Coca, Cocaine, Freebase and Crack

"Deaths involving cocaine and psychostimulants have increased in the United States in recent years; among 70,237 drug overdose deaths in 2017, nearly a third (23,139 [32.9%]) involved cocaine, psychostimulants, or both. From 2016 to 2017, death rates involving cocaine and psychostimulants each increased by approximately one third, and increases occurred across all demographic groups, Census regions, and in several states. In 2017, nearly three fourths of cocaine-involved and roughly one half of psychostimulant-involved overdose deaths, respectively, involved at least one opioid. After initially peaking in 2006, trends in overall cocaine-involved death rates declined through 2012, when they began to rise again. The 2006–2012 decrease paralleled a decline in cocaine supply coupled with an increase in cost. Similar patterns in death rates involving both cocaine and opioids were observed, with increases for cocaine- and synthetic opioid-involved deaths occurring from 2012 to 2017. From 2010 to 2017, increasing rates of deaths involving psychostimulants occurred and persisted even in the absence of opioids."

"Our findings of a reduction of health problems, are consistent with harm reduction programs for people who inject drugs [19], including needle exchange programs and supervised injection sites, where they are effective in reducing overall negative health consequences. By providing users with high-quality smoking equipment and reducing the dependence on unsafe equipment, the unintended negative consequences, including exploding pipes, burns, and inhaling brillo fragments, are further reduced."

"We observed that the increase in crack pipe distribution services coincided with a corresponding increase in the uptake of crack pipes obtained through health service points only. Further, rates of reporting health problems associated with crack smoking declined significantly after the crack pipe distribution program was implemented. In the multivariable analysis, compared to obtaining crack pipes through other non-health service sources only, obtaining pipes through health service points only was significantly and negatively associated with reporting health problems from smoking crack. These findings suggest that the recent expansion of crack pipe distributions in this setting has likely served to reduce health problems experienced by crack smokers, achieving the desired outcome of the program.

"While crack users are obtaining their safe crack smoking equipment from health service points, they may also be exposed to education around safer smoking techniques and practices, by being in direct contact with service providers in the community. This may also have the benefit of exposing drug users with no connections to health care to available providers in their area [27]. A previous study of an outreach-based crack smoking kit distribution service indicated that unsafe smoking practices such as using Brillo pads and sharing crack paraphernalia remained prevalent, even after the implementation of the service [10], suggesting the importance of placing such service in a continuum of broader health service system and ensuring the availability of smoking kits to reduce risky smoking behaviours."

"Cocaine-related ED visits were predominately made by individuals who were older, male, and Black. Potential reasons include differences in drug supply, disparities in comorbidities, socioeconomic disadvantage, and other factors related to structural racism that can affect health and healthcare access [41, 42]. Complications from cocaine use are disproportionately higher in Black communities, where rates of cocaine-related deaths are comparable to the rates of opioid-related deaths in white individuals [41]. Yet cocaine-related harms have been understudied in recent years. This is alarming given overdose deaths in Black individuals are rising faster compared to whites [43, 44], and in our study, cocainerelated visits were as likely to result in admission as opioid-related visits. As attention toward the rising epidemic of stimulant-related deaths increases, interventions addressing stimulant use must address racial equity and pay attention to both cocaine and psychostimulant use to avoid further exacerbating racial and economic disparities [45]."

"• In 2018, there were 14,666 drug overdose deaths involving cocaine in the United States for an age-adjusted rate of 4.5 per 100,000 standard population (Figure 1)."

"• The age-adjusted rate of drug overdose deaths involving cocaine remained stable from 2009 through 2013 ranging from 1.3 to 1.6 per 100,000, then increased on average by 27% per year from 2013 through 2018.

"• For males, the rate increased from 2.1 in 2009 to 6.4 in 2018. For females, the rate increased from 0.7 in 2009 to 2.6 in 2018. For each year, rates were 2.4 to 3.0 times higher for males than females."

"• Throughout the study period, the rates of drug overdose deaths involving cocaine were highest for the non-Hispanic black population, followed by non-Hispanic white and the Hispanic population (Figure 3).

"• In 2018, the rate of drug overdose deaths involving cocaine in the non-Hispanic black population (9.0 per 100,000) was nearly twice that of the non-Hispanic white population (4.6) and three times that of the Hispanic population (3.0).

"• In general, for each group, the rate remained stable from 2009 through 2013–2014, then increased in subsequent years. The rate for the non-Hispanic white population was the same in 2017 and 2018 (4.6)."

"Supervised inhalation rooms (SIR) have the potential to minimise the aforementioned barriers to care and harms associated with crack cocaine smoking [12,21]. Modelled after supervised injection facilities, SIRs are regulated environments in which people can smoke pre-obtained drugs with sterile equipment under the supervision of nurses or other trained staff [22]. These facilities aim to reduce high-risk drug use practices and blood-borne infections, increase contact between PWUD and health and social services, and improve public order through reductions in public drug use [23]. To date, SIRs have been implemented in seven countries: Canada, Germany, Luxembourg, Netherlands, Switzerland, Spain and France [24–26]. In contrast with the significant evidence of the health and community benefits of supervised injection sites, rigorous evaluation of the specific outcomes of SIRs is lacking [24,27]. However, it is plausible that many of the demonstrated health benefits associated with supervised injection sites could extend to SIRs, with available evidence suggesting that SIRs have potential to improve public order, connect PWUD with health and social services, and reduce drug-related harms [11,25]."

"Methodology and Limitations

"Seizure data are obtained from OFO administrative records and is considered reliable. Estimates of the total cocaine flow are provided by the Defense Intelligence Agency (DIA).¹⁵ The U.S. Government does not have an estimate of the share of the total cocaine flow that passes through land POEs, but the U.S. Drug Enforcement Agency’s National Drug Threat Assessment states that the Southwest Border remains the key entry point for the majority of the cocaine entering the United States. The DIA estimate is based on a U.S. Government estimate of cocaine departing South America towards the United States, and additionally incorporates estimates of cocaine movement, cocaine production, and U.S. consumption derived from various U.S. Government agencies. The estimated amount of cocaine available to enter the United States (estimated flow in Table 15) is derived by finding the difference between the estimated amount of cocaine departing South America toward the United States and the sum of documented cocaine removals, consumption in the Transit Zone, and documented departures from the Transit Zone towards non-United States destinations.

"Available Data and Discussion

"Total seizures dropped to 19,000 kilograms in 2019, the lowest in the 2016-2020 period and down 35 percent from the 2016 to 2019 average. Land seizures dropped to 7,000 kilograms in 2019, the lowest in the period and down 18 percent from the 2016 to 2019 average. Estimated flow rose to 905,000 kilograms, but was still down 15 percent from the 2016 to 2019 average. The drop in total seizures and rise in estimated flows resulted in the seizure effectiveness rate halving from the previous year to 2.1 percent."

"● The age-adjusted rate of drug overdose deaths involving cocaine increased slightly from 1.6 deaths per 100,000 standard population in 2002 to 2.5 in 2006, decreased to 1.3 in 2010, then increased to 8.2 in 2022; the rate in 2022 was 12.3% higher than the rate in 2021 (7.3) (Figure 5).

