Cocaine Use: Recommendations in Treatment and Rehabilitation

3. Distribution of Cocaine Use in Canada

This section describes the characteristics of users and the trends in use. Because cocaine is an illicit drug, the number of users can never be determined definitively. Not everyone who uses cocaine will admit use if asked in a survey, or will accurately recall consumption. Not all users will be charged or convicted. However, data are available that give some idea of the prevalence of cocaine use. Typical indicators include survey data from national and local telephone surveys, school surveys, police-and court-generated data, and treatment studies.

3.1 National Surveys of Adults

Recent national surveys of Canadians 15 years or older that have included questions on alcohol and other drug use are the 1985 Health Promotion Survey, the 1989 National Alcohol and Drug Survey, the 1990 Health Promotion Survey, the 1993 General Social Survey and the 1994 Canada's Alcohol and Other Drugs Survey (for a summary, see McKenzie and Single, 1997). National surveys generally poll a representative sample of Canadians (15+ years) from the 10 provinces, but not the Yukon nor the Northwest Territories, and these surveys average an 80 percent response rate. However, it should be remembered that telephone surveys (which are the typical method used) may underestimate the prevalence of cocaine use, because they miss groups that are more likely to use cocaine, such as prison inmates; persons in residential treatment facilities or other institutional facilities; and individuals who are homeless and therefore lack a stable address or telephone. An additional problem is that only a small number of people admit using cocaine (below 1%), and this increases the possibility of sampling error. Other problems common to the interview process include selective responses and memory gaps. Still, the large sample numbers and the diversity of respondents in such surveys ensure a reasonable picture of cocaine use by Canadian adults. Information from these surveys allow examination by demographic characteristics such as age, gender, occupation, marital status and education.

Among Canadians aged 15 and older, survey data indicate that cocaine users tend to be young (20-34 years), single and male. They are also more likely to have completed some post-secondary education, to describe their occupations as semi-skilled or students, and to be classified in the lowest income bracket. Cocaine users are most likely to be found in cities with larger than 100,000 population in British Columbia and Quebec. Lifetime use of cocaine is also highest among those aged 20-34 years, and men are about twice as likely to report current or lifetime use as women.

National survey data also indicate that self-reported cocaine use in the year prior to the survey dropped slightly from 1985 (0.9% indicated that they had used in the last year) to 1994 (0.7%). Between those years, use appeared to peak in 1989 (1.4%) and reached its lowest rate in 1993 (0.3%). Overall, the data suggest that there has been little change in cocaine use over the past 10 years (Figure 1). Findings are similar in the United States. Based on results from the U.S. National Household Survey on Drug Abuse (NIDA, 1998), in 1996, about 0.8% of the U.S. population 12 years and older were current users, with peak use among those aged 18 to 25 years (2.0%).

Figure 1 - Cocaine Use in Canada

Sources: 1985 Health Promotion Survey, 1989 Alcohol & Drug Survey, 1993 General Social Survey, 1994 Canada's Alcohol & Other Drugs Survey

3.2 Women and Cocaine Use

There is a convergence of national and student surveys showing that females are less likely to use cocaine than males. For example, the 1994 Canada's Alcohol and Drugs Survey had 0.5% females reporting cocaine use compared to 0.8% males, meaning men were 60% more likely to use cocaine (McKenzie and Single, 1997).

Other studies have highlighted some differences between male and female cocaine users. For example, Powis et al. (1996) surveyed 558 individuals who use cocaine in a range of community settings in a U.S. city. They found that women tended to be younger, use smaller amounts of cocaine than men, and were less likely to be people who injected drugs. Also, women were less likely to report that they had undertaken treatment.

Relationships with males was a substantial influence on cocaine use by women. Most females who inject cocaine were introduced to this practice by cocaine-injecting sexual partners.

3.3. Youth and Cocaine Use

3.3.1 Student Surveys

School studies using secondary school student self-reports provide information on cocaine use by young people.

