A. INTRODUCTION
Although the vast majority of Americans do not use illegal drugs, their use by a small minority affects the public health of the United States in many ways. This chapter focuses on cocaine use and its public health impact on the national community. The chapter analyzes both the impact of cocaine generally, and, where possible, the different impacts of powder and crack cocaine specifically. Section B examines current use data, including demographic information indicating use trends by such factors as gender, age, and race, through the findings of four separate national data collection efforts monitoring cocaine use. Section C examines various health effects of cocaine use, including the link between cocaine use and sexually transmitted and other diseases and the effects of cocaine use during and following pregnancy. Section D surveys other social problems affected by cocaine use, including the impact of cocaine use on social institutions and the workplace, and the connection between cocaine and domestic violence. Finally, Section E examines the availability of treatment for cocaine users.
B. TRENDS IN COCAINE USE IN THE UNITED STATES
The federal government funds several major data collection efforts to measure the prevalence of drug use across the nation. Each of these efforts taps a different data source for information on a specific population subgroup. No single dataset is currently available to provide precise national estimates of either casual or heavy drug use or precise demographic breakdown of users. When these separate data sources are examined collectively, however, a broad view of cocaine use in the United States emerges.
It is important to note that the data presented here relate to cocaine users and not cocaine traffickers. There is little statistical data on the overall numbers or demographic breakdown of cocaine traffickers. The information that is available on cocaine traffickers is discussed in Chapters 4 and 7.
Drug use statistics from four data sources are presented here:
The National Household Survey on Drug Abuse (NHSDA);
The Drug Use Forecasting Program (DUF);
The Drug Abuse Warning Network (DAWN): Hospital Data; and
The Drug Abuse Warning Network (DAWN): Medical Examiner Data.
Table 3 describes the characteristics of these data sources including the limitations on their application to drug use analyses.
1. Drug Use Among the Household Population
The National Institute on Drug Abuse (NIDA) has annually conducted the National Household Survey on Drug Abuse (NHSDA). This self-report survey produces estimates of drug use among household members aged 12 years and older in the contiguous United States. One of the NHSDA's limitations is its omission of the homeless, prisoners, and those in residential drug treatment.
a. General Prevalences
Data from the 1991 NHSDA indicate that while most people reported they have never used cocaine, 11.5 percent of the population reported using it at least once during their lifetime, 3.0 percent reported using it at least once in the past year, and 0.9 percent reported using it in the past month. National Institute on Drug Abuse, National Household Survey on Drug Abuse: Main Findings 1991 58 (Table 4.4) (May 1993) (hereinafter "NHSDA:1991"). National trend data from the NHSDA indicate that recent cocaine use (i.e., use at least once during the previous year) peaked at 6.0 percent between 1985 and 1988 and has declined since. Id. at 60 (Table 4.6). In 1988, 4.1 percent of the population were using cocaine at least once during the survey year, compared to 3.0 percent in 1992. Similarly, monthly use of cocaine has declined since 1988. In that year, the NHSDA estimated that 1.5 percent of the population were using cocaine at least once in the past month, compared to 0.6 percent in 1992.
For four years since 1988, the NHSDA has asked about the use of crack separately from general cocaine use. Trends in the use by the general population of the two forms of cocaine are shown in Figure 5. While use of all cocaine has declined, the use of crack has remained relatively stable. The data indicate that 0.5 percent of the population were using crack at least once a year during 1988, compared with 0.4 percent in 1992. From 1988 through 1992, NHSDA reports no change in the monthly use of crack (0.2%).
Table 3
Figure 5
According to the NHSDA report, crack cocaine use was most common among young and middle-aged adults, males, especially those who were Blacks, residents of metropolitan areas, those with less than a high school education, and the unemployed. Id.
Although the NHSDA data indicate that the number of casual users of all forms of cocaine has declined substantially, from 7.3 million in 1988 to 5.5 million in 1990, the same data indicate that the number of hard-core users has remained fairly constant. The NHSDA study estimated more than 2.1 million "heavy" cocaine users for 1991, a number that has changed little since 1988, and reported approximately 620,000 Americans (0.3%) using cocaine on a weekly basis. In fact, this number has remained fairly constant since 1985. Id. at 40, 60. These findings suggest that little progress has been made in combating cocaine abuse within the hard-core user population. See e.g., D. Hunt and W. Rhodes, Office of National Drug Control Policy, Characteristics of Heavy Cocaine Users Including Polydrug Use, Criminal Activity, and Health Risks (Dec. 1992).
According to the NHSDA data, among those who used cocaine at least once in the past year, insufflation ("snorting") is the most common route of administration. A total of 76.0 percent of such cocaine users snort cocaine, while 27.9 percent smoke cocaine. About equal percentages (10.8% and 10.5%, respectively) either ingest or intravenously inject cocaine. NHSDA: 1991, supra note 1, at 61 (Table 4.7). Data on routes of administration reflect that some number of respondents reported using more than a single route of administration during the survey year. Figure 6 details the NHSDA data on prevalence of the various routes of administration of cocaine.
b. Age and Trends in Cocaine Use
The rates of those who reported using cocaine in any form during each of the survey years are consistently and significantly highest for individuals aged 18 to 25 years, peaking in 1979. Since 1985, the data indicate a steady decline in use across all age groups. Id. at 27 (Table 2.7). Figure 7 demonstrates rates of use in the survey years by age group.
The NHSDA reports that crack cocaine is most popular among young adults ages 18-25. However, of those who used cocaine in the past year, a higher proportion of 12- to 17-year-olds used
Figure 6
Figure 7
crack (26.7%) compared to 18- to 25-year olds (13.0%), 26- to 34-year-olds (15.7%), or 35 years and older (21.4%). Id. at 56, 63 (figures derived from Tables 4.2 and 4.9).
In addition to the NHSDA, NIDA conducts an annual survey of drug use among high schoolers. That survey also has shown a decline in both powder and crack cocaine use since 1986 (the first year the survey included questions on crack cocaine use). In 1986, 12.7 percent of twelfth graders reported using cocaine (of any kind) at least once in the reporting year. In 1994, 3.6 percent reported using cocaine in the reporting year. Similarly, in 1986, 4.1 percent of twelfth graders reported using crack cocaine at least once in the reporting year versus 1.9 percent in 1994. It is worth noting that in the last year (between 1993 and 1994) there was a slight increase in both crack and powder cocaine use among young people (a 0.4% increase for crack and a 0.3% increase for powder) National Institute on Drug Abuse, Monitoring the Future Study, (Table 3) (Dec. 1994).
