Treatment for Stimulant Use Disorders
Treatment Improvement Protocol (TIP) Series 33
Richard A. Rawson, Ph.D.
Consensus Panel Chair
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 99-3296
Printed 1999
This publication is part of the Substance Abuse Prevention and Treatment Block Grant technical assistance program. All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.
This publication was written under contract number 270-95-0013 with The CDM Group, Inc. (CDM). Sandra Clunies, M.S., I.C.A.D.C., served as the CSAT government project officer. Rose M. Urban, M.S.W., J.D., C.S.A.C., served as the CDM TIPs project director. Other CDM TIPs personnel included Cara Smith, editorial assistant; Raquel Ingraham, M.S., project manager; Mark A. Meschter, former editor/writer; Mary Smolenski, Ed.D., C.R.N.P., former project director; and MaryLou Leonard, former project manager. Special thanks go to consulting writers Warren Bickel, Ph.D.; Gregory L. Greenwood, Ph.D., M.P.H.; Mitchell Markinem, M.A., N.C.A.C. II; Sara Simon, Ph.D.; and Ronald D. Stall, Ph.D., M.P.H., for their considerable contributions to this document.
The opinions expressed herein are the views of the Consensus Panel members and do not reflect the official position of CSAT, SAMHSA, or the U.S. Department of Health and Human Services (DHHS). No official support or endorsement of CSAT, SAMHSA, or DHHS for these opinions or for particular instruments or software that may be described in this document is intended or should be inferred. The guidelines proffered in this document should not be considered as substitutes for individualized client care and treatment decisions.
Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of substance use disorders, provided as a service of the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Treatment (CSAT). CSAT's Office of Evaluation, Scientific Analysis and Synthesis draws on the experience and knowledge of clinical, research, and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private substance use disorder treatment facilities as alcoholism and other substance use disorders are increasingly recognized as major problems.
The TIPs Editorial Advisory Board, a distinguished group of substance use experts and professionals in such related fields as primary care, mental health, and social services, works with the State Alcohol and Other Drug Abuse Directors to generate topics for the TIPs based on the field's current needs for information and guidance.
After selecting a topic, CSAT invites staff from pertinent Federal agencies and national organizations to a Resource Panel that recommends specific areas of focus as well as resources that should be considered in developing the content of the TIP. Then recommendations are communicated to a Consensus Panel composed of non-Federal experts on the topic who have been nominated by their peers. This Panel participates in a series of discussions; the information and recommendations on which they reach consensus form the foundation of the TIP. The members of each Consensus Panel represent substance use disorder treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A Panel Chair (or Co-Chairs) ensures that the guidelines mirror the results of the group's collaboration.
A large and diverse group of experts closely reviews the draft document. Once the changes recommended by these field reviewers have been incorporated, the TIP is prepared for publication, in print and online. The TIPs can be accessed via the Internet on the National Library of Medicine's home page at the URL: http://text.nlm.nih.gov. The move to electronic media also means that the TIPs can be updated more easily so they continue to provide the field with state-of-the-art information.
Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance use disorder treatment is evolving and that research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey "front line" information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either Panelists' clinical experience or the literature. If there is research to support a particular approach, citations are provided.
This TIP, Treatment for Stimulant Use Disorders, supplies substance use disorder treatment providers with vital information on the effects of stimulant abuse and dependence, discusses the relevance of these effects to treating stimulant users, describes treatment approaches that are appropriate and effective for treating these clients, and makes specific recommendations on the practical application of these treatment strategies. Research on animals has demonstrated the profound effects that stimulants can have on the central nervous system, and new technologies have begun to document the stimulant-induced neurological impairments in humans. Researchers now believe that these impairments underlie the cognitive deficits that are often seen in chronic stimulant users.
Effective treatment strategies must recognize the impact that stimulant abuse and dependence have on the user's ability to respond to treatment. The treatment strategies that are described in this TIP have been scientifically validated as effective in treating people with stimulant use disorders. These strategies address the specific problems and needs that are inherent to chronic stimulant users.
This document discusses in detail the practical application of these treatment strategies and makes recommendations to improve treatment outcomes for stimulant abuse and dependence. The document also provides for clinicians and primary care providers an overview of the medical aspects of stimulant use. Furthermore, treatment issues for special groups and settings are reviewed.
