THE SOCIAL AND HEALTH CONSEQUENCES OF COCAINE USE
- An introduction -
Ladies and gentlemen,
Every day, I pass a small park on the way to my office. In this
park along the road a group of people is sitting, standing or lying
down, all with bottles of wine in their hands or tins with beer.
They are not very neatly dressed, sometimes they show up in rags
and some have hairdos that look like a Zoo.
Mostly they are talking. They seem engaged in quite energetic talking
but at the same time some sit listening quietly and some even seem
This group is a group of street drinkers, or bums. They
all know each other and their place of congregation is the little
park. Quite clearly they have no jobs, at least not at the time
I see them socialising. Most of them are men.
One of my other frequent experiences is that I talk to a group of
usually very well dressed people in a nice room, often during the
afternoon, at occasions that in Dutch are called a reception.
A reception will be created when for instance some one says good
bye as a professor and goes to another university. Also we have
receptions after a doctoral thesis has been defended. During these
receptions people stand and almost all have glasses in their hands,
filled with red wine, white wine or sometimes even stronger drinks
like gin or whiskey. People laugh, have energetic discussions or
wander quietly from person to person. All of these people have jobs.
They are both men and women, in almost equal proportions.
The two observations serve as lesson one in the sociology of drug
use. The drug that played a role in the two described situations
was of course alcohol, and the topic of my presentation to day,
Cocaine use and its social and health consequences, will be modelled
along the structure that these two situations allow me to create.
Let me begin with the following. Answering a question about the
social and health consequences of alcohol use, what answers would
each of you think about first?
Each of you would probably say: please tell me what kind of alcohol
use do you mean? Right. So, answering the question about cocaine:
what cocaine use do you mean?
In their book The Steel Drug Patricia Ericson and her colleagues
begin by showing that cocaine use in America happens in all sorts
of social circumstances and groups.
Cocaine users can be found in poor ghettos of North American cities,
but also in the chique suburbs or rich dwellings. She quotes a study
by Wallace that says that most crack cocaine users in that study
come from dysfunctional ghetto families with substantial social
problems (Erickson et al, 1994 ,83) . But in our own cocaine
user studies we found crack cocaine users among well employed highly
functional completely integrated cocaine users (Cohen and Sas, 1994)
 as was also observed by Waldorf and colleagues in their California
studies ,  and by Reinarman and Levine. 
How then are we going to approach the question what health and social
consequences cocaine use can have?
Lesson number two. We have to be prepared that a simple answer to
this question does not exist. Quite clearly, as is the case in the
two groups of alcohol users I started to describe, we should be
ready to accept that the answers to the question may be very different
from one kind of cocaine user to the next. Very much depends 1)
on the group to which the user belongs and 2) the use patterns of
Let us start with the group to which the user belongs.
In the years before the eighties, a lot of studies appeared about
cocaine users who would be under some sort of clinical regimen.
Like we can now see in Amsterdam , many opiate users chose cocaine
as a second drug, or after some time of opiate use, replaced their
primary opiate use with primary cocaine use.
In groups where unemployment is the rule, criminal behaviour as
well, poor housing conditions prevail and where social integration
into dominant labour or family culture is low, the user of cocaine,
or of alcohol, or of what ever drug will behave very differently
from when the user is part of another sub culture. If you do not
go to work, why would you stop using cocaine at 9 oclock at
night? If you do not have to impress your boss every morning by
looking brilliant, the contextual restraints on your time management
are really different than when you have.
If you are not part of a culture in which you eat every day, and
eat well, the health consequences of alcohol, but also of cocaine,
will be different than when you eat well and regularly. If you smoke
cocaine to escape constantly some sort of social misery, the effects
you seek are different from when you smoke cocaine to take off on
an adventure of sexuality and excess.
Apparently people seek effects that they sometimes get from drugs,
and try to get those effects again. The type of drug effects people
seek can be very different, even with the same drug. The two types
of alcohol users I introduced to you in the beginning, are seeking
different types of effects from alcohol. The choice of effects depends
very much on your social home, but also on your character and the
interplay between situation and mood.
So, let us now look at the use pattern of a drug. By use pattern
we mean scores on variables like typical amount of use, typical
frequency of use and typical intensity of intoxication. We usually
also define as part of the use pattern the type of situation a consumer
selects for use.
