Cocaine a Special Report

In 1982, a man--call him Tom--was hospitalized for aplastic anemia, a bone-marrow disease. Tom underwent surgery twice. He was 22 years old and psychologically normal, according to his physicians. One effect of his illness was sores in his mouth. As part of his treatment, for pain, he was given the topical anesthetic cocaine--about a third of a gram every four hours for 16 days. It got into his blood stream the same way cocaine gets into the blood stream of people who snort it: through the membranes that line the nose and mouth. A report in the New England Journal of Medicine explained what happened as a result:

Day 16 the patient's pulse rose ... to 140 [beats] per minute, and he had nausea, vomiting, headaches, insomnia, chills and fever, in spite of other normal vital signs. During the next 18 hours, he reported seeing ants on his clothes, in his food, on nursing personnel and throughout his room; his euphoric mood was punctuated by irritability and pressured speech. He saw "shadows" of his mother and related a hallucination in which he witnessed a cardiac arrest in an adjacent room. He became increasingly garrulous and active, pacing his room, cleaning his drawers, upholstering a chair [sic] and retaping his intravenous needle. During the next six hours, he exhibited jerking muscular movement, twitching of his head and extremities and a fine tremor. A tentative diagnosis of toxic cocaine psychosis was made.

There are a number of important implications of Tom's experience. For one thing, it was the first time cocaine psychosis had been observed in a controlled hospital setting. Such severe psychological reactions to cocaine had been reported by recreational users, but they remained rumor. Tom's case showed us what may sound absurd to people who have taken the drug without ill effects: Cocaine can make you crazy.

And his case also implied something far more complex and difficult to deal with. For when the doctors had reduced the dosage of cocaine to a third of a gram every 12 to 15 hours, Tom's behavior returned to normal. He recovered from the psychosis and tolerated the regular use of cocaine quite well.

What does Tom's case mean? Is cocaine dangerous? Is it safe in small doses? Is it addictive (and what does addictive mean)? Does cocaine eventually make you crazy? Or was there something special about Tom that made him see ants?

To answer such questions, Playboy sought out the top scientists, psychologists and psychiatrists doing work in cocaine research. What we learned was that the study of cocaine has by no means been thorough. There is little funding and there are few major researchers. The ones who are deeply involved, the quintessential experts, are represented here. And although they all seem to be reaching more or less the same conclusions independently--rather alarming news about cocaine--they are quick to admit that their findings need corroboration.

In part, that corroboration has been slow in coming due to the politics of drug research. Much of the study is funded by the Government through the National Institute on Drug Abuse (NIDA), and cocaine has traditionally been a hot potato. Many people in Government circles are reluctant to encourage research that doesn't say cocaine is 100 percent bad for 100 percent of the people. Tom's case is not black and white enough. Cocaine, in short, suffers from a public-relations problem. It has no Betty Ford.

The three scientists who have done the most significant cocaine research with humans in this country in the past ten years are Drs. Mark S. Gold, Ronald K. Siegel and David E. Smith. There are many other scientists who have done important work with animals and with the measurement of cocaine's chemical effects on the human body. But those are the nation's top experts concerning the larger questions: Is cocaine bad for me? How bad? Is it addictive? What will happen if I take it? Can I recover if I get into trouble taking it? Can it kill me?

Dr. Gold, director of research at Fair Oaks Hospital in Summit, New Jersey, established the National Cocaine Helpline, which people could call for help with cocaine problems. To everyone's surprise, some 400,000 people called during the first year. No one had guessed that the nation's cocaine problem was that large. Using the callers as a sample, Gold has generated the world's largest statistical base for information about the way people use cocaine (as opposed to the way scientists use cocaine on people in laboratories) and what it does to them.

Dr. Siegel has recently completed the first scientific study of regular cocaine users over a long period--nine years. Prior to Siegel's experiment, funded by NIDA, no one had ever determined what would happen to a group of people who used cocaine for nearly a decade. Siegel's findings are published here for the first time.

Dr. Smith founded the Haight-Ashbury Free Medical Clinic in 1967 to treat the victims of the drug explosion of the Sixties. In the decade and a half since then, he has become an internationally known researcher studying all drug addiction. His clinic and research facility are on the cutting edge of cocaine research and the receiving end of what he, Siegel and Gold agree is a major cocaine-abuse epidemic.

At this point, these three authorities are in agreement about three other important facts: (1) Cocaine is an addictive drug; (2) it is much more dangerous than we thought; (3) we need a lot more research before we know precisely how cocaine works and to whom it presents a danger.

•

The Haight-Ashbury Free Medical Clinic is located on Clayton Street between Haight and Page, near San Francisco's Golden Gate Park. For anyone who was there in the Sixties, the history pours off the street like vapor. The same junkies I saw there in 1967 and 1968 seem to be standing in the same line going up the stairs to the same clinic. But there have been changes as well. Dr. David Smith is no longer just an idealistic young doctor trying to help out junkies. He and a handful of colleagues around the world are changing the way we look at all drug addicts, from those we see in the gutter to those who appear on The Tonight Show.

