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Chapter 8    Summary and conclusions
The study presented here is a unique and coordinated effort of a multidisciplinary team of scientists and city politicians to increase knowledge of the real extent and nature of cocaine in Europe. It has often been said that in the case of new drug epidemiological trends, Europe follows the United States, with a five to ten year lag. Is this commonsense knowledge or is it a dangerous myth used to incite panic and promote political interests and ambitions?
This book describes the results, conclusions and recommendations of an intensive study of cocaine use in the cities of Barcelona, Rotterdam and Turin. The aim of the study was to provide a rational, politically relevant, contribution to the assessment and reduction of the harm linked to the drug that appears to have captured the imagination of Europe. Cocaine is a drug with a multiple personality. It has many faces and it is rooted in all strata in society. The intention of this book is to present a soundly based evaluation of the true nature and extent of cocaine use in Europe. The method to achieve this evaluation was the study of a broad-based sample of cocaine users in three, culturally diverse, European cities.
A new way of conducting policy-oriented drug research is presented and a novel methodology explained. This approach proved useful as a means of overcoming the barriers between scientists and politicians which have plagued earlier research in the field of drugs. Multidisciplinary teams were formed, made up of local decision makers, policy planners and independent scientists. Regular meetings were held in each city to discuss interim results and any problems which had occurred. Later meetings were devoted to drafting recommendations and conclusions. This way of working assured the scientists that their work was politically relevant and would not be 'hidden at the back of a drawer', while politicians could see that the financial investment in research would yield a tangible pay-off. They would be provided with a lot of information about the phenomenon. The pay-off for the researchers and politicians is that on the one hand the results of the study have influenced current political and scientific attitudes, and that, on the other, they have revealed publicly the facts on cocaine use in Europe.
In all, 363 cocaine users in the three cities cooperated with in-depth interviews. The use of an innovative methodology involving the synthesis of snowball and targeted sampling and network analysis meant that data were collected on an additional 1,635 cocaine users who were the contacts of the interviewed users. It represents the largest specific database, to date, of local community-based samples of cocaine users. This is a remarkable achievement, considering that the entire project was completed in two and a half years, and involved the coordination of three research sites, each in a different country with its own language and distinct social, political and cultural setting.
The main conclusions of this book have an impact on a broad range of issues. The subject, the nature and extent of cocaine use in three distinct cities, poses a complexity of practical and scientific problems which are intrinsic to the study of hidden populations. This would be difficult even on a single research site. Snowball sampling provided the common point of departure for the three multidisciplinary teams in each city. Many of the conclusions reached in the study are original. The one thing we are all aiming for is a better understanding of the worldwide issue of cocaine use. If this book stimulates debate, discussion and research into the nature and extent of cocaine use in other local communities, it will have achieved its objective.
   
8.1 Methodology
This book, on the nature and extent of cocaine use in three European cities, deals with the particular complexity of a hidden and rare phenomenon. The research project required a novel approach. The method of snowball sampling was used as the basic premise for a research process centred on diversified methodology. The researchers discarded the traditional opposing claims of quantitative versus qualitative methodologies in favour of a multi-method approach which integrated tools originating in different traditions of research. This combination of quantitative and qualitative methods demonstrated a flexibility which characterized the whole research process.
Operationally, all three cities shared a similar research design centred on fieldwork, snowball and targeted sampling, network analysis and typology construction. The basic knowledge of the circuits and social environments of the target population was obtained through fieldwork. In turn, this formed the basis for contacting the respondents for the interview. The fieldwork established a special relationship of trust between researchers and respondents without which it would not have been possible to conduct the in-depth interviews. The combination of snowball and targeted sampling and network analysis also made it possible to collect relational data on the contacts of the respondents. By means of these network data more insight was obtained into the complex relationships between cocaine users, their contacts, and the various circuits in which cocaine is used. Intensive fieldwork, snowball and targeted sampling proved an effective methodology for contacting strata of hidden populations.
The analysis of the research data differed according to the specific context encountered in each city. The combination of personal network analysis and qualitative analysis facilitated an interpretation of the patterns and significance of cocaine use which could not have been achieved by looking only at individual characteristics. The analysis of the network relations between users and the significance assumed by cocaine in these ties is distinctly new. Levels that are often kept separate in theory and empirical analysis, e.g. the levels of macro-social phenomena and the micro-level of social relations and individual strategies, have been linked in the multilevel methodology of this study. The study was organized on a multi-centric basis with three independent research sites and designed to permit controlled comparisons of results.
