CRACK COCAINE USE SCENE IN THE CAPITAL OF THE STATE OF SANTA CATARINA/BRAZIL: THE (IN)VISIBILITY OF USERS

ESCENAS DEL CONSUMO DE CRACK EN LA CAPITAL DE SANTA CATARINA/BRASIL: LA (IN)VISIBILIDAD DEL USUARIO

ABSTRACT

Objective:  to describe the characteristics of the crack cocaine use scene, its surroundings and consequences.

Method:  this study was based on the Time-location Sampling methodology. Between January and June 2011, 41 crack use scenes were mapped in Florianópolis (Brazil). After randomly selecting the scenes to be observed, the days and shifts for in-depth observation were selected by lottery, for a total of 98 scenes/shifts, this atep was performed between December 2011 and March 2012. The observations were recorded in a field diary, and were examined using content analysis and discussed based on the Brazilian and international literature on the topic.

Results:  the results show that crack cocaine use scenes were more concentrated in the central regions of Florianópolis. Policing was very ostensive in the communities surrounding these areas, which are strongly marked by drug trafficking. Healthcare, prevention and authority actions were incipient in the locations of substance use, which shows the invisibility of crack users in society.

Conclusions:  more investments are needed so that public policies work to help drug users access social and healthcare services.

DESCRIPTORS Crack cocaine; Drug and narcotic control; Harm reduction; Mental health; Public health

RESUMEN

Objetivo:  describir características de la escena del consumo de crack, su entorno y evoluciones.

Método:  utilizada metodología Time-Location Sampling. Entre enero y junio de 2011 fueron mapeadas 41 escenarios de consumo de crack en Florianópolis (Brasil). Escenarios a observarse elegidos aleatoriamente, se sortearon días y turnos para la tarea, totalizando 98 escenas/turno, etapa realizada entre diciembre 2011 u marzo 2012. Observaciones registradas en cuaderno de campo, examinadas por análisis de contenido y discutidas según literatura nacional e internacional.

Resultados:  los escenarios de consumo de crack se concentraron en regiones centrales de Florianópolis. Vigilancia ostensiblemente aplicada en comunidades cercanas, marcadas por el tráfico de drogas. Las acciones de cuidado, prevención y autoridad resultaron ser incipientes en lugares de consumo de la substancia, expresando la invisibilidad del usuario de crack frente a la sociedad.

Conclusiones:  se requieren mayores inversiones para que las políticas públicas actúen permitiendo que el consumidor de la droga acceda a equipos sociales y de cuidado.

DESCRIPTORES Cocaína Crack; Control de medicamentos y narcóticos; Reducción del daño; Salud Mental; Salud Pública

RESUMO

Objetivo:  descrever as características da cena de uso do crack, seu entorno e desdobramentos.

Método:  o projeto se valeu da metodologia Time-Location Sampling. De janeiro a junho de 2011 foram mapeadas 41 cenas de uso de crack em Florianópolis (Brasil). Após seleção aleatória das cenas a serem observadas, sortearam-se os dias e turnos em que essas seriam observadas em detalhe, totalizando 98 cenas/turno, atapa realizada entre dezembro de 2011 a março de 2012. As observações, registradas em caderno de campo, foram examinadas via análise de conteúdo e discutidas à luz da literatura nacional e internacional.

Resultados:  o estudo identificou que as cenas de uso de crack se concentram nas regiões centrais de Florianópolis. O policiamento ocorre de maneira ostensiva nas comunidades próximas a estas áreas, fortemente marcadas pelo tráfico de drogas. As ações de cuidado, prevenção e autoridade se mostraram incipientes nos locais de uso da substância, o que denota a invisibilidade do usuário de crack perante a sociedade.

Conclusões:  são necessários maiores investimentos para que as políticas públicas atuem a fim de possibilitar que o usuário da droga acesse os equipamentos sociais e de cuidados.