The most comprehensive student surveys have been carried out in Ontario biannually over a 22-year period from 1977 onward. Rates of use were at their peak in 1979, when 5.1% of grade 7 to 13 students reported use in the previous 12 months. This was followed by a steady decline to 1.5% in 1993. Since then use has climbed again, with 4.1% of students reporting use in 1999 (Adlaf et al., 1999) As with adults, males are more likely to report use than females. Students in grades 11and 13 reported the highest rate of use (Adlaf et al., 1999). Rates of use of crack among Ontario students remained stable from the mid-eighties, when it made its first appearance, until 1993. At between 1.0% to 1.4% since that time, rates have increased to 2.3% (Adlal et al., 1999).

Although peak rates of use are somewhat higher among surveys of U.S. high school seniors, they also show a similar decline from a peak of 13.1% in 1985 to 3.1% in 1992, and then a slight increase to 4.9% in 1996. Student surveys done in British Columbia, Alberta, Manitoba and the Atlantic provinces, indicate that rates of use are quite variable across the country. Only British Columbia and Ontario distinguished between cocaine and crack use. Recent surveys show that cocaine use is highest among students in British Columbia (7.8%), followed by Manitoba (5%) and New Brunswick (4.8%). The average for all the Atlantic provinces was 3.4%. (Alberta Alcohol and Drug Commission, 1997; Addictions Foundation of Manitoba , 1995; Health Promotion Institute, 1995; Prince Edward Island, 1996). Information is also available by city from the Canadian Community Epidemiology Network on Drug Use (CCENDU) (Poulin, 1997), which shows that the prevalence of use of crack or cocaine among adolescents was highest in Montreal (6.1%), followed by Halifax (4%) and Vancouver (4%), Alberta (3%), and, finally, Toronto (1.9%). These findings are illustrated in Figure 2.

Figure 2 - Student Self-Reported Drug Use
Canada,Various Years

Source: CCENDU, 1997

The most recent CCENDU report (Poulin, Single and Fralick, 1999), includes more recent figures (1997) for only some of the CCENDU sites. In Winnipeg, 5.5% of students who were using drugs other than alcohol, reported past year cocaine use; in Toronto, 3% of students reported cocaine use and 2% crack use; in Fredericton, 5% reported crack or cocaine use.

Comparison of Aboriginal and non-Aboriginal student drug use is provided in a study by Gfellner and Hundleby (1995), who administered self-report questionnaires to Grade 7-12 students in a non-metropolitan Prairie city. Students were surveyed annually from 1990 to 1993. Study findings indicate a greater prevalence of cocaine use among Aboriginal (registered Aboriginals and Métis) youth, compared to Non-Aboriginal students (Figure 3). In 1990, 4.9% of Aboriginal students reported cocaine use, compared to 1.1% of non-Aboriginal students, meaning they were 4.5 times as likely to use cocaine. By 1993, 4.7% of Aboriginal students reported cocaine use, making them only about twice as

likely to use as non-Aboriginal students (2.6%). On the other hand, reported crack use doubled for both Aboriginal and non-Aboriginal students from 1990 to1993. In 1990, 4.2% of Aboriginal students reported crack use, compared to 8.1% in 1993.

Crack-using non-Aboriginal youth totalled 1.8% in 1990, and increased to 3.4% in 1993. However, caution should be exercised in generalizing these findings to other Canadian locales.

Figure 3 - Aboriginal and Non-Aboriginal Students' Cocaine Use

Student surveys often suggest higher rates of cocaine use by adolescents than national surveys of Canadians 15 years of age and older. This may be due to the setting (home versus school) and survey design, which may lead to student under-reporting in national studies (Gfroerer, Wright and Kopstein, 1997). Students may be more comfortable reporting cocaine use in the school than in the home, where their parents may be in the vicinity. The orientation of questions toward students on a school-based survey may also increase truthful reporting. Finally, school surveys include students in grades 8 and 9, while some national surveys do not include those below 15 years of age.

