A psychiatric view on the crack phenomenon nowadays

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INVITED EDITORIAL

A contemporary psychiatric view on the crack phenomenon

Felix Kessler^I; Flavio Pechansky^II

^IPsychiatrist. Deputy Director, Center for Drug and Alcohol Research, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.

^IIPsychiatrist. Director, Center for Drug and Alcohol Research, HCPA, UFRGS.

In the early 1980's, American social ethnographers described in the literature a new and powerful form of cocaine use - inhalation of the vapor expelled from burning cocaine rocks, manufactured by "cooking" the basic paste combined with sodium bicarbonate. When burnt in a glass pipe or another recipient, it produced a typical crackling sound, and was therefore named crack. Its use in this format allowed for a massive discrimination of the substance into the brain, thus obtaining more stimulating and extremely pleasant effects. The drug onset was also fast, but more transient, and users described an almost uncontrollable craving while using the drug. Initial reports on individuals that dared to try crack described them as "slaves" of its effects; many ended up by collapsing due to the organic damage. At that time the rocks were sold for about 25 dollars, according to articles published in newspapers in Los Angeles and New York. However, even after 1 year of an intense campaign by the lay media on this issue, the Drug Enforcement Agency in the USA still considered this form of cocaine use as a minor problem when compared with inhaled cocaine.¹

Some of these data and anecdotic reports were confirmed - such as the great dependence potential of crack - while others were not, such as its mortality rate. Anyhow, in the early 1990's, many reviews on this theme were published as a counterpoint to the myths and scientific evidence relative to crack, in addition to warning authorities of the possibility of an epidemic, and suggesting prevention and treatment forms for dependence and associated problems associated.^2,3 However, American publications have surprisingly been reduced since the past decade, and several of these issues are still unanswered - especially regarding treatment of this dependence.

The history if crack in Brazil followed a similar path, but with a delay of approximately 10 years in relation to the northern hemisphere. After the turn of the millennium, many reports on this theme were produced, showing growing concern by health professionals and investigators about crack by the population, as well as its consequences. Quantitative and qualitative studies were developed, and showed that the price of crack rocks in Brazil were much lower - about 2 dollars. It was also observed that many old cocaine users decided to replace the injected by the smoked form. Due to a higher cost and difficulty to carry the pipes, Brazilian users ingeniously developed a way of smoking by means of aluminum cans with poked holes and aided by cigarette ashes, which enhanced combustion. In addition to continued risk of lip burning, the possibility of increasing levels of aluminum in the blood of crack users has been recently suggested, which might cause more damage to the central nervous system. As to risk of exposure to HIV, a study published in 2006 by Pechansky et al.,⁴ analyzing a pool of 1,449 drug users in Porto Alegre, showed that the profile of crack users is much similar to that of injectable cocaine users. They both have low socioeconomic levels and higher tendency of exchanging sex by drugs, which yields a very high seroprevalence rate when compared to that of cocaine snorters.

More than a specific damage to the individual's organism, it is clear to the Brazilian scientific and lay community that crack is a large-impact drug. Presently, one of the main issues being discussed in the country is the prevalence of its consumption. The main studies in this area were conducted by the Brazilian Center of Information on Psychotropic Drugs (CEBRID), and crack use was included only in the last surveys, corroborating studies that suggest an actual increase in crack consumption. The fifth survey, conducted among elementary and high school students in Brazilian public schools, found that 2% of students aged 18 years or less have used cocaine at least once, and 0.7% have used crack.⁵ However, it is important to stress that epidemiological studies obtained from schools have a natural data collection bias, since they report data from students that are enrolled, attending school and present in the classroom during data collection. Crack, due to its peculiar characteristics, is not a drug that allows its user to be in a teaching environment, and the data obtained are probably underestimated. Similarly, the second household survey conducted with individuals aged 12-65 years in the 108 largest Brazilian cities and published in 2007 also reached that same percentage average of crack use, except for the south and southeast regions, which usually have higher rates of cocaine use.⁶ A recent study coordinated by the Center for Drug and Drug Research at UFRGS in five outpatient and hospital treatment centers in four Brazilian capitals found that 39.4% of the patients sought treatment due to crack use. However, evaluation of the number of crack dependents in the Brazilian population has not been investigated, and would demand more complex measurement methods.