The high schooler survey also provides trend data on the occasional use of cocaine and crack by young adults. Among young adults NHSDA data indicate a decline in the use of both of these drugs. From 1987 through 1993, there was a 71 percent (13.6% to 3.9%) decrease in the proportion of young adults reporting the use of cocaine within the past year. Also declining substantially were the proportion of young adults reporting cocaine use within the past 30 days, which decreased by 77% (4.8% to 1.1%) between 1987 and 1993. During this period, the data show a 58 percent drop in the proportion of young adults that used crack at least once in the past year. From 1987 to 1990, the proportion of young adults reporting crack use within the past month decreased 60 percent (1.0% to 0.4%). However, from 1990 through 1993, the percentage of young adults reporting crack use within the past month remained constant.
c. Race and Trends in Cocaine Use
Public opinion tends to associate the country's drug crisis, specifically its perceived "crack problem," with Black, innercity neighborhoods. M. Fullilove, "Perceptions and Misperceptions of Race and Drug Use," 269 Journal of the American Medical Association 1034 (Feb. 24, 1993). The NHSDA found that cocaine in any form was used by 2.8 percent of Whites, 3.9 percent of Blacks, and 3.8 percent of Hispanics in the survey population during the 1991 reporting year. NHSDA: 1991, supra 1, at 56. Because Blacks and Hispanics comprise significantly smaller percentages of the total population, the majority of those reporting cocaine use were White. The survey found that of those reporting cocaine use at least once in the reporting year, 75 percent were White, 15 percent Black, and 10 percent Hispanic. And of those reporting crack use at least once in the reporting year, 52 percent were White, 38 percent were Black, and 10 percent were Hispanic. (Thus, within racial categories, 0.3% of Whites, 1.5% of Blacks, and 0.6% of Hispanics reported crack cocaine use at least once in the reporting year.)
The survey found that of those reporting any form of cocaine use at least once in their lifetime, 82 percent were White, 10 percent Black, and 8 percent Hispanic (within racial categories, 11.8% of Whites, 11.2% of Blacks, and 11.1% of Hispanics reported some form of cocaine use in their lifetime). Of those reporting crack cocaine use at least once in their lifetime, 65 percent were White, 26 percent Black, and 9 percent Hispanic (within racial categories, 0.3% of Whites, 1.5% of Blacks, and 0.6% of Hispanics). See, e.g., S. Belenko, Crack and the Evolution of Anti-Drug Policy (1993). Because so few report crack use in the past month, NIDA does not publish a racial breakdown of those figures. Id. at 49-50. Of Blacks using cocaine, more than twice as many reported using powder cocaine than using crack cocaine. Percentages of use by race have shifted somewhat over time, but percentages of all races using cocaine have steadily declined since 1985. NHSDA:1991, supra note 1.
A significant limitation on the observations that may be made from data on race and cocaine use trends is that race is highly correlated with place of residence, and neighborhood-level social and environmental conditions are significant factors driving drug abuse. Also, as will be discussed in Chapter 4, the ability to distribute crack cocaine in single-dose amounts makes crack cocaine more marketable in lower-income neighborhoods than powder cocaine, sold only in larger, more expensive quantities.
A recent study reanalyzed NHSDA data using neighborhood and social condition explanatory factors. The analysis found that crack cocaine smoking did not depend strongly on the race of the individual, but instead on social conditions. The study noted that if factors such as drug availability and social conditions are held constant, the odds of crack cocaine use within a population do not differ significantly by race/ethnicity. M. Lillie-Blanton, J. Anthony, and C. Schuster, "Probing the Meaning of Racial/Ethnic Group Comparisons in Crack Cocaine Smoking," 269 Journal of the American Medical Association 993, 996 (Feb. 24, 1993). Consistent with this, a study in the Miami, Florida metropolitan area, which recruited a street-based sample of 350 cocaine users, found few differences in level of crack use among participants aged 13-29 years based on the race of the individual. With the exception of one sub-group (Hispanics aged 20-29 years), more than 90 percent of participants reported that crack was the primary form of cocaine used, regardless of race. The authors also report that among older cocaine users (aged 30-49 years), Whites are more likely to report crack as the primary form of cocaine used and Blacks are least likely to use crack as their primary form of cocaine ingestion. Lockwood, D., Pottieger, A., Inciardi, J. Crack Use, Crime by Crack Users, and Ethnicity. For publication in: Darnell F. Hawkins (ed) Ethnicity, Race and Crime, Suny Press, 1994. See also United States Sentencing Commission, Hearing on Crack Cocaine 73-75 (statement of Dr. Jerome H. Skolnick, Professor of Law at the University of California at Berkeley) for further support of this funding.
d. Other Demographic Trends in Cocaine Use
Metropolitan Areas. The NHSDA data indicate that the highest rates of cocaine use were reported in large metropolitan areas. Of those surveyed from large metropolitan populations, 3.4 percent reported using cocaine in the past year, compared with 3.0 percent of those from smaller metropolitan populations and 2.3 percent of those from non-metropolitan populations. NHSDA: 1991, supra note 1, at 56 (Table 4.2).
Gender. The 1992 NHSDA indicates that 3.2 percent of males reported using cocaine at least once in the past year, compared to 1.7 percent of women. National Institute on Drug Abuse, National Household Survey on Drug Abuse: Population Estimates 1992 115 (Table 21-A) (Oct. 1993) (hereinafter "1992 Population Estimates"). In 1991, the rate of males using cocaine in the past year (4.1%) was more than twice that for females (2.0%). Id. Since 1985, the rates of use for men have been roughly twice as high as the rates for women, although rates of use for both genders have consistently declined.
Employment. Of the people reporting cocaine use during the 1991 reporting year, 71.4 percent were employed. NHSDA:1991, supra note 1 at 56 (Table 4.2) (this reflects an estimated 0.9 million adult employed cocaine users). However, the rate of use is higher for the unemployed. NIDA's 1991 survey indicates that 11.8 percent of unemployed persons used cocaine in the past year, compared to 3.2 percent of the employed. Id.
2. Drug Use Among the Arrestee Population
The Drug Use Forecasting (DUF) program collects data on drug use by arrestees but does not distinguish between crack and powder cocaine. U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, Drug Use Forecasting 1993 Annual Report (Nov. 1994). These data result from analysis of voluntary and anonymous urine samples collected at booking centers across the country. As will be discussed in Chapter 6, various factors including the national drug enforcement strategy, local law enforcement training, priorities, and resources, and individual prosecutorial discretion affect police charging decisions. All of these factors affect the demographics of arrestees generally, and, thus, of arrestee populations sampled for DUF analysis.
The DUF 1993 Annual Report indicates that cocaine use among arrestees remains at high levels and continues to be the most prevalent drug used by arrestees in 1993. The percent of male arrestees testing positive for the use of cocaine range from a low of 19 percent in Omaha, Nebraska, (where 54% tested positive for any drug) to a high of 66 percent in Manhattan, New York (where 78% tested positive for any drug). The percent of female arrestees testing positive for cocaine ranged from a low of 19 percent in Indianapolis, Indiana (where 51 percent of female arrestees tested positive for any drug), to a high of 70 percent in Manhattan, New York (where 83% of female arrestees tested positive for any drug). Consistent with DUF findings since 1987, cocaine remains the most pervasive drug among both male and female arrestees.
