Characterization of the crack cocaine culture in the city of São Paulo: a controlled pattern of use
In the city of São Paulo, the culture of crack use has undergone considerable changes over these 11 years since it was first described. The sociodemographic profile of the users is practically the same and most use is still compulsive, with significant physical, moral and social impairment among them. Sole use of crack has overwhelmingly been replaced by associations between crack and other drugs, thus characterizing users in the city of São Paulo as multiple drug users.
Multiple drugs were initially used to modulate the positive and negative effects of crack, but this has added multi-dependence and comorbidities to the psychiatric state that already existed. In addition to making it difficult to identify the severity of crack use, multiple drug use makes it difficult for patients to adhere to possible therapeutic interventions, and for these to be successful.
In parallel, the sensation of urgent need for crack has stimulated users to undertake illegal activities. This intensifies the process of social marginalization and the risks to the individual’s liberty and physical, psychological and moral integrity. Prostitution is highlighted: since this has extended to men, it predisposes crack culture to significant risks.
Taken together, the implications associated with crack use constitute an important public health problem. Intervention programs and public policies need to be developed to control it. On the other hand, the present study has indicated that controlled use of crack exists, with characteristics differing from compulsive use. This consists of a crack use that is more rational, with fewer individual and social implications. The strategies that were intuitively developed were similar to the measures adopted by former users to reach a state of abstinence. These are important alternatives for damage reduction and even for halting the use of crack.
Along general lines, it is emphasized that information for reducing the damage or for achieving abstinence may come from the crack user himself, who has the specific knowledge. This indicates the need for detailed studies in this respect.
Some crack users achieved a controlled pattern through self-control or self-regulation strategies that were individually and intuitively developed, based on his own beliefs and values. Such strategies could be efficiently incorporated into harm reduction programs, thereby minimizing risks that are associated with compulsive use. These strategies were also reported by former users, at the time they were using crack. These strategies are thus a possible means of achieving a state of abstinence and are therefore a relevant tool for therapeutic intervention programs.
Among the strategies adopted, the following were mentioned:
1. Replacement of the crack rock with “milder” forms of consumption (e.g. crack mixed with tobacco or marijuana) or through the use of other psychotropic substances.
According to the interviewees, marijuana was used as a palliative for the negative effects of crack. Using marijuana was an important strategy for reducing the damage associated with chronic use of crack, such that it diminished the craving and the other symptoms associated with the syndrome of abstinence from crack. This would, over the long term, make it possible to reintegrate users socially and into productive work.
2. Removal from the social context of crack. This is an efficient intuitive strategy, since one of the reasons that leads to renewed use is the “environmental trails” associated with it, such as the place where crack is consumed and fellow users.
3. Reprogramming of thoughts and behavior, especially at idle moments.
4. Decreased use of drugs that are known to interfere with the effects of crack and/or the frequency and quantity of use. This step seems to be subsequent to strategy 1 in the process towards achieving controlled use.
Although some of the strategies for achieving controlled use appear contradictory, particularly regarding items 1 and 4 (because they stimulate and reduce, respectively, the use of other substances that interfere with the use of crack, like alcohol), there is a need for studies describing these strategies in depth and identifying a possible chronological order between them, thus categorizing them as steps within a broader recovery process.
Revista Saúde Pública