"● The age-adjusted rate of drug overdose deaths involving psychostimulants with abuse potential (subsequently, psychostimulants), which includes methamphetamine, amphetamine, and methylphenidate, was 4.0% higher in 2022 than the rate in 2021 (10.4 compared with 10.0).

"● The age-adjusted rate of drug overdose deaths involving psychostimulants increased more than 34 times from 2002 (0.3) to 2022 (10.4), with different rates of change over time."
 

"Tusi is a relatively new drug concoction that is marketed using the phonetic translation of “2C.” This name, especially when mentioned verbally, has great potential to incorrectly refer to 2C. This was likely an intentional marketing tactic. Variations in spelling include “tuci,” ”tucci,” and “tussi,” and tusibí and tucibí (17,18)—which even further misrepresent the specific compound 2C-B. The mixture is also sometimes referred to as “pink cocaine” (“cocaina rosada” in Spanish) despite cocaine rarely being a component of the concoction. Tusi is almost always found in the form of pink powder, often accompanied with a sweet smell resulting from food coloring (18). Tusi reportedly now has a relatively low cost in some areas with some reports suggesting a gram can now cost as little as $10 USD (19), although costs might shift as popularity continues to increase.

"It is unknown to what extent people who use or seek tusi are aware of its potential contents. Most drug-checking studies reporting on its contents have been conducted in Latin America where the concoction appears to be most popular. Such studies have typically not found tusi to contain 2C/2C-B, but rather ketamine combined with MDMA, methamphetamine, cocaine, opioids, and/or new psychoactive substances (17). In fact, one study conducted in Chile found that 99% of submissions said to contain 2C contained ketamine and <1% contained actual 2C series drugs (17). A drug checking study that analyzed drug samples submitted at fixed sites and dance festivals throughout Colombia detected a wide range of drugs in tusi including ketamine, MDMA, 3,4-methylenedioxyamphetamine (MDA), cocaine, methamphetamine, synthetic cathinones, 1-(4-Bromo-2,5-dimethoxyphenyl)-2-aminopropane (DOB), local anesthetics such as lidocaine, and opioids such as oxycodone and tramadol (19). 2C-B was typically not detected. Energy Control, the leading drug checking organization in Spain, has also found that almost all samples of tusi submitted test positive for ketamine plus MDMA with or without additional drugs. Similar to other studies, 2C-B was rarely detected (18). Energy Control reports that, on average, a third (34%) of the volume of tested samples is ketamine and 11% MDMA. Similar mixtures of drugs detected in tusi have been reported on social media by drug checking organizations in the United Kingdom, Switzerland, Australia, and Canada (17)."

"The tusi phenomenon complicates the drug landscape because it has the potential to confuse both people who use and researchers alike. With respect to people who use, given the drug concoction’s name, people may assume the drug is 2C/2C-B. Since many partiers are unfamiliar with 2C series drugs (14), there is also potential for people to simply think this is a new (and perhaps benign) drug – especially given that the powder is pink with a sweet scent. The concoction’s other name, “pink cocaine,” may also lead some to believe this is a form of cocaine. This is an issue because cocaine is often used to balance out the effects of alcohol and unintentional ketamine use combined with alcohol use can lead to adverse reactions (21,22). Regardless of what people who use believe is in this concoction, batches tend to greatly fluctuate regarding which drugs and how much of them are mixed in. As such, this concoction may lead to unpredictable effects. Pre-mixed combinations of various drugs can also interact and have synergistic effects. This situation is even further complicated by the fact that many people in scenes that use tusi (e.g., party scenes) engage in polydrug use (19) which can lead to larger than planned doses or even further unintentional drug combinations. Tusi can also contain highly potent stimulants such as methamphetamine, which can be particularly dangerous or unpleasant if unknowingly consumed. As tusi acquires more popularity as a mystery powder, more people may create their own drug amalgamations to sell under its name, and similar to the current cocaine situation in the US (23), fentanyls may begin to appear in tusi, which will increase potential for overdose and death. A task force in California has already seized 4.4 lbs. of pink powder containing ketamine and despropionyl fentanyl (24), but this is a fentanyl precursor, which is thought to be relatively inactive (25).

"The tusi phenomenon also has the potential to complicate drug research. While toxicology studies tend to be more focused on testing which substances people have been exposed to, clinical, epidemiological, and social science studies that rely primarily on self-report can be affected. Most drug surveys do not query the use of actual 2C series drugs, so it is unlikely that such surveys will begin to ask specifically about tusi. Those who add questions about this concoction may assume tusi and 2C are the same product and collect unreliable data. It is also important to differentiate between what a product is called and what drug or drugs are present in the product. In this case, currently, ketamine appears to be the most common and most abundant drug present in tusi. While the two leading national drug surveys in the US do query ketamine use, “correct” responses to questions about use would depend on the participant knowing they were exposed to ketamine in tusi. As such, use of drugs such as ketamine or MDMA that was present in tusi will likely be underreported. Similarly, the use of synthetic cathinones (“bath salts”) is commonly underreported among people who use ecstasy because they are unaware that the ecstasy they used contained these compounds (26,27). Prevalence of ketamine use already appears to be increasing in the US (28), and increasing use of tusi will further drive increases, but estimated increases would likely depend on people knowing that they actually used ketamine."

"Cocaine use includes the use of crack cocaine. Estimates of crack use are presented separately as well. Among people aged 12 or older, the percentage who were past year cocaine users decreased from 2.5 percent (or 5.9 million people) in 2002 to 2.0 percent (or 5.5 million people) in 2019 (Figure 13 and 2019 DT 7.2). Estimates of past year cocaine use among people aged 12 or older fluctuated over time. The percentage in 2019 was lower than the percentages in 2002 to 2007, was higher than the percentages in most years from 2011 to 2014, and was similar to the percentages in 2008 to 2010 and in 2015 to 2018.

"Percentages for past year crack use among people aged 12 or older decreased from 0.7 percent (or 1.6 million people) in 2002 to 0.3 percent (or 778,000 people) in 2019 (2019 DT 7.2). The percentage of people in 2019 who used crack in the past year was lower than the percentages in 2002 to 2009, but it was similar to the percentages in 2010 to 2018.

"Aged 12 to 17
"Among adolescents aged 12 to 17, the percentage who were past year cocaine users decreased from 2.1 percent (or 508,000 people) in 2002 to 0.4 percent (or 97,000 people) in 2019 (Figure 13 and 2019 DT 7.5). The percentage of adolescents in 2019 who used cocaine in the past year was lower than the percentages in most years from 2002 to 2014, but it was similar to the percentages in 2015 to 2018.

"Percentages for past year crack use among adolescents decreased from 0.4 percent (or 100,000 people) in 2002 to less than 0.1 percent (or 11,000 people) in 2019 (2019 DT 7.5). The percentage of adolescents in 2019 who were past year crack users was lower than the percentages in 2002 to 2008, but it was similar to the percentages in 2009 to 2018.

"Aged 18 to 25
"Among young adults aged 18 to 25, the percentage who were past year cocaine users decreased from 6.7 percent (or 2.1 million people) in 2002 to 5.3 percent (or 1.8 million people) in 2019 (Figure 13 and 2019 DT 7.11). As for people aged 12 or older, estimates of past year cocaine use among young adults fluctuated over time. The percentage of young adults in 2019 who were past year cocaine users was lower than the percentages in 2002 to 2007 and was higher than the percentages in 2010 to 2014, but it was similar to the percentages in 2008 and 2009 and in most years from 2015 to 2018.

