MEDICINE AND PUBLIC ISSUES

Evolving Patterns of Drug Abuse MARK H. GREENE, M.D., STUART L. NIGHTINGALE, M.D., and ROBERT L. DuPONT, M.D., Atlanta, Georgia, Rockville, Maryland, and Washington, D.C.

The sharp rise in drug abuse in the past decade has led to the development of new sources of information on drugabuse trends. These include surveys, drug-related emergencies, drug-abuse treatment, hepatitis rates, and various types of law enforcement information. This paper summarizes data currently available for heroin, marijuana, cocaine, amphetamines, and barbiturates. Heroin use occurred in epidemic form in the late 1960s. Some cities, which had experienced a subsequent decline in heroin use, recently have reported an increase again. Marijuana use has increased steadily. The abuse of amphetamines and barbiturates appears to be growing. Trends on cocaine use are unclear. The development of ongoing, quantitative datacollection systems is beginning to clarify many of the issues regarding drug-use patterns and trends. With the possible exception of survey data, however, each indicator provides data only on selected segments of the drug-using population.

DURING THE PAST DECADE, few medical-social problems

have generated the level of controversy associated with drug abuse. National interest in problems related to drug use began in the 1960s, since which time federal, state, and local agencies have responded to a growing demand for treatment and rehabilitation services with the commitment of extensive fiscal and manpower support. The federal government has attempted simultaneously to follow trends in drug-abuse incidence and prevalence in order to target treatment and rehabilitation services, develop appropriate drug-abuse prevention activities, set clinical and biomedical research priorities, facilitate appropriate drug-control decisions, and determine training needs. In short, the epidemiology of drug abuse has become a critical subject with a multitude of practical applications, and there is a variety of indicator systems that "track" changing patterns of drug use and the problems associated with such use. By focusing on several specific drugs and their associated problems and patterns of use, we will characterize current trends in drug abuse. It is clear that drug abuse is not a • From the Bureau of Epidemiology, Center for Disease Control, U.S. Public Health Service, Atlanta Georgia; the Division of Resource Development, National Institute of Drug Abuse, Rockville, Maryland; and the Special Action Office for Drug Abuse Prevention, Executive Office of the President, Washington, D.C.

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monolithic phenomenon. Rather, it is a composite of many problems, each with its own characteristics with respect to high-risk populations, patterns of use, and associated social, personal, and medical problems. Although the data base for assessing drug-use trends is still rudimentary, it is possible now for the first time to sketch the outline of national patterns. We will begin with a brief description of those indicators currently being used to assess trends in illicit drug use, and then turn to a more detailed consideration of the trends and patterns that have been observed with respect to specific drugs or classes of drugs: heroin, marijuana, cocaine, barbiturates, and amphetamines. We will not discuss problems related to alcohol abuse, although it is clear that alcohol is often abused by users of other licit and illicit drugs. Our intent is [1] to summarize currently available data on drug use trends, [2] to make our readers aware of the source materials used in making this assessment (because much information is contained in special government reports that have received limited distribution), and [3] to encourage the medical community to join in the ongoing effort to better understand and use drugabuse trend data. Drug-Abuse Indicators

Illicit drug use is difficult to study because individuals involved in illicit activities of any kind are often unwilling to identify themselves or to share information about their activities. As a result, much of the data collected must be obtained from special populations that only imperfectly represent the drug-using population as a whole. Most individuals from whom data are collected have encountered significant personal, medical, social, or legal problems in conjunction with their drug use, and thus often represent the most pathological end of the spectrum of drug users. Another source of bias is introduced because populations accessible for study (school children, members of households, and so forth) may not provide representative samples of those currently using drugs in the community at large. Thus, we are often forced to rely on indicators of drug use that are indirect and to assume that those people who do have drug-related problems represent an important segment of the drug-using population at large. Pragmatically, our attention as physicians is focused, of necessity, on those people who present with problems, making inforAnnals of Internal Medicine 83:402-411, 1975

Table 1 . Comparison of Use Rates for Various Drug Classes as Reported in Selected Surveys*

Population Surveyed General 19721 19731 Adolescents 1970§ 1974§ Men 1969|| 1974||

Any Illicit Use

Regular Illicit Use Marijuana

Cocaine

Barbiturates

Amphetamines

NA NA

3.5 1.9

0.1 0.09**

NA 0.3

NA 0.7

19.5 19.2

1.1 1.0

15.9 24.5

NA NA

2.2 1.4

2.8 3.1

9.0 2i.O

0.7 1.3

6.0ft 21.0ft

NA NA

3.0 6.0

6.0 13.0

Heroin

Marijuana

Cocaine

Barbiturates

Amphetamines

1.1 0.1

15.0 5.1

2.7 0.6

4.0 0.6

5.0 1.3

3.5 3.4

42.5 55.5

NA NA

15.6 14.4

1.1 2.7

20.0 52.0

NA NA

6.0 11.0

Heroin

* Expressed as a percent of the study population. NA = Data not available. t Reference 4: Individuals age 11 and older; ever used; regular = at least once a week. t Reference 17: Individuals age 14 and older; use in the past 6 months; regular = 3 to 5 times weekly. § Reference 32: students grades 7 to 12; use in past year; regular = 50 times per year. || Reference 31: Young adult men; use in past year; regular = 2 times per year. ** Regular use of cocaine was defined as "at least every 1 to 2 weeks during the past year." t t Regular use of marijuana was defined as "daily or weekly use sometime during the previous year"

mation gathered about these individuals of great interest. Given those limitations, the data sources to be discussed are indicators rather than absolute measures of drug-use trends. They can provide a wealth of information regarding whether use of a particular substance is increasing or decreasing and the demographic and geographic distribution of those users who come to our attention, but, in general, cannot provide accurate measurements of the absolute number of users. They provide little information on those individuals who are able to use illicit drugs without ever coming to the attention of the authorities, except as these people choose to reveal their drug use in population surveys. We will briefly consider, then, those sources of data that are indicators of this elusive problem. The rationale underlying the use of each of these indicators has been presented in detail elsewhere ( 1 , 2 ) . SURVEYS

