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EPIDEMICS IN THE UNITED STATES

An unusual occurrence of drug use or an unusual occurrence of problems connected with drug use can be referred to as epidemics of drug use and drug abuse. In the mid-1990s in the United States, there were multiple indications that the nation had gone through its second major epidemic of COCAINE use and now was in the end-stages of that epidemic.

The first U.S. epidemic of cocaine use started in the late nineteenth century and early twentieth century when cocaine was marketed widely in a variety of forms, including Coca-Cola, Vin Mariana (a wine containing cocaine), and other cocaine products sold without a doctor's prescription. That epidemic subsided, in part because of increased federal and state restrictions on importation and marketing of cocaine, as well as new labeling requirements for patent medicines and other over-the-counter products.

From 1920 through the early 1960s, cocaine use in the United States was not a usual occurrence outside of relatively small circles of HEROIN users, movie and television stars, jazz musicians, and others who came into contact with illicit suppliers of the drug. In the early 1970s, when the federal government began supporting a series of national and state surveys of illicit drug use, cocaine use was found so rarely that it was difficult to get a reliable impression of the characteristics of the cocaine users—there were too few of them in the survey samples.

By studying the series of survey reports from 1972 through the mid-1990s, it is possible to plot the growth of this second U.S. epidemic of cocaine use from what had been typically low levels of use to increasingly greater numbers of cocaine users. The peak years of the epidemic use seem to have been in the late 1970s, which were followed by declining numbers of cocaine users in subsequent years, notwithstanding a small rally in the mid-1980s in connection with the emergence of crack-cocaine smoking.

Although the number of active cocaine users in the U.S. population has dropped back toward the levels observed in the early-to-middle 1970s, it seems that an epidemic of cocaine dependence is still very much in evidence, if the definition of cocaine dependence is meant to encompass very frequent cocaine use as well as the cocaine dependence syndrome described in the more formal terms of clinical research. That is, as the epidemic of cocaine use subsided in the late 1980s and early 1990s, there was no parallel falling off in the numbers of daily or other frequent cocaine users, and there was no clear drop in the number of people actively affected by cocaine dependence. Indeed, in the mid-1990s, the number of active cases of cocaine dependence in the population seems to be greater than it ever has been in the nation's history. Thus, it can be said that the epidemic of cocaine dependence is not yet over, for there continues to be an unusually large number of cocaine-dependence cases in the population. There is not yet enough evidence to say whether fewer newly occurring cases of cocaine dependence are developing in the U.S. population. Once it can be shown that the new occurrence of cases has fallen off, it can then be said with more confidence that the nation has entered a declining phase in this most recent epidemic of cocaine dependence.

With their attention focused upon a declining number of cocaine users in the early 1990s, the American public and politicans seemed to turn their attention away from the nation's cocaine problems. At the same time, the level of support for treatment of drug dependence dropped from relatively high levels of expenditures in the mid-1980s, even though the number of people suffering from cocaine dependence had remained about the same as it was during the late 1980s. This set of circumstances underscores the political importance of drawing a distinction between epidemics of drug use versus epidemics of drug dependence or drug-related problems. It is likely that many Americans equated declines in the number of cocaine users with declines in the number of cocaine-dependent persons: they were not aware that the epidemic of cocaine dependence continued even as the epidemic of cocaine use was subsiding dramatically.

Coincident with decline of cocaine use within the United States, several other drugs have been the subject of increased attention and use, including drugs whose past popularity has re-emerged in recent years. This comeback of older drugs might be due to newer cohorts of drug users with no experience of friends suffering the adverse consequences associated with the drug, or possibly due to a change in either the availability, purity, or administration of the drug which would make its use more attractive, accessible, or reinforcing. Two examples of this re-emergence are methamphetamine and heroin.

Methamphetamine, a subgroup of amphetamines, was widely used in the 1960s and 1970s. Also known as "speed," "crank," "meth," "zip," and "ice," the medical and nonmedical uses of methamphetamine have included appetite suppression for weight loss, staying awake, and recreation. The stimulant effect is similar to that of cocaine, but with longer duration.