"Percentages for past year crack use among young adults decreased from 0.9 percent (or 266,000 people) in 2002 to 0.2 percent (or 61,000 people) in 2019 (2019 DT 7.11). The percentage of young adults in 2019 who used crack in the past year was lower than the percentages in most years from 2002 to 2015, but it was similar to the percentages in 2016 to 2018.

"Aged 26 or Older
"Among adults aged 26 or older in 2019, 1.7 percent (or 3.6 million people) used cocaine in the past year, and 0.3 percent (or 706,000 people) used crack in the past year (Figure 13 and 2019 DT 7.14). The percentage of adults in this population in 2019 who used cocaine in the past year was similar to the percentages in 2002 to 2009 and in 2016 to 2018, but it was higher than the percentages in most years from 2010 to 2015. The percentage of adults in this population in 2019 who were past year crack users was lower than the percentages in 2002 to 2007, but it was similar to the percentages in 2008 to 2018."

"The global supply of cocaine is at record levels. Cultivation doubled between 2013 and 2017, peaked in 2018 and rose sharply again in 2021. The process from coca bush cultivation to cocaine hydrochloride has also become more efficient, contributing even further to the global supply of cocaine.

"In parallel, law enforcement agencies are seizing greater amounts of cocaine. Preliminary figures for 2021 suggest a very sharp rise in seizures. In recent years, seizures showed an underlying upward trend across most regions, punctuatedf by a "bump" brought about by COVID.

"The COVID pandemic had short-term ramifications for the cocaine market across the world. In the origin countries of Bolivia (Plurinational State of) and Peru, cultivation rose and eradication efforts were curtailed during the pandemic. Yet traffickers struggled to get their product to market, creating an overabundance of coca leaf that pushed down prices.

"During the pandemic in Brazil, traffickers increased the use of aircrafts to get cocaine into the country. This led to an overall rise in the amount of cocaine coming into Brazil just as outgoing flows began to fall. The pandemic also had a possible impact on domestic consumption.

"In Western and Central Europe, the pandemic appears to have had a temporary restraining effect on the ongoing expansion of the cocaine market. Following a period of steady growth, cocaine seizures stabilized in 2020 before rebounding in 2021. Wastewater-based indicators also suggest a dip in consumption that recovered in 2021.

"Wastewater measurements from Australia suggest consumption declined by approximately one half in the year from late 2020, before rebounding moderately in the last quarter of 2021. This was probably linked to the lockdowns and curfews that reduced opportunities to use drugs in social settings. These measures may have also made it more onerous for criminal groups to coordinate their activities.

"Outside of the principal markets, the pandemic affected trafficking activities in Africa, Asia, and East and Southeast Europe. Seizures fell during 2020 in those regions, before rebounding in 2021. In South Africa, the authorities reported traffickers were increasingly using maritime routes since the pandemic."

"Of the 1,220,143 deaths with involved drugs listed on the death certificate, 130 560 (10.7% of all decedents) were found to have stimulants listed. Among stimulant-involved deaths, 93,689 decedents (71.8%) were men, the median (interquartile range) age was 45 (34-54) years, and 98,635 (75.5%) were White (Table). Of these, 120,803 certificates (92.5%) listed only illicit stimulants, 5544 (4.2%) listed only medical stimulants, and 3524 listed both types (2.7%). Among illicit stimulants, there were 77,013 deaths (61.9%) involving cocaine, 49,602 deaths (39.9%) involving methamphetamine, and 817 deaths (0.7%) involving 3,4-methylenedioxymethamphetamine. Among medical stimulants, there were 8240 deaths (90.9%) involving amphetamine, 295 deaths (0.3%) involving methylphenidate, and 615 deaths (0.7%) involving pseudoephedrine. Among all 3 stimulant groups, the proportion of deaths that also involved opioids was substantial; concomittant use of benzodiazepines and antidepressants was also not uncommon.

"Stimulant mortality has risen rapidly since 2010 (Figure). The mortality rate involving all stimulants rose from 2.913 deaths per 100,000 population in 2010 to 9.690 in 2017. Mortality rates increased among all medical stimulants (ARR, 1.226; 95% CI, 1.202-1.250), amphetamine (ARR, 1.118; 95% CI, 1.082-1.155), cocaine (ARR, 1.234;95% CI, 1.222-1.245), and methamphetamine (ARR, 1.278; 95% CI, 1.261-1.295)."

"Cocaine use is on the rise at the global level. The number of people who use cocaine has been increasing at a faster rate than population growth. The main markets for cocaine worldwide are North America, Western and Central Europe, followed by South and Central America and the Caribbean.

"The current increase in cocaine supply at source in Latin America coupled with the expansion of trafficking of the drug eastward may potentially lead to an expansion of the still limited markets in Africa and Asia. From an estimated 21.5 million users of cocaine in 2020, that number would increase to 55 million, should the prevalence in Asia, Africa and the rest of Europe increase to the level of Western and Central Europe, and by an additional 24.5 million should it increase in those (sub) regions to the level of North America. Asia, where cocaine use is comparatively very low, has the largest potential for an increase in the number of cocaine users, largely due to its population size, in a scenario whereby the prevalence jumps by 1.32 percentage points to align with that of Western and Central Europe, the number of users would increase to over 40 million in Asia from the current 2 million."

"North America, with its large consumer base,⁶⁸ continues to be one of the main destinations for cocaine trafficked from South America. Mexico is an important transit country functioning as a gateway for cocaine reaching the United States,⁶⁹ which accounts for the majority of cocaine users in North America,⁷⁰ as well as Canada (primarily via the United States, but also directly from Mexico⁷¹). Cocaine reaches Mexico from South America via different routes: via maritime shipments, especially using go-fast boats; via clandestine flights; and also, via land.

"Maritime trafficking appears to be the dominant modality along the western (Pacific) coast of the Central American landmass,⁷² with several identified maritime routes ending directly on the western coast of Mexico, including states like Chiapas, Oaxaca, Guerrero, Michoacan, Jalisco and Sinaloa,^{73 74} while others make landfall further south, in Central American countries with a coast on the Pacific, such as (from north to south) Guatemala,^{75 76} El Salvador,^{77 78 79} Nicaragua,^{80 81} Costa Rica^{82 83} and Panama,⁸⁴ before continuing the journey north. Traffickers rely extensively on go-fast boats for trafficking along this route,⁸⁵ but other vessels, including semi-submersibles⁸⁶ and fishing boats,^{87 88 89} are also used. The US Drug Enforcement Administration estimated this route to account for 74 per cent of cocaine flowing north out of South America.⁹⁰ Ecuador is a major departure country for cocaine leaving the South American landmass along this route.^{91 92} Once the vessels reach or approach the Pacific coast of Central America, cocaine may also be transferred to other maritime vessels to continue northward along the coast.^{93 94 95 96}"

