:
"Society needs to help those who get addicted to break the cycle of poverty. They need to get off welfare, bring up their self-esteem, have decent wages. These people do not want to be on welfare. No one ever worked but they do not want to be where they are in their lives. Society cannot squeeze them out by building huge towers on the east side and making them move down the street." (Linda04)
From an intermediary who is a computer programmer:
"People should address the larger spiritual questions." (Gary04)
From a 60-year-old female ex-user:
"If people had decent lives and decent jobs a lot of the drug problem would go away, people would have hope then". (Lisa06)
From an ex-recreational user:
"Change their social class instead of educating them on the sins of drug use. Take them out, treat them for their chemical dependence if they happen to have one, educate them and give them a job. Something to take up their time, something else to rely on. [Then they will] feel better about themselves, they won't need a crutch." (Lisa12).
From a current recreational user:
"[The consultant] advises more extensive treatment [of addiction] and of the social problems that lie behind the addiction" (Linda08).
Authors' Recommendations concerning Prevention. "Prevention" is a broad term that is used in various senses with relation to drugs. We will discuss two of these, "drug education" and "primary prevention".
Drug Education. Education is a provincial function in Canada, but British Columbia actually may have more control over treatment and law enforcement than it does over drug education. This is because the bulk of drug education is, unfortunately, carried out by television and other mass media over which the province has little control. These media messages condemn cocaine and other illicit drugs in ways that are partly true, but largely exaggerated, and occasionally outright lies (Trebach, 1987; Alexander, 1992). At the same time these media messages are enticing with respect to other, "good" drugs, like cold remedies, over-the-counter analgesics, and new families of psychoactive pharmaceuticals such as "Prozac".
Media messages are so powerfully composed and so often repeated that education in the schools cannot alter their influence to any great extent. It is pointless for educators to expend scarce resources either to support anti-drug messages that are already powerfully conveyed, universally known, and of dubious value. Likewise, it is futile to oppose them in a public school context. The futility of opposing them arises in part from the fact that many people in every community vigorously oppose any unconventional treatment of drug issues in school and that school authorities will not risk an uproar by defying these people.
It would seem obvious that, in the long run, both individuals and society will respond best to drugs when they are accurately informed about their effects and about the variety of perspectives from which they can be viewed. However, it is possible that, in the current milieu, attempts at balanced, truthful drug education must await post-secondary education. There, in a more critical climate, under the protection of academic freedom, it is possible to teach unconventional truths about drugs. The Chief Investigator and other colleagues have published results of experiments with post-secondary drug education (which are still under way) in other sources. One promising result of this experimentation has been a demonstration that most university students let go of the distortions that are conveyed in normal media presentations on drugs when they are exposed to current research in a even-handed manner (Alexander, Lewis, van Wijngaarden, and van de Wijngaart, 1992).
We have found, by the way, no indications that letting university students know that drugs like cocaine can be used in a rewarding and apparently harmless way leads them to experiment with cocaine. The inclination towards casual experimentation with cocaine seems to us to grow from an attitude of rebellion towards social convention and legality that is quite independent of a student's view of the possible effects of cocaine. Students who are content within the confines of a society that they regard as legitimate and fundamentally benevolent are not inclined to violate its most intensely expressed taboos.
Under these conditions, it might be the case that continued provincial expenditures on drug education either in public schools or through the media might be less useful than provincial expenditures on other issues.
"Primary Prevention." The assumption that underlies primary prevention is that healthy, socially integrated, personally satisfied people are unlikely to use drugs in a way that is self destructive. The Key Informant interviews show that many people, users and non-users of cocaine alike, subscribe to this assumption, but the interviews provide no direct evidence to confirm or disconfirm it. Some of the authors have discussed various types of evidence that support this view in other publications (Alexander, 1990; Matthews, 1992; Wong and Alexander, 1991), but the issue cannot be discussed at length here. The remainder of this section is based on acceptance of this assumption.