I waited for Smith in the clinic's pharmacy, an upstairs room in an old house where detoxification drugs are dispensed to the patients. A sign on the door said, Mixing your Meds with Booze or dope can kill you. The room was close with people and cigarette smoke and the smell of sweat. A sign on the counter read, If you can't keep it together and lose your pills after leaving here, tough shift.

The pharmacy counter had been knocked together from plywood and two-by-fours, and behind it sat the doctor of pharmacology, Greg Hayner, a big, bearded man in a plaid shirt and blue jeans, dispensing pills and friendly banter. Next to him was a registered nurse, though you wouldn't have known it from her blue jeans and sweat shirt. "You come in here pinned again, I'll cut you off cold," she told one junkie who had eaten all his prescription pills the first night because he couldn't stand the pain. Behind her was a closet full of drugs. The walls were haphazardly decorated with posters of Santana, Grateful Dead, Stones, Traffic, Big Brother and the Holding Company, Dan Hicks and His Hot Licks--it was a museum of the Sixties, all those great bands that brought us all those great drugs.

But this was the last temple of junkies, seekers of atonement. This was the place where they made their last stand or died trying. It was serious business. Hayner picked up the phone and talked for a minute. Then he put his hand over the mouthpiece and said to the nurse, "This lady just did a shitload of coke and has all the symptoms of a heart attack and wants to know what to do." He was cool, as if handling a client who wanted to know what stock to buy today.

"She should go to an emergency room," the nurse said.

"I mean, numbness, nausea, pain in the left arm--everything."

"Emergency room. Just in case."

Most who go there are heroin addicts, and they know what their problem is: smack. Everybody knows you can overdose on smack. The woman on the line was another kind of junkie. Her problem was more complicated: She didn't know you could overdose on cocaine.

Smith publishes some of his scientific work with an M.D. researcher named Donald R. Wesson. Insiders call their papers Smith & Wessons, and their publication often comes with the impact of a .38 Special. Smith wears large spectacles and his skin is drawn and tan. He rolls his eyes heavenward as he talks of cocaine.

"I study addictive disease," he says. "Addiction may be a disease itself. That's how we regard it and that's how we treat it. There is a commonality of addictive process regardless of the drug." In other words, what you're taking does not matter as much as who you are. Some people will take the drug--any drug--and not get addicted. Others will take it once and be inexorably drawn to it. The drug is the same; the people are different.

Addiction is a term that has long been ill defined and often redefined. Today it has been defined again, though this time in a way seemingly more practical than ever before. An addictive drug is one that can produce in a significant number of people three conditions: (1) compulsion; (2) loss of control; and (3) continued use of the drug in spite of adverse effects. (continued on page 148)Cocaine(continued from page 114) Obviously, that leaves room for interpretation. The presumption is that we are all sensible enough to make reasonable interpretations. By that definition, for example, food could be considered addictive. And while some people, using nothing more dangerous than food, exhibit all three symptoms, no sensible person is going to suggest that we classify food as addictive. The fact is that the addictive properties of a substance appear to be far less important than a person's tendency to become addicted.

Years ago, scientists proposed the existence of an addictive personality--mental characteristics that link all addicts--but it has not stood the tests of time and further research. When an addict stops using the drug, his personality changes. He no longer fits the addictive personality.

Smith believes there may be something physically different about addicts that makes them get hooked on drugs. They have a disease. "My perception," he says, "is that it is a multifactorial illness, including psychophysiology, environment and pharmacological factors." Mind, body, environment and the drug itself interact to produce addiction.

If what Smith says is true, the implications are remarkable. If you suffer from addictive disease and try cocaine, alcohol, heroin or some other addictive drug, you will develop all the symptoms: compulsion, loss of control and continued use of the substance in spite of adverse consequences. If you do not have the disease, you may try those drugs and not suffer any ill effects. (Little is known about why some people become addicted to heroin and not cocaine, or to alcohol and not heroin, or to amphetamines and not cocaine, though addiction to several drugs at once is common.)

"Interestingly," Smith says, "the person who is addicted to cocaine responds differently the very first time he uses it. Later, he'll use terms that are qualitatively different from those that others use to describe the experience of taking cocaine the first time: 'This is the greatest thing that ever happened to me' or words to that effect. An alcoholic will use terms that are qualitatively different, too." The person with addictive disease, then, is mentally and physically different from the rest of the population, according to the findings of Smith and others.

That does not mean that someone who does not have addictive disease is immune to addiction. If you forcibly administer heroin to someone long enough, he will develop a physical dependence that can cause illness and even death. Physical withdrawal symptoms from cocaine addiction do exist, though they are not nearly as severe as those from heroin and alcohol. And they are insignificant in light of cocaine's devastating psychological effects during addiction and withdrawal.

"It is neither that coke is safe nor that everyone who touches it becomes addicted," says Smith. "If 100 people use cocaine, not all will become addicted to it. Not all people will become addicted to alcohol. Ten percent of the people who use alcohol become alcoholics. In our experience, ten percent of the people who are exposed to cocaine become addicted to it. About 30 to 40 percent will have an episode of dysfunction." That means they will have a seizure or a coke binge that makes them sick or in some other way feel the ill effects of the drug.