Surveys have been used extensively to assess the extent and nature of drug use by many different populations within the general community. The National Institute on Drug Abuse (NIDA) recently published an annotated bibliography of the most current of these studies (3). In general, these studies have been of greatest value in assessing drugs other than heroin, except when the population under study is a particularly high-risk group with respect to heroin abuse. Comparability between such studies has been a major methodological problem due to a lack of uniform definitions and methodologies. (A major effort is currently underway at the federal level to establish uniform procedures intended to solve this problem.) Selected data from currently available surveys by drug are compiled in Table 1. Almost all general population surveys of drug use are limited by the likelihood that samples will fail to include individuals who are heavy drug users. Thus, household surveys miss the "street people" who have high rates of use but no permanent address. This limitation should be borne in mind in interpreting the survey data to be presented here. The information collected by the National Commission on Marihuana and Drug Abuse currently represents the best national data on drug-use rates and patterns (4). Another national household survey using a similar methodology is currently in the field, with results expected by late 1975.

MEDICAL INDICATORS

The Drug Abuse Warning Network (DAWN): The Drug Enforcement Administration (DEA) and NIDA jointly operate a national data-collection system, which is known as the Drug Abuse Warning Network ( D A W N ) . Data are collected on a monthly basis from nearly 1300 reporting facilities around the United States regarding details of drug-abuse episodes as they are identified in hospital emergency rooms, hospital inpatient facilities, medical examiner offices, and crisis centers. Reports are submitted on all episodes involving drugs with the exception of those involving alcohol used alone; episodes involving alcohol plus the use of any other drug are reported. The system has been designed to collect data intensively in 29 cities designated as critical target areas. In addition, it includes a nationally representative sample of hospital emergency rooms and medical examiners that is intended to permit national trend analysis. Detailed demographic data pertinent to the circumstances and nature of drug use are collected for each reported episode. The spectrum of episodes reported runs the gamut from questions about the use of a particular drug requested of a "hot-line," to trauma suffered while intoxicated, to death from overdose (5). Hepatitis Data: In view of the close association between parenteral drug abuse and hepatitis B, it has long been thought that trends in nontransfusion-associated hepatitis B should be a valuable indicator of trends in intravenous drug use. Recent work by the Institute for Defense Analysis (sponsored by the Drug Enforcement Administration) in analyzing national hepatitis-surveillance data collected by the U.S. Public Health Service Center for Disease Control (CDC) has made these hopes a reality (6). Other investigators have corroborated the validity of using hepatitis B trends as an indicator of parenteral drug use (7). Hepatitis surveillance data are summarized by the CDC on an annual basis. TREATMENT PROGRAM DATA

Data regarding the numbers, demographic characteristics, 'geographical distribution, drug use, medical, and social histories of drug users enrolled in treatment programs are a third major source of information. Such data are collected from federally funded treatment programs through the data system known as CODAP (Client Oriented Data Acquisition Process) operated by NIDA (8). This system has been operational since April 1973 and produces reports on a quarterly basis (9). Other information is available on treatment capacity and use and "waiting lists" within the Greene et at. • Drug Abuse

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CODAP, and Polydrug Inpatient Programs* Table 2. Race/Sex Characteristics of Abuserss of Various Drugs> as Identified byDAWN, 1 Source t

Race/Sex

Heroin

Marijuana

Cocaine§

Barbiturates

Amphetamines

CODAP

Total White/Male White/Female Black/Male Black/Female Other/Male Other/Female Total White/Male White/Female Black/Male Black/Female Othert Total White/Male White/Female Black/Male Black/Female Other/Male Other/Female

100 28 9 42 12 5 3 100 40 17 26 11 5 100 52 21 17 6 3 1

100 50 24 15 4 4 2 100 49 34 9 5 3 100 64 25 7 3 1 0

100 39 9 36 7 5 3 100 45 22 23 8 3 100

100 51 32 8 4 2 2 100 37 46 6 10 2 100 43 43 5 5 2 1

100 59 30 5 2 2 2 100 45 41 7 5 3 100 53 34 5 3 3 2

DAWN

Polydrug

* Expressed as percent; columns may not add 1to 100% as a result of rounding off figu res. t CODAP = Client Oriented Data Acquisition Process; DAWN = Drug Abuse Warniiig Network; PolydrujI = Polydrug Abuse Research Projects. t Sex breakdown of "other" racial groups not available. § Insufficient numbers for analysis: only 11 of the nearly 2300 per sons in the PolydrujI data base reported c:ocaine as their primary drug problem.

total universe of treatment and rehabilitation programs, regardless of their source of funding. LAW ENFORCEMENT DATA

Stride: The Drug Enforcement Administration collects data on drug specimens submitted for analysis to its regional laboratories. Information on the cost, purity, and quality of drugs seized or purchased (by undercover agents) is entered into a computerized data-collection system known as STRIDE. This system provides particularly detailed data on heroin "buys" and seizures made by DEA agents around the country. Similar data also are available from the state and local law enforcement agencies in selected jurisdictions. These data are analyzed to assess the illicit drug market at both the wholesale and retail level. Aggregate data on the quantity of various drugs seized also are available on a regional basis. (10). Treatment Alternatives to Street Crimes (TASC): TASC is a federally-funded program developed to facilitate the identification of drug users within populations of arrestees and provide an opportunity (when appropriate) for the referral of drug users from the criminal justice system into the drug-abuse treatment system. This program has been instituted in 20 cities in the United States, each of which collects the usual demographic and historical information from its clients, as well as attempting to verify the history of drug abuse with urine testing at the time of arrest. While treatment data are reported through CODAP (see above), this program within the criminal justice system does provide data on drug use by individuals who may not be referred into treatment. MISCELLANEOUS INDICATORS

