By Peter Cohen
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 to sleep.
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 the user.
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 o’clock 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 user’s 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 groups.
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 individual
- 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 other drugs.
- 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 cities.
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.
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