3. Hospital Emergency Room Episodes
The Drug Abuse Warning Network (DAWN) gathers data on drug-related emergency room visits and medical examiner cases as reported from selected hospitals and medical examiners in specified metropolitan areas. DAWN data for 1992 indicate an upward trend in drug-related (any drug type) hospital emergency room visits since 1990, with an estimated 433,493 such visits in 1992. National Institute on Drug Abuse, Series 1, Number 12-A, Annual Emergency Room Data 1992 85 (Table 4.03) (Mar. 1994) (hereinafter "1992 Emergency Room Data"). Note that alcohol in combination with any other drug remains the largest component of emergency room drug episodes. Data demonstrate a similar trend in cocaine-related episodes, with the total increasing from one percent of all emergency room visits in 1978 to 27.6 percent in 1992. Cocaine ranked second only to alcohol in drug mentions.
The 119,843 cocaine-related episodes reported in 1992 represented an 18-percent increase from 1991. Cocaine-related emergency care was divided fairly equally among detoxification (25.7%), unexpected reaction (24.0%), and chronic effects of habitual use (19.5%). Id. at 44 (Table 2.14). The number of visits related either to unexpected reactions from cocaine or to its chronic effects increased by more than 50 percent since 1990. Cocaine-related emergencies were also sometimes associated with overdosing (13.6%). Id. at 44 (Table 2.14). Information on reason for emergency room visit was missing for 15.3 percent of cocaine drug abuse mentions. In addition, between 1991 and 1992, cocaine mentions increased for almost every demographic subgroup. Id. at 41 (Table 2.11). In 1992, 57.7 percent of episodes involved Blacks, 26.6 percent involved Whites, and 9.9 percent involved Hispanics. Id.
While cocaine-related episodes have risen, increased use of other drugs has contributed to the overall increase in emergency room episodes. Since 1990, heroin-related episodes have risen considerably: in 1992, the 48,003 mentions represent a 34-percent increase compared to the previous year. Id. at 85 (Table 4.03). Between 1990 and 1992, the number of heroin-related emergency room episodes more than doubled in Boston, Baltimore, and New York City. Id. at 88 (Table 4.05b). Marijuana- and hashish-related episodes are at their highest levels since 1988 and reflect a 48-percent increase between 1991 and 1992. PCP has received increased mentions as well. Id. at 85 (Table 4.03).
In addition to information on reasons for seeking emergency care, the DAWN Emergency Room Data examine motives for drug use by those who sought emergency room care. Of those reporting use due to drug dependence or for recreational purposes, 64.6 percent reported dependence on cocaine and 12.5 percent reported recreational use of cocaine. Id. at 43 (Table 2.13). For drug-use motive, 13.8 percent of the information on cocaine mentions is missing. Although alcohol (30.9%) remains the most frequently mentioned drug used in combination with other drugs, cocaine (25.7%) ranks a close second. Id. at 49 (Table 2.19).
DAWN does not distinguish between crack cocaine and powder cocaine; however, information on route of administration is a proxy for distinguishing between the two forms of cocaine. Injection or snorting involves only powder cocaine; smoking (inhalation) is most likely to involve crack cocaine, although it could involve "freebasing" powder cocaine (see Chapter 2 for a further discussion of routes of cocaine administration). For cases in which information on the route of administration was available, DAWN reported that 38.2 percent of emergency room admissions involved smoking; 17.5 percent involved injection; and 11.3 percent involved snorting. Id. at 47 (Table 2.17). In 30 percent of the cases, the route of administration was unavailable. Id. These data indicate that most cocaine-related hospital emergencies involve the two most rapid routes of cocaine administration - inhalation and injection - but that episodes involving smoking are two times higher than those involving injection. Figure 8 illustrates DAWN data on cocaine-related emergencies by the primary reported route of cocaine administration. Figure 8 also arrays cocaine death data by route of administration.
The emergency room data indicate significant increases in cocaine-related visits, and the DAWN report provides three possible hypotheses for the increases. First, the DAWN report posits that higher purity levels may account for the increase in emergency room visits. The Drug Enforcement Administration reports that the average purity of an ounce of powder cocaine increased from 58 percent in 1990 to 74 percent in 1992. During that time, the number of cocaine-related emergency room visits attributed to overdose increased by 47 percent. 1992 Emergency Room Data, supra note 23, at 45.
Second, changes in patterns of use, such as route of administration or dosage amount, may impact on the number of emergency room visits. For example, DAWN posits that the emergence of crack smoking in the mid-1980s may be responsible for the increase in cocaine mentions. DAWN data presented in Figure 8 illustrate that smoking was the most common administration route for cocaine-related hospital emergencies.
Finally, reports of an increase in the rate of polydrug use may account for the change. Past DAWN reports indicate that cocaine users, in general, are more likely to be polydrug users than are users of other drugs. Id. at 49 (Table 2.19). As mentioned in Chapter 2, polydrug use the concurrent use of two or more drugs significantly increases the risk of injury or death. For example, in 1992, 60.0 percent of cocaine-related emergency room admissions Id. and 73.2 percent of all cocaine-related deaths involved at least one other drug. National Institute on Drug Abuse, 1992 Medical Examiner Data 31 (Table 2.17) (1994) (hereinafter "1992 Medical Examiner Data").
Figure 8
Consistent with the increased toxicity of concurrently administered cocaine and alcohol, Concurrent use of cocaine and alcohol results in the body's manufacture of cocaethylene, a pharmacologically active metabolite that stimulates the cardiovascular system and produces the same feelings of euphoria as cocaine. The effects of cocaethylene are similar to - but more intense, longer-lasting, and more toxic - than those of cocaine alone. W. Hearn, S. Rose, J. Wagner, A. Ciareglio and D. Mash, "Cocaethylene is More Potent than Cocaine in Mediating Lethality," 39 Pharmacology and Biochemistry and Behavior 531-533 (1991). medical emergencies are most likely when the drug used with cocaine is alcohol. Their concurrent use accounted for 40.8 percent of cocaine-related emergency room admissions. 1992 Emergency Room Data, supra note 23, at 51 (Table 2.21). Concurrent use of cocaine and heroin is the second most likely cause of cocaine-related emergency room admissions (12.7%). Id.
4. Medical Examiner Reports
DAWN gathers data on the number of deaths related to drug use. In 1991, 135 medical examiners in 21 metropolitan areas reported a total of 7,532 deaths that involved drug overdoses or in which drug abuse was a contributing factor. 1992 Medical Examiner Data, supra note 39, at 11 (Table 2.01). These data do not include deaths involving AIDS, homicide-related drug abuse deaths, or cases for which the drug used was unknown.
Consistent with the research discussed above, 74.5 percent of drug-related deaths involved polydrug use. Id. at 13 (Table 2.03). Among cocaine-related deaths, concurrent use with alcohol was the most deadly combination. The cocaine/alcohol combination was involved in 37.1 percent of cocaine-related deaths, 1992 Medical Examiner Data, supra note 39, at 33 (Table 2.19). followed closely by opiates and heroin, involved in 29.5 percent of deaths. Id.
