43

DRUG ABUSE*
DON C. DES JARLAIS, PH.D.
Director of Research
Chemical Dependency Institute
Beth Israel Medical Center
New York, New York

T HE PROBLEMS OF AIDS, drug use, and homelessness are closely intert-

wined in New York City, and must be addressed concurrently. The issue
of drug abuse in this city is not about a single drug problem but about multiple
drug problems. It is critical that we begin to devise a variety of strategies for
these problems rather than to rely on any one single strategy.
For addicts many serious problems are associated with physical and psy-
chological dependence on drugs. Drug use is often out of control, lives focus
solely around using drugs, and they are basically incapable of such other roles
as employee, parent, or friend. But the problems of drug dependence are not
the only problems associated with illicit and licit drug use in New York City.
There are specific health issues associated with drug use, including AIDS and
an epidemic of sexually-transmitted diseases. Syphilis has increased dramati-
cally since the crack epidemic occurred in New York City. The trading of
crack for sex has been associated with dramatic increases in syphilis in many
large urban centers in the United States and some rural areas, such as south
Georgia. '
Another critical aspect of problems associated with drug use is child
health. We are now seeing large numbers of children with in utero exposure
to drugs, cocaine in particular. Estimates run to as many as 10,000 children
per year born with in utero cocaine exposure. We do not yet have reliable
longitudinal data on the effects of cocaine on the human fetus. Early data are
remarkably disturbing, indicating that in utero experience can interfere with
the ability to learn, to regulate emotions, and to form satisfactory social
relationships with caregivers.2 Some estimates indicate that it may take hun-
*Presented in a panel, Some Critical Health Care Problems of the City: AIDS, Drug Abuse and
Homelessness, as part of the Annual Health Conference, The Challenge of Health Care in the Nation's
Cities, held by the Committee on Medicine in Society of the New York Academy of Medicine May 16,
1990.

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44D.D. JARLAIS
JARLAIS

dreds of thousands of dollars for each child to develop the special preschool
and early school interventions needed to overcome the effects of in utero
cocaine exposure.
An additional problem is that illicit drug sales have become an immensely
profitable industry in this country. In some neighborhoods of New York City
it is by far the largest single industry with considerable economic strength.
Because this drug industry is illegal it greatly and adversely affects how
health care is delivered to people with drug use problems. The health prob-
lems associated with this industry will not simply remedy themselves because
public health and political officials wish that the industry did not exist.
RESEARCH ESTIMATES OF DRUG USE
There are various ways of estimating the number of drug addicts, drug
abusers, and drugs in the city. First, information is regularly collected on
people coming into drug abuse treatment. This treatment information is sup-
plemented by household surveys, where people are interviewed in their
homes about their drug use. In New York there are also various forms of
"street surveys" where ex-addicts are out on the street interviewing people
who come to where drugs are openly bought and sold. Information about drug
use is also collected from the criminal justice system, particularly the Drug
Use Forecasting System. In New York, as in a number of other large cities
throughout the country, people who are arrested and held overnight are
interviewed about their drug use, and a urine sample is collected from them
on a voluntary basis. The drug use forecasting system obtains high rates of
participation. In New York City over the last several years, drug use forecast-
ing data have stabilized, and slightly more than 80% of all urine samples
collected show some evidence of illicit drug use, primarily cocaine.3 There
are also data from various health systems, including hospital emergency
rooms and the medical examiner's office. When we take all of these various
data sources and try to integrate them, we can be relatively accurate about
trends in drug use. However, we do not yet have a completely satisfactory
way to estimate the total number of people likely to have drug problems,
whether we call them addicts, abusers, misusers, or simply users.
TRENDS IN THE USE OF MAJOR DRUGS
Looking at the trends over the last five years in New York in terms of
heroin injection, it seems relatively constant with an estimated 200,000 regu-
lar heroin users.4 One important figure in the calculation of this estimate of
200,000 is that we have had more than 100,000 people enter methadone
Bull. N.Y. Acad. Med.
 DRUG ABUSE 45