Smith believes he is treating the same disease in every case, whether the symptom is alcoholism, heroin addiction, amphetamine or cocaine or sedative addiction. Richard Pryor, Betty Ford, Daniel J. Travanti, Johnny Winter, Thomas "Hollywood" Henderson, Johnny Cash and Keith Richards all have the same disease.

"It means people can experiment with coke and not abuse it," Smith says. He is quick to add that it is quite a dangerous experiment. In addition, there are some special problems that go along with cocaine addiction. For one thing, the coke addict tends to be very naive about the drug he's taking.

"We see intelligent, successful individuals who have inadequate information about cocaine. The heroin addicts know heroin is dangerous and addictive. Cocaine addicts don't know what a street junkie knows." Smith says that he sees cocaine addicts who are amazed to learn that it can kill you. "And we've known for 100 years that cocaine can kill you.

"These are people who are highly motivated to quit," Smith adds. "These people see it and they become compulsive. I know a lawyer who had quit successfully, and one day a client tried to pay him in cocaine. He put a big pile of coke on the desk. And the lawyer tried for an hour to throw it in the toilet, but he couldn't touch it. His drug hunger was so strong that he had to call a friend to throw it in the toilet, because he was unable to touch it without actually using it up. Cocaine is like Kryptonite for these people."

•

"Substance-abuse disorders are a disease, but whether or not they're all one disease has yet to be proved," says Dr. Mark Gold. He established the toll-free number 800-Cocaine to help people having problems with cocaine and was astounded to find that some 1100 people a day called during the first year of operation (May 1983 to May 1984). In one three-month period, 100,000 people called. "An incredible 22,000,000 Americans--one out of every ten--report that they have used cocaine at least once," Gold says. "And every day, some 5000 teenagers and adults try it for the first time. Currently, we're stable at 1000 to 1200 calls a day on the hotline. I keep waking up and expecting no one to call, but there they are."

By asking the callers questions, Gold has been able to build an unprecedented body of information about cocaine users. Of a randomly selected 500 people who called 800-Cocaine, for example, "more than nine in ten said they had sometimes used their supply of the drug continuously until it was exhausted, no matter how much they had on hand." That is significant because it is the first of three conditions in the current definition of addiction: compulsion.

Large percentages of Gold's sample reported serious problems, most of them psychological and social. "For example, 45 percent of the 500 respondents said that they had stolen money from their employers and from family or friends to support their cocaine habit."

Based on his experience with the hotline, Gold says, "It's definitely true that there are people who have used cocaine and not become addicted; there's no question about that. But remember that to become a heroin addict, you have to use the drug multiple times a day for weeks. People have tried heroin and not become addicted, too." In other words, the risk is not worth it. In that regard, he and Smith are in complete agreement.

"We have learned some rather interesting things from our people," Gold says. "For example, looking at available statistics won't give you an idea of how many people define themselves as having a problem. There are people who take cocaine once a month and define themselves as addicted. They think about it all the time, they try to pick up [people] who might have it, they change their lives to put themselves in a position where they'll get the drug. Fewer than half of our callers use the drug every day."

If that's true, what is the problem? If fewer than half aren't even using it every day, why are they bothering to call?

"Because it's interfering with their lives in some way and they feel they need help. Of course, we also get those people who say, 'I only use it on Friday nights and I've never had a problem.' And we say, 'Thank you' and include that in our data." Why do they call? "Coke users like to talk to people," says Gold.

"But bear in mind that cocaine does cause medical problems, psychiatric problems, problems with lovers, family, work," (continued on page 194)Cocaine(continued from page 148) he adds. "But most important is the fact that it confuses the user and convinces him that he has no problem. Heroin users know they're in trouble. The differences are tremendous. The heroin user wakes up with the sniffles and knows that he is going into withdrawal. He can continue the run by getting more heroin, he can get methadone or he can join a detox program and quit. Cocaine gives you the signal that nothing is wrong. Cocaine users wake up from a seizure and call us, asking, 'If I use less, will I have another seizure?' There's almost a suspension of reality, as if it's someone else who's having all these problems. The drug use becomes so important to the brain that the brain sees that nothing else is more important."

Gold is an expert on how drugs work on the brain and the body. He introduced the first nonaddictive treatment for heroin withdrawal, clonidine, for which he won an American Psychiatric Association research award. He also pioneered the use of naltrexone, which makes people immune to heroin readdiction: The heroin passes through the body of a naltrexone user and is eliminated without causing addiction. "We know how heroin works," Gold states emphatically. "If you O.D. on heroin, we shoot you up with Narcan and you wake up. That tells you that we know exactly what heroin does in the brain. We're just starting with cocaine."

Derived from the leaves of the coca plant, cocaine was the first local anesthetic discovered and remains the only naturally occurring local anesthetic known. It is generally considered too dangerous to use for most medical procedures, because it sometimes causes seizures, even at low doses--no one seems to know why. Cocaine has largely been replaced in the operating room by such synthetic drugs as Xylocaine (lidocaine), though it is still used in more than 150,000 nasal operations each year. Cocaine, in conjunction with other drugs, has also been successfully used to relieve depression in terminal-cancer patients.