In total, 45.8 percent of the drug-related deaths involved cocaine (either alone or in combination with another drug). Cocaine was the most frequently mentioned substance (46.0% of total episodes) among all drug-related deaths. The next most frequently mentioned substances were alcohol in combination with other drugs (34.1%) and heroin/morphine (38.7%). Id. at 16 (Table 2.06a). The number of drug-related deaths involving cocaine increased 20 percent between 1990 and 1991. Id. at iv. As shown in Figure 8, the most frequent route of administration for cocaine-related deaths was injection (12.7%). Id. at 30 (Table 2.16). Note that for 73.0 percent of the medical examiner reports on cocaine-mention deaths, data on the route of administration were missing. Cocaine-related deaths have been associated most commonly with respiratory failure, acute increase in blood pressure, rupture of a weak cerebral blood vessel, and major convulsive seizures. Id.
For the medical examiner data, cocaine was the drug most frequently mentioned for all age groups, for both sexes, and for two of the three racial categories: Blacks and Hispanics. The data show 43.5 percent of all mentions involved Blacks, 39.1 percent involved Whites, and 15.9 percent involved Hispanics. Id. at 26 (Table 2.12). Cocaine ranked third in frequency for Whites, behind alcohol in combination with another drug and heroin/morphine. Id. at 18-20. Route of administration and form of the drug were unavailable in most cases, making it impossible to determine how many of the deaths could be attributed to crack cocaine. Therefore, statistics for cocaine include all forms of the drug.
5. Combined Results for NHSDA, DUF, and DAWN
The data outlined above measure different aspects of the drug abuse problem and reflect patterns among different populations. A study conducted in 1992 for the Office of National Drug Control Policy combined results from NHSDA, DUF, and DAWN, along with several other reports, to estimate the number of heavy cocaine users in the United States. Hunt and Rhodes, supra note 5. This study does not distinguish between powder cocaine and crack cocaine.
The study estimated that the casual use of all forms of cocaine has decreased since 1988, while the number of hard-core users has remained fairly constant. Id. at 6 (Table 1). The study estimated more than 2.1 million heavy cocaine users in 1991, a number that has changed little since 1988. However, the number of casual users declined substantially from 7.3 million in 1988 to 5.5 million in 1990. See, e.g., Hunt and Rhodes, supra note 5; NHSDA: 1991, supra note 1.
A study utilizing much of this same data, conducted by the Rand Foundation and released in 1994, similarly found that fewer Americans are now using cocaine than in the 1980s. S. Everingham and C. Rydell, Drug Policy Research Center, Modeling the Demand for Cocaine 27 (Figure 3.8) (RAND) (1994). The report concluded, though, that total consumption has remained roughly constant, because of consumption by heavy users. Id. at 15-18. Heavy users were defined in the study as those using cocaine at least once a week. The report calculated that heavy users accounted for more than two-thirds of the total demand for cocaine in 1992, up from less than one-half in 1980. Id.
C. COCAINE USE AND HEALTH EFFECTS
The use of illicit drugs, including all forms of cocaine, impacts the public health of the United States in many ways. This section examines various health effects of cocaine use, including the link between cocaine use and HIV infection, sexually transmitted diseases, and the effects of cocaine use during and following pregnancy.
1. Cocaine and Disease Transmission
Cocaine use raises serious public health concerns about disease transmission due to the patterns of cocaine use, the commonly associated phenomenon of user binges, and the rise of "shooting galleries" (for powder cocaine) and "crack houses" (for crack cocaine). These concerns center on four major areas: 1) HIV and AIDS transmission; 2) other sexually transmitted diseases (STDs); 3) prostitution; and 4) other diseases.
a. Cocaine and HIV/AIDS Transmission
i. Intravenous Cocaine Injection
More than 30 percent of individuals with Acquired Immunodeficiency Syndrome (AIDS) are abusers of intravenous (IV) drugs. Thousands of other IV drug abusers carry the Human Immunodeficiency Virus (HIV), the virus that causes AIDS. G. Pratsinak and R. Alexander (Eds.), Understanding Substance Abuse and Treatment 157 (1992). Intravenous drug users who share needles, syringes, or other drug equipment (such as drug-injection cookers or cotton balls) can exchange small amounts of blood on these articles and transmit the virus. D. Longshore and M. Anglin, HIV Transmission and Risk Behavior among Drug Users in Los Angeles County 1991 Update (1991).
The spread of the AIDS virus is positively associated with IV drug injection. Id. In the prototypical "shooting gallery" environment, drug injection equipment is passed from one user to another, producing an increased risk for the transmission of the HIV virus. M. Wallace, M. Galanter, H. Lifshutz, and K. Krasinski, "Women at High Risk of HIV Infection from Drug Use," 12 Journal of Addictive Diseases 83 (1993). In addition, IV cocaine use is believed to present a higher risk of HIV infection than do the use of heroin or other IV drugs because of the relatively short-lived euphoria of cocaine (i.e., cocaine injectors are more likely to reinject frequently to sustain the drug high than are abusers who inject other illicit drugs such as heroin). "New Evidence Links Cocaine Use and HIV," 30 Journal of Psychosocial Nursing 45 (1992). Consequently, cocaine injectors who frequent "shooting galleries" are at the greatest risk.
ii. Sexual Transmission
Drug use has been associated with an increased risk of HIV transmission through the high-risk sexual activity of users. Belenko, supra note 12, at 41 (1993). Compared to powder cocaine injectors, crack cocaine smokers exhibit more high-risk sexual behaviors, including multiple sexual partners, sex without condoms or other barriers, and sexual activity during or following drug use. R. Booth, J. Watters, and D. Chitwood, "HIV Risk-Related Sex Behaviors among Injection Drug Users, Crack Smokers, and Injection Drug Users Who Smoke Crack," 83 American Journal of Public Health 1146-1147 (1993). See also, B. Edlin, M.D., et al., "Intersecting Epidemics - Crack Cocaine Use and HIV Infection Among Inner-City Young Adults," The New England Journal of Medicine 1422 (Nov. 24, 1994). Whether crack cocaine is the cause of this association cannot be determined due to limitations in the available data. The relationship between crack cocaine smoking and high-risk sexual behavior holds across demographic and lifestyle groups. Longshore and Anglin, supra note 60, at 37. Another factor increasing the risk of HIV infection among crack cocaine users concerns "sex for crack," where an individual exchanges sex for a dose of crack cocaine. U.S. General Accounting Office, The Crack Cocaine Epidemic: Health Consequences and Treatment 20 (Jan. 1991). Although the practice of trading sex to support a drug habit is not unique to crack cocaine between one-quarter and one-third of all drug users have traded sex either for drugs or for the money to buy drugs Longshore and Anglin, supra note 60, at 28. this practice is common in "crack houses" that sell the drug and provide a location for its use. Consequently, rates of HIV infection are nearly equal between crack cocaine smokers who are at greater risk due to high-risk sexual practices and powder cocaine injectors who are at greater risk because of the potential for infection from shared injection equipment. Booth et al., supra note 65, at 1147.