8.2 General characteristics
In comparing the characteristics of cocaine users in the three cities, the researchers had to take into account the fact that the samples were not random. However, it was possible to add the population of nominees to the population of respondents, increasing the total of N three to ten times. This enlarged sample made for greater representativeness. Where there were no data available concerning the nominees and the samples could not be enlarged, the distribution of most of the variables was acceptable. On the basis of these procedures, it was possible to obtain a meaningful comparison of the characteristics of cocaine users in the three cities. Overall, the comparative analysis showed more similarities than differences in the general characteristics of cocaine users.
Most cocaine users are men. Cocaine users are predominantly in age range 21-35 years. Their educational background ranges from secondary school to higher education and all types of occupation are represented. The great majority of users started taking the drug before the age of 25, after experience with alcohol and cannabis. Rather than replacing other drugs, cocaine is often combined with them, particularly alcohol, cannabis, amphetamines, XTC and LSD. Part of the respondents also used (or had used) heroin. The level of cocaine use appeared to vary, but there is usually a soft (low frequency, low amounts) initiation that increased considerably in the heaviest period. The patterns of use tend to present one or more peaks but discontinuous, constantly increasing and continuous, same level patterns were also found. People who used heroin in addition to cocaine, took cocaine more frequently and at higher levels than those who never used heroin.
The most prevalent way of use is intranasal, although during the period of heaviest use the percentage of respondents using cocaine intravenously or by way of free basing increases. Most of the respondents who injected cocaine also used heroin. Free basing is a way of use employed by both heroin and non-heroin users. In Rotterdam cocaine is administered by way of sniffing, injecting, basing and chasing the dragon whereas the Barcelona respondents sniff, inject and base cocaine. In Turin, cocaine is only taken by way of sniffing and injecting.
The most prevalent circuits of use during the initial period are the intimate and entertainment circuits. Each city showed differences relating to other periods. In Barcelona, there was a spread into other circuits while in Rotterdam the hard drug circuit became more important. In Turin the entertainment circuit emerged as more important after the initial period.
Cocaine use and criminality do not necessarily go hand in hand. Only a few people engage in criminal activities linked to cocaine use though there is an increased tendency in the period of heaviest use. Involvement with dealing in the cocaine market is limited. The perception of users of cocaine-related problems varies greatly and few make use of services to assist drug addicts. In Rotterdam more respondents have contact with these services than in Barcelona and Turin. Cocaine users who also use heroin have more serious problems than those who have never used heroin.
8.3 Typologies
A deeper examination of the nature of cocaine use required a typology construction. This method goes further than the usual description of cocaine users found in literature. The common research design employed in the three cities allowed for the development of different approaches to the complex work of typology construction. As the analysis proceeded, the significance of cocaine within the lifestyles of people became an important theme. Cocaine has various meanings and can play many different roles. It can range from peripheral to central in a user's lifestyle. Heroin, on the other hand, has a greater overall impact on lifestyles.
The socio-economic status of users does not play any significant role in cocaine use and cannot be employed as a means of predicting problems. With cocaine it seems that it is not so much the substance itself but the significance attached to the drug that is relevant to the occurrence of problems. The significance of cocaine within each lifestyle is linked to the way it is used and the level of use. These, in turn, are strongly related to problematic aspects. Taking all of this into account, great variations in cocaine lifestyles can be distinguished. These variations can be grouped into two large categories in which the perception and use of heroin plays a major role.
One category of cocaine users also use heroin (Poly-drug Type). They are part of the heroin subculture where the use of drugs is a central feature of the lifestyle. The consumption of cocaine generates serious problems both for the individual and the community. Problems increase and become more severe when cocaine, used intravenously or by way of basing, replaces heroin.