DESCRITORES Cocaína; crack; Controle de medicamentos e entorpecentes; Redução do dano; Saúde mental; Saúde pública

INTRODUCTION

Drug use is as old as mankind itself, whether for therapeutic, recreational or ritualistic purposes. Starting in the early 20th century, the circulation and use of these substances began to be regulated. Some were officially forbidden, under the allegation that they represented a threat to social order and were related to health problems, disorderly conduct, and urban violence. The expansion of capitalism coupled with these substances’ illegality contributed to the growth of Brazilian and international drug trafficking, expanding commercial markets, and, despite attempts to deter it, drug use still grows.1 In various scenarios, including cities in rural United States (especially in previous decades),2 and in Brazil, crack cocaine has become easily available for a couple of dollars (or reais, in Brazilian currency). This market force, together with the particularities of the drug itself, with its almost immediate pleasurable effect after being smoked,3 contribute to its dissemination and use.

São Paulo was the first city in Brazil to register the presence of crack cocaine, in 1991, and where the term “Cracolândia” ("Crackland”) was coined to designate a location where up to hundreds of crack cocaine users congregate and maintain a network of relationships that establish the exchange, selling and use of the drug.4 Over the years and with the lack of success of merely hygienist and repressive actions, crack cocaine is no longer limited to large urban centers and has reached small and medium municipalities. Even though the drug is not the most commonly used in Brazil, its use draws the attention of society because, in the public imagination, it is connected to trafficking, violence, marginalization, prostitution, sexually transmittable infections/diseases, among other real or perceived problems, relative to social or public safety issues.

In addition to Brazil’s enormous size, it is also very culturally and socioeconomically diverse. Drug use varies among its cities. The large cities in the Southeast of Brazil tend to have “Cracklands” while other cities have specific locations for crack cocaine use, but with a lesser number of users, such as in Florianópolis, the capital of Santa Catarina (Brazil). In this city, where public drug use scenes are rarely seen by authorities and civil society.

Twenty years after the appearance of crack cocaine in the Brazilian illegal market, its presence has caused many additional difficulties. These include direct or indirect effects (even though the problems perceived are not necessarily based on empirical evidence, as they are poorly documented in Brazilian research). To address these effects, urban planning, public safety, healthcare programs, research, and policies must focus on drug users and their locations of use.³

Different countries adopt different approaches to policies for crack cocaine use. In May 2010, The Brazilian government established the Integrated Plan for Facing Crack and other Drugs - Crack Can be Overcome (Crack, é Possível Vencer) to increase the provision of health treatment to drug users, tackle traffic and criminal organizations, and expand drug use prevention actions. This is a coordinated initiative of the federal, state and municipal governments and civil society. The plan is based on three key elements: health care - expanding the capacity for providing users and their families with care; prevention - strengthening the protection network against drug use; authority - addressing drug trafficking and overt and proximity policing.5

To collaborate with the effective implementation of policies, it is important to identify the reality of Brazilian territories in terms of crack cocaine use. Thus, the aim of the present study was to describe the characteristics of crack cocaine use scenes and their consequences.

METHOD

This was an exploratory qualitative study part of a national project called “Profile of Crack Cocaine Users in 26 capital cities, the Federal District, nine metropolitan regions, and Brazil”. The present study addresses and analyzes the specific findings relative to Florianópolis, the state capital of Santa Catarina.

This nationwide survey used the time-location sampling methodology to select samples and collect information about crack users, a population that is often difficult-to-reach and very hidden. Thus, based on in-depth knowledge about the places visited by this population and on an ethnographic study of its characteristics and dynamics, random selection was used to select the participants, anchored in blocks of time. This decision was grounded in the chosen conceptual framework and on the empirical observation about the specific places and times (or shifts) visited by this population.6

It is important to emphasize that the present article is a cut-out of the research mentioned above, reporting only one stage of the observation of the crack cocaine use scenes identified. Florianópolis is divided into five health districts: North, South, East, Center, and Continent. First, visits were made to the territories in these five districts between January and June 2011 to gather information from social services regarding the locations, days, and times in which crack cocaine users gathered to use the drug. All the scenes informed by social services were visited by the research team to confirm their existence. They were also mapped out by five agents of the Municipal Guard and five harm reduction agents. In this step “use scene” was defined as any group with at least three people who were involved in handling, sharing and/or using crack cocaine in an open public space. Each visit to the territories in the health districts was carried out with the help of a Municipal Guard agent and a harm reduction agent. All the use scenes identified by the team were located in the Center and Continent Health Districts.