Drug-related increases in HIV/AIDS transmission are not solely limited to the drug users themselves. For example, an increasing percentage (34% in 1991, up from 29% in 1986) of new female AIDS cases links transmission to heterosexual contact with high-risk partners. T. Ellerbrock, S. Lieb, P. Harrington, T. Bush, S. Schoenfisch, M. Oxtoby, J. Howell, M. Rogers and J. Witte, "Heterosexually Transmitted Human Immunodeficiency Virus Infection Among Pregnant Women in a Rural Florida Community," 327 New England Journal of Medicine 1704 (Dec. 10, 1992).
b. Cocaine and Other Sexually Transmitted Diseases
The same high-risk sexual behaviors that increase the likelihood of HIV transmission among crack cocaine smokers also increase the risk of sexually transmitted diseases (STDs) such as gonorrhea, herpes, and syphilis. The nationwide increase in syphilis in the late 1980s paralleled the growth in crack cocaine use. In some areas, the increase was concentrated among powder cocaine and crack cocaine users as well as prostitutes. Cases of penicillin-resistant gonorrhea also rose, with the new cases occurring in greater numbers among young Blacks, prostitutes, persons in low-income neighborhoods, and drug abusers. U.S. General Accounting Office, supra note 67, at 20-21.
Research indicates that crack cocaine users are significantly more likely to contract STDs than are intravenous powder cocaine users. For example, crack cocaine smokers were up to twice as likely as IV cocaine users to test positive for syphilis and gonorrhea. Booth et al., supra note 65, at 1146.
Public health professionals report that it is difficult to contain the spread of syphilis within the high-risk populations of either cocaine users or prostitutes. J. Hibbs and R. Gunn, "Public Health Intervention in a Cocaine-Related Syphilis Outbreak," 81 American Journal of Public Health 1259 (Oct. 1991). The difficulty is the ineffectiveness of established public health procedures for identifying and notifying sexual partners. Within the sexually active populations of crack cocaine smokers, including prostitutes and those who exchange sex specifically for crack (or for the money to acquire it), individuals are often unable or unwilling to provide information on the identity of their sexual partners or the location of crack houses. Centers for Disease Control, "Alternative Case-Finding Methods in a Crack-Related Syphilis Epidemic - Philadelphia," 40 Morbidity and Mortality Weekly Report 77 (Feb. 8, 1991).
Further, because members of these populations generally are not preventive health care consumers who receive regular medical attention, their infections are more likely to remain undiagnosed. Undiagnosed syphilis infections are spread easily. Public health officials are trying to develop alternative methods for case-finding to combat the crack-related spread of sexually transmitted disease. Centers for Disease Control, "Selective Screening to Augment Syphilis Case-Finding - Dallas, 1991," 42 Morbidity and Mortality Weekly Report 424 (June 11, 1993).
Finally, an increase in the non-HIV STD rates can trigger an increase in HIV infection rates. For example, genital sores produced by syphilis can provide open wounds that facilitate HIV transmission during sexual contact. U.S. General Accounting Office, supra note 67, at 21.
c. Cocaine and Other Diseases
Disease spread among drug users is a continuing concern of public health practitioners. In addition to the spread of the HIV virus and sexually transmitted diseases, transmission of other major diseases has been associated with cocaine use. For example, viral hepatitis is a disease that can be transmitted in the same manner as HIV/AIDS. N. Benowitz, "Clinical Pharmacology and Toxicology of Cocaine," 72 Pharmacology and Toxicology 9 (1993). Given the behavior profiles of IV cocaine abusers and crack smokers, users of either form of cocaine can be exposed. G. Comer, M. Mittal, S. Donelson, and T. Lee, "Cluster of Fulminant Hepatitis B in Crack Users," 86 American Journal of Gastroenterology 331 (1991). Also, as compared to the general population, powder cocaine users are at greater risk of contracting pneumonia, and crack smokers are at greater risk of exhibiting bronchitis, chronic cough, and black sputum. M. Ellenhorn and D. Barceloux, Medical Toxicology: Diagnosis and Treatment of Homeless Persons (1988).
2. Cocaine-Exposed Infants and Children
Another area of concern cited by policymakers is the danger of maternal drug use on children. "Cocaine-exposed infants" are newborns who have been exposed to cocaine prior to birth. "Crack babies," a term widely used in the media, is misleading because of the inability to determine whether the fetus's prenatal exposure was due to crack cocaine or some other form of cocaine. While many health practitioners associate cocaine-exposed infants with crack cocaine use, it must be noted that exposure to either powder cocaine or crack cocaine prior to birth produces the same types of symptoms and problems for the infant. Many health practitioners have noted a significant increase in cocaine-exposed infants since crack cocaine use became widespread. Researchers and scientists do not distinguish between the two forms of cocaine, however, and results of perinatal cocaine exposure studies apply to all forms of cocaine.
In addition, when children of drug-addicted mothers develop poorly, it is difficult to pinpoint the precise root of the problem. Factors other than cocaine abuse that affect the physiological or behavioral development of a child are commonly seen among cocaine-abusing women, and their presence may confound the results of research on developmental effects. J. Ellis, L. Byrd, W. Sexson and C. Patterson-Barnett, "In Utero Exposure to Cocaine: A Review," 86 Southern Medical Journal 725, 730 (July 1993). This document is an extensive review of available literature on the subject in which Ellis et al. summarize others' findings and draw some general conclusions based on the works they reviewed. These factors include poor nutrition, cigarette smoking, other drug use, National Institute on Drug Abuse, "Developmental Effects of Prenatal Drug Exposure May Be Overcome," NIDA Notes (Jan./Feb. 1992). lack of prenatal and postnatal care, and dysfunctional parenting. Each of these factors can cause many of the effects discussed below and limit the conclusions that can be drawn about the effects of cocaine exposure on infant and child development.
a. Incidence of Perinatal Drug Exposure
Existing data cannot estimate accurately the total number of in utero drug-exposed newborns due to several factors. National Institute on Drug Abuse, Maternal Drug Abuse and Drug Exposed Children: Understanding the Problem 12 (Sept. 1992). NIDA's National Pregnancy and Health Survey used a national probability sample covering approximately 5,000 hospital-delivering mothers in 106 hospitals. The hospitals screened the mothers for drug use upon admission and collected information on type of drug, frequency and duration of use, route of administration, doses consumed, infant status, and length of stay in the hospital. First, most research to date has focused on urban hospitals and as such reflects only the general demographics of the country's urban areas. Therefore, results from these studies cannot be generalized to the population as a whole. Second, these studies rely on mothers' self-reporting (a scenario that presents obvious incentives to underreport drug use) or on urine screenings at hospital admission (which may detect very recent drug use but will fail to detect use earlier in pregnancy). Consequently, the prevalence of drug-exposed infants may be underestimated. There is consequently no data reflecting the degree of exposure. The studies do not address at what levels of in utero exposure the exposed infant is likely to be affected. Note also that most studies of the effects of maternal cocaine use were conducted in the mid-1980s, prior to the surge in crack cocaine use.