"Although some clandestine flights have been observed along the Pacific coast of Central America, including some affecting the Mexican airspace close to the border with Guatemala,⁹⁷ and some departing from Ecuador to various destinations,⁹⁸ this mode of conveyance appears to be more pronounced along the eastern (Caribbean) coast, where flights are extensively used alongside maritime shipments to facilitate the northward flow of cocaine from South America towards Mexico.⁹⁹ Venezuela (Bolivarian Republic of) is a major point of departure for such flights.^{100 101 102} While some of these flights appear to reach Mexico directly (close to its southern borders, for example in the state of Quintana Roo),¹⁰³ others land on the Guatemalan side of the Mexico-Guatemala border,¹⁰⁴ or else in Honduras^{105 106} or Belize.¹⁰⁷

"Cocaine is also trafficked through Central America towards Mexico via land routes, sometimes crossing several land borders sequentially from south to north.^{108 109 110 111} Small quantities are trafficked already across the Colombia-Panama border,¹¹² but trafficking by land often comes after earlier segments of the itinerary involving maritime or air modalities; specific instances of this transition to land routes have been documented for example in trafficking from El Salvador into Guatemala (after reaching El Salvador via maritime routes through the Gulf of Fonseca),^{113 114 115} from Honduras into Guatemala (after reaching Honduras by air^{116 117}), and from Guatemala into Mexico (after reaching Guatemala by air¹¹⁸).

"Once cocaine enters Mexico, it is trafficked internally towards the United States, predominantly by land, and also by means of internal clandestine flights.¹¹⁹ In contrast with the important role of containerized shipping on maritime routes used for trafficking to Europe, cocaine trafficking from Mexico into the United States has been mainly documented across the shared land border using non-containerized mode of conveyance (even if sometimes commingled with legitimate goods), often concealed in vehicles, and sometimes using underground tunnels and drones.¹²⁰ However, the use of maritime vessels for trafficking into the United States, including through official points of entry, has also been observed.¹²¹

"Aside from cocaine transiting through Mexico, a minority of cocaine reaches the territory of the United States via the eastern Caribbean route, whereby the drug moves northwards from Venezuela (Bolivarian Republic of) towards the Caribbean islands via a combination of go-fast vessels and fishing boats, and reaches the United States via Puerto Rico and Florida, bypassing the landmass of Central America and Mexico entirely; the Dominican Republic functions as an important transit country on this route.^{122 123 124} Furthermore, maritime containers are used to traffic cocaine from the Dominican Republic to ports in Florida, Georgia, Philadelphia, and New York.¹²⁵"

"Cocaine use includes the use of crack. Estimates of crack use are presented separately as well. Among people aged 12 or older in 2022, 1.9 percent (or 5.3 million people) used cocaine in the past year (Figures 13 and 18 and Table A.5B). The percentage was highest among young adults aged 18 to 25 (3.7 percent or 1.3 million people), followed by adults aged 26 or older (1.8 percent or 3.9 million people), then by adolescents aged 12 to 17 (0.2 percent or 40,000 people).

"In 2022, an estimated 0.3 percent of people aged 12 or older (or 918,000 people) used crack in the past year (Table A.5B). The percentage of crack use could not be calculated with sufficient precision for adolescents aged 12 to 17.13 The percentage among adults aged 26 or older (0.4 percent or 877,000 people) was higher than the percentage among young adults aged 18 to 25 (0.1 percent or 39,000 people).

"By Race/Ethnicity

"In 2022, cocaine use in the past year among people aged 12 or older did not differ significantly among racial or ethnic groups (Table B.7B). Percentages ranged from 0.9 percent among Asian people to 2.3 percent among American Indian or Alaska Native people. However, Black people (0.9 percent) were more likely to have used crack in the past year compared with White (0.3 percent) or Hispanic people (0.1 percent)."

"Trafficking in cocaine continued to increase in 2020 despite the COVID-19 pandemic, and global quantities \ of cocaine seized (not adjusted for purity) increased by 4.5 per cent, to a new record high of 1,424 tons, with quantities of cocaine paste and cocaine base seized rising by 16 per cent, to 108 tons, and quantities of cocaine hydrochloride seized rising by 4 per cent, to 1.105 tons (and only seizures of “crack” cocaine and non-specified types of cocaine showing smaller growth rates). Overall, estimates of global quantities of cocaine manufactured and seized show a strong positive correlation (with a correlation coefficient of 0.88 between 2005 and 2020),²⁰ suggesting that the interception of cocaine has kept pace with the increasing supply of and trafficking in cocaine. In fact, long-term data indicate that quantities of cocaine seized have increased far more than quantities manufactured, although the comparability of the two data sets is limited by the potentially varying levels of purity of seized quantities over time. Between 2010 and 2020, global potential cocaine manufacture, expressed in 100 per cent purity, rose by 75 per cent, while global quantities seized (not adjusted for purity) rose by 125 per cent.²¹ Uncertainty regarding the purity of seized cocaine across all countries prevents a precise calculation of interception rates, but the data suggest that they increased, although not by enough to reduce the amount of cocaine available for consumption.

"Longer-term increases in global cocaine seizures show a clear upward trend over the past two decades, notably in the period 2015–2020, primarily driven by a shift towards seizures made in South America, notably in the countries where most of the cocaine manufacture takes place. The total quantity seized in South America is now five times as high as in North America, in contrast to the period 1999–2001 when overall cocaine seized in North America was higher than in South America. At the same time, data also show a shift from the Caribbean towards Central America in terms of the quantity of cocaine seized over the last two decades, reflecting a general shift towards trafficking cocaine from Colombia along the Pacific route to Central America and North America instead of via the Atlantic Ocean and the Caribbean.

"North America, the world’s largest consumer market for cocaine, reported strong increases in seizures of the substance in the period 2015–2020, as did Europe, the second largest consumer region, up to and including 2019, before stabilizing in 2020. Total quantities of cocaine seized in Asia and Africa peaked in 2019, while quantities seized in Oceania continued to trend upwards in 2020."

"The global area under coca bush cultivation remained basically unchanged in 2020, at 234,200 ha,^a 5 per cent below the peak in 2018. The decrease in the area under coca bush cultivation in Colombia of 7.1 per cent in 2020 was offset by increases in Peru (13 per cent) and the Plurinational State of Bolivia (15.3 per cent).

"Potential cocaine manufacture grew 11 per cent in 2020, compared with the previous year, reaching a new record high of 1,982 tons (adjusted to 100 per cent purity). Manufacture increased by 8 per cent in Colombia and by a combined total of 16.5 per cent in Peru and the Plurinational State of Bolivia. Global cocaine manufacture has now more than doubled since the low of 2014.²"

"Approximately 21.5 million people are estimated to have used cocaine at least once in the past year in 2020,^c representing 0.4 per cent of the global population aged 15–64. The estimated prevalence of use has increased slightly since 2010, but the number of people who use cocaine has increased more, by 32 per cent, owing to global population growth. The trends have to be interpreted with caution, owing to the wide uncertainty intervals of these estimates.

"All indicators suggest a long-term overall increase in cocaine use over the past decade, but information about trends in 2020 is inconclusive. Only fourteen countries provided new survey data on cocaine use, out of them eight for 2020, a year when methodological adjustments, particularly for face-to-face surveys, may have affected data collection and undermined comparability with earlier data.