After mapping the use scenes, the data were sent to Fundação Osvaldo Cruz (FIOCRUZ) for coding. Next, the different locations, days, times/shifts for the field teams to conduct observations were randomly selected. Forty-one crack cocaine use scenes were observed in Florianópolis, and of these, 39 were chosen for observation, because the others were too inaccessible (due to safety issues). Next, the shifts per scene were selected at random (morning - 6 am to 12 pm; afternoon - 12 pm to 6 pm; night - 6 pm to 12 am), for a total of 98 scenes/shifts. Minimum observation time was 30 minutes. All the observations were coded using numbers, which represented the location and shift in which they had taken place, in accordance with research ethics principles. Example of coding: Code - scene: 29; scene 2943, in which 29 refers to the location of drug use and scene 2943 refers to the time and day of visitation. The coding process and the random selection of scenes were carried out by the central FIOCRUZ team (according to the book) and then sent to the institutions that were participating in the study to begin the observation phase.

Between December 2011 and March 2012, crack cocaine use was observed in all of the 98 scenes/shift. The data were recorded in field diaries created and formatted for this purpose (included in the Annex of the original study7). The observers gathered the following information about the characteristics of crack use scenes: physical and geographic space, the movement of people in the location, the presence of commerce, policing, and drug trafficking. The visits were carried out by two observers for safety reasons (municipal guard agents). However, the field diary was filled out individually to qualitatively enrich the study. Thus, 196 field diaries were read in full and submitted to qualitative analysis.

Qualitative analysis was carried out according to the methods and procedures pertinent to content analysis,8 following the three established phases: pre-analysis, in which the material was organized to make it operational, systematizing the initial ideas; exploring the material through data codification, classification and categorization, and data processing, in which the information was condensed and highlighted, culminating in reflexive and critical analysis of the material.

The present article presents the findings relative to the empirical data by extracting descriptions of the scenes and transcripts of some of the observations recorded in the field diaries.

RESULTS

In terms of physical and geographic characteristics, the crack cocaine use scenes were observed in the central regions of the Center and Continent Health Districts. A high number of scenes/shifts had commerce (57 scenes/shifts - 55.86%) and people/pedestrians and automobile traffic in the vicinity (29 scenes/shifts - 67.62%). In 27 scenes/shifts (26.46%), there were health institutions in the proximities, primarily Basic Health Units. Some scenes/shifts also contained institutions such as fire departments, courts of justice, daycares, schools, churches, legislative assembly, labor office, sports foundation, and the environmental military police.

Of the 98 scenes/shifts, 46 (46.9%) were observed at night, and only in six (5.88%) was there any lack of street lighting. Regarding the urban cleanliness of the locations where crack cocaine use scenes occurred, precarious conditions were identified in 56 scenes/shifts (54.88%), such as accumulated trash, presence of human or animal waste, malodor, vestiges of crack cocaine use, among other materials, as shown in this excerpts: there is too much filth, the place looks like it's also used as a bathroom, trash is accumulated everywhere [...] crushed cans, pieces of radio antennas and empty lighters [...] The location is malodorous and humid, when it rains, the water pools at the location (Code - Scene: 31; Scene 3162).