maintenance treatment alone since 1978 in the city. It is also evident from
current street surveys that a large number of heroin addicts never enter meth-
adone treatment. At least 25% of the people interviewed in these street
surveys have never been in any form of drug abuse treatment in New York
City, much less in methadone-maintenance only.5
In terms of cocaine injection, there is a tremendous overlap with heroin
injection. It is difficult to find a research subject who has injected only one of
these drugs without injecting the other. These are not completely identical
populations, and many people who inject both drugs have a strong preference
for one or the other of the two. But there is a very large overlap, with a best
estimate of 200,000 regular cocaine injectors in New York City.
Smoking crack has increased dramatically over the last six years. Studies
conducted back in 1983 and 1984 did not ask about crack use, even though it
was starting to appear in the city. Now our estimates run anywhere from
50,000 to 400,000 people smoking crack in New York City. Presently we do
not have a good understanding of the natural history of crack use: how many
people try crack, develop problems, and will come in for treatment or be seen
by the police; how many try crack, decide they do not like it, and never use it
again; and how many people use it on an irregular basis,only at parties with
certain friends or only on special occasions. We do not understand the distri-
bution of crack users by frequency of use or how use may change over time
for an individual. Compared to other drugs, crack appears to have a higher
potential of rapid transition from first use to problem use. It is also quite
certain that crack is not instantly addictive, that one can try crack and never
use it again. Probably no more than 30% of people who experiment with
crack develop problem use.
There is a growing concern about a transition from crack use to heroin
use -people starting out with crack, becoming "strung out" with crack use,
and discovering that heroin has excellent pharmacological properties for
relieving that sense of being "strung out." We have seen this transition in
earlier epidemics from methamphetamine overuse to heroin use and heroin
addiction, and there is a strong potential for people having problems with
crack to self-medicate with heroin. Right now, street information would
indicate that alcohol is the most commonly used psychoactive substance to
self-medicate excessive crack use, but heroin is also a possibility. While there
is considerable dissatisfaction with the present methadone treatment system,
evidence indicates that we may be on the verge of another epidemic of heroin
addiction, given the ready availability of heroin in New York City and the
potential for people using heroin for self medication of crack problems.

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We have been tracking crack use with the question of whether or not its use
might supplant intravenous drug use over time. Crack has probably become
the more popular drug with the younger, newer generation of drug users in
New York City.When we were tracking this closely, from late 1985 to the
middle of 1987, we saw dramatic increases in the number of crack users
coming into our treatment system. But we saw no decrease at all in the
number of people coming into treatment because they were injecting cocaine.
Crack use is becoming an additional drug problem, not one that is easily
going to replace other forms of drug misuse, such as injection of illicit drugs.
We did one small study of women with pelvic inflammatory disease in a
sexually transmitted diseases hospital clinic here in New York City.6 Most of
the women were young African-American adults. Within this group, 14%
were HIV-positive. A variety of factors were associated with being HIV-
positive in this group, including having injected drugs, having sex with an
intravenous drug user, having smoked crack, or having sniffed cocaine.
When we looked at the correlations among these various drug-related risk
behaviors, almost all of the correlation coefficients were statistically signifi-
cant. Again, we should think of drug problems as interrelated rather than
single problems, and the problem of crack (which is related to sexual activity
and sexually transmitted diseases, such as pelvic inflammatory disease and
HIV) as occurring in a complex, and neither easily isolated nor easily at-
tacked as single problems.
HIV INFECTION
Regarding the AIDS problem among intravenous drug users in New York
City, we have seen a stabilization of HIV infection rates in New York City
among drug injectors for the past six years. Data collected in Manhattan
would indicate approximately 50% of the people coming into treatment are
HIV-positive.7 This stabilization does not mean an absence of new infec-
tions. Cohort data indicate perhaps a 2 to 7% annual new infection rate among
seronegative intravenous drug users. Along with the rate of new infections,
there is also a turnover in the intravenous drug use population. Some people
leave intravenous drug use because they stop on their own, because they
successfully seek and receive treatment, or because they develop various
diseases such as AIDS and die. New people are still starting to inject drugs
and, as far as we can tell, the rate of new injection has not decreased since the
beginning of the AIDS epidemic in the United States as a whole or in New
York City.
We have conducted one small study of people who were sniffing heroin but
not injecting at the time they entered the study.8 These people were randomly

Bull. N.Y. Acad. Med.