"In the European Union, surveys among people who use drugs occasionally suggest decreases in the use of powder cocaine,³⁷ but not of 'crack' cocaine.³⁸ It is likely that occasional cocaine use, often linked to recreational activities, was affected by the COVID-19 pandemic and resulting social-distancing measures. However, regular use and use among people with substance dependence may have remained less affected by these factors.³⁹ More detailed data suggest that decreases in use among occasional users may have been short-lived.

"Alternative sources of information, albeit each with its own limitations, confirm the trend observed in global estimates concerning people who use cocaine. Qualitative reporting on cocaine trends provided by national experts, even in countries without population surveys, suggests an increasing trend in cocaine use over the past decade, with a halt between 2019 and 2020. This data source is limited by a lack of scientific rigor in some cases, but its advantage is that, in countries where quantitative assessments are not in place, expert reporting is able to rely on a variety of information sources, including small-scale studies."

"In 2022 past-year use of crack cocaine was at or near historic lows. Annual use levels among 8th, 10th, and 12th grade students were all less than 1%. Like cocaine, crack use dropped sharply from 1986—when its use was first measured—through 1991. Consistent with other illicit drugs, its prevalence then increased during the 1990s drug relapse, peaked in the late 1990s, and has since declined to today’s low levels of use.

"Questions on crack cocaine were first introduced into the survey in 1986, when information gathered routinely in MTF showed some indirect evidence of the rapid spread of crack cocaine. For example, we found that the proportion of all 12th graders reporting that they had ever smoked cocaine (as well as used it in the past year) more than doubled between 1983 and 1986, from 2.4% to 5.7%. In the same period, the proportion of those who said that they had both used cocaine during the prior year and at some time had been unable to stop using it when they tried doubled (from 0.4% to 0.8%). In addition, between 1984 and 1986, the proportion of 12th graders reporting daily use of cocaine also doubled (from 0.2% to 0.4%). We think it likely that the rapid advent of crack use during this period was reflected in all of these changes, though we did not yet have a direct measure of its use.

"All results from 2020 are from surveys completed before March 15, 2020, when national social distancing policies were implemented and the survey halted due to pandemic concerns."

In 2015, among people aged 12 and older in the United States:
38,744,000 people had used cocaine at least once in their lifetime.
4,828,000 people had used cocaine in the past year.
1,876,000 people had used cocaine in the past month.
9,035,000 people had used crack at least once in their lifetime.
833,000 people had used crack in the past year.
394,000 people had used crack in the past month.

Datatable: Estimated Prevalence of Cocaine and Crack Use in the US, by Demographic Characteristics

"In Brooklyn, Mandler (2016, 2018) found that the most common chemicals used to stay awake during the night shift were energy drinks, cocaine, and the ADHD drug Adderall. Cocaine helped his interlocutors stay alert during shifts, while also engaging in the party, which was a challenge."

"Past-year cocaine use in 2015 among 12th graders has been essentially the same across regions and varied between 1.8% and 2.3%, with the exception that the West stood out and climbed to 4.4% in 2015 (Figure 5-10b; also Tables 36-38 and Figure 81 in Occasional Paper 86). In past years regional variation in cocaine use was the largest observed for any of the drugs. Large regional differences in cocaine use emerged when the nation’s epidemic grew in the late 1970s and early 1980s. By 1981, annual use had roughly tripled in the West and Northeast and nearly doubled in the Midwest, while it increased only by about one-quarter in the South. This pattern of large regional differences held for about six years, until much sharper declines in the Northeast and West reduced the differences substantially. In recent years use has been in a fairly steady decline in all regions in all grades although in 2015 there was some increase in three of the regions among 10th graders and in the West among 12th graders. For most of the years of the study, the West had the highest level of cocaine use at all three grade levels, but in recent years the differences have not been very large or entirely consistent.

"In all three grades, past-year crack use has almost always been highest in the West, although these differences are considerably smaller today than in the past (Tables 39-41 and Figure 87 in Occasional Paper 86). When crack use was first measured among 12th graders in 1986, there were large regional differences, with the West and Northeast again having far higher prevalence than the Midwest and South. Crack use dropped appreciably in all four regions over the next several years (though prevalence did not peak in the Midwest until 1987 or in the South until 1989, perhaps due to continued diffusion of the drug to areas that previously did not have access). Because the declines were large and very sharp in the West and Northeast, little regional difference remained by 1991, although the West still had the highest level of use. After 1991 or 1992, during the relapse phase of the drug epidemic, there were increases in all regions, but particularly in the West. Again, the West showed the largest increases and the highest levels of use at all three grades, while the other three regions were fairly similar in their annual prevalence of use. In general, all regions showed evidence of a leveling or decline in crack use at all three grade levels in recent years, along with a diminution of regional differences."

"Comparing absolute numbers of total cocaine seizures and manufacture could be misleading. To understand the relationship between the amount of annual seizures reported by States (694 tons cocaine of unknown purity in 2010) and the estimated level of manufacture (788-1,060 tons of cocaine of 100 per cent purity), it would be necessary to take into account several factors, and the associated calculations would depend on a level of detail in seizure data that is often unavailable. Making purity adjustments for bulk seizures, which contain impurities, cutting agents and moisture, to make them directly comparable with the cocaine manufacture estimates, which refer to a theoretical purity of 100 per cent, is difficult, as in most cases the purity of seized cocaine is not known and varies significantly from one consignment to another. The total amount of seized cocaine reported by States is also likely to be an overestimation. Large-scale maritime seizures, which account for a large part of the total amount of cocaine seized, often require the collaboration of several institutions in a country or even in several countries.⁷⁶ Therefore, double counting of reported seizures of cocaine cannot be excluded."

According to the UN Office on Drugs and Crime:

• In Colombia in 2018, a kilogram of cocaine typically sold for $1,654.
• In Peru in 2018, a kilogram of cocaine typically sold for $2,000.
• In Mexico in 2017, a kilogram of cocaine typically sold for $12,500.
• In the United States in 2018, the price of a kilogram of cocaine typically ranged from $4,000-$45,000. The price of a kilogram of crack in the US ranged from $15,000-$40,000.

"• Hispanics now have the highest annual prevalence for crack and cocaine at all three grade levels. The prevalence of cocaine for Hispanic students has tended to be high compared to the other two racial/ethnic groups, particularly in the lower grades. It bears repeating that Hispanics have a considerably higher dropout rate than Whites or African Americans, based on Census Bureau statistics, which should tend to diminish any such differences by 12th grade, yet there remain sizeable differences in the upper grades.