This TIP represents another step by CSAT toward its goal of bringing national leaders together to improve substance use disorder treatment in the United States.
Other TIPs may be ordered by contacting SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI), (800) 729-6686 or (301) 468-2600; TDD (for hearing impaired), (800) 487-4889.
Karen Allen, Ph.D., R.N., C.A.R.N.
President of the National Nurses Society on Addictions
Associate Professor
Department of Psychiatry, Community Health, and Adult Primary Care
University of Maryland
School of Nursing
Baltimore, Maryland
Richard L. Brown, M.D., M.P.H.
Associate Professor
Department of Family Medicine
University of Wisconsin School of Medicine
Madison, Wisconsin
Dorynne Czechowicz, M.D.
Associate Director
Medical/Professional Affairs
Treatment Research Branch
Division of Clinical and Services Research
National Institute on Drug Abuse
Rockville, Maryland
Linda S. Foley, M.A.
Former Director
Project for Addiction Counselor Training
National Association of State Alcohol and Drug Directors
Washington, D.C.
Wayde A. Glover, M.I.S., N.C.A.C. II
Director
Commonwealth Addictions Consultants and Trainers
Richmond, Virginia
Pedro J. Greer, M.D.
Assistant Dean for Homeless Education
University of Miami School of Medicine
Miami, Florida
Thomas W. Hester, M.D.
Former State Director
Substance Abuse Services
Division of Mental Health, Mental Retardation and Substance Abuse
Georgia Department of Human Resources
Atlanta, Georgia
Gil Hill
Director
Office of Substance Abuse
American Psychological Association
Washington, D.C.
Douglas B. Kamerow, M.D., M.P.H.
Director
Office of the Forum for Quality and Effectiveness in Health Care
Agency for Health Care Policy and Research
Rockville, Maryland
Stephen W. Long
Director
Office of Policy Analysis
National Institute on Alcohol Abuse and Alcoholism
Rockville, Maryland
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center and Matrix Institute on Addiction
Deputy Director, UCLA Addiction Medicine Services
Los Angeles, California
Ellen A. Renz, Ph.D.
Former Vice President of Clinical Systems
MEDCO Behavioral Care Corporation
Kamuela, Hawaii
Richard K. Ries, M.D.
Director and Associate Professor
Outpatient Mental Health Services and Dual Disorder Programs
Harborview Medical Center
Seattle, Washington
Sidney H. Schnoll, M.D., Ph.D.
Chairman
Division of Substance Abuse Medicine
Medical College of Virginia
Richmond, Virginia
Richard A. Rawson, Ph.D.
Executive Director
Matrix Center and Matrix Institute on Addiction
Deputy Director, UCLA Addiction Medicine Services
Los Angeles, California
Felipe G. Castro, M.S.W., Ph.D.
Professor
Hispanic Research Center
Department of Psychology
Arizona State University
Tempe, Arizona
James W. Cornish, M.D.
Assistant Professor of Psychiatry
Director, Division of Pharmacotherapy
Treatment Research Center
University of Pennsylvania
Department of Veterans Affairs Medical Center
Philadelphia, Pennsylvania
Frances R. Levin, M.D.
Assistant Professor
Clinical and Educational Activities
Division on Substance Abuse
Columbia University
New York, New York
Michael J. McCann, M.A.
Research Coordinator
Matrix Center
Los Angeles, California
Arlene Hall, R.N., M.S., C.D.
Director of Nursing
Hope House
Crownsville, Maryland
Stephen Higgins, Ph.D.
Professor
Departments of Psychiatry and Psychology
Ira Allen School
University of Vermont
Burlington, Vermont
Kyle M. Kampman, M.D.
Assistant Professor of Psychiatry
Treatment Research Center
University of Pennsylvania
Philadelphia, Pennsylvania
Quintin Kingfisher
Medical Resources
Tribal Health
Lame Deer, Montana
Judy Knobbe, M.S.W., L.I.S.W., C.A.D.C.
Director
Heart of Iowa
Area Substance Abuse Council
Cedar Rapids, Iowa
Wendy Lay
Program Specialist
Bureau of Alcohol and Drug Abuse
State of Nevada
Carson City, Nevada
Scott M. Reiner, M.S., C.A.C., C.C.S.