 DRUG ABUSE
DRUG ABUSE 47

assigned to an AIDS prevention group versus a control group. We then

followed them up at an average of eight months later. In the experimental
group, 14% went on to injecting drugs, and in the control group more than a
third went on to inject drugs. All people in both groups had been given full
information about AIDS and the dangers associated with drug injection. The
experimental group got an additional six to eight hours worth of small group
counseling, but in both groups there were a substantial number of people who
went from sniffing heroin to injecting it within this relatively short follow-up
time period.
When we looked at factors associated with transition from sniffing heroin
to injecting heroin, the most important ones were having a close personal
relationship with someone who was already injecting drugs -either a close
friend or a relative -and some experimentation with intravenous drug use in
the prior six months. If people had a good role model for injecting drugs they
were very likely to go to injection, or if they were already in the process of
experimenting with injection, they were also likely to continue injecting
during the follow-up period. These people all knew about AIDS. Scare tactics
have never been effective deterrents for keeping people away from drug use.9
One can provide information to children about lung cancer and drunken
driving and not prevent their future experimentation with cigarettes and alco-
hol. One can educate people about AIDS, but there is no guarantee that this
will keep them from starting to inject drugs.
CONCEPTUAL MODELS FOR PREDICTING TRENDS IN DRUG USE
There are several conceptual models for thinking about the drug problems
here in New York. The first conceptual model comes from traditional infec-
tious disease epidemiology and deals with self-limiting epidemics. We have
seen drug epidemics, such as the epidemic of cocaine use early in the century
here in New York, that were basically self-limiting. A limited pool of people
were willing to try cocaine, and once that pool of people tried cocaine, few
new people were willing to start using the drug. People with cocaine prob-
lems often served as negative examples for new users, so that, in some sense,
a drug problem epidemic can be actively self-limiting. Clearly, not everyone
in society is susceptible to experimenting with illicit drugs, and generating
enough negative examples of people with drug problems may further cut
down on the rate of new recruitment.
Another conceptual model that may apply particularly to crack use is the
theory of irreversible technological revolutions. Certain technological ad-
vances are essentially irreversible. The smoking of drugs, particularly strong
potent drugs like cocaine, may be an irreversible technological innovation in

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48 D.D. JARLAIS

our society because its form produces a very intense pleasure without having
to inject the drug. It is probable that this innovative form of drug administra-
tion will spread to other drugs beyond cocaine. We have seen some evidence
now of people smoking mixtures of cocaine and heroin and reports from
Hawaii of people smoking methamphetamine. Smoking of strong illicit drugs
may be an innovation that we cannot reverse.
The third conceptual model comes from anthropology and sociology, that
certain social groups in any society are under structural stress and subject to
problems such as poverty, discrimination, and racism that create a high
liability for developing drug problems. This applies to legal drugs as well as
illegal drugs. For this type of drug problem we shall need to address the
underlying social factors to bring down rates of drug problems in these
socially-deprived groups.
Determining how each of these three models applies to the current drug
problems in New York will be necessary if we are to adopt rational planning
to address the problems.
REFERENCES
1. Holloway, T.: Syphilis, Crack and AIDS: Conducted During 1987-1990.
Rural Georgia's New Epidemic. Way- 6. Hoegsberg, B., Dotson, T., Abulafia, O.,
cross, GA., Southeast Health Unit, 1990. et al.: Social, Sexual and Drug Use Profile
2. Howard, J., Beckwith, L., Rodning, C., of HIV (+) and HIV (-) Women with
and Kropenske, V.: The development of PID. Poster presentation at the Fifth Inter-
young children of substance-abusing par- national Conference on AIDS, Montreal,
ents: Insights from 7 years of intervention Canada, 1989.
and research. Zero to Three 9(5):8-12, 7. Des Jarlias, D.C., Friedman, S.R., No-
1989. vick, D., et al.: HIV-1 infection among
3. National Institute of Justice: 1988 Drug intravenous drug users in Manhattan.
Use Forecasting (DUF). Washington, J.A.M.A. 261(7):1008-12, 1989.
S.C., Department of Justice, 1990, p. 2. 8. Des Jarlias, D.C., Casriel, C., Friedman,
4. State of New York: Third Annual Update S.R., and Rosenblum, A.: AIDS and the
to the Division of Substance Abuse Ser- transition to illicit drug injection: Results
vices Statewide Comprehensive Five- Year of a randomized trial prevention program.
Plan for 1984-85 through 1988-89. Al- Am. J. Public Health. Unpublished
bany, 1986. manuscript.
5. Community AIDS Prevention Outreach 9. Sherr, L.: Fear arousal and AIDS: Do
Demonstration Project (CAPOD): Out- shock tactics work? AIDS 4(4):361-64,
reach Intervention of Street Recruited In- 1990.
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Bull. N.Y. Acad. Med.