With alcohol we all know a typical kind of user, who will consume
some alcohol every day, but in low amounts and to very low or even
zero levels of intoxication. They visit a bar after work or have
a drink at home while chatting with kids. One could give such a
use pattern a name, like frequent use zero intoxication. This is
a very neutral type of name. Another possibility is that a daily
wine user, who chooses the wine very carefully to match the chosen
food of the day, but not as a vehicle for intoxication, could be
named as a gourmet alcohol user. The same is true for cocaine, although
with cocaine users taste can be important, but in a very different
way as for a wine user. A cocaine user will appreciate the mellow
bitter taste, or the subtle freeze in the back of the tongue.
We have found a substantial proportion of cocaine users who would
use the substance every day but with very little amounts, less than
0.5 gram a week, who like to experience the freeze, or the very
mild post dinner stimulation, very much like people who have coffee
after dinner. For this they need very small lines of cocaine, even
if their wealth or available stock of cocaine in their office drawer
would allow much greater quantities of use.
However, use patterns may involve infrequent but large amounts (usually
called binge use), or frequent use plus high amounts - the so called
high frequency, high intensity use patterns. To study both health
and social consequences of use one has to distinguish very carefully
between the use patterns.
- The story of the consequences -
Looking at pattern of use plus looking at social or cultural group
a user belongs to, one can see distinct types of cocaine use where
the social and health consequences are almost nil. If cocaine use
does not interfere with eating, if it does not interfere with social
functioning both in the inner group as in relation to outside groups
the social consequences are nil.
However, it is possible to identify daily users of cocaine, where
the amount of use is higher or very high, and where the level of
intoxication is desired to be high, and where the users group
is willing to create the social background for this type of frequent
high intensity use. Here the social consequences will be small in
the primary group to which the user belongs, but quite dramatically
negative in relation to outside groups.
An other aspect is the determination of behavioural consequences
of cocaine use. We all know that sport fans, certainly when the
sport is soccer, can be quite violent amongst each other. This violence
tends to be amplified by alcohol, and the same can be said of cocaine.
In groups where inner violence is accepted or even desired, cocaine
can facilitate this behaviour. The consequences for the in-group
are usually small, which can not be said for relations with outside
But we can see with alcohol, as with cocaine, that some users will
use to excess, or consume so much to support a particular behaviour
or emotional effect that even the inner group is not going to accept
this. If this happens, as will occur with some users, the social
consequences are severe. Heavy consumers will find themselves with
deeply disturbed social relations, sometimes resulting in complete
ostracism and even death. Quite probably these rare use patterns
are driven by complex problems that justify the choice of these
patterns although ultimately they may prove to be very counter productive.
Most often, such extreme use patterns are left behind as soon as
the user finds some possibility of more useful adaptation. 
However, also quite destructive social consequences can happen to
a consumer of cocaine who has no conspicuous use pattern at all.
Imagine some one who lives the life of a highly valued and well
known adviser to the Minister of Health. However, in her free time
she invites artists and actors to her very nice flat on the river
side. Cocaine is snorted and one of the elderly guests makes a mistake,
snorts too much cocaine on top of his whiskey and has a heart attack.
The guest is taken to the hospital and fortunately survives, but
the story is out and in the papers. Gone is the career of the adviser
to the Minister of Health!
So, let me construct a conclusion to all these remarks, and then
move on to discussing some self reported consequences of cocaine
use in groups that have different use patterns. Answering questions
about health and social consequences of cocaine use is not quite
possible if one does not first define:
- what cultural background the user has
- what the social and cultural, and above all, economic context
of the user is during the use career
- what specific functions the use of cocaine has for a particular
- how well a user is able to prevent making mistakes, both in situations
in which she shows her cocaine use to others, as well as in preventing
mistakes on the level of depth of intoxication or combination with
- Self reported effects on health and on social situation -
In the year 2000 Tom Decorte, a Belgian criminologist, published
his work on use patterns and careers of cocaine users. He recruited
his respondents in the vast night club scene of Antwerp but also
in the more marginalised sectors of the city. 
As we did in our own cocaine user studies, he compared his outcomes
with those of other researchers who had recruited most of their
cocaine users in the dominant cultural communities in their respective
I have chosen to present to you some of his conclusions, distilled
from long lists of effects, both physical and psychological.
Such long lists of effects can be examined in all the sources I
mentioned to you. But interpreting such lists is what counts.