Throughout the period from about 1885 to 1906, patent medicines containing cocaine were widely distributed in the U.S. The most famous one is Coca-Cola, though it is no longer considered medicine and no longer contains cocaine. A major epidemic of cocaine addiction occurred here at the time. As a result of that, as well as of hysterical unsubstantiated stories in the press about crime waves caused by cocaine, the Harrison Narcotics Act of 1914 restricted the sale of cocaine and effectively ended its use in the United States. By the time the drug resurfaced in the Sixties, we seemed to have forgotten its effects. And although more than ever is now known about the exact mechanisms by which cocaine produces its effects, the drug is still mysterious in many ways.

Chemical changes in the brain trigger certain responses that are associated with survival of the individual, as well as of the entire species: the drives to obtain water, food and sex, for example, and the instinct of flight (i.e., running from danger).

"Two drugs appear to cause the same neurochemical changes," says Gold, "the opiates [e.g., heroin] and cocaine. Cocaine stimulates the most powerful, the most compelling reinforcement areas of the brain, basically the apparatus that took billions of years to be put in place to make certain that we survive long enough to reproduce. We consider these to be the most important functions of life."

Cocaine somehow gets access to the areas of the brain (the amygdalae and the lateral hypothalamus) in which those chemical changes occur and allows you to make those changes at will. In addition, cocaine takes control of the use and manufacture within the body of essential chemical message transmitters, such as dopamine, which transmits sexual and feeding signals, and norepinephrine, which transmits signals to flee in the face of danger. When you take cocaine, it feels as if it's the most important function in life, because cocaine causes your body and brain to send those essential life-protecting and life-producing signals: the need for sex, food, water, flight. So, of course, you take more.

"The cocaine then dominates or subverts the basic drives until they become secondary," Gold says. "Cocaine in the disease state becomes pre-eminent over survival of the species or even survival of the individual." In other words, you no longer want food, water or sex. The brain is getting a clear signal: More cocaine is what's needed.

"So extreme is cocaine's effect in this respect," Gold wrote in Psychiatric Annals, "that ...it alone can replace the sex partner of either sex.... Cocaine can produce spontaneous ejaculation without direct genital stimulation." But, he warns, "tolerance to the sexual-stimulating effect of cocaine rapidly develops and subsequently impotence and sexual frigidity are seen in chronic cocaine users."

Gold says, "More distant drives, such as interpersonal relationships, work, family, friends, become even less important. Cocaine becomes the primary drive. Even though the drug has no specific survival value, the person acquires a new drive that he makes into a primary reinforcing drive on the basis of fooling the brain."

Of course, if Smith is correct, if cocaine addiction is a multifactorial illness, including the spirit as well as the flesh, then there must be more to it.

Paul Erlich, program director of Forest Farm Community, a Marin County drug-treatment clinic that employs Smith's philosophy of addiction and treatment, says, "We teach that the urge to use exists in a primary and primitive part of the brain and is energized by both a powerful biochemical process and a strongly conditioned learning history." He says that one of the big problems in stopping the use of cocaine (or any other addictive drug), even after the body is free of it, is the role the drug plays in a person's emotional life. Your body may no longer need the drug, but that doesn't mean you don't want it.

According to Erlich, a major issue "in the final phase of treatment, which generally begins after about a year of recovery, is the problem of 'arrested maturity.' During the progression of chemical dependency, regardless of age at onset, drug use becomes the primary means of responding to emotional and interpersonal issues. Alternative responses fail to develop beyond this point. The development of self-awareness, self-esteem and the capacity for real intimacy with others is severely curtailed. The earlier the onset of addiction, the greater the deficits. Once drug use has ceased ... the recovering person is ready to resume personal growth by addressing repressed feelings and unresolved conflicts."

As cocaine becomes the source of and repository for essential chemical survival messages in the brain, so, evidently, can it serve the same function for all of a person's emotional responses, from love and joy to hate and rage. Based on that, it would seem the most dangerous drug of abuse. It is, then, confounding when we look at what actually happened in the only long-term study done with people who use cocaine regularly. Because they didn't all go crazy, and they didn't all end up addled or addicted. Some, in fact, just got bored and stopped.

•

Dr. Ronald Siegel does his work in a two-bedroom apartment on a quiet, treelined street in the manicured hills of Los Angeles. For the past ten years, his work has been primarily of two kinds. One is the most fundamental and essential kind of research on cocaine use: determining what happens to people who use it for a long period of time. It was a natural outgrowth of the other, more lucrative type of work he does: counseling the famous and wealthy for cocaine addiction, including such people as movie producer Julia (The Sting, Close Encounters of the Third Kind) Phillips, as well as captains of industry, movie stars, comedians, professional athletes and race-car drivers who do not wish their relationship with Siegel to be known.

We met the weekend Marvin Gaye was shot to death, allegedly by his father, amid rumors that the famous rhythm-and-blues singer had been experiencing fits of cocaine-induced violent behavior. Word was that Gaye had taken cocaine and then beat people. The last person he had beaten, supposedly, was his father.

I sat on a couch. Siegel sat on a leather chair. Between us was a table that had been fashioned from the hatch of a large wooden ship. From the stereo speakers behind me, I could hear a man moaning and crying. "Oh, please, God, let me out of here," the man wept. "Oh, God. Everything in my life was Katy."