Methamphetamine use has appeared in outbreak and epidemic form in Asia, the Pacific Islands, and primarily southwestern parts of the United States since the middle of the 20th century, often in the form of "ice" smoking (i.e., inhalation of volatile fumes). In the early 1990s less than two percent of the population over the age of twelve had tried methamphetamine, according to national estimates. This number increased fifty percent in the later part of the decade and now remains relatively steady as we enter the 21st century. Among teenagers, the number of methamphetamine users doubled during the 1990s. Emergency room admissions associated with methamphetamine use increased nearly 350 percent from the early to the middle of the 1990s; admissions to treatment increased nearly four hundred percent from the early to the late part of the decade. Outbreaks of "ice" smoking have spread northward and eastward from the southwestern United States, suggesting an epidemic pattern in the United States in the 1990s, still persisting in the year of publication.

Prevalence estimates of heroin use had been relatively consistent during the 1980s, but early in the 1990s the purity of the drug increased dramatically, as did its availability. The heightened purity allowed for modes of administration other than injection, such as snorting and "smoking" (inhalation of volatile fumes), opening a door to heroin use for the drug users who otherwise might abstain due to an aversion toward injection.

Initiation of heroin use among youths in the mid-1990s was at its highest level in nearly 30 years. From the mid-1990s to the end of the decade, the proportion of heroin users using needles remained unchanged while the proportion sniffing or snorting increased from 50 percent to 75 percent. Much of the new heroin use is within the population under age 25. Heroin use started to increase in the early 1990s and continued through the end of the decade. It now seems to have stabilized.

OTHER PAST DRUG EPIDEMICS

An epidemic during the third century B.C. of "hanshi" use at the end of the Han dynasty in China and the spread of tea drinking prior to 900 B.C., might be the earliest documented epidemics of PSYCHOACTIVE DRUG use in the world, not counting outbreaks of excessive ALCOHOL use (see ASIA, DRUG USE IN).

In the 1600s, in Europe, there were epidemics of CHOCOLATE (cocoa) consumption, TOBACCO consumption, and COFFEE consumption. These epidemics followed shortly after colonization of the Americas by Europeans and were sustained by ever-increasing supplies of these products shipped from the cash-poor colonies.

During the nineteenth century, many Europeans became enthusiastic about the inhalation of ether, an intoxicating volatile substance that was investigated for its medical uses by John Snow, one of the fathers of modern epidemiology. Although definitive statistics are not available, it appears that nonmedical inhalation of ether spread through Ireland in an epidemic fashion during the nineteenth century, as did inhalation of NITROUS OXIDE (laughing gas) in the United States. Also during the nineteenth century, China and several other countries experienced epidemics of OPIUM consumption, especially opium smoking. In part, an increased spread of opium smoking in the Americas prompted passage of antiopium legislation, which ultimately produced international agreements that curbed the supply and distribution of opium and opium products worldwide.

It has been said that the international agreements on these drugs were less effective than the public-health and punitive actions taken within countries to curb opium smoking. For example, harsh jail sentences were imposed for violation of city, state, and federal laws concerning opium, and a tradition of executing "drug criminals" was started in some countries. In Communist China, according to some stories, capital punishment of drug dealers and drug users account for the virtual disappearance of drug problems in that country. The truth of these stories cannot be known.

About the same time that the international agreements on opium and opium products were passed, the United States experienced an increase in tobacco smoking, ultimately with peak population levels of tobacco smoking occurring during World War II and the following years, before declines occurred in conjunction with the surgeon general's 1962 report on smoking and health and other publicity about the health hazards of smoking. When one considers the social climate of the 1990s, a time when tobacco smoking was not at all a socially approved drug-use practice, it may be difficult to imagine that during World War II Lucky Strikes and other cigarettes were passed out to soldiers as part of their daily food rations. This turned out to be an effective way to sustain the epidemic of tobacco smoking, but one cannot be sure whether the tobacco industry's intent was primarily to boost the morale of soldiers or to create and build market strength for tobacco cigarettes. Someone interested in the history of epidemiology might be able to sort this issue out, if industry records from that time were opened for inspection.

A more definitive case can be built for the marketing strategies that have been used to increase and build market strength for smokeless tobacco products such as snuff. There was a tremendous increase in the youthful usage of smokeless tobacco between 1970 and 1985. This increase has been traced to deliberate marketing strategies, including formulation of relatively low-cost, "unit dose" supplies of tobacco snuff that had been flavored to increase palatability.

