THE MYSTERY OF THE TAINTED COCAINE

What's a drug used to deworm livestock-a drug that can obliterate your
immune system-doing in your cocaine? Nobody knows.

A granulocytosis can kill you, but its symptoms are frustratingly
broad. Some people's throats close up. Some people get diarrhea. Some
people get skin infections, sores in their mouth or anus, or just a
fever. Some people have it, don't know it, and get better without
seeing a doctor. Some people don't see a doctor until it's too late.

Basically, agranulocytosis is a catastrophic crash in a person's
immune system, which can turn a zit, a scratch, or even the bacteria
that normally live in and around your body into a life-threatening
infection. In one vividly described case from the 1920s, an otherwise
healthy 40-year-old woman came down with a mysterious fever. Over the
next nine days, under the care of baffled physicians, she sprouted
"brownish papular eruptions" all over her face and body, necrotic
abscesses on her neck and buttocks, and "a greyish-green dirty
membrane" covering her mouth and throat with "scattered small greyish
ulcers." In one cubic millimeter of blood, her doctors found 4,000,000
red blood cells but only 1,000 white blood cells. Then, after a blood
transfusion, she died.

Agranulocytosis is rare and typically caused by medications:
Antibiotics, gold salts (to treat arthritis), and some anti-psychotic
drugs can trigger the crash. But lately, doctors have been seeing more
and more cocaine users with mysterious cases of agranulocytosis linked
to a mysterious cutting agent called levamisole. Levamisole was
discovered in 1966 and studied for its ability to rev up the effects
of chemotherapy drugs and people's immune systems. It also turned out
to work wonders with intestinal worms. Levamisole is an
immunomodulator, meaning it can either strengthen or weaken your
immune system, depending on your genes and what other drugs you might
be taking. But too many patients came down with agranulocytosis, the
studies were discontinued, and the FDA withdrew its approval of the
drug.

One of the last studies on levamisole use in humans was in 2001, when
Iranian researchers gave the drug to a group of girls who lived in
crowded, unhygienic conditions with uncontrollable lice infestations.
According to the International Journal of Dermatology, a 10-day course
of levamisole tablets was "completely effective": The girls took the
drugs, and the drugs poisoned the lice. (The study didn't mention
whether the drugs poisoned the girls.)

These days, levamisole is mostly used by farmers to deworm cows and
pigs-and, for some reason, it's also used by people in the cocaine
trade. The DEA first reported seeing significant amounts of
levamisole-tainted cocaine in 2005, with 331 samples testing positive.
Then the numbers spiked: The DEA found 6,061 tainted samples in 2008
and 7,427 in 2009. One DEA brief from 2010 reports that between
October 2007 and October 2009, the percentage of seized cocaine bricks
containing levamisole jumped from 2 percent to 71 percent.

Which is not only sudden, but odd. Levamisole is not like other common
cutting agents-sugar, baking powder, laxatives, etc.-in three
important ways:

1. It's more expensive than other cuts.

2. It makes some customers sick.

3. It's being cut into the cocaine before it hits the United
States.

This last mystery is the most puzzling. Typically, smugglers like to
move the purest possible product-less volume means less chance of
detection-and cut their drugs once they cross into the United States.

So what's the incentive to use a relatively expensive cut of something
that makes your customers sick and increases your smuggling risk? Even
stranger: The cocaine trade, in both smuggling and production, has
fragmented in recent years (more on that in a minute). If there's no
central production, how did hundreds and hundreds of independent shops
come to use the same unusual cutting agent?

Nobody seems to know, including experts I spoke with on both coasts of the
United States: doctors, scholars, chemists, think-tank fellows, research
scientists, federal and state public-health analysts, law enforcement
agencies from the Seattle Police Department to the DEA, and even people who
work in and around the drug trade. Everyone has theories, but nobody has
answers.

It's a mystery.