Substance Abuse Program Supervisor
Substance Abuse Services Unit
Virginia Department of Juvenile Justice
Richmond, Virginia
Ewa Szumotalska Stamper, Ph.D.
Police Psychologist
Honolulu Police Department
Private Practice in Clinical and Addictions Psychology
Honolulu, Hawaii
Arnold M. Washton, Ph.D.
Private Practice of Addiction Psychology
Parkland, Florida
Dennis A. Weis, M.D.
Medical Director
Powell Center for Disease Control
Iowa Lutheran Hospital
President
American Society of Addiction Medicine
Iowa Chapter
Des Moines, Iowa
The Treatment Improvement Protocol (TIP) series fulfills SAMHSA/CSAT's mission to improve treatment of substance use disorders by providing best practices guidance to clinicians, program administrators, and payors. TIPs are the result of careful consideration of all relevant clinical and health services research findings, demonstration experience, and implementation requirements. A panel of non-Federal clinical researchers, clinicians, program administrators, and client advocates debates and discusses their particular area of expertise until they reach a consensus on best practices. This panel's work is then reviewed and critiqued by field reviewers.
The talent, dedication, and hard work that TIPs panelists and reviewers bring to this highly participatory process have bridged the gap between the promise of research and the needs of practicing clinicians and administrators. We are grateful to all who have joined with us to contribute to advances in the substance use disorder treatment field.
Nelba Chavez, Ph.D.
Administrator
Substance Abuse and Mental Health Services Administration
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
Over the last 20 years, the use of stimulants has risen to national and international prominence. Stimulant use and its consequences have brought havoc to many communities across the United States and have prompted strong responses from Federal, State, and local governments and organizations. For example, the relatively minor problems of cocaine use in the 1960s and 1970s have grown to become major medical, legislative, and law enforcement issues in the 1990s. The devastation wrought by the crack cocaine epidemic is familiar to most Americans.
Similarly, the use and abuse of another stimulant, methamphetamine (MA), have risen dramatically in recent years. Widespread use and abuse of MA have led to a greater awareness of the problem and have inspired policymakers, legal officials, and service providers to focus increased efforts toward the personal and societal effects of this drug. Concerns that MA abuse may result in another epidemic led to passage of the Comprehensive Methamphetamine Control Act of 1996.
The explosive growth of stimulant use triggered a flurry of research. The results are tremendous advances in fundamental knowledge of stimulant use disorders and on the basic function of the brain and addictive disorders in general. Yet today, there are few reports that describe either the fundamentals of stimulant use disorder treatment or the success of various treatment interventions.
This Treatment Improvement Protocol (TIP) describes basic knowledge about the nature and treatment of stimulant use disorders. More specifically, it reviews what is currently known about treating the medical, psychiatric, and substance abuse/dependence problems associated with the use of two high-profile stimulants: cocaine and MA.
The scientifically based information in this TIP is presented in a manner that makes it available and relevant for clinicians and other "front line" substance use disorder treatment providers. It offers recommendations on treatment approaches, recommendations to maximize treatment engagement, strategies for planning and initiating treatment, and strategies for initiating and maintaining abstinence. Also included are recommendations for the medical management of stimulant users and recommendations regarding special groups and settings.
The Consensus Panel that developed this TIP tried to emphasize those treatment techniques and principles that have been established with empirical support. However, because the "science" of treating stimulant use disorders is barely a decade old, the Panel also reviewed and synthesized a set of techniques and principles developed and supported by leading addiction specialists, but with less empirical support. This document delineates those treatment suggestions and recommendations that are empirically supported and those that are currently based on consensus opinion.
The purpose of this TIP is to advance the understanding of treating the substance use disorders associated with the abuse of cocaine and MA. The Consensus Panel's recommendations summarized below are based on both researched and clinical experience. Those supported by scientific evidence are followed by (1); clinically based recommendations are marked (2). Citations to the former are referenced in the body of this document, where the guidelines are presented in full detail. To avoid sexism and awkward sentence construction, the TIP alternates between "he" and "she" in generic examples.