Another category of cocaine users (the majority) do not use heroin. Within this category, there is great variation regarding significance of use and problems with use. First we can distinguish the Leisure Type, a group of users who are well integrated in society and use the drug only in context of leisure activities. In addition to cocaine, they also use legal drugs (alcohol, tobacco) and/or illegal ones (cannabis). Problems directly linked to the use of cocaine are rare or non-existent. Secondly, there is the Instrumental Type, a group which, in addition to consuming cocaine in leisure situations, also uses cocaine as an energy booster at work or for other purposes. This type of use can generate definite problems (physical, psychological or economic) for some users. Most are capable of solving these problems without outside help. Finally, we can distinguish the Cocainist Type, a small minority of users. This group has serious problems. Cocaine has become the central element in their life.
A clear distinction must be made between cocaine users who also take heroin and those who use only cocaine. These two groups inhabit totally separate worlds. Heroin and, above all, the rejection of the needle as dangerous are the elements determining the exclusion/inclusion in each category. The needle is seen as a symbol of social rejection, delinquency, AIDS, and death. This perception is often shared by those who are addicted to heroin and who see themselves as rejected by non-addicts. The way of use draws a clear line of distinction between the categories: intranasal (non-heroin) and intravenous (heroin). In this sense it is very important to emphasise that basing as a way of use, is different. It does not have the same negative connotation as injecting and is not linked to the so-called junkies. Most users in the non-heroin category who have serious problems with cocaine, use basing as the main route of ingestion. Basing may be considered as dangerous as injecting because in a relatively short time it can lead to compulsive consumption and related problems. Due to their lack of a negative attitude towards basing, the Instrumental Type, and those grouped under the Cocainist Type who are sniffing, should be considered as a risk group.
To summarize, the intranasal use of cocaine is the most common way of use and only a minority of users have serious problems related to use (a small proportion of the Cocainist Type). The compulsive and problematic use of cocaine is more related to the intravenous consumers of heroin and free basing. Non-heroin users who have basing as the main route of ingestion run the risk for cocainerelated problems.
From an intervention point of view it is important to take account of two distinct groups. The group of poly-drug users, most of whom have problems with heroin and with cocaine can usually be reached through already existing drug assistance agencies. The second group, who do not use heroin and the overriding majority of whom have no problems with cocaine, usually solve their own problems and do not need any form of assistance. Only a few have serious problems and need outside help. This group will avoid services provided for the poly-drug group since they do not wish to be identified as junkies. They can be reached only by drug assistance which is specifically designed for them. Prevention efforts should be directed towards risk groups such as the Instrumental Type. For this group, cocaine has an instrumental meaning which is related to more habitual use and risky route of ingestion (basing).
8.4 Spread, dispersion and extent
Cocaine use is widely spread in the three cities and occurs among different age-groups, occupational categories and in various locations. In all three cities, cocaine is closely related to the social dimensions. Having a definite symbolic value, cocaine often enhances socialization and is used mainly in social settings and convivial environments. The close connection between cocaine and the leisure/entertainment and nightlife world is seen in all three cities. Certain differences were noted, however. In Barcelona and Rotterdam, cocaine is used in public locations (though in specific areas which assure some privacy of use), while in Turin use is mainly in a private environment with close friends. In all three cities, preference for private use before going out for an evening is linked to the wish to avoid dangerous situations. Some respondents used cocaine to enhance their work performance but consumption in the workplace is not high in any of the three cities.
Most respondents had easy access to cocaine. The practice of offering cocaine to other users is widespread. Women, in particular, are more likely to be invited to use cocaine whereas they rarely provide it for others. The procurement of cocaine without going outside the circuit of friendly contacts (traffic between friends) was frequently seen in all three cities. The relationship between user and dealer can also be characterized by mutual trust, discretion and the absence of conflict.
The analysis of personal contact networks carried out in the three cities reinforces the findings of the qualitative analysis. The spread of cocaine use has a relatively open nature. The respondents said that their nominees (the people they named as users) use cocaine mainly, but not exclusively, in the leisure/entertainment and private circuits. Some nominees used it in the work circuit. Social relations among users are not, in the main, characterized by the use of cocaine. Although there is a high degree of mutual awareness of cocaine use between respondents and nominees, cocaine is not a social adhesive which in itself establishes stable social ties between users. Social contact between respondents and nominees is rarely characterized by the presence of cocaine. Thus, the relationships between cocaine users seen in the study (the social networks) are built upon primary ties specified by such variables as age, friendship, circuit and heroin use. Even the Cocainist Type, for whom cocaine plays a dominant role in his lifestyle, continues to function in other relationships and often uses cocaine socially, as well as alone.