The Brazilian media has reported cases of crack use in middle and high classes, but scientific evidence still has to confirm whether this is an alarming rate. Hartman & Gollub, in 1999, analyzed articles published in American newspapers on the "crack epidemic" and concluded that they were sensationalist, since they had no scientific foundation and could have caused the authorities to shift the focus from more relevant social problems.⁷ It was shown that, with the improvement in the American economy in the 1990's and the input of other drugs, such as high-potency opioids and the so-called designer drugs, there was a 60% reduction in crack use. It is necessary to know whether in Brazil this phenomenon will be the same, or whether there will be an epidemic of larger proportions. In 2008 a review was published on the profile of Brazilian crack users, confirming that in fact most users are young, male, and have low income.⁸ Crack use in higher classes might often be associated with psychiatric comorbidities, such as personality and mood disorders. Regardless of these figures, what draws attention in the expansion of crack use is the speed of the individual's mental, organic and social life deterioration. The phenomenon of children (crack babies) intoxicated by this drug during pregnancy should also be stressed. It is known that crack use during pregnancy may trigger spontaneous abortions, early delivery, reduced fetal growth and other perinatal changes. In addition, those who are born alive may have mental retardation or other mental and behavioral disorders that will bring serious consequences for their lives.^9,10

The association between crack use and mortality is not direct. It is undeniable that the mortality rate in crack users is high, but it is important to understand that deaths are more commonly associated with drug trafficking elements, dispute over points of sale/use or confrontations with the police than with the damage caused by the drug itself. A cohort study conducted in São Paulo for 5 years and including 131 users showed that the main causes of death were homicide and AIDS.¹¹ Many studies have correlated crack use and increased violence, especially during withdrawal periods, and the relations between such aggressiveness and mortality is strong. The regions where there is a large consumption of crack usually have higher rates of violence and crime in general.

Crack is a hard-to-treat drug - especially considering the current models that are put forward in Brazil. Most authors state that the approach should be multidisciplinary and divided into several stages through a complex model of a biopsychossocial nature, especially focusing on strategies to prevent relapse. Use of medications usually helps, although there is no one considered efficacious for crack use. Such approach commonly includes individual, family and social aspects, focused on more severe problems associated with dependence, such as psychiatric, legal and employment problems. It is worth considering that preventive approach models, such as harm reduction, seem to have little effect on this population of users. Measures such as disposable pipes or other strategies that are predominantly based on maintenance and safe use - quite acceptable in other modalities of substance use - do not have confirmed efficacy with crack users. Therefore, the strategy that seems to show better results needs to include a long-term treatment structure, which contemplates an initial hospitalization in a psychiatric environment located inside a general hospital, and further extended to a service model based on closed therapeutic communities or with high degree of treatment intensity, also for long periods - frequently 6 months to 1 year. It is worth stressing that family and social networks play an essential role in treatment adherence, due to low patient motivation, and in long-term monitoring during the period of maintenance of withdrawal. Cases that have hard access to the health system or that do not have external support usually have low recovery rates. For such cases, the health team should be proactive, using techniques focused on treatment adherence and incentives.¹²

Unfortunately, the rise of crack in Brazil coincided with the policy of closure of psychiatric beds, and the public health network has no capacity to absorb all cases. According to João Alberto Carvalho, president of the Brazilian Psychiatric Association, Brazil has only 1,800 psychiatric beds in general hospitals.¹³ The main challenge is to apply preventive policies for the population under higher risk of having contact with crack, which should include social programs and rewarding occupational alternatives. As for treatment of identified cases, the guidelines from the Brazilian Department of Health must comprehend the medical assistance model based on case severity. It is also necessary to have service programs and policies that are based on available scientific evidence on treatment of drug dependence. In order to be more effective, these models demand higher availability of public resources than the treatments used for other chronic diseases, which often generates a certain resistance. If these measures are not implemented soon, newspapers will continue to report an increased number of articles and images about the lack of attention given to the impact of this drug - whether as users chained in beds by their relatives as a result of the lack of structure provided by the State, or in the police section.

REFERENCES

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Publication Dates

• Publication in this collection
  06 Jan 2009
• Date of issue
  Aug 2008