"• An examination of racial/ethnic comparisons at lower grade levels shows Hispanics having higher levels of use of many of the substances on which they have the highest levels of use in 12th grade, as well as for several other drugs. For example, in 2015, other cocaine (i.e., powder cocaine) had a lifetime prevalence in 8th grade for Hispanics, Whites, and African Americans of 2.0%, 0.9%, and 0.9%, respectively. In fact, in 8th grade -- before most dropping out occurs -- Hispanics had the highest levels of use of almost all substances, whereas by 12th-grade Whites have the highest levels of use of most. Certainly the considerably higher dropout rate among Hispanics could help explain this shift, and it may be the most plausible explanation. Another explanation worth consideration is that Hispanics may tend to start using drugs at a younger age, but Whites overtake them at older ages. These explanations are not mutually exclusive, of course, and to some degree both explanations may hold true.¹⁴"

"Recent trials with extended-release formulations and higher dosages of PPs, particularly prescription amphetamines, have shown promising results promoting abstinence from cocaine and reducing drug use. PPs’ potential as an “agonist-type” treatment seems to be better explored with higher dosage regimens and at clinical settings that have direct observed dosing available. The results from patients with comorbid opioid use disorders are particularly encouraging, and this may be due to the fact that high dosages of potent PPs were used, and this population is already enrolled to a healthcare facility that offers daily attendance, supervised medication intake, evidencebased psychosocial interventions, and a wide-range of ancillary services. A widely used and successful model of treating opioid use disorder or incorporating mobile technology solutions to monitor and enhance medication adherence may now be assessed for treatment of individuals with psychostimulant use disorder and incorporate prescription amphetamines as an agonist intervention. Considering the major public health impact of untreated PSUD, and the absence of the widely accepted pharmacological intervention, there is an urgent need to conduct implementation studies of this treatment approach."

"• In 2013, there were 601,000 persons aged 12 or older who had used cocaine for the first time within the past 12 months; this averages to approximately 1,600 initiates per day. This estimate was similar to the number in 2008 to 2012 (ranging from 623,000 to 724,000). The annual number of cocaine initiates in 2013 was lower than the estimates from 2002 through 2007 (ranging from 0.9 million to 1.0 million).
"• The number of initiates of crack cocaine ranged from 209,000 to 353,000 in 2002 to 2008 and declined to 95,000 in 2009. The number of initiates of crack cocaine has been similar each year since 2009 (e.g., 58,000 in 2013).
"• In 2013, most (81.9 percent) of the 0.6 million recent cocaine initiates were aged 18 or older when they first used. The average age at first use among recent initiates aged 12 to 49 was 20.4 years. The average age estimates have remained fairly stable since 2002."

"Data on people in drug treatment who mentioned cocaine products as their primary drug are limited to 26 countries, 20 of them in Europe, and show an increasing trend over the past decade. However, 70 per cent of the countries reported a decrease in the number of such patients in 2020, compared with the previous year, possibly confirming the general decrease in treatment delivery during the pandemic rather than a decrease in the number of people with cocaine use disorders.

"Wastewater-based epidemiology offers an additional source of information on trends in consumption of cocaine,^d although this method is limited to a relatively small number of cities, concentrated in Europe, followed by Oceania and Asia.⁴⁰ Long-term trend data with relatively good subregional coverage is only available for Western and Central Europe, although there were available paired data points for 2019 and 2020 for 66 cities across various regions. On average, the standardized quantity of findings of benzoylecgonine, the metabolite that signals the passing of cocaine through the human body, in wastewater dropped by 13 per cent from 2019 to 2020. However, the number of cities witnessing increased benzoylecgonine levels was almost identical to the number of cities experiencing decreases. As data became available for 2021, the trend seems to have returned to its pre-pandemic increasing trajectory. Overall, a 17 per cent increase in average loads was observed in 66 locations with available paired measurements. While 19 locations have recorded a decline and 9 locations a stable situation,^e 38 locations witnessed increases between 2020 and 2021.^f"

"In the final analysis, the notion of the 'crack baby' is a myth. So-called 'cocaine babies' and 'crack babies' are more likely suffering from their mothers’ multiple drug use (particularly alcohol), and/or are 'poverty babies' suffering from a lack of medical care and poor nutrition."

"Cocaine continued to be reported as a drug of concern in CEWG areas in all four regions of the United States. The impact of cocaine abuse continued to be reported by area representatives as high in Baltimore/Maryland/Washington, DC; Boston; Chicago; New York City; Philadelphia; and the South Florida/Miami-Dade and Broward Counties area. However, the decline in cocaine indicators reported at recent CEWG meetings continued to be observed by many area representatives. Seven of 19 CEWG area representatives reported decreasing indicators for cocaine: Atlanta; Baltimore/Maryland/Washington, DC; Chicago; Denver/Colorado; Detroit; San Francisco (where the decline was a key finding for this reporting period); and Texas. Eight CEWG area representatives reported mixed indicators for cocaine (with some increasing, some decreasing, and some stable): Boston, Los Angeles, Maine, Minneapolis/St. Paul, New York City, Philadelphia, Phoenix, and Seattle. Cocaine indicators were reported as stable from 2012 to 2013 by four area representatives: Cincinnati, St. Louis, San Diego, and South Florida/Miami-Dade and Broward Counties."

"An overdose may cause severe anxiety, panic, agitation, aggression, sleeplessness, hallucinations, paranoid delusions, impaired judgment, tremors, seizures, and delirium. Mydriasis and diaphoresis are apparent, and heart rate and blood pressure are increased. Death may result from myocardial infarction or arrhythmias.

"Severe overdose causes a syndrome of acute psychosis (eg, schizophrenic-like symptoms), hypertension, hyperthermia, rhabdomyolysis, coagulopathy, renal failure, and seizures. Patients with extreme clinical toxicity may, on a genetic basis, have decreased (atypical) serum cholinesterase, an enzyme needed for clearance of cocaine.

"Patients who inhale cocaine may develop an acute pulmonary syndrome (crack lung) with fever, hemoptysis, and hypoxia, that may progress to respiratory failure.

"The concurrent use of cocaine and alcohol produces a condensation product, cocaethylene, which has stimulant properties and may contribute to toxicity."

"Once the cocaine has been legally produced from the coca leaf, it is exported to various countries for medicinal use, basically as a topical anesthetic (applied to the surface, not injected, only treating a particular area). In the United States the crystalline powder is imported to pharmaceutical companies who process and package the cocaine for medical use. Merck Pharmaceutical Company and Mallinckrodt Chemical Works distribute cocaine in crystalline form (hydrochloride salt) in dark colored glass bottles to pharmacies and hospitals throughout the United States. Cocaine, in the alkaloid form (base drug containing no additives such as hydrochloride in the crystalline form) is rarely used for medicinal purposes. Cocaine hydrochloride crystals or flakes come in 1/8, 1/4 and 1 oz bottles from the manufacturer and has a wholesale price of approximately $20-$25/oz (100% pure).
"Cocaine is still a drug of choice among many physicians as a topical local anesthetic because the drug has vasoconstrictive qualities as it stops the flow of blood oozing. And although synthetic local anesthetics such as novacaine and xylocaine (lidocaine) have been discovered and are used extensively as local anesthetics, they do not have the same vasoconstrictive effects as cocaine."

"Coca is regarded as a sacred leaf by some of the indigenous American communities of the Andes and Amazon basin, where it has been used for a variety of purposes for thousands of years (Mortimer, 1974). As a consequence, the legal status of coca is sometimes ambiguous in South America, complicating efforts to control cocaine production. Bolivian and Peruvian laws allow the growing of some coca in order to supply long-standing, licit, local consumer markets for coca leaves (‘chewing’) and derived products, mostly coca tea, in both countries. The International Narcotics Control Board (INCB) has recently called for the suppression of these legal coca markets under Article 49, 2e, of the 1961 Single Convention on Narcotic Drugs, which requires the elimination of coca consumption ‘within twenty-five years of the coming into force of this convention’ (INCB, 2008a). Additionally, some coca is grown legally in Peru and Bolivia for processing into decocainised flavouring agents that are sold to international manufacturers of soft drinks under Article 27 of the 1961 Single Convention. Finally, the ‘chewing’ of coca leaves and the drinking of coca tea appears to be tolerated for some communities or in some regions in a number of South American countries, including Argentina, Brazil, Chile, Colombia and Ecuador."