3.3.2 Street Youth

Young people who reside in and around Canada's downtown cores are much more likely to consume large amounts of cocaine and other drugs. According to the 1999 CCENDU (Poulin, Single and Fralick, 1999), 85% of Vancouver street youth report cocaine use, with more than half reporting frequent use. Also, 48% of males and 32% of females reported injection drug use. Rates were somewhat lower in other cities, with 31% of Toronto street youth reporting cocaine use and 31% crack use. In Montreal, the reported use was 32% and 18% for cocaine and crack respectively, and, in Halifax, the figures were 33% and 20% (1991 figures).

The substantial prevalence of cocaine use among street youth is a cause for concern. Use of cocaine can lead to injection drug use, which increases the risk of hepatitis and HIV infection. The expense of drug use also promotes involvement in criminal activities such as drug dealing, theft and prostitution to support regular use (Inciardi et al., 1994).

3.4 Official Crime Statistics

Official charges and conviction data, which are available from police forces across Canada, indicate the number of cocaine possession and trafficking offences. Police charges emanate from the Controlled Drugs and Substances Act

(which replaced the Narcotic Control Act) and provide a yearly record of the number of individuals charged with cocaine-related offences. Conviction data, which are generated through the courts, identify the number of individuals found guilty of cocaine offences.

Changes in rates of drug charges from year to year may not always reflect changes in cocaine-use patterns, but instead may depend on resources committed by law-enforcement agencies to detect users, as well as on the agencies' perception of cocaine's availability and associated problems in their jurisdiction. Convictions represent a smaller number than charges because some charges are withdrawn, plea bargained, or dismissed by the court by "not guilty" findings.

Figure 4 - Trends in Cocaine and Marijuana Offence Rate per 100,000
Canada 1977-1996

With these caveats in mind, police data show an upward trend in cocaine possession charges. Increases start in 1977, peak in 1989 and then stabilize in the 1990s. In comparison, cannabis-possession offences declined steadily in the 1980s until the beginning of the 1990s, when they started to increase again (Figure 4). This trend is viewed as representing a move by law-enforcement agencies to target more serious drugs (Wolff and Reingold, 1994).

Figure 5 - Trends in Cocaine and Marijuana Possession Offences
Canada 1977-1996

In 1977, cocaine possession made up 1% of all drug-possession incidents, but, by 1996, it had increased to 11%. Conversely, marihuana possession made up 93% of all incidents in 1977, but declined to 80% by 1992.

Figure 6 - Trends in Cocaine and Marijuana Trafficking Rate per 100,000
Canada 1977-1996

Since 1977, police have also shifted their attention away from possession and directed it toward trafficking and cultivating offences (Figure 6). As a proportion of all drug trafficking offences, cocaine increased almost sevenfold, from 4% in 1977 to 27% in 1996.

3.5 Morbidity and Mortality

Hospital-discharge records provide information on individuals who use cocaine who develop serious health problems as a result of their use. CCENDU (Poulin, 1997; Poulin et al., 1999) provides information on morbidity for large Canadian urban centres (Vancouver, Calgary, Regina, Winnipeg, Toronto, Montreal, Fredericton and Halifax). Vancouver had the highest rate per 100,000 of hospital discharges involving a cocaine-related diagnosis (using the measure of all diagnostic levels, rather than just the most responsible diagnosis) with rates of 106 and 35, in 1995 and 1996 respectively. However, other sites (e.g. Calgary, Winnipeg) showed increased rates between 1995 and 1996. This is shown in Figure 7.

Figure 7 - Cocaine-Related Hospital Discharges
Canada 1995

Cities that are part of the CCENDU project also provided data on deaths that involved cocaine. In 1996, mortality rates for cocaine-related deaths per 100,000 were one or less in Calgary, Toronto, Montreal and Halifax, with Regina and Fredericton reporting a rate of zero. These rates were generally consistent with those for 1995. However, in Vancouver, the rate was 28 in 1996, an increase from in 1995.