A variety of other drug-abuse trend-data sources exist. Some of these have been established by local drug-abuse programs, most notable of which are those in Washington, D.C., San Francisco, New York, Chicago, Boston, Phoenix, and 404

Atlanta (11-16). A series of pilot Polydrug Abuse Research Projects in 12 major cities is supported by NIDA. These inpatient demonstration programs provide demographic data on nonopiate drug abusers (17). These programs, together with DAWN and CODAP, provide data on various drug-using populations (see Table 2). The Armed Forces Entrance and Examination Stations (AFEES) have provided data on drug abuse among inductees during the past several years and urine screening programs within the active duty military worldwide has yielded useful trend information. The Uniform Crime Reporting System of the Federal Bureau of Investigation Collects arrest data from almost all major cities in the United States on drug and nondrug charges (18). However, due to extreme variability in the classification and reporting of such crimes, these data have so far proved of limited usefulness. Observations on Trends in Drug Abuse TRENDS IN HEROIN USE

Opiates have been abused in the United States since the mid-nineteenth century, with heroin emerging as the most widely abused of this family in the second decade of the twentieth century (19). From that time until the 1960s, two patterns of opiate dependence were generally described. The first typically involved morphine dependence among southern, rural, middle-class whites, often with a physician initiating the opiate use as part of a therapeutic regimen for a legitimate medical problem. The second pattern involved heroin dependence among urban-dwelling minority-group members, often those involved in so-called "bohemian" lifestyles (20). This latter group tended to be in their late twenties or thirties. As a rule, these opiatedependent individuals were not heavily involved in criminal activity before onset of their addiction (21). In the mid1960s, for reasons that are still poorly understood, a major shift in the nature of heroin addiction in the United States occurred. The mid-to-late teenage years suddenly became the highest risk period for onset of heroin use among individuals who were primarily minority-group, inner-city, unemployed, unmarried, male, high-school drop-outs with

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a history of criminal activity that antedated their involvement with heroin. The incidence of heroin use, which previously had been at a rather low (endemic) level, suddenly assumed epidemic proportions. Using year of first heroin use (reported by identified heroin users) as an indicator of the incidence of heroin use ( 1 ) , virtually every major city in the United States witnessed an explosive increase in the number of new heroin users detected. For a typical "epidemic curve," see Figure 1. With few exceptions, incidence in America's largest cities peaked in the years between 1967 and 1970 and subsequently declined. During this same period, other indicators of heroin use also increased in major cities: the number of heroin-related deaths (Figure 2 ) , the number of cases of hepatitis B (Figure 3), the demand for addiction treatment services, heroin-related arrests, seizures of heroin, and so forth. Even though the number of new users being created in our major cities began to decline in the early 1970s, a large number of the active users created during the epidemic period remained active users. In addition, during the past 5 years, heroin use spread from its origins in our largest cities to the suburbs (22) and smaller cities of the United States (23, 24). A major response to this problem from both a treatment and a law enforcement point of view began in 1969. Within a few years, there were over 180 000 people being

Figure 2. Number of heroin-related acute narcotics-overdose deaths in Washington, D.C, based on data obtained from the Medical Examiner of the District of Columbia. These data are thought to be an indirect indicator of relative heroin-use prevalence. See References 2, 23, and 24.

Figure 1 . Year of first heroin use reported by new patients admitted to heroin treatment programs in Washington, D.C. Data are complete through October 1974. This distribution is an indirect indicator of relative heroin-use incidence trends, particularly when corrected for the known lag between onset of heroin use and subsequent entry into treatment. See References 1, 23, and 24.

treated for drug abuse nationwide. About 70% of these were in treatment for opiate abuse. Two thirds of those opiate-dependent individuals received methadone as part of their treatment. Simultaneously, local, state, national, and international law enforcement activities directed towards reducing the availability of heroin within the United States were strengthened. These efforts resulted in the disruption of the Turkish-Corsican-French heroin distribution system in mid-1972. By late 1972, there appeared to be a decline in the prevalence of heroin use in those parts of the United States which had relied upon the "French Connection" as their primary source of heroin. A relative scarcity of heroin was documented in Northern California and all along the Eastern seaboard. Statistics from DEA showed a decline in the potency of heroin available at the street level, with a concomitant rise in the cost of heroin. Hepatitis rates declined, heroin-related deaths diminished, the demand for addiction treatment services declined, diminishing numbers of heroin users with relatively recent onset of heroin use were identified, and heroin-related arrests declined. This decline in the magnitude of the heroin problem occurred in conjunction with the widespread availability of treatment services and what appeared to be a marked reduction in heroin availability (the so-called "East Coast heroin shortage") (25). However, the trends in heroin use observed in the reGreene et a/. • Drug Abuse

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Figure 3. Annual numbers of cases of hepatitis reported to the Center for Disease Control, possibly related to parenteral drug abuse. Included are all cases of nontransfusion-associated hepatitis B, plus those cases of hepatitis A occurring in excess of the number expected among individuals aged 15 to 35 years. Data for 1974 are estimated, based on preliminary information available through September 1974. See Reference 6.