Decorte says that our data and those from some major community
samples... show that cocaine provides a wide range of positive effects
to those who use it in moderation: more energy, an intellectual
focus, enhanced sensations and increased sociability and social
intimacy. Social, sexual or recreational activities and work can
be enlivened, and many respondents use the drug not only in pleasurable
but also in productive ways (Decorte 2000, p. 260.)
Usually, health professionals, law enforcement agencies, politicians
and media reports take the position that in the long run, illicit
substances can only have adverse effects......Contrary to this official
discourse, our repondents accounts show that well known adverse
effects are often experienced as minor discomforts, and that level
of use (including dose and frequency of use) set, and setting factors
all have important impact on the balance of positive and negative
experiences with cocaine . (Decorte 2000, p. 261)
For the Canadian researcher Erickson and her colleagues the most
interesting negative effects of cocaine are hallucinations and paranoia.
So they choose to investigate these effects. They found that even
these apparently inevitable pharmacological effects
are not so inevitable at all. Paranoia tended to diminish or not
occur when people had a greater number of cocaine using friends,
and hallucinations also tended to co vary with the presence of others
during consumption, and with lower frequencies of use. (Ericson
et all, 1994 p. 209)
We should conclude that most negative effects are always offset
by positive effects, and that for the large majority of cocaine
users the cost benefit comparison of cocaine tends to fall on the
positive side. On the other hand, adverse drug effects occur always,
and the only way to influence the seriousness of these effects is
to keep use patterns inside social settings.
For all drug use and drug users, social exclusion and marginalisation
are the worst settings, and sometimes people use drugs in ways and
in quantities that unintentionally create these adverse settings.
On the other hand, exclusion and marginalisation are often actively
enhanced by our own policies and by our own assistance institutions.
The best harm and crime reduction money can buy is to lower marginalisation
and exclusion of drug users, even if this would mean that the drugs
they (still) like to use have to be made available to them at acceptable
costs. In my view daily and regular use, under certain circumstances
also called addiction ,  is far less of a danger to people
than social exclusion. Progressive drug policies confront drug related
exclusion, more than they confront (intense) drug use per se.
Our institutions that assist this type of users can play a significant
and positive role here if they are willing to accept the user- perceived
usefulness of this use pattern from the beginning of their involvement.
1. Erickson, Patricia, et al (1994), The Steel Drug. Cocaine and
crack in perspective.2nd Edition. New York: Lexington Books.
2. Cohen, Peter, & Arjan Sas (1994), Cocaine use in Amsterdam
in non-deviant subcultures. Addiction Research, Vol. 2, No. 1, pp.
3. Waldorf, D., C. Reinarman, and S. Murphy (1991), Cocaine changes.
The experience of using and quitting. Philadelphia: Temple University
4. Waldorf, D. (1977), Doing coke: An ethnography of cocaine users
and sellers. Washington: Drug Abuse Council.
5. Reinarman, C., and H. Levine (1997), Crack in America. Demon
Drugs and Social Justice. Berkeley: University of California Press.
6. Decorte, T. (2000), The taming of cocaine. Cocaine use in European
and American cities. VUB University Press.
7. Peele, S., and R. DeGrandpre (1998), Cocaine and the Concept
of Addiction: Environmental Factors in Drug Compulsions. Addiction
8. Cohen, P., (2004), Bewitched, bedeviled, possessed, addicted.
Dissecting historic constructions of suffering and exorcism. Presentation
held at the London UK Harm Reduction Conference, 4-5 March 2004.
9. Our institutions that assist this type of users can play a significant
and positive role here if they are willing to accept the user- perceived
usefulness of this use pattern from the beginning of their involvement.
I thank prof. Nicolas Grahame Ph.D , Dept. of Psychiatry - Indiana
University School of Medicine-, for his remarks and editing of this
Cohen, Peter (2004), The social and health consequences of cocaine
use. An introduction. Presentation held at the Nationale Designerdrogen-
und Kokainkonferenz, 3-4 June, 2004, Kursaal Bern, Bundesamt für
Gesundheit, Bern, Switzerland. www.cedro-uva.org/lib/cohen.social.html] ©Copyright
2004 Peter Cohen. All rights reserved.
Included in the Archiv Sterneck.net with permission from Peter Cohen. - Thanks!-