Among the users, many seemed to be living on the streets, because in addition to remaining in often very unsanitary locations, they frequently presented skin injuries, poor health, or other healthcare needs. There were also pregnant women in the scenes. Some of the following transcriptions portray this reality: extremely poor oral health, teeth apparently broken and with cavities (Code Scene: 03; Scene 353). They all looked malnourished [...] and terrible personal hygiene (Code Scene: 10; Scene 1023). The woman seemed to be pregnant (Code Scene: 01; Scene 163).

In none of the scenes were the users approached by healthcare professionals, social workers, harm reduction agents, public health agents, community or religious leaderships, or any other social actors.

Regarding drug dealing, of the 98 scenes/shifts observed, drug was clearly being sold in four scenes/shifts, and in two of these, the dealers were at the location exclusively to deal the drug, without using it themselves; and in the other two scenes/shifts, the dealers were also users. In three scenes/shifts, only suspected drug dealing activities were recorded. The following transcripts illustrate the drug trafficking observed in the scenes.

Man, around 35 years old, smoked crack cocaine in a pipe [...] bought more drugs from another man, approximately 20 years old, white. He sold him the drug and left the scene (Code - Scene: 2; Scene 211).

Man, brown-skinned, approximately 40 years old, sells candy at the nearby traffic light, brought with him some stones of crack cocaine and sold them to the couple at the scene. He smoked the crack from a can and left the scene (Code - Scene: 32; Scene 3263).

In most of the scenes/shifts, the users arrived there already with the drug, and in some cases, they were given crack stones by friends, and rarely, in exchange for sexual favors. A possible reason for this is that, of the 39 scenes in which this was observed, nine (23.07%) were located next to trafficking points. Consequently, of the 98 scenes/shifts, users had easy access to drug dealing in 25 (25.51%) of them. In some scenes/shifts, users would leave, go to the drug sales point, and return to the location to keep on using. Some examples:

two brown-skinned men came down from the hill. One of them [...] had drugs in his hand, sat on the ground and smoked it from an aluminum can (Code Scene: 4; Scene 441).

to smoke the drug from a pipe, after its use, he went to the drug sales point “trash alley” - located 200 meters away from the scene (Code Scene:5; Scene 512).

With regards to policing, it was reported when fighting drug trafficking in the communities close to the use scenes:

policing at the scene is very rare, but in the community adjacent to the scene, it was intense, being that a military police tactical group, the civil police center for special operations and special operations battalion frequently made incursions up to the hill looking for criminals, and when this happens, the users run away into the tunnel (Code - Scene: 2; Scene 212 - Code - Scene: 3; Scene 353 - Code - Scene: 5; Scene 531).

The police passed close to the crack cocaine use locations in 41 (41.84%) of the scenes/shifts; however, they did not approach the users in any of them. Sometimes police patrol caused users to disperse temporarily, or did not affect the scene use at all: Intense police patrol, but drug use starts up again a few minutes after they leave (Code - Scene: 9; Scene 923). Police patrol in the vicinity has intensified because of complaints of small thefts in vehicles parked closed to the scene; however, it has not affected the use scene (Code Scene: 10; Scene 1023).

It is worth noting that 9 (23.07%) scenes, and consequently 22 (22.45%) scenes/shifts were located next to police institutions: because the scene is located at the entry of the police center of operation building, Civil Police Captures, police vehicles often pass by the scene, but users cannot be seen by the police officers, so it all ends up going unnoticed by the police most of the times (Code - Scene: 16; Scene 1623). Police vehicles pass by the location several times, because there is a police station 200 meters away (Code - Scene: 25; Scene 2533).

It is also worth mentioning that while in many scenes, the users sought out drugs in places that were out of sight, both by the police and the population, in other places, they were not in the least concerned about being seen with the drug:

the users were gathered on a staircase that leads to an underground level; therefore they were out of sight of those walking by (Code - Scene:10; Scene 1023).

ehen we arrived at the scene, there were three homeless individuals lying under a tree, talking [square in the city center]. They all seemed to be approximately 35 years old, they lit up and smoked four cigarettes. Then came a guy who looked 18 years old, he brought a crack stone and they smoked them right there, without any concern about being seen using the drug. Several people walked by the location, including pregnant women and children (Code - Scene:13; Scene 1363).