For purposes of this TIP, the substances included in the category of "stimulants" include the derivatives of the coca plant (cocaine hydrochloride and its freebase form, "crack") and the synthetically produced amphetamines, with a primary emphasis on illicitly produced MA (and its smokable form, "ice"). Certainly there are other stimulants that are more widely used (e.g., caffeine) or that produce major health problems (e.g., nicotine); however, an extensive discussion of issues associated with these substances is beyond the scope of this document.
Because of recent health care reforms, most individuals who seek help for stimulant dependence now receive treatment at structured outpatient treatment programs. Accordingly, this document provides recommendations for treatment strategies and techniques that are most relevant to the treatment of stimulant-dependent patients in structured outpatient treatment programs. However, many, if not most, of these strategies and techniques can be integrated into other types of programs, regardless of the setting or therapeutic orientation.
Psychosocial treatment approaches that incorporate well established psychological principles of learning are appropriate for and effective in treating stimulant users. In an effort to make these approaches consistently effective, the Consensus Panel recommends the use of carefully prepared treatment manuals to minimize differences among therapists. (2) Treatment manuals increase the likelihood that therapists will deliver a uniform set of services to their clients. However, the therapist's clinical judgment and flexibility are extremely important to the treatment process.
The Consensus Panel recommends a contingency management approach for treating stimulant users. (1) A particularly successful version is the community-reinforcement-plus-vouchers approach in which couples counseling, vocational training, and skills training are combined with rewards for negative drug tests (i.e., "clean" urinalysis results).
Relapse prevention systematically teaches clients
The Consensus Panel recommends this approach for use with stimulant users. (1)
Research indicates that the following may be appropriate interventions for stimulant users:
A number of other psychosocial models and approaches have been described, and some used widely, for the treatment of stimulant use disorders, including:
To maximize treatment engagement, programs must make treatment accessible. Having treatment programs in areas convenient to clients is associated with lower attrition rates. (1) Treatment should be provided during the hours and on the days that are convenient for clients. (2) Programs should be located near public transportation and in a part of town viewed as safe for evening visits. (2)
Address clients' concrete needs, including transportation, housing, and finances. (1) Some logistical barriers can be overcome by onsite services, through agreements with subcontractors, or by referrals. These can include onsite child care services, referrals to temporary shelters, vouchers for lunches, targeted financial assistance, assistance with paperwork regarding insurance, or filing for disability benefits. (2)
Because ambivalence about treatment is common among treatment-seeking stimulant users, methods to "screen out" those who are "in denial" are counterproductive and impede treatment entry. (2) The initial interview should be scheduled within 24 hours after the client initially contacts the program. (2)
Initial assessments should be brief, focused, and nonrepetitive. (2)
Individuals need a thorough, clear, and realistic orientation about stimulant use disorder treatment. Clients should acquire a good understanding about the treatment process, the rules of the treatment program, expectations about their participation, and what they can expect the program to do for them and in what time frame. (2)
Addiction treatment is more effective when a client chooses it from among alternatives than when it is assigned as the only option. Thus, it is important to provide clients with options and negotiate with them regarding the treatment approaches and strategies that are the most acceptable and promising. (1)
Whenever possible, family and significant others who support the treatment goals should be involved in the treatment process. (2)
Counselors should be warm, friendly, engaging, empathetic, straightforward, and non-judgmental. Authoritarian and confrontational behavior by the staff can substantially increase the potential for violence. (2)
To organize treatment strategies, it can be helpful to view the treatment process as consisting of
The Consensus Panel recommends treatment for 12 to 24 weeks followed by some type of support group participation. (2)
Clients should have a written schedule of expected attendance they can keep and give to family members who may be involved in treatment. It does not appear appropriate to deliver these services on an ad hoc or as needed basis. (2)
The initial period of stimulant abstinence is characterized by symptoms of depression, difficulty concentrating, poor memory, irritability, fatigue, craving for cocaine/MA, and paranoia (especially for MA users). The duration of these symptoms varies; in general, symptoms typically last 3 to 5 days for cocaine users and 10 to 15 days for MA users. (2)
The first several weeks of treatment have some relatively simple and straightforward priorities.