"Modern archaeology suggests that descendants of nomadic Siberian people may have established communities in the Andes Mountains as early as 10,000 B.C.E.³⁷ Aymara-speaking tribes migrated to the Bolivian altiplano³⁸ around 700 B.C.E, and sometime after 700 B.C.E, Andean people began growing coca in the altiplano.³⁹ Before the Spanish conquest, Indians of eastern Bolivia grew coca for tea, chewing, and ritual use."

(History of Coca) "Archaeological evidence has confirmed that the coca leaf has been cultivated and used by the indigenous people of the Andes region for at least 4,000-5,000 years while other estimates put this as far back as 20,000 years. By the time of the Spanish colonial conquest, coca use extended all the way from what is today Costa Rica and Venezuela, through the Brazilian Amazon (coca’s place of origin) and on down to Paraguay, northern Argentina and Chile."

"Most Americans first learned about crack cocaine through media stories, which usually disclosed tragic details of public figures’ addictions. Coverage of the dangers associated with the use of all forms of cocaine intensified in 1979 with the emergence of the practice of smoking cocaine, colloquially referred to as 'freebasing.'⁶³ Rolling Stone magazine focused on smokeable forms of cocaine, calling it the 'top-of-the-line model of the Cadillac of drugs,' yet cautioned that 'freebasing seemed to be much more dangerous than snorting.'⁶⁴ In 1980, when comedian Richard Pryor sustained third-degree burns after reportedly using a butane torch to light cocaine freebase, newspapers capitalized on the incident.⁶⁵ Outlets including The Philadelphia Inquirer, Chicago Tribune, and The Boston Globe ran stories about the new trend of freebasing cocaine.⁶⁶
"In 1985, The New York Times became the first major media outlet to use the term 'crack cocaine,'⁶⁷ and a follow-up article appeared on the front page less than two weeks later, detailing crack cocaine and its intensely addictive quality.⁶⁸ By 1986, major news outlets had declared crack cocaine usage to be in 'epidemic proportions.'⁶⁹"

"One of the main properties of the coca leaf, which has been and continues to be used industrially, is its medical potential as an anaesthetic and analgesic. This characteristic of cocaine, which was part of ancestral practices and knowledge in the Andean-Amazon region, came to light in the 1880s and led to a revolution in medical science, particularly in surgery. As a local anaesthetic, it offered an alternative for operations that had previously been painful and hazardous. These properties were used to ease childbirth pains and dental treatments, among other things, taking the coca leaf and cocaine rapidly to the pinnacle of pharmacology and medicine.
"In 1923, Richard Willstatter of the University of Munich synthesised the cocaine molecule for the first time, basing his work on the molecule found in the coca leaf and maintaining its anaesthetic and energizing effects, which later found a series of applications. Unlike natural cocaine isolated from the coca leaf, the synthetic version lacks vaso-constrictive properties. This was useful for some applications, but not for others. A long list of pharmaceuticals (benzocaine, novocaine/procaine, lidocaine, etc.) was soon included in the anaesthetist’s vade mecum."

"Cocaine is derived from the coca plant, which, upon consumption, anesthetizes and stimulates the central nervous system.⁷⁵ The coca plant can be chewed to induce a high and is difficult to obtain in the United States, as cocaine is usually exported from South America in powder form.⁷⁶
"The chemical name for powder cocaine is cocaine hydrochloride, which is created through a complex process of heating and cooling coca leaves.⁷⁷ After pulverizing coca leaves into a coarse powder, alcohol is added and distilled off in order to extract the most pure form of cocaine alkaloid.⁷⁸ Powder cocaine is ingested intranasally, through snorting, and takes effect within five to fifteen minutes; the euphoria lasts up to two hours.⁷⁹
"Cocaine freebase, first created in the 1970s, is smokeable. To create cocaine freebase, cocaine hydrochloride must be heated and then mixed with ammonia and ether.⁸⁰ The substance cools and yields smokeable cocaine crystals after drying.⁸¹ Ether, an extremely flammable substance, renders the process of smoking cocaine freebase quite dangerous.⁸² After inhalation, cocaine reaches the brain within ten seconds, and the high lasts for up to five minutes.⁸³
"In the 1980s, a less dangerous form of cocaine freebase was invented: crack cocaine.⁸⁴ When cocaine powder is mixed with baking soda to form a paste and heated, the substance hardens into rocks.⁸⁵ This product was given the street name 'crack,' for the crackling sound it makes when smoked.⁸⁶"

"Cocaine is a sympathomimetic drug with CNS stimulant and euphoriant properties. High doses can cause panic, schizophrenic-like symptoms, seizures, hyperthermia, hypertension, arrhythmias, stroke, aortic dissection, intestinal ischemia, and MI. Toxicity is managed with supportive care, including IV benzodiazepines (for agitation, hypertension, and seizures) and cooling techniques (for hyperthermia). Withdrawal manifests primarily as depression, difficulty concentrating, and somnolence (cocaine washout syndrome).
"Most cocaine users are episodic recreational users. However, about 25% (or more) of users meet criteria for abuse or dependence. Use among adolescents has declined recently. Availability of highly biologically active forms, such as crack cocaine, has worsened the problem of cocaine dependence. Most cocaine in the US is about 50 to 60% pure; it may contain a wide array of fillers, adulterants, and contaminants.
"Most cocaine in the US is volatilized and inhaled, but it may be snorted, or injected IV. For inhalation, the powdered hydrochloride salt is converted to a more volatile form, usually by adding NaHCO3, water, and heat. The resultant precipitate (crack cocaine) is volatilized by heating (it is not burned) and inhaled. Onset of effect is quick, and intensity of the high rivals IV injection. Tolerance to cocaine occurs, and withdrawal from heavy use is characterized by somnolence, difficulty concentrating, increased appetite, and depression. The tendency to continue taking the drug is strong after a period of withdrawal."

"Cocaine is a strong central nervous system stimulant that increases levels of dopamine, a brain chemical (or neurotransmitter) associated with pleasure and movement, in the brain’s reward circuit. Certain brain cells, or neurons, use dopamine to communicate. Normally, dopamine is released by a neuron in response to a pleasurable signal (e.g., the smell of good food), and then recycled back into the cell that released it, thus shutting off the signal between neurons. Cocaine acts by preventing the dopamine from being recycled, causing excessive amounts of the neurotransmitter to build up, amplifying the message to and response of the receiving neuron, and ultimately disrupting normal communication. It is this excess of dopamine that is responsible for cocaine’s euphoric effects. With repeated use, cocaine can cause long-term changes in the brain’s reward system and in other brain systems as well, which may eventually lead to addiction. With repeated use, tolerance to the cocaine high also often develops. Many cocaine abusers report that they seek but fail to achieve as much pleasure as they did from their first exposure. Some users will increase their dose in an attempt to intensify and prolong the euphoria, but this can also increase the risk of adverse psychological or physiological effects."