mainder of the United States were different. Traditionally, the Southwestern states (including Southern California) were not dependent upon Europe for their heroin supply. The heroin for this part of the country appeared to come from Mexico*. Interruption of the European sources of heroin would not have been expected to have a major impact on heroin use in those parts of the country dependent upon the Mexican supply system. And, in fact, the data available suggest that high-potency, inexpensive heroin continued to be available, and that rates of heroin use continued at a reasonably high level in the West and Southwest, even during the 2 years of the East Coast heroin shortage (24). A statistical method for estimating the total number of active heroin users in the United States (26) showed a peak of 626 000 at the end of 1972, declining to 556 000 by mid-1974 (Table 3 ) . Given the high concentration of both known heroin users and individuals in the high-risk segment of the population in those parts of the country that were supplied by the European heroin distribution system, it is possible that the total number of heroin users declined nationally during the regional heroin shortage described. However, it is also clear that one obscures a great deal of important information when one speaks of heroin trends only in national aggregate terms. Heroin * There are several features that distinguish European from Mexican heroin. European is a fine, white powder usually diluted with lactose and quinine. Mexican heroin is a coarse, brown granular material most often diluted with lactose and procaine. Before 1973, brown heroin was found only rarely on the East Coast and white heroin only rarely appeared in the Southwest. 406

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remained a serious problem in many parts of the country even during the East Coast decline. The relative decline that was noted was primarily regional and clearly temporary. Developments in heroin-abuse trends during the past year serve to confirm the dynamic nature of this problem. There now have been reports from three major cities (Washington, D.C., San Francisco, and Boston) regarding an increase in the prevalence of heroin abuse (15, 16, 27). All three previously had described a sharp decline in heroin use during 1972 and 1973. Most recently (mid-1974 to present) these cities have experienced an increase in the demand for treatment services, increased availability and potency of heroin in the streets, and increased number of heroin-related deaths. These local data are supported by data at the national level as well. Hepatitis B case rates for 1974 are projected at somewhat higher levels than for 1973 (although part of this increase may represent increased use of testing for hepatitis B-associated antigen). The number of heroin-related episodes reported to DAWN from its emergency rooms around the country have increased from approximately 1700 per quarter in early 1973 to 2400 per quarter in the third quarter of 1974. The bulk of this increase has occurred in reporting centers located in the Eastern United States. The demand for heroin-addiction treatment services has increased nationally, eliminating the unused treatment capacity that had developed during 1973. Finally, national data from the DEA laboratory system show that the potency of heroin specimens studied from the Eastern United States has increased and the cost of heroin in this region has decreased during the latter part of 1974. Thus, the average cost of a milligram of pure heroin at the street level in the Eastern United States, which rose from $0.90 to $2.80 during the heroin shortage, decreased to $2.00 in the third quarter of 1974. Similarly, the purity of street-level heroin, which had dropped from 8% to 3 % during the shortage, once again has risen to 7 % . High-potency, low-cost heroin is felt to be a reliable indicator of high heroin availability. During the past 3 years, there has been no major change in heroin price or purity in other regions of the United States. There are many possible explanations for the sudden rise in East Coast heroin availability, but that which appears to be most reasonable in view of all available data points to Table 3. National Estimates of Heroin-Use Prevalence*

Date of Report

Active Heroin Users on DEA Addict Register J

Total Estimated Heroin Users in the United States J

31 December 69 31 December 70 31 December 71 31 December 72 30 June 73 31 December 73 30 June 74 30 September 74 31 December 74

NA 68 864 82 294 95 392 NA 98 988 92 416 90 854 91750

315 000 524 000 559 000 626 000 612 000 579 000 556 000 NA 724 900

* NA = data not available. t See Reference 10. t See Reference 26. Numbers

the development of a new heroin distribution system in those parts of the United States previously dependent upon European heroin. Nationwide analysis of heroin samples submitted by DEA field agents shows that Mexican (brown) heroin has gradually spread across the United States during the past 2 years and is now the most common form of heroin found in almost all parts of the country. The maps in Figure 4 illustrate the gradual encroachment of the brown heroin distribution system into areas of the country where previously only white heroin had been available. This observation regarding increased prevalence of heroin use in conjunction with increased heroin availability suggests that heroin supply may play a larger role in determining extent of use than had been suspected. TRENDS IN MARIJUANA USE

Survey Data: The most current information regarding trends in the rates and patterns of marijuana use in the United States can be found in the 1973 and 1974 Marihuana and Health Report prepared for Congress by the National Institute on Drug Abuse (28, 29). The demographic and geographic patterns of use of this drug have been characterized fairly well. At least 15% of the general population age 11 and older has used marijuana on at least one occasion. Among those who have ever used approximately half are current users (that is, have used within the past month). Among current users, at least half use marijuana at least once a week. Rates of use may be considerably higher or considerably lower, depending on the segment of the population under study. The highest rates of use have been reported among so-called "hippies" and highschool dropouts. There appears to be a slight preponderance of men among marijuana users, although this distribution varies considerably from study to study. Other findings that have been reported with a reassuring degree of consistency include the facts that: urban residents use at higher rates than rural residents, use is greater among those with higher levels of education and income, and use is more frequent in the Northeast and Western United States than in other regions. There have been no clearly documented interracial differences in rates of marijuana use. Differences observed in various studies are most likely related to sampling bias. There are two longitudinal studies of drug use that are of particular interest in this regard. In the first, a nationwide sample of male high-school students selected in 1966 has been followed periodically since that time (30). When these individuals were high-school seniors, approximately 20% had tried marijuana. At the most recent follow-up, in 1974 (5 years later), more than 62% had tried marijuana (31). In addition, the proportion of those using at least once a week rose by a factor of 3.5 from 6% to 21 %. The second longitudinal study that provides valuable data in monitoring marijuana-use trends is the San Mateo, California, series which looks at students from grades 7 through 12 (32). Rates of use by both class and sex have continued to increase during the 7 years in which this study has been underway, with highest rates among seniors studied in 1974 (62% male students and 58% female students used once during previous year). However, the

Figure 4. Availability of brown (Mexican) heroin. Data were obtained from laboratory analyses of heroin specimens submitted to Drug Enforcement Administration regional laboratories. Results express the proportion of brown heroin found among all heroin specimens analyzed during the three time periods shown.