DISCUSSION

Crack cocaine use scenes

The scenes of crack cocaine use in Florianópolis were located in the central regions of the city and demonstrated poor sanitary conditions. Additionally, the users, who were apparently living on the streets, presented visible poor health, which results in greater risk for developing infections and other pathologies. Identifying and understanding the main needs of the population that compose crack cocaine use scenes allows for the planning and implementation of care actions. Considering the characteristics of the crack cocaine use scenes and users, the following are necessary: a safe place to sleep and carry out personal hygiene and grooming, and caring for wounds and injuries; a place for meals; dignified work to earn some income, complete prenatal care; drug education and treatment according to the user's need and consent; and harm reduction actions.

The literature shows that a minority of crack cocaine users access healthcare and social services,9^-10 which may be explained by the presence of various obstacles present in mental health care services in Brazilian municipalities: low integration with harm reduction policies; lack of managers and professionals qualified to work with crack cocaine users, and reduced capacity to meet the demand, especially in crises; a precarious intersectoral approach among social assistance, health care, and public safety services; programs that are not based on mental health policies; irregular provision of mental health services; mental health not considered priority; low coverage of the Family Health Strategy program; low integration with the Social Work Reference Center (CREA) and the Specialized Center for Social Work (CREAS) with the Family Health Strategy and the Psychosocial Care Center; and the presence of repressive actions marked by prejudice and the violation of human rights.11

These difficulties sustain actions whose approach to users is focused on treatment aimed at detoxification and abstinence. Such logic needs to be overcome, with emphasis to harm reduction actions, incentivizing educatioln, and addressing social vulnerabilities and health promotion.

Crack cocaine users that use the drug compulsively, i.e., who are motivated by "jonesing”, use several stones successively to continue feeling the desired effect. This is called binging, which can result in risk behaviors that compromise users’ health and social relationships, possibly leading to severed ties with family, friends, school and work, which ends up reinforcing their involvement with the drug and sometimes makes them live on the streets.3^,11 Currently, the existence of controlled crack cocaine use has been proven, i.e., there are users who can consume the drug and maintain their regular activities, such as work and school, and family ties, and are able to go without using the drug for days.12 This reality suggests that the crack cocaine use phenomenon surpasses its pharmacological effects and is influenced by social, environmental and emotional issues. Thus, it is essential that public policies and their actors address all these issues.3 On reflecting on the different patterns of crack cocaine use and the singularity of the reasons that lead individuals to use, discontinue or start using the drug again, it is necessary to learn more about users and address them in their singularity, negotiating care proposals that ensure their safety, health care, and social insertion.

In light of this reality, in which drug users do not seek out care services, it is worth noting that even though the observed locations were surrounded by many health, public safety and social assistance institutions and several social services, as well as the presence of many passersby, these scenes were not approached by any of the social actors that represent these services to work with drug users regarding the care mentioned and discussed above. Thus, it is necessary to identify why these actors have not taken action before this social reality, in accordance with existing public policies.

In the context of the collective imaginary that emphasizes the guilt of drug users and demonizes the substance, crack cocaine users are often defined as that which they consume, and therefore, Brazilian media reports often refer to them as “crackheads”. In other words, they become the product itself, associated with violence, marginality or mental illness, and the social and cultural aspects involved in the phenomenon are not comprehensively addressed, nor are the possibilities of caring for this population outside of repression and institutionalization through imprisonment or hospitalization.13 Thus, the media tends to reinforce stereotypes, treatments and policies and contributes to the persistence of a hospital-centric and biomedical discourse, which does not adopt a broader concept of health and reinforces generalist, hygienist and social exclusion actions.14

A study about the publicity campaign spots “Crack Can be Overcome” showed that these are not focused on the educational aspects of drug use, not addressing psychological, social, legal and politicoeconomic aspects. Instead, they reproduce information based on common sense, centered on fear and tragedy. No educational information is presented, nor do they shine a light on the ignorance surrounding the topic of chemical dependence. Instead, the program is based on the bias that there is an intimate relationship between criminality and substance use.15 Thus, this shows that educational campaigns, which should mobilize society to care for this population, end up perpetuating prejudice against the population and marginalizing users even more.