3.6 Treatment Agency Admissions

The proportion of people receiving treatment for cocaine use provides information about the number of people experiencing drug-related problems and the availability of services. The first CCENDU report (Poulin, 1997) found that, in spite of the apparently high rates of morbidity and mortality associated with cocaine use in Vancouver, that city reported one of the lowest proportion of individuals in treatment who use cocaine (11%), while Halifax reported the highest (28%). The authors of a study on seroconversion among people who inject drugs observed that as early as 1990 the lack of appropriate treatment services, especially for individuals who use cocaine, was identified as a major barrier for those using British Columbia's needle-exchange programs (Strathdee et al., .

3.7 Cocaine Injection Drug Use, and Hepatitis C and HIV

Canada, a significant proportion of people inject drugs are now injecting cocaine, this appears to increase the risk of HIV seroconversion (Strathdee et al., 1997; Blanchard and Elliot, 1998). Among people inject drugs in Vancouver, Strathdee et al. (1997) found that cocaine was the main drug injected by 72% of those who were HIV-positive and 62% of those who were HIV-negative. HIV-positive people who inject drugs were more likely to be established users of injectable drugs, to engage in commercial sex work and to inject with others.

Figure 8 - HIV Prevalence Among Injection Drug Users
Selected Canadian Cities

Vancouver figures are from 1988-89 and 1996 respectively (Source: Patrick et al. 1997). Winnipeg estimates are from 1990 and 1998 (Jamison and Elliot, 1998). Montreal figures are from 1990 and 1996 (Hankins and Tran, 1996).

High rates of HIV and Hepatitis C infections among people who inject drugs have been reported in other large Canadian urban centres as well (Figure 8). Despite the longstanding availability of needle-exchange programs and street nurse programs, Vancouver now has the highest estimated rate of HIV prevalence among people who inject drugs in North America, followed by Montreal (Canadian Centre on Substance Abuse and Canadian Public Health Association, 1997). The second CCENDU national report identifies high rates of Hepatitis C among people who inject drugs in Vancouver's population, while other CCENDU sites also report concerns regarding Hepatitis B and C rates among their populations of people who inject drugs (Poulin et al., 1999).

The risk of HIV associated with injected drugs is of particular concern for women. For males, injection drug use accounted for 18.5 % of AIDS cases in 1999 compared to 1.1% prior to 1990. For females the increase has been from 7.3 % prior to 1990 to 31.7 % in 1999 (Health Canada, 2000) Similarly, the Strathdee et al. (1997) Vancouver study of 1006 people who inject drugs (353 subjects were women) noted that "subjects testing HIV-positive at baseline were more likely to be women" (Strathdee et al., 1997).

Although there are no definitive answers as to why people who inject cocaine are at greater risk of HIV infection than those using other injectable drugs such as heroin, recent studies have identified a number of risk factors associated with injecting cocaine. Based on initial results from a multi site study, the cocaine working group of the National Institute of Drug Abuse concluded that, overall, cocaine users tend to engage in more HIV-related risk behaviours, including needle sharing and unprotected sex (Compton, Lamb and Fletcher, 1995). In comparison to heroin users, people who inject cocaine are injecting more frequently on a daily basis thus increasing the likelihood of using contaminated needles (Hudgins, McCusker and Stoddard, 1995).

It should also be noted that the risk of infection may be related both to needles and to other paraphernalia. In a study by Shah et al (1996), 85% of infected needles collected from a drug "shooting gallery" had evidence of HIV. This study also found traces of HIV DNA in contaminated water used for rinsing needles, infected cotton swabs and infected "cookers" (spoons or bottle caps for dissolving drugs). The likelihood of infection because of contaminated needles or other paraphernalia is also true for Hepatitis C. HCV (hepatitis C) is transmitted more easily through the blood than HIV. It is also more potent than HIV and is acquired earlier after sharing needles.

Compared to HIV, HCV is 10 to 15 times more infectious by the spread of blood (Heintges and Wands, 1997). This situation is further exacerbated by high prevalence rates of HCV infection among populations that inject drugs; even the occasional sharing of needles and other drug paraphernalia carries an extreme risk.