While tobacco consumption was increasing worldwide, Japan's population was affected by an epidemic of METHAMPHETAMINE use during and especially after World War II; later distribution of this drug was seen throughout other countries of the world, including the Scandinavian nations and the United States. At one point in the 1950s, it was estimated that 2 percent of Japan's population had taken methamphetamines nonmedically. It also has been said that especially harsh jail sentences and other criminal penalties accounted for the termination of the amphetamine epidemic in Japan, but as noted in regard to capital punishment and prior Asian drug epidemics, there is no good evidence on this issue. Between 1945 and 1965, other countries saw amphetamine epidemics come and go without the implementation of especially harsh criminal penalties.

The prevalence of nonmedical STIMULANT use in the 1950s did not reach the 2 percent level in the United States as it had in Japan, but it was sufficiently widespread to yield congressional hearings that focused especially upon AMPHETAMINE use by long-distance truckers (e.g., those who used the drug to promote vigilance and stamina for lengthy trips) and by homemakers (e.g., those who took amphetamines to curb their appetite or because of their mood-altering effects). In part, these epidemics should be understood in relation to the relatively widespread availability of amphetamines in a context of limited regulation of supplies and distribution. These epidemics resulted in legislation and social action to reduce the supply and control the distribution of the amphetamine drugs. In the United States, two especially relevant pieces of federal legislation were the Drug Abuse Control Amendments of 1965 and the CONTROLLED SUBSTANCES ACT of 1970; these laws were directed at controlling the use of the amphetamines as well as the use of other drugs.

The usage of marijuana and the psychedelic drugs (e.g., LSD) grew during the 1960s and seems to have peaked during the 1970s. In the 1990s, there were conflicting reports of increasing consumption of these drugs, especially LSD. By some accounts, the nation entered a new phase of LSD usage. It appears, however, that this nationwide increase was not detectable in population estimates from the NATIONAL HOUSEHOLD SURVEY ON DRUG ABUSE, and it is possible that the apparent nationwide epidemic actually remains quite limited in scope.

Several noteworthy developments occurred in relation to HEROIN and the OPIOID drugs during the late 1960s and early 1970s. One important clinical and epidemiological research group based at the University of Chicago developed important innovative strategies for community-level intervention directed at outbreaks of heroin use and heroin dependence. An important element in the group's intervention plan was to employ outreach workers, including staff in recovery from heroin dependence, who would spend enough time on the street corners to identify both new and old users of heroin and to help them get into treatment and stay in treatment. In addition, in Britain, Richard de Alarcon adapted classical methods of epidemiologic research to study the diffusion of injecting drug use (especially injecting heroin use) as an epidemic phenomenon, by plotting the person-to-person spread of the epidemic over time and across the cities of that country.

In 197l, President Richard M. Nixon declared a "war on drugs" following a period of increased heroin use in the United States: he did this partially in association with the return of Vietnam veterans, many of whom had become users of heroin and other opioid drugs during their overseas tours of duty. This epidemic of the late 1960s and early 1970s was documented most readily by examining statistics on clients entering treatment for heroin dependence, including the lag of several years that separated users initial injection of heroin to their first admission for treatment. Despite the war on drugs, a decline in heroin use in the early 1970s was followed by another smaller epidemic of heroin use or dependence during the mid-1970s, followed by apparent decreases in the occurrence of heroin dependence during the late 1970s and early 1980s. The early decrease appears to have coincided with the decrease in importation of heroin to the United States from supplier countries such as Turkey and the mid-1970s increase with the emergence of Mexico and Southeast Asia as suppliers of illicit opiates.

When heroin is the drug of choice and heroin availability declines, users often take other drugs that provide the same functions—either opiate drugs derived from the opium poppy such as morphine or synthetic opioids derived in the chemistry lab and not requiring cultivation products from poppy fields. One example of a synthetic opioid is the so-called China White, which spread through the United States, especially on the West Coast. The number of overdoses linked to China White and related synthetic opioid drugs seemed to increase until the mid-1980s. Since then, there have been declines in the incidence of this type of overdose, possibly because of the increased supplies and street-level purity of poppy-derived heroin.