rate of growth of this trend appears to be slowing somewhat. It is interesting to note that student use of marijuana in this survey falls in the same general range as student use of tobacco. Codap Data: From a treatment point of view, data available through CODAP show that approximately 13% of patients enrolled in federally funded drug treatment programs (and reporting to CODAP) report that marijuana is their primary drug of abuse. There is considerable controversy regarding the interpretation of these data. The frequency of use reported by these "primary marijuana abusers" is less than once a week for nearly 4 5 % of the patients. This raises a serious question regarding whether entry into treatment is directly related to use of the drug for many of these patients. Some of these individuals are referred to treatment programs as a result of having been found with marijuana in their possession by law enforcement or school authorities. It is probable that many of these persons are having no problems directly related to their drug use but are referred because of concerns others have about their drug use. Greene et al. • Drug Abuse

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DAWN Data: Data on various drug crises attributed to marijuana is provided by DAWN. During the 9 months between July 1973 and March 1974, there were nearly 160 000 drugs mentioned in reports to DAWN. Marijuana comprised 1% (n = 1273) of all emergency room drug mentions, 3% (n = 236) of all inpatient-unit drug mentions and 15% (n = 7483) of all crisis-center drug mentions. This distribution by facility type reflects the kinds of acute problems likely to occur in association with the use of marijuana, with panic reactions or "bad trips" predominating over the more life-threatening type of overdose seen with depressants, for example. The race and sex distribution among individuals reporting problems with marijuana show that young white men are involved most frequently. TRENDS IN COCAINE USE

There has been much speculation regarding an increase in the use of cocaine in the United States. The suggestion regarding a sharp increase in the extent of cocaine use has received a great deal of attention in the popular press. Cocaine is now being referred to as the new "in" drug and the various implements and rituals associated with the use of cocaine have become subject to extensive commercial exploitation (33). Survey Data: The most recent national survey (conducted in the fall of 1972) showed that 3.2% of the adults (age 18 and older) and 1.5% of the youngsters (age 12 to 17) reported that they had ever tried cocaine (4). Between 1 and 1.5% of all those interviewed reported that their most recent experience with cocaine had been during the 6 months before interview. Data summarized by the National Commission on Marijuana and Drug Abuse indicated that 1.2% of junior high-school students, 2.6% of senior high-school students, and 10.4% of college students have had some experience with cocaine. As with many of the drugs under discussion here (except heroin), use seems to be higher among men, urban dwellers, Western U.S. residents, and individuals with higher levels of income and education. Even among populations with relatively high rates of "ever use" (for example, college students), rates of regular cocaine use are quite low, with 0.1% of respondents indicating use at least every 1 to 2 weeks during the year prior to interview. CODAP Data: Quarterly admissions for primary cocaine abuse to federally funded treatment programs, as reported to CODAP, have been constant at about 1 % of all admissions from mid-1973 to the present. During CODAP's first year of operation, 1325 of the 125 600 individuals admitted for treatment reported cocaine as their primary drug problem. An additional 10% of patients reported to CODAP claimed that cocaine was a secondary drug problem (their major reason for admission being problems related to some other drug). The most frequent drug with which cocaine was mentioned as a secondary problem was heroin (12% of all primary heroin abusers report cocaine as the secondary drug problem). In general, the primary cocaine users reported to CODAP did not differ significantly in their age, race, and sex characteristics from all other CODAP patients. The drug most frequently cited 408

as a secondary drug problem among primary cocaine users was marijuana (28%) and more than 23% of primary cocaine abusers reported having additional problems with more than three drugs at the time of entry into treatment. DAWN Data: During DAWN's first 9 months of operation, cocaine comprised 1% of all drugs reported to the system (2092 of 168 000 mentions). The vast majority of these reports were received by the crisis center component of DAWN. Cocaine problems coming to the attention of hospital emergency rooms and inpatient units occurred primarily in the setting of cocaine use in conjunction with other drugs, while the vast majority of cocaine mentions at crisis centers involved cocaine alone. Thus, serious problems associated with cocaine use seem to occur primarily when cocaine is used in combination with other psychoactive substances. It is of significance, however, that overall cocaine mentions have not increased as a percentage of all drug mentions within the past 2 years of monitoring at all facilities within the DAWN system. Law Enforcement Data: DEA law enforcement statistics show rather different patterns. In fiscal year 1971, DEA agents were involved in the removal of 688 pounds of cocaine from the illicit drug market. By fiscal year 1974, this figure had increased to 1651 pounds. Similarly, the number of individuals arrested by Federal drug agents for cocaine-related offenses reached 1725 in fiscal year 1974, a 20% increase over the previous year. There seems to be a wide disparity between law enforcement data, which has been interpreted by some to mean that cocaine availability has increased considerably during the past 4 years, and trend information from DAWN and CODAP which shows fairly constant and low levels of cocaine-related reports. The increase seen through the law enforcement "window" may represent an increased cocaine availability per se. Also, it is conceivable that, given the route of administration (that is, predominantly inhalation rather than injection) and the relatively low frequency of use (which may be in large part dictated by the high cost of the drug), many more individuals are using cocaine, but this use does not lead them into either the medical or drug-abuse treatment systems or bring them into contact with the law. TRENDS IN BARBITURATE AND AMPHETAMINE USE

Survey Data: While heroin, marijuana, and cocaine* are only available through illicit channels, psychoactive medications with abuse potential are commonly prescribed by physicians (34), and thus widely used in the population at large. It should not be surprising, then, to find that these medications are used without medical supervision or are diverted from legitimate channels altogether to become part of the illicit drug market. Data from the National Marihuana Commission Survey show that 56% of adults and 20% of all youth have had experience with one or more of the proprietary (over-the-counter) or prescription sedatives, tranquilizers, or stimulants, and that about 70% of the "ever users" have used within the past year. Further, their data suggest that 10% of the adult population has * Cocaine is medically available but diversion from legitimate sources is thought to be nil.