What We Do Know

Some people are getting sick from levamisole and a few have died, but
it's impossible to pin down exact numbers. In April 2008, a lab in New
Mexico reported an unexplained cluster of 11 agranulocytosis cases in
cocaine users. In November 2009, public health officials in Seattle
announced another 10 cases. The CDC began a surveillance program in
eight states.

During levamisole's early clinical trials for cancer and autoimmune
disorders, around 10 percent of the patients developed
agranulocytosis. If the nation's cocaine supply is so thoroughly
tainted, why aren't 10 percent of cocaine users going to hospitals
with unexplained infections?

"Maybe 10 percent are experiencing pressure on their neutrophils,"
says Dr. Phillip Coffin of the University of Washington, who has
studied drug use in New York City and Seattle. (Neutrophils are the
type of white blood cell wiped out by agranulocytosis.) "But only a
proportion of them are getting sick enough and using enough that they
come to our attention. And an even smaller proportion of those people
are coming to the attention of physicians who are aware of the
cocaine-levamisole problem. There are many steps in the pathway that
have left such a small number of cases being reported."

The problem might be-and probably is-larger than we know. And, because
of budget crunches, last month the CDC abandoned its surveillance
program in Washington State. This is worrisome not only for people
who've already gotten sick and are likely to get sick again (doctors
at Harborview have reported seeing the same patients multiple times
for agranulocytosis), but because levamisole has a cumulative effect:
The more you're exposed to it, the more likely you are to get sick,
and even if you've had levamisole-tainted cocaine and not gotten sick
doesn't mean you won't get sick from levamisole-tainted cocaine in the
future. With the DEA reporting such a radical increase in the
percentage of tainted cocaine (which more than doubled between 2008
and 2009), the number of people at risk is also increasing radically.

The Cocaine Trade

So who's lacing the world's cocaine with levamisole and why? "I
honestly can't tell you," says Sanho Tree of the Institute for Policy
Studies, a think tank based in Washington, D.C. An internationally
recognized scholar, Tree has spent his career studying the drug
trade-if anyone (outside of a drug cartel) should know where and why
levamisole is being cut into the world's cocaine supply, it's him.

The ubiquity of tainted cocaine could, he says, be an unintended
consequence of the drug war. Centralized drug-producing operations,
like the old Medellin and Cali cartels, depended more on consistency
of product and long-term business relationships. But after those
cartels were infiltrated and disrupted, hundreds of small shops-many
of them family-operated-jumped into the void. "We can't even count
those operations, much less infiltrate and break them up," Tree says.

Recent developments in Colombia's guerilla wars have also destabilized
business as usual. Right-wing paramilitary death squads-which are on
U.S. lists of international terrorist organizations-have been fighting
against Colombia's Marxist-Leninist guerillas for years on the
government's behalf. Both the guerillas and the paramilitaries have
been involved in the country's black market, but, Tree says,
"guerillas deal more with peso economy"-the trade within Colombia-"and
the paramilitary death squads made a play for the coastal regions.
They were cutting the guerillas off from weapons and from smuggling
zones. Those dynamics have been shifting over the past few years. The
death squads were officially disbanded by government but have
reemerged: same people, different names." (In 2007, the produce
distributor Chiquita pled guilty to paying almost $2 million to these
paramilitary death squads. U.S. congressman William Delahunt said
Chiquita was only "the tip of the iceberg" of U.S. businesses getting
tied up in paramilitary groups, which means those businesses are
implicitly tied up with the cocaine trade.)

"As a result, there's much less accountability within Colombia now,"
Tree says. "The drug market is much more fragmented. Who are you going
to complain to? Plus, you've got the meat grinder in Mexico"-where
gangs ship South American product into North America. "Will any of
these people even see each other again? Who knows? It's shorter-term
careers these days."

Meanwhile, Peruvian shops are also stepping up production to compete
with the small Colombian producers-the dynamics across the South
American cocaine market are shifting rapidly and violently.