The voice was that of Robert LaCava, one of Siegel's favorite examples of the potential effect of cocaine. The police had picked up LaCava standing nude in his living room. His girlfriend, Katy, was nude in the bath, with ligature marks around her neck and the back of her head crushed. She had blood coming out of her nose and ears. The police took LaCava to the station, put him in a room with a tape recorder and waited.

"Oh, God, just take me to the psycho ward."

Listening to LaCava's moans and weeping, Siegel says, "He's just starting to realize what's happened, and he's having an emotional response to it."

On the tape, a police detective said, "Calm down, now, Bob. We just have to figure out what happened."

"I sniffed cocaine. I went insane," LaCava cried.

Siegel, a former marathon racer who has climbed the inhospitable Andean slopes where coca grows, has a penchant for the melodramatic. He likes to tell horror stories, delights in the demonstrative. Siegel calls the sometimes hideous antics of cocaine addicts "forensic theater." His practice, not to mention his nine-year study, has given him a special insight few researchers have. Because of his stature in the scientific community, he is often called in on cases such as LaCava's as an expert witness to testify about the effects cocaine can have on people.

"His blood level of cocaine made John Belushi look like he'd been to a garden party," Siegel says of LaCava. "This guy was flying." LaCava, suffering acute and chronic cocaine psychosis, smashed his girlfriend's skull and strangled her with a telephone cord. Smith, Gold and Siegel agree that cocaine does not make people kill. But it has special properties that make people react in ways they might never react otherwise.

"If you remove the illegality and you look at it just pharmacologically, all three major drugs of abuse--alcohol, heroin and coke--can produce a continuum of effects from mild intoxication to death. There's nothing magical about that. And it doesn't automatically transform people."

Siegel makes his point by quoting Joel Fort, a physician and author of Alcohol: Our Biggest Drug Problem. "For example, if you look at 'the most common group drug experience in America, the cocktail party,' you have a group of people ingesting the same drug in the same amount in the same setting over the same period of time. 'Some drinkers were passive or drowsy, some boisterous or aggressive, some amorous or lascivious.' So it's not the drug, it's the drug in combination with what you are. Cocaine is not a magical elixir. It's simply a chemical with certain properties. It's the nondrug variables that make the difference."

In other words, Siegel is saying the same thing Smith and Gold said: Addiction is a disease, regardless of the substance.

But how, then, does cocaine come to be associated with violence, such as LaCava's attack on his girlfriend?

"Cocaine hallucinations," Siegel says, "come with what we call a clear sensorium. You don't see the walls melting, the way you might with acid. If you're on acid, things are so weird that you know you're having hallucinations--at least, most of the time you do; there are exceptions even to that. But with coke, everything looks correct. Only you might see bugs crawling on your skin. And since your senses are heightened, not dulled, since you are not stuporous, you believe that there really are bugs crawling on your skin. I had one patient come in with burns all over his body, because he'd tried to burn the bugs off with a blowtorch. Since there is no distortion in what you perceive, you believe what seems to be happening to you. Your hearing is much more acute when you're high on cocaine. So you hear a car door slam down the block and you think, That's a police-car door. They're coming to get me. Pretty soon, you find yourself saying, 'Hey, I'm going to get my gun and check this out.'"

Siegel says that cocaine "ignites a fire in the brain." It's as if the sun has gone down and you build a nice cozy fire in the fireplace. And now you can no longer see the real world out the window but only the reflection of the fire in the glass.

"You see the furniture of your mind," he says. "If you continue to fuel the fire, you go through a continuum of predictable effects: euphoria and sexual enhancement, then dysphoria, sadness, weight loss, sexual disinterest. Then paranoia, gradual suspicion, feelings of grandiosity at times. Startle reactions, what we call checking behavior, in which you're constantly looking around, checking out your environment. Impulsive behavior and a gradual progression to a psychosislike state with auditory and visual hallucinations at times. And that's the point at which you'll be blow-drying your hair and keep hollering out, 'Who's there?' and nobody will be there. You're hearing voices calling your name. That's the point at which you may decide to get your gun and go check it out."

I wondered about cocaine's lethality; interestingly, not one of the subjects in Siegel's study died. He estimates that deaths related to cocaine use and abuse occur at a rate of "about one per day, and that would include some gunshot wounds, too." In New York State, however, cocaine emergency-room deaths were reported to number 518 in the third quarter of 1981 alone. And in a survey of 2240 physicians, 15 deaths were reported while cocaine was used as an anesthetic in controlled surgical procedures with lifesaving equipment and professional help present.

One of the problems in making meaningful guesses at how many people are dying from cocaine poisoning is that not all coroners and emergency-room physicians know what to look for. When cocaine kills, it does so due to convulsion (epilepsylike seizures), cardiac arrhythmia (heart-attack-like symptoms) or respiratory collapse (you stop breathing, your heart is pumping like mad and your lungs fill up with fluid). Since those symptoms are all associated with other diseases and conditions, it is impossible to know how many times a coroner may miss a cocaine death.