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used these prescription psychoactive drugs for nonmedical purposes: 4% used sedatives and 5% used stimulants in this fashion. Of the youth interviewed, 6% had used these drugs for nonmedical purposes. In the Johnston survey cited earlier (31), experience of the study group with amphetamines and barbiturates has been examined at three points in time {see Table 4). In this population of American men currently in their early twenties, use in both drug categories is clearly increasing. The data from the San Mateo studies show a different trend (32). Amphetamine use was reported by 16% of the high-school students studied in 1968, with this proportion rising to a peak of 23.6% in 1972, since which time it has declined somewhat to 19.2%. Data from this group on barbiturates was not collected until 1970, at which time 15.6% of the students reported having ever used. The rate in 1974 was 14.4%. Thus, at least in that particular population, rates of use of stimulants and depressants do not appear to be rising. CODAP Data: Individuals involved with sedative/ hypnotic and stimulant drugs are treated for drug abuse within the current formal treatment system. Of the 126 000 individuals reported by CODAP from April 1973 to August 1974, the primary drug of abuse was barbiturates for 7546 (6%), amphetamines for 5696 (4.5%), and minor tranquilizers for 822 (0.6%). Of further interest is the fact that these same substances constituted secondary drug problems for an additional 7.7%, 4.6%, and 0.8% respectively. For amphetamines and barbiturates, daily use was the most common pattern. The majority of patients with barbiturate or amphetamine problems were less than age 18 at the time they began using their problem drugs. In general, these were white male patients. DAWN Data: The data from DAWN corroborate the fact that problems related to these substances are not uncommon. The sedative/hypnotics, along with minor tranquilizers account for approximately 28% of the drugs reported to the DAWN system, with stimulants accounting for 9% of drugs mentioned. Among individuals experiencing problems with the sedative/hypnotics, women comprise the majority. Roughly equal numbers of men and women have problems with the stimulant group. Selfdestruction becomes a significant factor in the reported motivation of those involved with depressants, whereas euphoric effects and dependence are more frequently cited by those having problems with the stimulants. Data from the medical examiner component of DAWN show 5243 drugs mentioned in conjunction with deaths. The barbiturate sedative/hypnotics account for 20% of these drugs and are the second most common class of drugs reported in conjunction with deaths (the first being the narcotic analgesics with 25%). Nonbarbiturate sedative/hypnotics account for 4%. In all these drug categories, nearly 50% of the deaths were diagnosed as suicides, and from 18% to 25% as accidental overdoses. This is in sharp contrast to the heroin/morphine deaths in which at least 85% were probable accidental overdoses. In addition, other drugs were identified frequently in the tissues of the decedents. Thus, 63% of individuals from whom barbiturates were isolated had one or more addi-

Table 4. Amphetamine and Barbiturate Use in Young Adult Men Studied Longitudinally in 1969, 1970, and 1974*

Year

Amphetamines Ever Used

Barbiturates

Used During Past Yeai

Ever Used

Used During Past Year

6 9 19

6 8 11

ai /Q

1969 1970 1974

9 15 32

9 13 21

* See Reference 31.

tional drugs reported. Multiple drug use, then, is a very common pattern not only among those seen in treatment settings, but also among those who die*. Law Enforcement Data: Data from federal, state, and local law enforcement sources provide only a modicum of information on supply, distribution, and use of amphetamines and barbiturates. In addition, purchases and seizures are determined by changing national and local enforcement priorities, thus limiting the usefulness of these data as trend indicators. Amphetamines, tranquilizers, and barbiturates have generally not been major focuses for law enforcement investigation. Historically heroin and cocaine have been the primary concern of the enforcement community. Further, existence of legitimate medical uses for barbiturates, tranquilizers, and amphetamines makes an assessment of use versus abuse of these substances quite complex. Polydrug Pilot Project Data: Further information on individuals requiring treatment for problems related to the use of the sedative/hypnotics and stimulants has been obtained from the Polydrug demonstration projects supported by NIDA. These programs consist of inpatient facilities that systematically exclude individuals with primary opiate- or alcohol-abuse problems and are located in 12 major cities around the country. Among the patients treated during these programs' first year of operation, the sedative/ hypnotic drugs were by far the most common as primary drugs of abuse (48% of all patients treated). Stimulants were the second most common (18%), and the tranquilizers were third (10%). When compared with the general population of the cities in which the programs were located, it became apparent that individuals between ages 18 and 35 were represented out of proportion to their share of the general population. Female patients tended to be somewhat older than male patients. These patients represent a group of drug users with an unusual amount of psychosocial disability. The majority have not finished high school and are unemployed. The men have been arrested an average of 2.2 times and the women 1.1. About half have had at least one acute drug overdose episode. A majority have received treatment on multiple occasions in the past: 12% have received previous treatment for alcohol-related problems (35% of these on more than one occasion), 53% have received previous psychi* This discussion has been couched in terms of numbers of drugs rather than numbers of deaths attributed to specific classes of drugs because of the controversy regarding what constitutes a drug death. There is no currently operational uniform system of nomenclature for classifying cases in which drugs may have played a role. Greene et a/. • Drug Abuse

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atric treatment (38% of these on more than one occasion), and 56% have received previous treatment for drug abuse (50% of these on more than one occasion). In addition, 22% of all patients treated by the Polydrug demonstration programs had a concurrent problem with alcohol at the time of their admission. Clearly, these individuals show an extreme degree of pathology in association with their drug use. For them, abuse of amphetamines and barbiturates is part of a serious constellation of social, behavioral, and medical problems. What is not yet clear is the degree to which use of these drugs has played a causal role in their personal and social problems. On the basis of NIDA's preliminary experience with these programs, it has been estimated that there may be as many as 3 million Americans who have serious problems in association with the abuse of legitimate psychoactive drugs. Summary and Conclusions