In addition to the cocaine epidemics already mentioned, there was a cocaine epidemic in the late twentieth century, which might have been sustained by the introduction of CRACK-cocaine, another unit-dose formulation of a psychoactive drug that reduces cost to a level that can be afforded (at least, initially) by many people. Other articles in this encyclopedia discuss reasons that crack-co-caine smoking might have helped sustain the epidemic of cocaine use, including differences in the pharmacologic, pharmacokinetic, and reinforcement profiles of crack-smoking versus nasal insufflation of cocaine hydrochloride powder. In this context, it is interesting to note that the epidemics of crack smoking and cocaine use ended when they did, during a period of widespread availability of cocaine in a low-cost formulation. In epidemiologic terms, this development carries three very important implications. First, given widespread availability, many Americans had opportunities to smoke crack or take cocaine powder and did not do so. In some important way, these were Americans who were not susceptible to widespread media publicity and other conditions that otherwise might have promoted the use of crack or other forms of cocaine.

Second, for many Americans who tried crack or cocaine powder, the use of these drugs did not compete well with alternative behaviors that were as readily available to them in their home and community environments. They found that there were other, more reinforcing ways with which to occupy their daily lives. This signifies that within the population, for those who have used cocaine, there are differences in the users' susceptibility to becoming cocaine dependent.

Third, within the American population, the balance of these several kinds of susceptibility must have changed over the course of the 1980s. For example, during many other epidemics of contagious disease, as the balance of susceptibility changes, the people who are more susceptible become surrounded by people who are less susceptible. Sometimes, the balance of susceptibility changes without any active and organized public health intervention, as in the case of a typical influenza epidemic in an elementary school population. Sometimes, the balance of susceptibility is changed quite deliberately by organized public-health action, as in the successful worldwide effort to eradicate deadly smallpox by making sure that susceptible persons were immunized against smallpox, and by making sure that infected individuals were surrounded by those who were not susceptible by virtue of either immunization or past infection.

In the case of a drug epidemic, as the more susceptible individuals in the population start to become surrounded by people who will not or do not take the drug, it must be increasingly difficult for them to come into contact with the drug at an individual level, even when the drug supply is great at the societal levels. Furthermore, as the balance of the several kinds of susceptibility changes within the population, there must be an evolution of the social-influence processes that promote the spread of drug use from person to person: Fewer people are being pressured by peers to use the drug; fewer people are talking about the drug in favorable terms; more people are talking about how they had a chance to use it, but it just didn't seem worth it; more people are talking about how they have used the drug but it just didn't do very much for them.

This sort of process must have taken place with regard to the cocaine epidemic for the balance of susceptibility to have changed within the population; otherwise, the epidemic of cocaine use would have persisted. Because we do not have an effective biological vaccine that would reduce susceptibility to cocaine use the way the smallpox vaccine reduced susceptibility to smallpox infection, this change in the balance of susceptibility had to have been caused by something else. Before the epidemic of cocaine use had started to decline, the social demographer K. Singh hypothesized that it would decline simply because of demographic changes in the U.S. population caused by a declining birth rate fifteen to twenty-five years earlier. Singh apparently reasoned that, numerically, there would be fewer and fewer people aged fifteen to twenty-five, and this by itself would change the balance of susceptibility in the population because the developmental period from age fifteen to twenty-five is one that is at especially high risk for starting illicit drug use.

Later, and after the epidemic of cocaine use had started to decline, two other main hypotheses emerged. One of these took note of the demographic changes to which Singh had pointed but also drew on three other interrelated epidemiologic observations, namely that (1) cocaine use almost always starts after MARIJUANA use has started; (2) a history of marijuana use probably is the strongest indicator of susceptibility for trying cocaine; and (3) most marijuana users try cocaine once or a few times but do not go on to become dependent upon it (i.e., they are in the second kind of susceptibility group already mentioned). These three epidemiologic observations were also linked with an observation from ethnographic research: When a young person is presented with an opportunity to try marijuana or cocaine, it very often is a slightly older person with a history of marijuana use who presents the opportunity. It might thus have happened that the cocaine epidemic had stopped growing and had started to end once the supply of cocaine had increased to a level where a large proportion of former and current marijuana users had been presented with an opportunity to use cocaine. When these marijuana users either declined to use cocaine or tried and then stopped using cocaine, they then no longer could serve as sources of diffusion to younger persons. That is, the change in balance of susceptibility within the population was related to the number of individuals who previously had tried marijuana and to whether they had completed the normative passage of (1) declining to use cocaine when it was offered to them or (2) trying cocaine a few times without becoming dependent upon it, thereby ceasing to be part of the vanguard of cocaine experimenters who in the glow of their first cocaine experiences would enthusiastically be offering cocaine to others.