Researchers using these limited data estimate that 7.5 to 17 percent of pregnant women use illicit drugs during their pregnancy, resulting in the births of 100,000 to 740,000 drug-exposed babies each year. A study of births in New York City reported that the proportion of birth certificates indicating maternal illicit substance abuse tripled between 1981 and 1987. Depending on the research, estimates of the number of cocaine-exposed babies born annually range from 30,000 to 160,000. D. Gomby and P. Shiono, "Estimating the Number of Substance-Exposed Infants," The Future of Children 22 (Spring 1991). W. Chavkin, "Treatment Programs Shun Addicted Pregnant Women," 2(15) Alcoholism & Drug Abuse Week 6 (Apr. 18, 1990). One study estimates that nationally two to three percent of all newborns have been exposed to cocaine. Id. at 23.
Although the national estimate of cocaine-exposed infants is notable at two to three percent, cocaine is used less frequently during pregnancy than other drugs. For example, fetal alcohol syndrome is a serious drug-related problem among newborns. Among its various problems, fetal alcohol syndrome is a known cause of central nervous system abnormalities. In addition, studies show that 38 percent of all newborns have been exposed to tobacco, and up to 12 percent of newborns have been exposed to marijuana. Gomby and Shiono, supra note 84, at 21-22.
b. Physiological Effects on the Fetus
Because the studies do not distinguish among cocaine-exposed infants, no medical evidence exists to indicate whether more infants are born to mothers who used crack cocaine during pregnancy versus those who used powder cocaine. Additionally, the research cannot determine whether a mother who uses crack cocaine during pregnancy is more likely to endanger her infant than a mother who uses similar amounts of powder cocaine. Further questions need to be explored in order to answer these questions. For example, the percentage of pregnant women who use crack cocaine as opposed to powder cocaine and whether pregnant crack users are likely to become frequent or binge users are two relationships that would appear to warrant further investigation.
Unlike infants exposed to narcotics or opiates prior to birth, cocaine-exposed infants are not born addicted to cocaine and typically do not experience withdrawal. However, cocaine use can produce detrimental effects on both the mother and the fetus. First, cocaine causes constriction of blood vessels that restricts the flow of oxygen and other vital nutrients to the fetus. The sudden constriction of blood vessels can also cause the placenta to tear away from the uterine wall, resulting in premature delivery. In addition, brain cells deprived of oxygen will atrophy and may die, leaving behind lesions on the surface of the brain, the effects of which are uncertain and may remain hidden for years. Heavy cocaine use during the later months of pregnancy can lead to a complete disruption of the fetal blood supply to an organ or a limb. Occasionally, cocaine-exposed children are born with obvious signs of abnormality such as organ deformities or shriveled arms or legs.
Cocaine use also is associated with in utero developmental problems, including increased incidence of spontaneous abortion, small head circumference, low birth weight, retarded growth, and urogenital abnormalities. See, generally, National Institute on Drug Abuse, supra note 82; Ellis et al., supra note 80, at 725; B. Zuckerman, "Effects of Maternal Marijuana and Cocaine Use on Fetal Growth," 320 New England Journal of Medicine 762 (Mar. 23, 1989). In addition, infants exposed to cocaine prior to birth are more likely to experience Sudden Infant Death Syndrome (SIDS), seizures, or neurobehavioral dysfunctions such as high irritability and arousal problems. See, Ellis et al., supra note 80, at 728. A recent study by Bauchner et al., found that risk of SIDS in infants exposed to cocaine was less than reported previously. The study reported that the elevated risk of SIDS among these infants probably reflects the health behaviors and socio-demographic characteristics of their mothers that are independently associated with SIDS. H. Bauchner, B. Zuckerman, M. McClain, D. Frank, L. Fried and H. Kayne, "Risk of Sudden Infant Death Syndrome Among Infants with In Utero Exposure to Cocaine," 113 Journal of Pediatricts 831, 834 (Nov. 1988).
c. Cocaine Exposure After Birth
In addition to uterine exposure, infants can be exposed to cocaine after birth in a variety of ways. Infants may be exposed indirectly through their mothers' breast milk or directly when nursing mothers apply cocaine to their nipples to reduce pain during breastfeeding. Infants may also be exposed, second-hand, to cocaine vapors via proximity to someone freebasing or smoking crack cocaine. Cocaine may also be deliberately administered to soothe colic or teething pain. United States Sentencing Commission, Hearing on Crack Cocaine 174 (Statement of Robert S. Hoffman) (Nov. 1993). Children suffering from cocaine poisoning via direct or second-hand vapor exposure may experience drowsiness, nausea, hallucinations, and coma. Infants exposed through breast milk may be susceptible to seizures, heart attacks, strokes, and death. Id.
d. Behavioral Effects on Infants and Children
Behavioral problems are the most commonly cited effect observed in cocaine-exposed children. A clear association has been found between maternal drug use and developmental difficulties. National Institute on Drug Abuse, supra note 82. For example, cocaine-exposed babies usually perform poorly on responsiveness tests. They are easily overstimulated, which can result in excessive sleeping or bouts of crying that may last hours.Id. For older children, maternal drug-use effects include developmental disabilities or behavioral dysfunctions. Researchers believe these adverse effects may be the result of cocaine's effect on the neurotransmitters, the signals that help control a person's mood and responsiveness.
e. Mitigating Behavioral Effects Through Intervention
Post-natal studies on cocaine-exposed children confirm that the physiological and behavioral development of these children is not determined solely by their mothers' drug use. Important factors include the quality of health care, family lifestyle, and the genetic disposition of both the mother and the child.
To mitigate complications, early intervention for cocaine-exposed children is crucial. One study examined 400 children exposed to cocaine or other drugs before birth and followed their subsequent development. Pregnant women in the study received prenatal care and participated in treatment programs during their pregnancy. Both the infants and their mothers received intensive postnatal support. I. Chasnoff, "Hope for a Lost Generation," School Safety 4 (Winter 1992). Importantly, researchers found that cocaine exposure does not affect intellectual functioning. Id. Of the children born to these mothers, 95 percent were "mainstreamed" in school and required no special educational interventions. Id. However, behavioral abnormalities continued for a small percentage of these children.
f. Economic Costs of Cocaine-Exposed Infant Care
In addition to physiological and developmental risks for both mother and fetus, the cost of caring for cocaine-exposed infants imposes an added burden on the health-care and welfare systems of this country. Costs of prenatal substance abuse are incurred in both the short and long term. Short-term costs include: longer hospital stays for both mother and infant, special care provided by neonatal intensive care units, lost productivity from job and family-related activities, and boarding of babies until child welfare systems can place the child in foster care. C. Phibbs, "The Economic Implications of Prenatal Substance Abuse," The Future of Children 114 (Spring 1991). "Boarder babies" refers to infants who stay in a hospital after they have been cleared for medical discharge. Typically, these infants no longer require medical attention but must undergo a social evaluation or placement in foster care, generally because their mothers are unable or unfit to care for them. Long-term costs, which are harder to quantify, can include: treatment for chronically ill or disabled children, treatment of AIDS-related illness, placements in foster care, and special education needs. Id.