A study carried out in the Federal District found that after teachers carried out the Drug Use Prevention Course for Public School Teachers, some of them fostered the protagonism of students and teachers, breaking with outdated ideologies, while others still practiced the pedagogy of fear, repression and protectionism, which makes school subjects reproducers of the old adage “just say no”. It is essential to involve the various school actors and activate the different levels of social networks inside and outside schools, in addition to aligning the political and ideological conceptions of the various professionals and institutions involved.16

Another important finding of the present study was that the scenes did not consist of regions completely defined by drug trafficking, as occurs in large urban centers, such as São Paulo and Rio de Janeiro (Brazil), but rather for its use. However, many of these scenes took place close to illegal drug trafficking, which facilitates access to the product. Consequently, policing should operate with the goal of identifying and arresting dealers, as well as breaking apart criminal organizations that work with illicit drug dealing in the communities close to the drug use scenes. This approach is aligned with the immediate actions established in the Integrated Plan for Facing Crack and other Drugs,5 which recommends facing crack cocaine traffic in areas with greater vulnerability for consumption.

The nationwide study about the use of crack cocaine showed that of the 7,381 users interviewed, 6.42% had worked with drug dealing in the last 30 days (prior to the interview) and 9.4% had earned money through other illicit activities such as theft, robbery, fraud, piracy and larceny. Reasons for arrest in the year prior to the interview included: drug dealing/manufacturing (11.36%); robbery (20.40%) theft, fraud, breaking and entering (19.43%); assault, fighting, domestic violence (13.95%); and homicide (4.56%); prostitution or pimping (1.71%); and violation of parole/treatment order/under bail (0.64%). These data show that a minority resorts to drug trafficking to obtain money, and that other factors related to public security and that deserve multiprofessional care (security, health care and social assistance) to be resolved.

Thus, there was no overt proximity (community) policing of the crack use scenes, because the police did not act at the scene to recognize crack users and then approach them in a way that enables educational actions and social reinsertion. This type of patrolling could even encourage the participation of the community in drug use areas to strengthen the prevention of violence and criminality, in addition to revitalizing these spaces.5

The (in)visibility of crack cocaine users

In light of the above, it is evident that crack cocaine users are invisible to the eyes of the police, health institutions, social assistance and the civil community. Thus, it is important to discuss issues relative to legislation and public policy that can ground actions to change this reality.

In 2006, Law No. 11.34317 established measures to prevent undue use, provide social assistance for and reinsertion of drug users and addicts, in addition to decriminalizing drug users, establishing different sentences for users and dealers. It determined that those who purchase, keep, store, transport or carry unauthorized or illegal or unregulated drugs will be submitted to the following penalties: warning about the effects of drug use, community service and educational measures that include attending educational courses or programs - the last two items must be applied in no more than five months and in cases of recurrence, the maximum time limit is ten months. Offenders must also be given free access to a health facility to receive treatment.

From this perspective, public safety agents are responsible for mapping out crack cocaine use scenes, recognizing the territory where they occur, identifying users and drug dealing points in order to abide by the legislation in force. They must also pay attention to the fact that small drug dealers are often users who sell the product to support their own substance use (a situation that was rare in the present study) and not drug trafficking agents, associated with organized crime. It is easier to differentiate drug dealers from users when the police creates a relationship with the territory and the community, and receives proper training and the necessary material and human resources to develop their work effectively, continuously and safely.