With his characteristic flair for the dramatic, Siegel places a brown-glass bottle in my hand. It is about the size of two packs of cigarettes. The label has a large C in the center and says, cocaine Hydrochloride U.S.P. Flaky Crystals. Below is the word Poison flanked by a red skull and crossbones.

"That skull and crossbones says it all," Siegel says. "For years, I had trouble understanding the problems with cocaine. We saw people using it and getting these reactions, and yet everyone said it wasn't addictive, it wasn't dangerous. And some people had no significant reaction at all. Then, one day, I was looking at the bottle, and I noticed that it very clearly said Poison on it. And although there are different effects with different people in low doses, no matter who you are, if I inject you with about a gram of pure cocaine, you will die. And once we started to look at this as a poison, we began to see explanations for the responses people have to the drug. I think it would be helpful if the skull and crossbones were on every gram sold in the United States. It would be a reminder that users are ingesting a drug with many properties, one of them being toxicity. It would be a helpful counterpoint to the image that cocaine has as a glamor drug."

•

In the middle Seventies, cocaine brought a new verb into the English language. That verb is "to base." I base, you base, he or she bases. It refers to smoking the free base of cocaine. Siegel's bottle with the skull and crossbones contained cocaine hydrochloride, which is the same flaky crystal (though considerably purer) that is sold on the street for sniffing. It is soluble in water, so when it touches the moist membrane in the nose, it dissolves and is transmitted into the blood stream, which carries it to the brain. It may take three to five minutes to get there. Its effects may persist for 20 minutes to an hour after that.

If the cocaine is separated--freed--from the hydrochloride salt, the result is purified cocaine base. It is not readily soluble in water and not suitable for sniffing. However, if a mild heat is applied to it, it vaporizes. The vapor, pure cocaine, is readily absorbed through the lungs into the blood stream and is carried on to the brain. It takes about seven seconds and can result in dozens of times the normal dose you might get from sniffing. Free-basers routinely smoke many times the lethal dose of cocaine. However, some 60 to 80 percent goes up in smoke and is lost into the room. If the full lethal dose gets into the lungs and is absorbed into the blood, the baser dies, usually after convulsion and respiratory collapse.

And although one can become psychotic from snorting cocaine, the most dramatic effects involve the free-basers and those few who inject the drug.

In Siegel's study, he classified five types of users: (1) experimental (used no more than ten times); (2) social-recreational (used infrequently but regularly in social settings; average, one gram per week); (3) circumstantial-situational (used to augment or enhance a specific situation, e.g., sex or work performance; average, two grams per week); (4) intensified (used at least once a day for a long time; average, three grams per week); (5)compulsive (addicted and unable to stop). In the report of his experiment, delivered to NIDA but not yet published when we went to press, Siegel wrote:

By 1978, 39 percent of the users had smoked cocaine ... and ten percent classified themselves as primarily cocaine free-base smokers. For the last five years of the study, there were two distinct populations of users: intranasal users (90 percent) and cocaine free-base smokers (ten percent).... All 99 users were classified initially as social-recreational users.... From 1975 to 1978, 75 percent of the users still in the study engaged in episodes of more frequent use ... but remained primarily social users. From 1978 to 1983, 50 percent of the users still in the study remained social-recreational (with continuing episodes of increased use), 32 percent of the users became primarily circumstantial-situational users, eight percent became intensified users and ten percent became compulsive users. Importantly, this latter compulsive group consisted entirely of cocaine free-base smokers.

In other words, ten percent of the people in his sample became addicted to cocaine, and all those who became addicted to it smoked free base. "Essentially," Siegel says, "there is no such thing as a social-recreational free-baser." Smith and Gold agree that although some people may try it once and never again, regular free-base users are destined for disaster.

A typical free-base story is unbelievable to most people. Basing is like putting your life on fast forward. You wake up and it's next year. Days go by like minutes. Money goes up like flash paper. It is not uncommon for someone with money, real estate and other valuable property to sit down to free-base a little and get up ten or 15 months later to discover that he has converted everything he owns to cocaine and smoked it. It sounds like a comedy skit, but it's not. Here are a few comments on free-basers from Siegel's monograph "Cocaine Smoking," published by the Journal of Psychoactive Drugs in 1982. Each paragraph refers to a different person:

He believed there was a secret tunnel under the bathroom floor and the [neighborhood] children were trying to enter his house. After smoking for several hours, he began to see children coming through the walls of the house. He ran into the bathroom, pulled up the rug and began shooting a gun at the floor. He then shot at the hallucinatory children coming through the walls, ran outside into the street and began shooting at the real children in the neighborhood. He was taken into custody at that time by police.

He reported smoking free base for the previous 12 hours and his hands appeared swollen and bleeding.... His girlfriend reported that the patient had held a gun to her head minutes earlier.... He exited the room, saw a police officer and started shooting at the officer. The officer returned the fire and the patient was eventually restrained after a lengthy and violent struggle with several officers.

She reported selling all her possessions and her house in order to maintain her cocaine supplies. Prior to consultation, she had carved on her arm I am a coke whore and attempted to kill her mother with the knife.

When examined, he had been on a 120-hour binge during which he smoked 25 grams of free base "knowing I could stop and quit." He was acutely manic and paranoid and stated: "I heard a woman talking, so I carry a gun at night. Always position myself for defense near windows. I'll shoot you if you don't help me.... I do nothing in life except base."