During the first 2 or 3 weeks, clients should be scheduled for multiple weekly visits, even if the visits are 30 minutes in duration or less. (2)
Immediately upon entering the treatment program, clients should be placed on a mandatory, vigilant, and frequent urine testing schedule. This schedule should continue throughout the treatment process, although the frequency of testing can be tapered as treatment progresses. Urine samples should be taken every 3 or 4 days so as not to exceed the sensitivity limits of standard laboratory testing methods. (2) Participation in self-help groups should be strongly encouraged but not required.
During the initial 2 weeks of treatment, it is important to assess the possible existence of other psychiatric conditions and, if present, initiate appropriate treatment, including medication. (2)
Research has revealed an association between stimulant use and a variety of compulsive sexual behaviors. These behaviors include promiscuous sex, AIDS-risky behaviors, compulsive masturbation, compulsive pornographic viewing, and homosexual behavior for otherwise heterosexual individuals. In order for treatment to be effective, these issues must be discussed openly and nonjudgmentally. (2)
Remind clients that proper sleep and nutrition are necessary to allow the neurobiology of the brain to "recover." Giving them "permission" to sleep, eat, and gradually begin a program of exercise, can help establish some behaviors that will have long-term utility. These behaviors will help them begin to think more clearly and begin to feel some benefit from their initial efforts in treatment. (1)
Establish structure and support. After the initial treatment engagement of 1 to 2 weeks, the focus is on the achievement of abstinence. Although there is no clear delineation between clients who are initiating abstinence and those maintaining abstinence, the initiating period occurs roughly from 2 to 6 weeks into treatment. (2)
Short-term goals should be set immediately and should be reasonably achievable. One such goal is complete abstinence from all substances for 1 week. (2)
Brief, frequent counseling sessions can reinforce the short-term goal of immediate abstinence and establish a therapeutic alliance between the client and counselor. Events of the past 24 hours are reviewed in each session and recommendations are provided for navigating the next 24 hours. (2)
For many clients, their secondary substance use may not have been associated with adverse consequences or compulsive use. As a result, such clients need help to identify the connections between the use of other substances and their stimulant addiction. (2)
Clients should be encouraged to throw out all substance-related items. (2) Family members, sober friends, or 12-Step sponsors should help with this task.
Clients must develop specific action plans to break contacts with dealers and other stimulant users and to avoid high-risk places that are strongly associated with stimulant use. (2)
Educate clients about learning and conditioning factors associated with stimulant use and the impact of stimulants and other substances on the brain and behavior, such as cognitive impairments and forgetfulness. (2)
Other steps to initiate abstinence include
Early slips should not be considered tragic failures but rather simple mistakes. When slips occur, counselors can make a verbal or behavioral contract with clients regarding short-term achievable goals. (2)
The core components of a functional analysis are
Relapse prevention techniques fall into the following categories:
Once clients learn to identify, manage, and avoid high-risk situations, the counselor and client should try to determine if the client is confident in her ability to use those skills in the real world through role-playing and other therapeutic techniques. (2)
So-called "war stories" that include euphoric recall and selective memory are powerful relapse triggers and should be strongly discouraged in recovery groups. (2)
The following recommendations are for medical personnel to help them recognize and treat problems that may arise for stimulant users with acute or chronic intoxication or in various phases of withdrawal.
The most common reasons for emergency room visits by cocaine users are cardiopulmonary symptoms (usually chest pains or palpitations); psychiatric complaints, ranging from altered mental states to suicidal ideation; and neurological problems, including seizures and delirium.
The major presenting symptoms for MA users pertain primarily to altered mental status, including confusion, delusions, paranoid reactions, hallucinations, and suicidal ideation. The rapid development of tolerance to its physiological effects among chronic MA users may explain the relative infrequency of cardiac complications in this group. (1)
The lethal dose of cocaine for 50 percent of novice users (LD50) is 1.5 grams. The LD50 for MA has not specifically been established, and there is significant individual variability to its toxicity. For example, doses of 30 milligrams can produce severe reactions, yet doses of 400 to 500 milligrams are not necessarily fatal. (1)
Uncomplicated intoxication requires only observation and monitoring in a subdued environment until symptoms subside over several hours.