In summary, currently available data suggest the following observations. HEROIN

Heroin use occurred in epidemic form in the United States during the mid-to-late 1960s, beginning in the inner cities of major metropolitan centers and then spreading to adjacent suburban and smaller communities. There was a decline in heroin-use prevalence in 1972 and 1973, primarily on the East Coast, which was associated with a sharp reduction in heroin availability. Both the availability of heroin and prevalence of heroin use in this region appear to be increasing currently, probably in association with the expansion of the Mexican heroin distribution system. MARIJUANA

Rates of marijuana use within the general population have been rising steadily over recent years, although this upward trend may be levelling off in the school-age population. Marijuana has become one of the most widely used psychoactive substances in this country. In excess of 15% of the general population have had some experience with this drug. Such findings highlight the need for a better understanding of the long-term consequences of marijuana use. Only with such information can we develop a rational policy regarding the role of marijuana in our society. COCAINE

Rates of cocaine use were relatively low in the Marihuana Commission national survey data. Assessment of current subjective impressions regarding a sharp increase in cocaine use awaits the results of the new nationwide drug use survey. It is of interest that this impression is not reflected in data regarding cocaine treatment and cocainerelated emergencies. The paucity of problems associated with cocaine use may be related to the high cost of the drug, its less hazardous route of administration, and the infrequency of prolonged, intensive regular use. Problems are identified in cocaine users most frequently in the context of cocaine use in conjunction with multiple 410

psychoactive substances. This disparity between statements regarding the extent of cocaine use and observed cocainerelated problems is a reminder of the fact that the trend indicators we employ often describe only the visible, crisisrelated portion of the drug-using population. This results in a view of the problem that is limited, although important, nonetheless. BARBITURATES AND AMPHETAMINES

Rates of abuse of these legal substances appear to be growing steadily, at least in the young-adult population. Individuals treated for abuse of these drugs appear to have serious, extensive, associated personal, social, and medical disabilities. The tendency of these persons to use multiple drugs (including serious problems with alcohol) increases the risks inherent in such behavior. Given the existence of legitimate medical uses for many of these drugs, control of this drug-abuse problem by supply reduction can be achieved only to a limited degree. The abuse of these drugs will no doubt continue to be a serious problem and may constitute one of the major challenges that lies ahead in the drug-abuse field. The sharp rise in drug abuse during the late 1960s has led to an attempt to monitor trends in drug abuse. The slow and difficult process of building a reliable data base has led to the initial results reported here. While it is still not possible to respond numerically to the deceptively simple question "how many addicts are there?", it is, for the first time, possible to look at rough trends in the use of a variety of drugs of abuse and problems associated with their use and to identify some major demographic, geographic, and behavioral characteristics associated with each drug. Major differences have been observed in* incidence and prevalence of drug use as a function of drug availability. Special studies at the regional and local levels have highlighted the remarkably heterogeneous nature of drug problems and their susceptibility to variations as a function of both the treatment and law enforcement efforts. The systems that constitute this drug-abuse trend data base are new and still evolving. It is our hope that through the publication of these initial results, with the ensuing professional discussion and criticism, these indicators will be improved substantially in the next few years. Although it is important to recognize the limited nature of these first results, it is of great significance that the findings are quantitative in nature, and that the data sources are now in the public domain. We hope that a wide range of professionals will make use of these new drug-abuse data sources so that our collective understanding and response to the problem can be made more realistic and effective. ACKNOWLEDGMENTS: Received 7 February 1975; revision accepted 5 June 1975. • Requests for reprints should be addressed to Robert L. DuPont, M.D., Director, National Institute of Drug Abuse, Rockwall Building, 11400 Rockville Pike, Rockville, MD 20852. References 1. HUNT LG: Drug incidence analysis. Special Action Office Monograph, Series A, No. 3. Washington, D.C., Executive Office of the President, Special Action Office for Drug Abuse

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Prevention, 1974 2. GREENE MH: Assessing the prevalence of heroin use in the community. Special Action Office Monograph, Series A, No. 4. Washington, D.C., Executive Office of the President, Special Action Office for Drug Abuse Prevention, 1974 3. GLENN WA, RICHARDS LG: Recent Surveys of Non-medical Drug Use—A Compendium of Abstracts. Rockville, Maryland, Department of Health, Education and Welfare, National Institute on Drug Abuse, 1974 4. Drug Use In America: Problem in Perspective. Washington, D.C., Second Report of the National Commission on Marihuana and Drug Abuse (GPO No. 5266-00003), 1973 5. Drug Abuse Warning Network Phase 11 Report. Washington, D.C., Drug Information Section, Special Programs Division, Drug Enforcement Administration, US Department of Justice, 1974 6. MINICHIELLO L: An Examination of Trends in Intravenous Drug Use Reflected by Hepatitis and DAWN Reporting Systems. Washington, D.C., Report to the Drug Enforcement Administration by the Institute for Defense Analysis, 1974

25. FRECK PG, COHEN RH, LAWSON JB, et al: Quantitative assess-

7. GARIBALDI RA, HANSON B, GREGG MB: Impact of illicit drug-

31.

8.