A 1985-86 cost analysis study at Harlem Hospital in New York City estimated neonatal cost differentials for cocaine-exposed versus unexposed infants. This study found that neonatal hospital costs were $5,200 higher for cocaine-exposed infants than for unexposed infants. Neonatal medical (physician) costs were $2,610 higher, and lengths of hospital stay increased by four days for cocaine-exposed infants when compared to unexposed infants. C. Phibbs, D. Bateman and R. Schwartz, "The Neonatal Costs of Maternal Cocaine Use," 266 Journal of the American Medical Association 1521 (Sept. 18, 1991).
Exposure to other illicit substances was associated with higher costs and longer stays as well. Id. Finally, the study suggests that drug treatment programs and prevention targeted at this population of users could substantially reduce the short-term costs of prenatal cocaine exposure.
g. Governmental Responses to Perinatal Drug Exposure
Many states have vacillated in their response to mothers giving birth to drug-exposed babies. Several states now have laws that allow child-abuse charges to be pressed against any woman with illegal drugs in her bloodstream who gives birth to a child , arguing that the presence of illegal drugs is prima facia evidence of child neglect. Other states have simply removed exposed babies from their mothers, making them wards of the state. However, some of these states have more recently turned to intensive treatment programs rather than removing the children from their mothers. These programs often adopt a carrot and stick approach, directing mothers whose newborns test positive for cocaine to enter a treatment program or give up the child. J. Willwerth, "Should We Take Away Their Kids? Often the Best Way to Save the Child is to Save the Mother As Well," 137 Time (May 13, 1991).
D. OTHER SOCIAL PROBLEMS AFFECTED BY COCAINE USE
In addition to its impact on public health, cocaine use may affect other social problems. This section reviews available information relating to the effects of cocaine use on domestic violence and social institutions, including the workplace and the family.
1. Cocaine and Domestic Violence
Studies of domestic violence have long pointed to alcohol and drugs as contributing factors in violence within the family. See, e.g., K. Leonard and T. Jacob, "Alcohol, Alcoholism, and Family Violence," Handbook of Family Violence (1988). However, most research examines the impacts of generic "substance abuse" rather than specific effects of individual drugs on either spousal abuse B. Miller, T. Nochajski, K. Leonard, H. Blane, D. Gondoli and P. Bowers, "Spousal Violence and Alcohol/Drug Problems Among Parolees and Their Spouses," 1 Women and Criminal Justice 55, 56 (1990). or child abuse. J. Bays, "Substance Abuse and Child Abuse, Impact of Addiction on the Child," 37 (4) Pediatric Clinics of North America (1990).
Research on domestic violence suggests that alcohol abuse by itself may represent a far greater risk for domestic violence than illicit drug use. M. de la Rosa, "Introduction: Exploring the Substance Abuse-Violence Connection," in M. de La Rosa, B. Gropper, and E. Lambert (Eds.), Drugs and Violence: Causes, Correlates, and Consequences 5 (1990). It is difficult to predict the potential outcome if illicit drugs are used in combination with alcohol. The psychopharmacological effects of an illicit drug may mitigate or enhance the effects of alcohol, and it is likely that the level and direction of the effects will vary by drug and by an individual's reaction to a drug. Id. at 184-188.
There is very little information concerning the relationship between cocaine and domestic violence or the relationship of crack versus powder cocaine and domestic violence. Researchers have consistently found, however, that domestic violence increases in families where there is alcohol or drug abuse. Bays, supra note 104, at 891. Most researchers agree "[i]t is . . . clear that the great majority of battery incidents are alcohol and/or drug related." A. Roberts, "Psychosocial Characteristics of Batterers: A Study of 234 Men Charged with Domestic Violence Offenses," 2 Journal of Family Violence 81, 82 (1987). The general consensus in the research community is that in domestic violence, alcohol abuse is more prevalent than drug abuse, Id. at 82. and the relationship between alcohol abuse and spousal abuse is the most significant. Most research shows that 60 to 70 percent of batterers are under the influence of alcohol. Correspondingly, only 13 to 20 percent of batterers are under the influence of some drug other than alcohol. Similarly, research shows an important association between alcohol consumption and violence against children.
2. Cocaine in the Workplace
Data from the 1991 NIDA National Household Survey indicate that 13.1 percent of full-time employees reported illicit drug use during the survey year. About half that rate, 6.3 percent, reported use of any illicit drug during the past month. NHSDA: 1991, supra note 1, at 35-36. In an earlier NIDA study on drugs in the workplace, 8.2 percent of full-time employees reported current illegal drug use. National Institute On Drug Abuse, Research on Drugs and the Workplace, NIDA Capsules 1 (1990). This shows a reduction in the rate of use from 8.2 to 6.3 percent between 1989 and 1991. "Current use" is defined as use within the past month. In comparison, 3.2 percent of the full-time employed reported use of cocaine in the past year and 1.0 percent reported use in the past month. NHSDA: 1991, supra note 1, at 56-57. Of the full-time employed, 0.4 percent reported use of crack cocaine in the past year. Id. at 63. Data on monthly use of crack cocaine among the employed were not available. Studies have shown that employees who have used illegal drugs recently consume more medical benefits, file more workers' compensation claims, are absent more often, and are fired more frequently than other workers. Id. at 2.
Although the cost of drug abuse to American businesses is difficult to determine, one study estimates that drug-induced absenteeism, accidents, fatalities, damages to equipment, insurance claims, tardiness, theft, and decreases in worker productivity cost American businesses tens of billions of dollars annually. S. Smarr, "The Dope on Drugs in the Workplace," 31 Bobbin 100, 100 (1989). In 1986, estimates for lost productivity alone resulting from drug and alcohol abuse ranged from $60 to $100 billion. T. Rosen, "Identification of Substance Abusers in the Workplace," 16 Public Personnel Management 197 (1987). Alcohol accounted for $50.6 billion in reduced productivity in 1980, compared with $25.7 billion for all other drugs combined. Estimates generally focus on the costs of alcohol compared to other drugs, rarely distinguishing between specific illegal drugs. Id. at 198.