It is difficult for researchers to estimate prevalence in hidden populations. In social research, the primary problem is the definition of a case, i.e. the unit on which to base the estimate. This unit often presents difficult and uncertain specification problems. In order to overcome this problem in our study, strict inclusion criteria of use of at least five times in the last half year or 25 times in a lifetime were applied. However, an important methodological achievement has been the development of new estimates derived from a combination of snowball random samples and the network approach based on the well documented capture-recapture or likelihood function methods. In Rotterdam, the prevalence estimates provided the best conditions for the application of the theoretical method of capture/recapture. These two estimators indicated that 12,000 cocaine users were active in the city of Rotterdam (minimum estimated 5,000; maximum 20,000), a 2% prevalence of the general population. In Barcelona, the Rotterdam estimates could not be applied because of different methodological conditions. Barcelona developed its own estimator based on a likelihood function to specify the probability that, given the initial sample of respondents, no repetitions among the nominees would occur. Barcelona estimated that the minimum number of cocaine users in the city lies between 12,000 and 15,000, a minimum prevalence of 0.7%-0.9% in the general population and therefore a higher total prevalence. In Turin, it was not possible to meet the conditions for the application of the method of prevalence estimation used in the two other cities.
8.5 Contextual differences
The socio-legal framework in each country ranges from prohibition of all the psychotropic substances in Italy, to a situation of toleration and de facto legalization of some substances in the Netherlands. Spain occupies an intermediate position. These differences influenced the way in which the study was carried out in the three cities. In Turin, the Italian socio-legal context made it, in the first place, difficult to recruit respondents and, secondly, to obtain information on other users from those who were recruited.
Knowledge about cocaine differed in each country, too. The Netherlands and Spain had already accumulated a large amount of data by European standards, while Italy was at a relative disadvantage. The advantage enjoyed by the researchers in Rotterdam and Barcelona enabled them to orient themselves more precisely and to formulate more specific working hypotheses. The Turin group compensated for a late start by benefitting from the experience of the other two cities. In closing, we note that the sociocultural characteristics of the three societies influenced, on the one hand, the spread and patterns of cocaine use and, on the other, the possibilities of making contact and developing a working relationship between researchers and users.
8.6 Policy
Certain general indications relevant to policy emerged from the research project. In recent years cocaine has been present in almost all environments, sectors and levels of society. It can, therefore, be regarded as an interclass drug. The form of the relationship between user and substance varies considerably and changes over time. Most patterns of use are integrated (or can be integrated) in society. Some patterns of use are connected with friendship or work circuits. They present mainly the intranasal route of ingestion, and do not seem to be either destructive or disruptive. Cocaine use can occur over many years, often in a discontinuous pattern. Many users think that they can interrupt use comparatively easily. Most users maintain that cocaine has not caused them problems of a physical, psychic, social or relational nature. Those who do perceive the risks and problems connected with use are mostly high-level users who are often injecting and who are the least integrated in society.
As far as individual and social risk are concerned, the main determinant appears to be the prior or concurrent use of heroin. The criminality connected with cocaine use is a limited phenomenon. It is difficult to argue that cocaine will replace heroin, for its spread involves new and different strata of the population. Cocaine is, therefore, a deceitful substance. It causes neither dependence nor evident problems as long as it is not abused. It is consistent with the emergent social values: pleasure, efficiency, prestige, success, power. In short, it does not seem that any explosive spread of cocaine abuse as has occurred in the case of heroin is to be expected with concurring deaths from overdose, psychological, physical and social impairment and correlated micro-criminality. Europe is not about to experience an epidemic with these disturbing features. The situation would be certainly different if crack cocaine should spread. Crack was not found in the course of the research and seems to be virtually nonexistent in Europe (except Great Britain). The properties of this substance and experience in the USA show that crack tends to spread in the particularly disadvantaged strata of society magnifying pre-existing violent and destructive potentials. Thus, from a policy point of view the prevention of a cocaine epidemic should have as its priority the mobilization of social workers to provide targeted information and to intensify efforts to keep existing social support networks of cocaine users free from new and violent marketing organizations and their specialized products such as crack cocaine.
 
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