Even the old Mexican shipping networks are breaking up as turf wars
make the smuggling routes less reliable and more expensive. Some gangs
are making an end run around Mexico by sea-the U.S. government has
begun intercepting homemade submarines, loaded with cocaine, that sail
by night just beneath the surface of the water. One of the first
narco--subs was found in 2000 in Bogota. "It had Russian blueprints
and the engineers fled just before the police arrived," Tree says. "In
Bogota-8,000 feet in the Andes and nowhere near any ocean. How corrupt
can you get?"

The U.S. has only intercepted around two dozen narco-subs so far.
"They've got no wake, no conning towers-just a snorkel sticking up for
air. By day they stay idle and throw a blue tarp over themselves so
they blend in with the ocean," Tree says. "As one intelligence officer
put it to me, rather frankly: 'You try finding a log floating in the
Pacific Ocean.'"

With such a fragmented drug market, accountability and quality control
decline. As Tree says, who are you going to complain to?

Which leaves the question of why producers and/or smugglers are
cutting their cocaine with levamisole. Why that, instead of a cheaper
and more benign cut?

"That," Tree says, "I don't know. This is the most interdisciplinary
field in the world. The people who focus on violence and the cartels
don't understand the pharmacology, and the people who understand the
pharmacology don't understand the economics and shifting forces of the
cartels. Nobody has a bird's-eye view of the whole thing."

Working Theories

In 2004, a controversy erupted in the horse-racing world. A string of
trainers with long and distinguished reputations were accused of
doping their horses after aminorex, an amphetamine, was detected in
their animals' urine. The penalty for doping horses with aminorex is a
one-to five-year suspension and a career-ending stigma. Accusations
flew, the trainers protested their innocence, and scientists stepped
in to investigate.

It turned out the whole thing was an accident: The horses had been
injected with levamisole for deworming, which their bodies metabolized
into speed. Studies in the 1970s had discovered that dogs experienced
"mood elevation" after receiving doses of levamisole. And a 1998 study
at Vanderbilt University showed that levamisole eased withdrawal
symptoms in rats addicted to morphine.

That study caught the attention of Dr. Mike Clark, an assistant
professor of psychiatry at Harborview Medical Center, who also studies
cocaine addiction in lab rats. "According to the study, levamisole
acts on all three monoamine neurotransmitters," he says. "That's
exactly what you'd expect from something that potentiates cocaine." In
other words, levamisole may heighten cocaine's effects-or might be a
stimulant all by itself. In the next few weeks, Dr. Clark will begin
an experiment of his own to find out (among other things) whether
levamisole, without any cocaine, can produce cocainelike effects in
lab rats.

If he can demonstrate that levamisole makes cocaine more potent, we'll
be a step closer to understanding what it's doing in the supply chain.
Other people have other theories, including:

. Something about the chemical structure of levamisole retains the
iridescent fish-scale sheen of pure cocaine, according to a chemist
with ties to the cocaine trade, giving cocaine cut with levamisole the
same appearance as pure cocaine.

. Levamisole is a bulking agent for crack. The process of making crack
involves "washing" cocaine and filtering out impurities and cutting
agents. Levamisole slips through this process, meaning you can produce
more volume of crack with less pure cocaine.

. Levamisole passes the "bleach test," a simple street test used to
detect impurities in cocaine. When dropped in Clorox, pure cocaine
dissolves clearly. Procaine (a common cutting agent) turns reddish
brown, lidocaine turns yellowish, and other impurities float to the
bottom. In a lab test conducted by -Dr. Clark, levamisole stayed clean
and clear.

If levamisole can do all of these things-pass the visual test, pass
the bleach test, pass the crack-purifying process, and provide a
stimulant effect either on its own or in conjunction with cocaine-it
explains not only why producers use it, but why so many small South
American producers have independently decided to start cutting their
"pure" product. "Think of it as evolution in action," Dr. Clark says.
Like a mutated gene that is beneficial to a species and is passed on
through the pressures of natural selection, levamisole has a variety
of benefits that become, in essence, selective pressures.