3. Social Isolation and Cocaine Abuse
When cocaine use becomes uncontrolled, an individual's links to the social and economic world can disintegrate. Physical, psychological, and behavioral changes can begin soon after an individual begins to use cocaine. However, in general, clear-cut and identifiable changes in the consistent cocaine user may not be apparent for three to six months for crack cocaine users or two years or longer for powder cocaine users. D. Allen and J. Jekel, Crack: The Broken Promise 34 (1991).
As users become cocaine dependent, their family and social lives disintegrate. They concentrate their energies on finding the next dose; employed users may spend all earnings on cocaine; a parent may leave children unsupervised for extended periods. Id. at 29.
Unemployed cocaine abusers, like unemployed abusers of many drugs, frequently are asked to leave the family due to the friction caused by the cocaine dependence. In a study of voluntary inpatients in a hospital unit, 18.7 percent of the 245 study participants had been asked to leave their homes. More than half of those asked to leave (51.1%) became homeless (entering the homeless shelter system, living on the street, or moving among temporary situations in homes of friends or relatives). B. Wallace, "Crack Addiction: Treatment and Recovery Issues," Contemporary Drug Problems 74 (Spring 1990).
Research confirms that those who are homeless and abuse drugs are most likely to abuse alcohol, P. Fisher, "Estimating Prevalence of Alcohol, Drug, and Mental Health Problems in the Contemporary Homeless Population: A Review of the Literature," 16 Contemporary Drug Problems 334 (1989). but abuse of other drugs is common. For example, one Los Angeles study reported that just under one-third of homeless shelter residents abused drugs other than alcohol, P. Koegel, A. Burnam, and R. Farr, "The Prevalence of Specific Psychiatric Disorders Among Homeless Individuals in the Inner City of Los Angeles," 45 Archives of General Psychiatry 1088 (1988). while another study in Los Angeles reported that half of the homeless individuals surveyed had used illegal drugs within the past month. L. Gelberg, L. Linn and B. Leake, "Mental Health, Alcohol and Drug Use, and Criminal History Among Homeless Adults," 145 American Journal of Psychiatry 194 (1988). Note that the sample included homeless individuals located in shelters, parks, parking lots, shopping malls, soup kitchens, beach areas, food distribution centers, and job service/social service assistance areas. Homeless shelters in New York City reported that the most frequently abused drug among shelter residents was cocaine, both powder and crack. W. Breakey and P. Fischer, "Homelessness: The Extent of the Problem," 46 Journal of Social Issues 40 (1990).
E. AVAILABILITY OF TREATMENT FOR COCAINE ABUSERS
1. Treatment Strategy
Treatment for cocaine dependency is similar in many ways to treatment for dependency on other drugs, including alcohol. Generally, the strategy has two stages: detoxification and treatment. Detoxification, the precursor to treatment, focuses on getting the abuser to stop drug use and on monitoring the abuser's body until it is free of the drug. Because cocaine is not physically addictive, withdrawal - although unpleasant - is not physically hazardous or life-threatening for cocaine abusers. Detoxification may result in symptoms of irritability, depression, anxiety, sleep irregularities, lack of energy, and strong cravings. Pratsinak and Alexander, supra note 59, at 90. The severity of withdrawal varies depending on the predominant route of drug administration, frequency of use, and dosage amount.
After detoxification, the recovering abuser's drug treatment focuses on avoiding a relapse into drug use. There are three traditional formats for drug treatment that are used alone or in combination to meet the needs of the patient. These are inpatient treatment, residence in a therapeutic community, and outpatient treatment. R. Rawson, "Cut the Crack: The Policymaker's Guide to Cocaine Treatment," 51 Policy Review 11 (Winter 1990). Inpatient treatment is the most expensive of the drug treatment formats. In this format, the individual becomes a medical patient in a hospital or other medical facility, typically for one month. The patient usually is expected to participate in after-care following discharge. Id. Residence in a therapeutic community involves residing with other recovering abusers for a year or longer in a structured, hierarchical regimen designed to instill responsibility. Id. Outpatient treatment is the most commonly used drug treatment: the individual remains in his or her usual living environment and visits a treatment center for counseling and therapy. A. Washton, "Outpatient Treatment Techniques," in A. Washton and M. Gold (Eds.), Cocaine: A Clinician's Handbook 117 (1987).
Regardless of format, all treatment programs encourage either individual and/or peer group counseling, behavioral therapy, and support networks. The 12-step program developed under Alcoholics Anonymous and adopted by Narcotics Anonymous and Cocaine Anonymous is often cited as an effective component for drug abuse treatment success.
2. New Concepts in Cocaine Treatment
An emerging area of cocaine drug treatment research involves the development of drugs that lessen the distress from and/or diminish the craving for cocaine. In particular, pharmaceutical companies are seeking to develop drugs to block cocaine euphoria, to address post-use dysphoria, to curb cocaine desire, or to control depletion of dopamine from nerve synapses. While several such current research projects may prove promising, to date there is no demonstrated effective pharmacologic treatment for cocaine abuse. Benowitz, supra note 77, at 10.
Another experimental therapy for the treatment of crack cocaine addiction involves acupuncture. The treatment structure involves daily sessions of 45 minutes for ten to 14 days. Five needles are inserted into each ear to stimulate detoxification and relaxation. Preliminary results appear to indicate that acupuncture, coupled with additional types of therapy, can assist in the treatment process U.S. General Accounting Office, supra note 67. and help control craving and withdrawal symptoms. B. Wallace, Crack Cocaine: A Practical Treatment Approach for the Chemically Dependent 165 (1991).
3. Potential for Successful Treatment
These approaches to drug treatment are available regardless of drug type. There are no indications that the success of any given approach is particularly correlated to the drug of abuse. Rather, the success rate across drug types is related directly to the length of treatment. For example, those who complete the residence program in a therapeutic community have a greater than 75 percent chance of being drug free five to seven years later. The success rates are approximately 50 percent for those who stay in the program one year and approximately 25 percent for those who stay in the program less than one year. Id. at 175.
Because crack cocaine's popularity is a relatively recent phenomena, research has not yet produced conclusions concerning which, if any, of these treatment formats is most appropriate for crack cocaine abusers. Id. at 80. However, as is true for other drug and alcohol abusers, the diverse population of crack cocaine abusers makes it unlikely that one single "best" treatment modality will be identified.
As it is for all drug abuse treatment, "success" for cocaine treatment is difficult to define. Treatment practitioners traditionally consider two or three years of drug abstinence a success. However, even short periods of abstinence or continued cocaine use at reduced frequencies can indicate a positive treatment outcome. Success rates for cocaine drug treatment - measured as abstinence of one year or longer - vary from 25 to 50 percent. The higher rates are characteristic of abusers who are professional or skilled workers, with much lower success rates for unskilled workers and long-time users who also use other drugs. Benowitz, supra note 77, at 9. One study found that outpatient treatment combined with drug testing, individual and group therapy, and relapse prevention achieved a 75-percent success rate for recovering crack cocaine abusers who finished the program. Washton, supra note 130, at 171.
United States Sentencing Commission