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10. 11. 12. 13. 14. 15.

associated hepatitis on viral hepatitis morbidity reporting in the United States. J Infect Dis 126:288-293, 1972 Client Oriented Data Acquisition Process National Management Handbook. Rockville, Maryland, National Institute on Drug Abuse, Department of Health, Education and Welfare, 1974 Quarterly Report on Drug Abuse Treatment and Rehabilitation Services for the CODAP National Management Central Administrative Unit. Rockville, Maryland, Division of Scientific and Program Information, National Institute on Drug Abuse, Department of Health, Education and Welfare, 1974 DEA Drug Enforcement Statistical Report. Washington, D.C., Drug Enforcement Administration, US Department of Justice, 1974 DUPONT RL, GREENE MH: The dynamics of a heroin addiction epidemic. Science 181:716-722, 1973 GREENE MH, DUPONT RL: Heroin addiction trends. Am J Psychiatry 131:545-550, 1974 HANZI R: The Dynamics of a Heroin Addiction Epidemic in Phoenix, Arizona. Paper presented to the National Drug Abuse Conference, Chicago, Illinois, 1974 NEWMAN RG, CATES MS: The New York City narcotics register—a case study. Am J of Pub Health (suppl) 64:24-28, 1974 NEWMEYER JA: A Further Look At the Heroin Addiction Epidemic in the San Francisco Bay Area. Paper presented to the North American Congress on Alcohol and Drug Abuse, San Francisco, California, 1974

16. RAYNES AE, LEVINE GL, PATCH VD: The Epidemiology and

Treatment of Poly drug Abuse. See Reference 15 17. BENVENUTO JA, LAU J, COHEN R: National Perspectives on

N onopiate / Poly drug Abuse. See Reference 15 18. Crime in the United States: Uniform Crime Reports. Washington, D.C., Federal Bureau of Investigation, U.S. Department of Justice, 1973 19. MUSTO DF: Early history of heroin use in the United States, in Addiction, edited by BOURNE P. New York, Academic Press, 1974, pp. 176-191 20. BALL JC: TWO patterns of opiate addiction, in The Epidemiology of Opiate Addiction in the United States, edited by BALL JC, CHAMBERS CD. Springfield, Illinois, Charles C Thomas Co., 1970, pp. 81-94 21. GREENBERG SW, ADLER F: Crime and addiction—an empirical study of the literature. Harrisburg, Pennsylvania, Governor of Pennsylvania's Council on Drug and Alcohol Abuse Report Series, Number One, 1973 22. LEVENGOOD R, LOWINGER P, SCHOOF K: Heroin addiction in

the suburbs—an epidemiologic study. Am J Public Health 63:209-214, 1973 23. GREENE MH, KOZEL NJ, HUNT LG, et al: An assessement of

the diffusion of heroin abuse to medium-sized American cities. Special Action Office Monograph Series A, Number 5. Washington, D.C., Executive Office of the President, Special Action Office for Drug Abuse Prevention, 1974 24. GREENE MH, KOZEL NJ, APPLETREE RL: Heroin use patterns

and trends in four cities on the Mexican-American border. Special Action Office Monograph Series A, Number 6. Washington, D.C., Executive Office of the President, Special Action Office for Drug Abuse Prevention, 1975

26.

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ment of the heroin addiction problem (phase I). Special Report to the Office of Science and Technology, Report No. R-188, Washington, D.C., Executive Office of the President, 1973 GREENWOOD JA: Estimating the number of narcotics addicts. Monograph. Washington, D.C., Drug Control Division, Office of Scientific Support, Bureau of Narcotics and Dangerous Drugs, U.S. Department of Justice, 1971 GREENE MH: Assessing Trends in Heroin Use at the Community Level. See Reference 15 Marijuana and Health: The Third Annual Report to the U.S. Congress from the Secretary of Health, Education and Welfare. Rockville, Maryland, The National Institute on Drug Abuse, 1973 Marijuana and Health: The Fourth Annual Report to the U.S. Congress from the Secretary of Health, Education and Welfare. Rockville, Maryland, The National Institute on Drug Abuse, 1974 JOHNSTON L: Drugs and American Youth. Ann Arbor, Michigan, University of Michigan Press, 1973 JOHNSTON L: Drugs and American Youth II—A Longitudinal Resurvey. Washington, D.C., Preliminary Report to the Special Action Office for Drug Abuse Prevention. Executive Office of the President, 1974 Student Drug Use Surveys in San Mateo California 1968-1974. San Mateo, California, San Mateo County Department of Public Health and Welfare, 1974 RHODES R: A very expensive high. Playboy Magazine, February 1975, pp. 131 ff.

34. PARRY HJ, BALTER MB, MELLINGER GD, et al: National pat-

terns of psychotherapeutic drug use. Arch Gen Psychiatry 28:769-783,1973 Addendum

The Government publications referred to may be obtained from the following sources. References 1, 2, 3, 23, 24, 28, and 29 may be obtained from the National Clearinghouse for Drug Abuse Information, Department of Health, Education and Welfare, 11400 Rockville Pike, Rockville, MD 20852. Reference 4 may be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402. References 5, 6, and 26 may be obtained from the Drug Information Section, Special Programs Division, Drug Enforcement Administration, U. S. Department of Justice, Washington, DC 20537. References 8 and 9 may be obtained from the Program Management Information Branch, Division of Scientific and Program Information, National Institute on Drug Abuse, Department of Health, Education and Welfare, 11400 Rockville Pike, Rockville, MD 20852. Reference 10 may be obtained from the Statistical Data Services Division, Drug Enforcement Administration, U. S. Department of Justice, Washington, DC 20537. Reference 18 may be obtained from the Correspondence and Tours Division, Publications Section, Federal Bureau of Investigation, U. S. Department of Justice, Washington, DC 20520. Reference 25 may be obtained from the office of Program Development and Analysis, National Institute on Drug Abuse, Department of Health, Education and Welfare, 11400 Rockville Pike, Rockville, MD 20852. Reference 31 may be obtained from the Contracts Management Branch, National Institute on Drug Abuse, Department of Health, Education and Welfare, 11400 Rockville Pike, Rockville, MD 20852.

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