The goals of primary prevention, i.e., good health, social integration, personal satisfaction, are among the goals of all governments, except those that are hopelessly lost in ideological autism and power struggles. Therefore, it may well be that the best road to prevention of drug problems is the one that the provincial government, and most other governments, are already on. It might be that the best preventative measure that politicians can provide is simply "good government" in all the aspects that are possible.
Paradoxically, this analysis suggests the possibility that the provincial government can best relieve the distress caused by destructive use of drugs by diverting funds away from some drug programs, such as anti-drug advertising, and putting these funds to work in the interest of programs that will promote the general well-being, for example job creation or school lunch programs. It is possible that visible expenditures on "drug abuse" may, in some cases, be a tempting way to create the illusion of solving a problem where the real solution is more difficult to achieve, but where the road toward a solution is clearly visible.
7. Changes in Cocaine Use:
I. Changes in Cocaine Use over the Last 5 years:
The consultants were generally tentative and contradictory in their descriptions of changes in cocaine use over the last five years, and almost half did not comment at all. Among those who did comment, there was a consensus that the meaning of cocaine use is changing in the culture of British Columbia. Cocaine in the recent past was associated with affluence, adventure, and restrictively high prices. It is now associated more with social marginality and ill health; it remains expensive, but prices have fallen considerably. Thus, cocaine is becoming less socially-acceptable in British Columbia than it already is. A bartender, familiar with a group of homosexual cocaine users stated:
"Cocaine was a fashionable drug and, as with any fashion thing, everyone sort of got into it at once. It was sort of a designer drug, only those who made a lot of money could afford it. That sort of mystique. it could be carried discreetly and used quickly, that sort of thing made it very fashionable... Now, cocaine now has a reputation as a drug that ruined a lot of people. With the economy taking a nose dive a lot of people found that a lot of corporate guys were taking a lot of cocaine. It destroyed a lot of reputations. It has the same sort of reputation as heroin, for example, in some ways, as very, very bad stuff." (Lisa17)
From a former freebase addict:
"Cocaine isn't as glamorous as it use to be. You have to keep it under wraps. It's not something you can tell your friends. It's very underground, it's not the in thing at all." (Lisa02)
A legal professional who has friends who use cocaine stated:
"It was known as a middle class drug. But now it seems to have the stigma of being a lower class drug which just happened a couple of years ago. It is starting to have the same aura as heroin. It is taking over heroin as the drug for the lower class." (Linda12)
From a 42-year-old ex-user, familiar with intravenous users:
"It is no longer the trendy hip expensive drug of choice. Now it is a seedy dirty business that no one likes to talk about or say that they use it." (Linda06)
From a former IV cocaine addict:
"The price of cocaine has gone down in the last few years. It use to be $350 - $400 [Canadian dollars] for an eightball of coke, now I can get it for $200." (Lisa04)
Beyond this consensus, the consultants' reports about the trends over the past 5 years were contradictory. There were reports of increasing use, decreasing use and stable use. Various other trends were mentioned, with only trends towards younger age of first onset and increased interest in freebasing being mentioned by more than an isolated consultant. According to an ex-addict who counsels in a male correctional facility:
"There has been a drop in age at first use. This is due to the lowering of the price." (Lisa13)
A bartender who uses cocaine stated:
"More younger people are using it now than before. They are starting younger because of the ease of availability of the drug." (Linda02)
From a recreational user:
"[There's] more of a tendency to free base the coke now." (Gary10)
From a professional, discussing heavy users in detox:
"I have seen a lot of snorters and IV users move to basing in the last five years." (Lisa07)
This conflicting information suggests that cocaine use in British Columbia is in a state of continual flux, with local fluctuations in prevalence and use patterns. Underlying this state of flux, the consultants' reports suggest that cocaine use, in one form or another, is well-established. None of the consultants even considered the possibility that it would disappear.