Not all basers turn to violence or thoughts of violence, of course. The journal Drug Law Report carried an article by Siegel in the autumn of 1983 that described the case of a man named Ori Love. Love tried cocaine for the first time and declared, "If God wanted to make the perfect drug, He would have made cocaine. Since cocaine is perfect, it must be God's gift. When I take cocaine into my body, I am partaking of God Himself."

Siegel wrote, "Subsequently, the defendant engaged in a 'religious crusade' to procure his sacrament--he held up a series of banks and savings-and-loan associations. Every day, he consumed one to three ounces of cocaine. This was confirmed by his brother and wife, who witnessed the progressive, albeit rapid, development of cocaine psychosis. During a three-week period covering the charges, the defendant went through $32,000 in cocaine and three seizures [i.e., convulsions]."

Siegel leaned across the table in his apartment. "When I interviewed Ori," he said, "we were sitting at a table like this, and there were Los Angeles sheriff's police sitting there with us. And Ori said, 'Doctor, if you were to put my release papers on one end of this table and an o-zee [ounce] on the other, I'd smoke that o-zee right now.'"

Indeed, one of the most remarkable characteristics of cocaine is its irresistibility. Gold points out the similarity between cocaine addiction in animals and the way addicted humans act. "Monkeys don't have a bias [in experimental settings]. They start out preferring females in heat and bananas. Then you give them cocaine. And by the time you're finished, they can't tell the difference between a male and a female and clearly don't recognize that food, water and sex are in any way important to them. Now, I don't see how we can be so grandiose as to say that won't happen to us."

"Cocaine is really pleasurable," Siegel says, "and monkeys really like that and will work harder for that than for any other drug. I see a lot of people in my practice who are very much like the animals in the experiments."

•

About one thing, all cocaine researchers seem sure: "We are in the middle of a cocaine-abuse epidemic," says Smith. "And our measurements indicate that it is still on the rise." Smith's Haight-Ashbury clinic sees about 125 people a day. In 1980, three percent of those were cocaine abusers. At the end of 1984, the figure will be about 20 percent.

"But the more amazing figures are those of Mark Gold," Smith admits. Indeed, if Gold's figures, culled from his 800-Cocaine surveys, are correct, there are perhaps more than 2,000,000 people who are in trouble with cocaine. "What's amazing about those data," says Smith, "is the number of dysfunctional people who are not in treatment."

Siegel disagrees. "I think it's a bit too early to evaluate that. You can't get those people [who call 800-cocaine] in to take a urine sample, blood sample or coke sample. There are lots of things you can't do that limit the data. On the other hand, it's a lot of data. It's a way of reaching people you couldn't otherwise get."

Gold has a few comments about Siegel's study, which began with 99 people and ended with 50. Some dropped out because they got tired of using cocaine. Others simply moved away or got bored with the demands being placed on them by the experiment. "There's no question that the findings are true," Gold says, "but whether they are representative is a different matter." In other words, the 50 people Siegel ended up with certainly did what he says they did, but that doesn't mean everyone else will do the same. Gold disagrees with Siegel and Smith on the question of what percentage of people who use cocaine become addicted.

"I would guess that rather than being ten percent," Gold says, "it would be closer to 30 percent. Siegel's was a very small sample and not representative. On the other hand, it's one of the only things we have."

Gold stresses the fact that availability and price--rationing, in essence--help keep cocaine-addiction figures low. "If you put animals in a cocaine study and use rationing imposed from the outside, they don't develop compulsive use," he says. "That's done for people by price and other factors. If you take the monkeys off rationing, they will self-administer cocaine until death. I'm not very satisfied with any models that minimize the potential disaster of unlimited access, since all previous models had to be revised and the predictions of the Seventies about cocaine liability and problems all had to be recalled like a used American-made automobile."

Smith, however, points out that regardless of their experimental techniques, most cocaine researchers who approach the problem systematically see the same general outlines. "It is clear that we're all coming up with the same impression. The disease concept of addiction maintains that people react differently to drugs."

Most promising, perhaps, is the idea that if only a few of us are likely to react compulsively to drug use, there may be some way to predict that behavior and to warn those people. "Seventy to 80 percent of our cocaine addicts have a family history of alcoholism," Smith says. "And, as with alcoholism, the biggest cocaine relapse comes with those who try to return to controlled use of cocaine. If you do develop true addiction, you can't go back." Remember, addiction is compulsion, loss of control and continued use in spite of adverse consequences.

In controlled experiments, hard data have been produced for alcoholism. Not only are children of alcoholics more likely to develop alcoholism but some test results indicate that the brain-wave patterns of sons of alcoholics are different from those of sons of nonalcoholics. But the closest anyone is willing to come to predicting who might have trouble with drugs is to say that if it has happened before, it can happen again.

"Without question," Smith says, "there is a predisposing factor with alcoholism. The research with cocaine is much newer and the data much softer. What's needed is a much more in-depth study that figures out the variables."