" Treatment of mild cocaine intoxication is generally unnecessary because the drug is extremely short-acting. Benzodiazepines are the preferred initial treatment for most toxic effects, including CNS excitation and seizures, tachycardia, and hypertension. Lorazepam 2 to 3 mg IV q 5 min titrated to effect may be used. High doses and a continuous infusion may be required. Propofol infusion, with mechanical ventilation, may be used for resistant cases. Hypertension that does not respond to benzodiazepines is treated with IV nitrates (eg, nitroprusside) or phentolamine; ?-blockers are not recommended because they allow continued ?-adrenergic stimulation. Hyperthermia can be life threatening and should be managed aggressively with sedation plus evaporative cooling, ice packs, and maintenance of intravascular volume and urine flow with IV normal saline solution. Phenothiazines lower seizure threshold, and their anticholinergic effects can interfere with cooling; thus, they are not preferred for sedation. Occasionally, severely agitated patients must be pharmacologically paralyzed and mechanically ventilated to ameliorate acidosis, rhabdomyolysis, or multisystem dysfunction.
"Cocaine-related chest pain is evaluated as for any other patient with potential myocardial ischemia or aortic dissection, with chest x-ray, serial ECG, and serum cardiac markers. As discussed, ?-blockers are contraindicated, and benzodiazepines are a first-line drug. If coronary vasodilation is required after benzodiazepines are given, nitrates are used, or phentolamine 1 to 5 mg IV given slowly can be considered."

"Black cocaine is created by a chemical process used by drug traffickers to evade detection by drug sniffing dogs and chemical tests. The traffickers add charcoal and other chemicals to cocaine, which transforms it into a black substance that has no smell and does not react when subjected to the usual chemical tests."

"Coca has traditionally been used in one of two ways: either as a chew or in coca tea.⁴⁵ Coca leaves contain many nutrients, including vitamins A and B, phosphorus, and iron.⁴⁶ In high-altitude communities where green vegetables are scarce, the extra nutrients provided by coca leaves are often much needed.⁴⁷ Coca is also widely used to diminish the effects of the decreased oxygen at high altitudes, as any visitor to an Andean city will discover.⁴⁸ Much like coffee, coca is a mild stimulant and is the social drink of choice for many. Coca is also believed to be a panacea for numerous ailments and is even used as an aphrodisiac.⁴⁹"

"Coca leaf consumption is an integral part of Andean cultural tradition and world view. The principle uses are:

"• Energizer: provides an energy boost for working or for combating fatigue and cold. Although it reduces feelings of hunger, the coca leaf is not considered a food.

"• Medicinal: in teas, syrups and plasters for diagnosing and treating a series of illnesses. It is used as a local anesthetic.

"• Sacred: to communicate with the supernatural world and obtain its protection, especially with offerings to the Pachamama, the personification and spiritual form of the earth.

"• Social: to maintain social cohesion and cooperation among members of the community, it is used in community ceremonies, as a 'payment' for labor exchange and a social relations instrument."

US Code violations for cocaine/crack cocaine and possible sentences:

Title 21 - FOOD AND DRUGS
CHAPTER 13 - DRUG ABUSE PREVENTION AND CONTROL
SUBCHAPTER I - CONTROL AND ENFORCEMENT
Part D - Offenses and Penalties

"(b) Penalties
Except as otherwise provided in section 849, 859, 860, or 861 of this title, any person who violates subsection (a) of this section shall be sentenced as follows:
...
"(ii) 5 kilograms or more of a mixture or substance containing a detectable amount of—
"(I) coca leaves, except coca leaves and extracts of coca leaves from which cocaine, ecgonine, and derivatives of ecgonine or their salts have been removed;
"(II) cocaine, its salts, optical and geometric isomers, and salts of isomers;
"(III) ecgonine, its derivatives, their salts, isomers, and salts of isomers; or
"(IV) any compound, mixture, or preparation which contains any quantity of any of the substances referred to in subclauses (I) through (III);
"(iii) 280 grams or more of a mixture or substance described in clause (ii) which contains cocaine base;
....
"such person shall be sentenced to a term of imprisonment which may not be less than 10 years or more than life and if death or serious bodily injury results from the use of such substance shall be not less than 20 years or more than life, a fine not to exceed the greater of that authorized in accordance with the provisions of title 18 or $10,000,000 if the defendant is an individual or $50,000,000 if the defendant is other than an individual, or both."

"(B) In the case of a violation of subsection (a) of this section involving—
...
"(ii) 500 grams or more of a mixture or substance containing a detectable amount of—
"(I) coca leaves, except coca leaves and extracts of coca leaves from which cocaine, ecgonine, and derivatives of ecgonine or their salts have been removed;
"(II) cocaine, its salts, optical and geometric isomers, and salts of isomers;
"(III) ecgonine, its derivatives, their salts, isomers, and salts of isomers; or
"(IV) any compound, mixture, or preparation which contains any quantity of any of the substances referred to in subclauses (I) through (III);
"(iii) 28 grams or more of a mixture or substance described in clause (ii) which contains cocaine base;
....
"such person shall be sentenced to a term of imprisonment which may not be less than 5 years and not more than 40 years and if death or serious bodily injury results from the use of such substance shall be not less than 20 years or more than life, a fine not to exceed the greater of that authorized in accordance with the provisions of title 18 or $5,000,000 if the defendant is an individual or $25,000,000 if the defendant is other than an individual, or both."

On August 3, 2010, President Barack Obama "signed an historic piece of legislation that narrows the crack and powder cocaine sentencing disparity from 100:1 to 18:1 and for the first time eliminates the mandatory minimum sentence for simple possession of crack cocaine."

"In July 1986, in the midst of a surge of articles regarding the crack 'epidemic'³⁷ both the United States Senate and the House of Representatives held hearings on the perceived crisis.³⁸ At these hearings, it was asserted that crack: (1) was more addictive than powder cocaine,³⁹ (2) produced physiological effects that were different from and worse than those caused by powder cocaine,⁴⁰ (3) attracted users who could not afford powder cocaine, especially young people,⁴¹ and (4) led to more crime than powder cocaine did.⁴²"

"Smoking of crack cocaine was found to be an independent risk factor for HIV seroconversion among people who were injection drug users. This finding points to the urgent need for evidence-based public health initiatives targeted at people who smoke crack cocaine. Innovative interventions that have the potential to reduce HIV transmission in this population, including the distribution of safer crack kits and medically supervised inhalation rooms, need to be evaluated."

"Critics note that the spraying has not prevented the tripling of the area under coca cultivation since Pastrana's inauguration, and that the spraying simply destroys the means of livelihood of subsistence farmers and displaces the crops deeper into the jungle. The coca producers have also adapted by developing new varieties of the coca plant, such as the Tingo Maria, which produces three times as much coca as the traditional varieties."

"Between 1998 and 2009, the area subjected to manual eradication increased from 3,125 ha to 60,577 ha, while aerial spraying—using a formula known as Roundup® (a mixture of glyphosate and Cosmo-FluxTM)—rose by more than 58 percent, from 66,029 ha to 104,772 ha.³ Between 2003 and 2009, the Bogotá government invested $835 million to underwrite these programs, a figure that is expected to surge to $1.5 billion by 2013.⁴"