II. Changes in Cocaine Use over the Next 5 Years:
Over half of the consultants did not venture to predict the future of cocaine use, and those who did, contradicted one another. Some informants were sure that cocaine use would increase, with more young people getting involved and crack/freebase cocaine use becoming increasingly prevalent. Others were sure that cocaine use would remain at about the same levels it is at now. Still others felt the prevalence would decrease. If there is a discernible trend in these data, it would be that the most dire predictions tend to come from former addicts who have had the most painful experiences. For example, the most alarming prediction came from a former heavy addict, dealer, and sometimes thug:
"There's a lot more coming, there's going to be crack, it's going to be cheaper, it' going to be deadlier. More people are going to use...There's this drug called Blue Haze which is supposed to be 100% addictive and makes you go insane after 10-15 uses. A buddy of mine explained how you use it, you break off a piece and put it in your eye and its absorbed right in, straight to the brain..."Ice" is already in the [provinces to the east of British Columbia]." (Lisa18).
From an ex-freebase addict, who knew several freebase addicts, who had died:
"I think it's going to be really scary. People are going to be real hard core. It's going to be the ones who are using that are going to be out there knocking over cars to get the money to do it. It's going to be a lot younger, and very gang-oriented." (Lisa02)
These can be contrasted with the following optimistic predictions, made by recreational users:
"He thinks there will be less use because of the increased effectiveness of eduction." (Linda11)
"It was just a fad and the fad has passed." (Bryan12)
III. Need for Intervention:
In general, the consultants expressed a need for intervention that might reduce or eliminate the use of cocaine in British Columbia. However, as shown in section 6, the consultants expressed no great faith in treatment, enforcement, or prevention as the means to accomplish this goal. The picture that emerges is a culture in which the use of cocaine is unpalatable (even to recreational users whose experiences have generally been positive), but in which a sizable minority is unwilling to relinquish it, and in which there is no real hope that it can be eliminated. This is the same picture that might be drawn of any number of other "vices", like prostitution, adultery, gambling, television watching, overeating and so forth.
The most sober conclusion may be that a kind of dynamic balance with respect to unpalatable practices of this sort is a part of normal social life. Perhaps British Columbia, and other societies, must anticipate a perpetual struggle to keep the occurrences of the activities that it designates as "vice" at a minimal level, without instituting modes of repression that are generally onerous. If this is the correct perspective, then no additional forms of intervention, beyond existing modes of treatment, enforcement, and prevention, are required within British Columbia, and no intervention on a national and international level can have much importance. "Vice" will remain part of the dynamic balance of society, whether or not any particular drug or other artifact is eliminated.
This sanguine conclusion is not meant to suggest that no problems exist or that cocaine is not associated with the most serious of these. All the vices entail major problems, but cocaine use may be one that attracts people whose problems are the most hurtful of all and whose futures are the most bleak. As a social worker, who works with intravenous cocaine-using prostitutes, told an interviewer:
"These individuals are the loneliest she knows--alone in the world with their drug." (Bryan06)
From another social worker, who works with IV addicts:
"Many of these users have AIDS or are HIV positive; they don't have much incentive to stop using..." (Gary02)
From a directionless freebase addict:
"If I had a life, I would be happy..." (Lisa03)
From a former heavy binge user, familiar with friends who had become addicted:
"[Cocaine] made you believe that you were important. It gave you a life. It gave you something to do everyday." (Lisa14)
From a 44-year-old, formerly-addicted, casual user:
"The drug filled a void in his life. His marriage, although never great had collapsed, and the drug helped to fill whatever whole that had left in the informant's life." (Bryan14)
8. Future Issues:
The authors found that certain perspectives about the future arose from the Key Informant Study. One of these is that cocaine has not come to British Columbia for a short visit. Rather, it has settled in and established itself in many communities and rural areas throughout the province. It is very unlikely that it will leave British Columbia very soon. A look at its history shows that cocaine has been here since the 19th century, although there was a long period in the early part of the 20th century when it disappeared from public attention and, probably, from widespread use. Unfortunately, this study and other current data suggest that AIDS may have arrived for a prolonged stay as well, in part because of its transmission through the needle-using community.
Beyond this general state of affairs, there are three issues that require attention in the near future.