According to the other main post-epidemic hypothesis, trends in the perceived danger or risk of harm associated with taking cocaine affected trends in cocaine use. Particularly after basketball star Len Bias died after smoking crack, more young people reported that they perceived there to be substantial risks of harm associated with taking cocaine. Concurrently, there were declines in reported levels of cocaine use. For a number of years, as surveys showed more and more young people reporting that they perceived cocaine use to be dangerous, the levels of cocaine use declined even further, despite increasing or stable levels of cocaine availability. These trends gave rise to the optimistic observation that perhaps it was the increases in perceived dangerousness of cocaine use that accounted for the declines in cocaine use. If such an observation were true, society might be able to stop or curb future epidemics by educating youths to perceive the harmfulness of drug use.

DRUG EPIDEMICS IN THE FUTURE

Singh's prediction based on an analysis of demographic changes in the population and the two main hypotheses that emerged after the epidemic of cocaine use had started to decline have historical importance. Although it was not possible to test these hypotheses about the 1975-to-1994 epidemic of cocaine use in the United States in any rigorous fashion, and it cannot be known for certain that any of them is correct, they may help in the plans for coping with future epidemics of drug use and drug dependence; they also offer pointers what kind of societal response might be needed if a rising line is perceived in the plotted curves of new epidemics. Nonetheless, until a more certain knowledge is acquired about the dynamics of epidemics of drug use, it will be premature for politicians or anyone else to ride to glory on the descending line of these curves. There is enough knowledge to take action, but not enough to say what specific combinations of public-health actions will be effective.

The array of public-health actions to stop or curb future drug epidemics have not yet been exhausted. In the 1970s, Dr. Jerome H. Jaffe and other experts suggested developing prevention strategies that would be based on concepts of reducing susceptibility to drug dependence. This might sound like science fiction, but recent new developments in molecular biology, immunology, pharmacology, and neuroscience have made a viable strategy of this type more plausible.

A relatively sharp increase in the use of steroids among youths towards the end of the 1990s suggests that investigation into its use, especially among males, might identify an emerging epidemic. Similarly, "club drugs" such as MDMA ("ecstasy"), Rohypnol, ketamine, and others, have shown increases in use and availability throughout the 1990s, primarily among youths and young adults.

Because of the novelty of these types of drugs, surveys designed to estimate the number of users have difficulty keeping up with their emergence in isolated outbreaks until use has persisted long enough and has become sufficiently prevalent to warrant inclusion in the survey assessments. For this reason, there are no definitive sources of epidemiological evidence on epidemics of drug use, akin to the evidence available for notifiable diseases such as syphilis and HIV infection. Readers interested in local area outbreaks and epidemics will find useful and sometimes definitive evidence in the periodic reports of Community Epidemiology Work Groups established by the United States National Institute on Drug Abuse, and its counterpart institutions in other countries.

In seeking to understand the future of drug epidemics in society, it will be necessary to complete more thorough studies of some predicted epidemics that did not materialize. For example, following the 1990/91 Persian Gulf war and 1992 posting of U.S. troops to Somalia in East Africa, it was said that the United States would suffer a khatcathinone epidemic as soon as the veterans returned with the experience of seeing khat used by the people of the Middle East and Somalia—and when cathinone (one of khat's active ingredients) was extracted or synthesized by underground chemists for distribution. So far, however, the prediction of the nationwide KHAT-cathinone epidemics has been wrong. There have been isolated epidemics in a few communities but apparently no widespread use, and it is not altogether clear what curbed the spread to other communities.

As of the early 21st century, many countries have conducted epidemiological surveys to estimate the number of drug users in their populations, and some countries maintain substantial surveillance efforts to assess whether and when drug epidemics are occurring. No country, however, has made a substantial investment in the empirical study of drug epidemics. Most of the hypotheses and theories about drug epidemics remain untested against epidemiologic evidence, including a recently stated and fairly elaborate theory that incorporates what might be the necessary conditions for the expansion, the maintenance, and the decline of drug epidemics. It must thus be said that the present stage of applying epidemiology to the study of drug epidemics is a fairly primitive one.

(SEE ALSO: Adjunctive Drug Taking; Alcohol; ; Amphetamine Epidemics; Education and Prevention; Epidemiology of Drug Abuse; High School Senior Survey; Opioids and Opioid Control; ; U.S. Government Agencies; Vulnerability as Cause of Substance Abuse)

CARLA STORR

JAMES C. ANTHONY

MARSHA F. ROSENBERG