•

Paradoxically, the problem with cocaine research at the moment stems from NIDA, the institution that funds most of it. NIDA has traditionally been a political tool serving the Presidential Administration. When Ronald Reagan took office, for example, he began using NIDA to attempt to fulfill his campaign promise to get tough on drugs and crime (see The War on Drugs: A Special Report, Playboy, April 1982). He wanted NIDA to provide the latest scientific evidence that marijuana caused brain damage, impotence, criminal behavior, madness, birth defects and a wide range of other ills that simply could not be proved to the satisfaction of any legitimate scientist. Nancy Reagan became the leader of a national parents' campaign against marijuana, and NIDA, caught in the middle of it, found itself in the odious position of having to publish or silently accept some rather radical and unsupportable opinions about the dangers of marijuana smoking.

The situation has not changed in its general outlines, but the current drug in question is cocaine, while marijuana, having failed to generate an epidemic of brain damage and crime, has taken a back seat.

"If you happen to be in the antimarijuana camp," Smith says, "you can say things that are totally without foundation and get supported. Now, NIDA wants us to say that everybody who touches cocaine immediately has irreversible brain damage, but it's just not true. But the political response increases rather than decreases the drug problem. In 90 percent of the cases, all recovery is complete. In fact, after a year in recovery, the patients are doing better than before."

Siegel agrees. "I was the first one in this country to say that cocaine was physically addicting. I've been arguing for changing our view of cocaine to that of a physically addicting drug. But because I say there aren't so many problems with the infrequent users, people object. The long-term use of cocaine doesn't seem to result in damage to any body system except the nose, and that can be taken care of with good hygiene. Cocaine has a remarkably clean track record for a drug that's so used and abused. The worst problems are the mental ones, and they can be terrible."

Which is one of the most curious points of all about cocaine. For while it can produce effects in certain individuals that make heroin addiction pale by comparison, a heroin or alcohol addict is left with permanent body and nerve damage after long-term abuse. The cocaine addict, as far as the research has been able to determine, gets away more or less scot-free. That, of course, assumes that he never uses cocaine again.

But NIDA--or, at least, its customer, the Reagan Administration--is not happy with anything less than the blackest picture of cocaine. For political purposes, cocaine must appear to be totally evil or else the issue is too murky to be of use. Both Siegel and Smith, as well as the other major cocaine researchers, say the problem is not the drug, be it alcohol, heroin, pills or cocaine. As Smith says, it's the nondrug variables. And we, the people, are the nondrug variables.

Gold views the problem more harshly. "Our experience in answering nearly 400,000 calls suggests very strongly that cocaine problems are not rare and not only problems that happen to somebody else. At one time, all of our callers had control of their cocaine use, and none of us can figure out how they lost it. I think anyone can be addicted if the frequency and potency of the drug are there. If anyone says otherwise, I would ask him to volunteer to take the drug four times a day for four months."

"As far as NIDA's concerned, if you apply the disease concept, you are advocating use," Smith says. "But stressing brain damage is counterproductive to recovery, because the motivation [of someone trying to quit] is to recover. If you give the addict no hope, he won't try. Alcohol is legal, so the quality of research on alcoholism has been very high. Because cocaine is illegal, the research has not been very good. We're just starting to get serious."

NIDA, Smith admits, makes it difficult for him to say what he wants to say. "NIDA's view is that researchers like us are saying that you can jump in the water and not get wet. But we know from clinical experience that a recreational cocaine user does not see a pile of cocaine and feel compelled to use it until it is gone." If you feel that compulsion, you have already gone beyond recreational use.

Smith stresses the need for redefining our way of looking at cocaine. He says that if he tells an addict that cocaine affects everyone in precisely the same way, the addict will be confused, because his senses tell him otherwise. "An addict sees someone else taking a little cocaine in a social situation and doesn't understand why he can't do the same." Obviously, a doctor can't tell his patient that that recreational cocaine user doesn't exist. The patient has seen it with his own eyes. So what can his doctor tell him if NIDA insists that all people react the same way to the drug?

"The current prevention climate is anti-treatment," Smith says. "Alcoholism is the best-studied addictive disease we know of, and that research should be updated and adapted to cocaine. Then we'll get some high-level research. Currently, alcoholism is regarded as a disease, while cocaine use is a crime. That's like saying cancer of the liver is a disease, while cancer of the lung is a crime. We work a lot with industry, and the attitude there is to treat the alcoholic and to fire the cocaine addict, even though the characteristics of the addictive process are very similar."

Erlich, head of Forest Farm Community, wrote, "Without treatment, the disease is fatal.... Once an individual develops addictive disease and the compulsion to use is established, it remains intact for one's entire life.... Resumption of use at any stage of recovery reconstitutes the compulsion at its highest level of intensity. Thus, there is no possibility of returning to controlled use.... We take the issue of relapse very seriously, as any relapse could be fatal."

The message of modern cocaine research, then, is clear: Cocaine is dangerous. And while some people can experiment with it, for others the prognosis is bleak. One recovering cocaine addict described it this way: "We're all on a plane flying around over Kansas. We're going to give everyone a knapsack. Some contain parachutes and some do not. Now, who would like to jump out of the plane? It's really fun if your parachute opens."

"The person who is addicted to cocaine responds differently the very first time he uses it."