I. Assessing the "Harm Reduction" Philosophy:
If destructive practices involving the use of cocaine and other drugs cannot be eliminated, the harm associated with them can be lessened. This could be done, for example, by disseminating information on the more safe and less safe ways of using drugs like cocaine, by taking steps to introduce more quality control in the illegal drug market, and insuring that clear needles are available to IV drug users. Of course, this is difficult in the context of the existing Draconian laws and the public and governmental inflexibility about cocaine laws, but there are many signs that there may be a shift towards a somewhat greater degree of flexibility in North American culture (see for example the May 1994 special issue of Rolling Stone magazine: "Drugs in America--The phoney war--The real crisis".) This shift is expressed in a vigorous "harm reduction movement" that originated in Europe and is making an impression in Canada (Fifth International Conference on the Reduction of Drug Related Harm, 1994).
However, the long range efficacy of harm reduction philosophy requires careful evaluation in the face of the facts of cocaine use. For example, there are some needle exchange programs in British Columbia, but they are still limited to a small number of locations. Their impact is further limited because of addicted users' careless attitudes about the usage of condoms or dirty needles. As described in this Key Informant report, many of the addicted users were nonchalanct about taking the necessary precautions. Their indifference to their own survival is not difficult to comprehend, given the bleak hopelessness of their lives. There is no way to convince people to take even simple precautions if life or death is a matter of indifference. This is not in its essence a cocaine problem, but a problem of a deeper malaise. It seems likely that problems like AIDS, and other forms of self destruction, may remain insoluble as long as the deeper malaise prevails, even with the advent of harm reduction programs.
II. Revising the Urban Focus
In British Columbia, cocaine use is as much a small town and rural phenomenon as an inner city phenomenon. All levels of involvement, binging and regular use, and a reliable supply of cocaine are found in the most remote areas that we were able to reach. Current international efforts to focus primarily on inner cities, in efforts to most effectively reduce the harm associated with drugs, may be unjustified in B.C.
A high prevalence of rural cocaine use may prove to be a special characteristic of places like British Columbia, where the rural culture is tightly linked to the urban culture, rather than having independent traditions and cultural histories. Contemporary culture spread into the B.C. interior from the cities of Europe, Eastern Canada, the United States, and later from Vancouver and Victoria. The indigenous Indian cultural traditions were mercilessly suppressed. There is little culture left in the rural areas that might resist the newest fads and vices from the city.
III. Choosing New Directions for Research:
Perhaps the biggest new insight that arose from the Key Informant research was the diversity of patterns of use which are practiced and the social nature of cocaine use for many people. Society has not yet allowed itself to know the people who use cocaine but, rather, has chosen to describe them with a grotesque and violent caricature that applied only to a small number of users described by the consultants in the Key Informant study. The myth of the solitary drug fiend, tottering perpetually on the brink of frenzy, madness, and mayhem, is little value in a rational analysis.
More needs to be known about the range of people who are involved in cocaine use, and the role that cocaine plays in the life of various subgroups within the larger cultural fabric. Ethnographic research, like the Key Informant study, and the pioneering research upon which it is based by Erickson and her colleagues in Canada, Cohen in the Netherlands, and Waldorf, Reinarman and their colleagues in the U.S., is uniquely suited to attain such knowledge, and more of it should be undertaken. Knowledge arising from studies of this sort is particularly suited to move society from the bizarre stereotypes of the past towards a productive analysis that can enrich the future.
9. Assessment of Key Informant Interview Instrument:
I. Positive Features:
Timeframe. The April 1, 1994 first draft of this report culminated eight months of training, interviewing, transcribing, analyzing, interpreting and writing. This was a workable schedule, although a more detailed data analysis was needed and could only be carried out to a limited extent, since all but one of the four interviewers found it impossible to continue in the project without additional remuneration or the certainty of receiving an authorship that could be cited on a CV.
Training. Throughout the interview phase of the Key Informant Study, there was a tension between the need for standardization implied by the questionnaire supplied by WHO and the need to allow interviewers and consultants to interact productively. In the end, both needs were met to a degree that seemed satisfactory to the Chief Investigator and the four interviewers. Four interviewers may be close to an optimum number for maintaining a reasonable degree of control over the method by which the interviews are conducted and, at the same time, allowing a creative diversity of perspectives, interview styles, and avenues for the recruitment of subjects.