Physical exertion and an overheated room can potentiate adverse effects because stimulants affect the body's heat-regulating mechanism at the same time that blood vessel constriction conserves heat.
Indications that agitation is escalating and moving toward paranoia and potential psychosis (losing touch with reality), with increasing risk for violence, may warrant pharmacological intervention. Fast-acting benzodiazepines such as lorazepam (Ativan) or diazepam (Valium) are useful for calming an anxious, agitated client. (1)
The greatest risk from the distinctive stimulant abstinence syndrome is that one may do harm to oneself or others. Because withdrawal-related dysphoria and depression can be particularly severe in stimulant users, risk of suicide is intensified, and sensitive management is essential. (1, 2)
Continuing agitation and persistent inability to fall asleep during withdrawal may also be treated symptomatically by using the antidepressant trazodone (Desyrel). Diphenhydramine (Benadryl) can also be used for its sedating properties. (1, 2)
Medical personnel must be prepared for the paranoia, aggression, and violence that often accompany stimulant use. These personnel should
There are a number of medical and psychiatric disorders that frequently accompany stimulant abuse and dependence. An awareness of these conditions is important for the safe and effective treatment of stimulant disorders. The conditions include
A diagnosis can be based on established DSM-IV criteria for amphetamine or cocaine use/abuse/dependence and other listed composites. (1)
An appropriate substance use history should include the substance(s) and medications used during the last 30 days; the specific substance(s) or combinations typically used with the usual dose, frequency, and route of administration; the duration of use/abuse; and the time and amount of last use as well as when the symptoms or complaints developed and how they have progressed. (2)
Stimulants typically can be detected in urine for approximately 24 to 48 hours following use and, maximally, for 3 days.
The Consensus Panel feels strongly that cultural competence in treatment extends beyond racial/ethnic sensitivity to understanding the mores of groups bound together by gender, age, geography, sexual preferences, criminal activity, substance use, and medical and mental illnesses. The Consensus Panel therefore recommends the following:
In stimulant use disorder treatment today, providers have the opportunity to move the role of scientifically based approaches into the forefront of the treatment effort. Recent findings from basic and clinical research serve as the foundation of the evolving treatment system for stimulant use disorders and have yielded an entirely new set of strategies and tools to assist in the treatment of stimulant-related clinical disorders.
As knowledge of stimulants and brain functioning continues to grow, new approaches are likely to be forthcoming.
The development of pharmacotherapies for the treatment of stimulant use disorders is a major priority of current research efforts, and it is likely that these efforts will provide some important new options in the near future. As these new treatments are introduced into the service delivery system and integrated into mainstream care, it will be essential for training tools, including this TIP, to be regularly updated.
In the early 1980s, thousands of people began to seek treatment to help them with their struggle to stop using cocaine. The U.S. health care system was rapidly overwhelmed. To many treatment experts who had spent their careers treating heroin addicts and alcoholics, the idea that someone would require "treatment" to discontinue cocaine use was a novelty. Among the first questions asked of the individuals seeking treatment were, "What do you need treatment for?" and "Why don't you just stop using?" Today, much more is known about addiction to cocaine and other stimulants. Although researchers, clinicians, and treatment providers have gained insights into why it is so difficult for stimulant users to stop using and why they need treatment, it is only recently that the substance use disorder treatment field has determined the most appropriate treatment approaches for these individuals.
When the U.S. cocaine epidemic was just beginning, there was a generally held assumption, even among addiction experts, that cocaine was not "truly addicting." A popular joke during this period was that "cocaine is God's way of telling you that you have too much money."
The cocaine epidemic that began in the 1970s peaked in the 1980s and slowly declined in the mid 1990s (Golub and Johnson, 1997). The pattern was similar to the first epidemic that occurred 30 years after cocaine hydrochloride was first isolated from coca leaves in 1885. During the first epidemic, physicians mistook cocaine's powerful stimulant properties as a cure for depression, morphine addiction, chronic tuberculosis, and a long list of other disorders. Physicians and other "healers" prescribed the drug for a range of maladies, and cocaine soon became the major active ingredient in many popular medicines, tonics, and elixirs (including the original formulation of Coca-Cola ®).
Eventually, however, the adverse effects of high-dose and consistent use were recognized. This recognition soon led to legislative