Instead of the traditional smuggling model, where centralized
producers ship pure product and cut it once it crosses the U.S.
border, levamisole (theoretically) behaves enough like cocaine that
producers can pass off cut kilos as 100 percent pure-even to the
smugglers who may believe they're shipping pure product to sell to
American wholesalers. This theory is supported by a couple of
findings, including reports of seizures in the DEA's Microgram
Bulletin. One flight from Guyana into New York's JFK airport contained
192 churros stuffed with levamisole-tainted cocaine. And DEA agents in
Bogota came across a magazine page coated in a "protective" plastic
laminate that was 21.5 percent cocaine, cut with levamisole. The
research and development labs that developed this relatively
sophisticated smuggling technique were at the source of production.
And the source of production was cutting its "pure" product with levamisole.

A source with close ties to the DEA confirmed this, saying a recent,
still-classified report has revealed that Colombian cocaine producers
are putting a great deal of effort into making sure they maintain
access to levamisole. "More than that," the source says, "I cannot
tell you right now."

The Test-Your-Own Kit

Because the official research on levamisole's effects on human beings
was stopped years ago-and, apart from Dr. Clark's pending experiments
with rats, there's been no official research on its effects when
combined with cocaine-there's still a lot we don't know. It's possible
that agranulocytosis is only one of its health hazards.

According to a 2009 article in the Journal of Analytic Toxicology,
levamisole-laced cocaine might also increase the risk of cardiac
problems: "Cocaine increases sympathetic activity by blocking the
reuptake of norepinephrine at the postganglionic synapse. Additive, if
not synergistic effects could be expected when the drugs are combined.
Concerns of increased toxicity with exaggerated pressure response or
development of arrhythmia could then arise when cocaine is combined
with levamisole."

Heart attack and cardiac arrest are two of the common causes of death
associated with cocaine overdoses-levamisole might exacerbate those
risks. It's hard to say: Cocaine, according to the latest Seattle/King
County drug trends report, released this June, is the most common
illegal drug detected in deaths, but its manner of killing is less
clear-cut than opiates. "Opiate overdose is pretty simple and
straightforward," explains -Dr. Coffin. "It's breathing. Keep them
breathing and they live. Cocaine is more difficult: Is it a massive
heart attack? Is it a stroke? It's not very well defined."

Currently, people who suffer cardiac problems associated with cocaine
are not tested for the presence of levamisole, so we really have no
idea what kind of damage this new cutting agent is inflicting on the
nation's cocaine users, nor the strain on already strapped public
funds-every time someone without health insurance lands in the
emergency room, it costs taxpayers thousands of dollars.

The fuzziness surrounding cocaine's destructive qualities makes
harm-reduction strategies more difficult for cocaine than for opiates.
Nobody doubts that cocaine is destructive. "It's toxic to heart-muscle
cells," Dr. Coffin says. "Even in its purest form, it's among the
worst recreational drugs for the cardiovascular system." But its
spectrum of harmful qualities, some of which are exacerbated by
levamisole, makes it tricky to pinpoint good maintenance programs for
chronic addicts. Opiate addicts, Dr. Coffin says, can live on
methadone or other controlled dosing mechanisms their entire lives
with no medical harm besides constipation and loss of libido. But
cocaine- and amphetamine-maintenance programs haven't shown any
conclusive results, despite attempts in Colombia to prescribe coca
tablets and tea to addicts.