Sampling. The focus throughout the Key Informant Study was on maximizing diversity. This focus provided a simple basis for making decisions and kept the experience of interviewing and analyzing the data fresh. We had limited success with forming "snowballs", the subjects were more often located by informal inquiry and by the volunteered publicity provided by the local CBC radio station
Data management and analysis. Although the NUDIST software is context-blind and language-dependent, these weaknesses were overcome to some extent, through reading all the interview transcripts, in-depth, prior to embarking on the NUDIST analysis. This allowed the researchers to ascertain which questions and concepts could be searched independently from the rest of the interview transcript, using the NUDIST software, and which were less-suited for this. A few concepts (i.e. group aspects, control, etc.) needed to be approached in a more holistic manner (by examining consultants' responses only within the context of the entire interview), due to consultants' answering some questions inconsistently, or addressing concepts in a piecemeal fashion, over several different questions.
Other sites with relatively large samples may benefit from using NUDIST or some similar software. Such qualitative analysis packages might prove indispensable for very large studies. In the future, research teams might be offered advice on preparing their interview protocols in certain ways before commencing research, in order to facilitate later data analysis by computer.
II. Negative Features:
Research Bias. It would be very easy to use this type of research as way of misrepresenting preconceived conclusions as objective findings. It requires a special vigilance not to slant_the results when the analytical process is essentially open-ended, although the compilation of standardized interview summaries for each interview and the utilization of the NUDIST software helped to minimize this risk. The British Columbia centre was aided in this vigilance by some rigorous editorial comments from Ruthbeth Finerman, technical advisor to the Key Informant study.
Some advance discussion of the problem of research bias would be useful for future Key Informant projects. Also, we believe that authors must be steadfast in refusing to offer answers to the kind of quantitative questions that cannot be answered with data that are not based on random sampling. Quantitative questions like "What percentage of the population was addicted?", "What proportion of casual users eventually progress to intensive use?" are being directed at the authors, although they cannot be answered on the basis of the Key Informant data.
WHO Questionnaire. The questionnaire originally provided by WHO proved to be too long and redundant for use in British Columbia. If other sites shared this experience, it will be important for the people who have worked with the existing questionnaire to confer in streamlining and reconstructing it for future use. This step should not be overlooked, because future mis-steps can be avoided by a small investment of energy now.
Interviewing. The validity and reliability of consultants' responses may have been limited, particularly in the case of addicted users, because interviews and observations were almost never conducted in the drug-using context. For example, depending on whether consultants were in their drug-using context or a more traditional one, systematically different behaviours and systematically different responses to questions like: why they use cocaine and other drugs, whether their friendships extend beyond the use of drugs, whether they are 'in control' of their drug use, etc., may have been detected (Matthews and Alexander, 1993). This could have a crucial impact on our understanding of the nature of addiction and ways to deal with it.
It would have also been beneficial to interview cocaine users on repeated occasions, both in the context in which their drug use occurs, as well as in the more traditional research context. A generally one-shot interview technique fails to facilitate interviewers' developing an overly strong rapport with their consultants. Interviewers are unlikely to infiltrate drug-using social groups to the same degree they might by using a stronger ethnographic approach.
In the British Columbia study, there was a very clear differences in the data collected by the four different interviewers. Upon reflection, we are convinced that this does not grow from bias on the part of the interviewers, but from a much more subtle chemistry which led different interviewers to find different sorts of consultants, and led consultants to agree to be interviewed by one interviewer, where they might have refused another. We feel that this problem can be best controlled by having a relatively large number of interviewers each of whom interviews a relatively small number of consultants. On the other hand, as mentioned above, it is important the number not grow so large that a reasonable standardization of the interviewing technique becomes impossible.
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[i]. This includes the 24 current users from Table 1 plus 3 "user/intermediaries" and 1 "user/professional".
[ii]. These percentages do not actually appear in the report of the random sample survey, but were produced by a simple recalculation of data that appear in the report (Co-ordinated Law Enforcement Unit, 1987, pp. 43-44).