One thing that can be done: develop an inexpensive field-test kit to
try to detect levamisole. Dr. Clark has invented such a kit and-in
association with The Stranger, a few folks in the local harm-reduction
community, and the People's Harm Reduction Alliance (PHRA), which runs
the U-District needle exchange-hopes to begin distributing kits in a
few weeks. Unfortunately, kits are technically drug paraphernalia
under Washington State law, not only because the kits will contain
cocaine residue, but because it is illegal for any person to possess
something used to "process, prepare, test, analyze, pack, repack,
store, contain, conceal, inject, ingest, inhale, or otherwise
introduce into the human body a controlled substance." It's a perfect
example of how drug prohibition laws make drugs more dangerous-an
unregulated market for cocaine, with no quality control, has
encouraged the use of levamisole as a cutting agent. And U.S. drug
laws make it illegal for users to test their cocaine for poison-if
users could, they might stop buying from dealers who sell tainted
cocaine, putting economic pressure on the market to be less dangerous.
It's a classically self-defeating chain of policies, but some antidrug
warriors defend it on the grounds that since drugs are illegal, users
get what they deserve. And if cocaine is perceived as more dangerous,
perhaps fewer people will use it.

This, of course, is a cruel, stupid, and expensive way to deal with
the problem. As Dr. Clark put it: "The idea of letting addicts die to
make drugs scarier is reprehensible."

It's not quite the same in the heroin world: Because of the public
outcry about the health risks of sharing needles, hypodermic syringes
have a special exemption. Crack users need similar exemptions.

"If you read the paraphernalia laws, cocaine is both the forgotten
drug and in some ways the most hated drug," says Shiloh Murphy,
director of PHRA, an independent nonprofit that isn't affiliated with
public-health-funded needle exchanges. He gestures behind him to a
tower of cardboard boxes full of hypodermic needles. "A young person
just starting to inject knows he shouldn't share his syringes," he
says. "But a 20-year crack veteran doesn't realize that every time he
smokes and burns his lips and passes on his stem, he could be
transferring the same diseases-it's open sores to open sores."

To combat this problem, Murphy has begun a controversial program to
distribute crack stems, rubber crack "condoms," and fresh steel wool
to users. (Steel wool, which is used as a filter in crack pipes,
weakens and flakes off after repeated use, sending red-hot chunks of
metal into users' throats and lungs, which leads to infections and
abscesses.) Murphy got the idea for his crack program one afternoon
two years ago, when he was approached by an angry crack user.

"I was sitting at the table, handing out flyers and things," Murphy
says, "and a man said to me: 'You're a real motherfucker, you know
that? You're sitting here with all these syringes and talking about
health. I use crack and my friends are dying of HIV and hepatitis C
and there's nothing on this table for us. I guess crack users are
always just left to die.' I said, 'You're right. I'm sorry. Tell me
what you need.' It was an enlightening moment for me."

"All we have to do," he says, "is save one person from getting HIV,
and we've become economically worth it." PHRA's annual budget is
around $385,000. Its budget for the crack program is currently $6,000.
The lifetime cost for the state to take care of an uninsured person
with HIV, he says, is half a million dollars. "We've saved the state
thousands and thousands of dollars."

Now Murphy will be at the forefront of our combined attempt to
distribute Dr. Clark's levamisole kits to cocaine users. The kits will
contain instructions for use, a fact sheet about levamisole and
agranulocytosis, and a survey on a prestamped postcard about where and
when the cocaine was purchased, whether it's powder or rock cocaine,
whether it tested positive for levamisole, and a few other research
questions. Hopefully, that data will help us-me, Dr. Clark, PHRA, and
a local harm-reduction organization called DanceSafe-develop a better
understanding of how levamisole-tainted cocaine is distributed through
the city and whether some neighborhoods face greater health risks than
others. (Is the cocaine you can buy on the street in Georgetown, for
example, more or less tainted than the cocaine at some millionaire's
house party in Bellevue?)

As for its illegality: After a meeting with ACLU lawyer Alison
Holcomb, Stranger publisher Tim Keck, and me, Seattle city attorney
Pete Holmes and King County prosecutor Dan Satterberg decided to allow
us to distribute levamisole test kits-and collect data about whether
people are finding levamisole-without prosecution. They notified new
Seattle police chief John Diaz, who supports the program.

The levamisole test kits will be available in a few weeks-watch for
updates in The Stranger and on Slog. This piece is the first in an
investigative series.