This multiprofessional perspective was adopted by the Integrated Plan for Facing Crack and other Drugs - Crack Can be Overcome. According to this program, crack cocaine is no longer a matter of safety, but a social and health issue. The city of São Paulo, based on this plan's resources and directives, created the Open Arms program, implemented in January 2014. To work the program, 200 Metropolitan Civil Guard agents received training about the philosophy behind community policing, forms of social mobilization and strengthening public spaces, peaceful conflict resolution, intersectoral network of assistance and health services, training with health professionals about drugs, and last, practicing using nonlethal weapons. In addition to theoretical empowerment, the work process was restructured and the guards were also given surveillance buses that carried out the video monitoring of all those who circulated in the region with the greatest concentration of drug users.18 A year after the beginning of the Open Arms program, there was an 80% reduction in the flow of crack users at the scene, 50% in vehicle thefts and 33% in thefts from people. Furthermore, there was an 83% increase in the number of arrests for drug dealing.19

The pillar of prevention is wide-reaching in its attributes, aimed especially at the education of professionals who operate in the three areas established in the Crack Can be Overcome plan. The courses are provided both in classroom and online format. Furthermore, the plan establishes proximity policing and educational actions about the topic in several social facilities, such as schools and communities, and in the media. It determines capacity-building of community leaders, municipal council members and other leaderships to work towards drug use prevention and develop preventive actions suitable to their local reality, in addition to training healthcare professionals, social workers and legal operators.5

The present study found flaws regarding intersectoral care actions and approaches to crack users, which shows the need for educational actions on the topic for all the civil population. In other words, it is necessary to consolidate the pillar of prevention in the studied municipality and thus train agents who can multiply this knowledge and skills by taking on leadership roles that collaborate to strengthening the citizenship of crack cocaine users.

The Open Arms program in São Paulo, for example, innovated in the provision of health care actions to its beneficiaries (crack cocaine users registered in the program), among them: providing shelter through affiliated hotels; hiring users to sweep and clean the streets in the central region for four hours a day for 15 Brazilian reais per work day; technical education for those interested; three free meals per day; and access to health services through directed referrals. Clinical treatment or abstinence was not imposed on individuals registered in the program. The location set aside for registration also worked as a space for physical exercise, cultural or organization activities, bathrooms, laundry machines, gym equipment, and a collective TV. The actions are carried out by social assistance, healthcare, culture, sports and leisure tames, with the support of urban security. In terms of health care, users could receive comprehensive care, including medical, nursing, dental and psychological care, actions to prevent sexually transmitted infections and diseases (STIs/STDs), as well as specific services for women, pregnancy and children. Regarding social work and assistance, many users began sweeping the streets and squares, others became more autonomous and found work outside the program, and numerous beneficiaries were issued new documents. It is worth emphasizing that the users included in the program who initiated work activities, accepted treatment, showed up to work every day and reduced their drug use.19

In Florianópolis, there were no intersectoral interventions in the observed crack cocaine use scenes. Therefore, municipal managers must strive to implement comprehensive care actions for this population. The municipality has the following facilities that can provide users with assistance: Basic Health Units, Street Health Teams, Psychosocial Care Centers, 24-hour Emergency Units, Mobile Urgent Care Service, CRAS, CREAS, High-Complexity Social Assistance Facilities (shelters and assisted housing), in addition to partnerships with Therapeutic Communities. All these institutions, together with public safety and civil society can be sensitized, empowered and provided with the necessary material and human resources to provide comprehensive care to crack cocaine users.

Other actions that structure the Integrated Plan for Facing Crack and other Drugs include carrying out studies and diagnostics about the topic to gather information aimed at perfecting public policies for drug use prevention, treatment, and social reinsertion of users, and facing the trafficking of crack cocaine and other illegal drugs. This branch of the program includes the research from which the present study was extracted, and in which the Municipal Guard of Florianópolis participated. Throughout this process, they were trained to work with crack users from a perspective that is in line with the public policies in force. With these agents’ participation in mapping and observing the scenes, they were sensitized and more empowered to work with this population, aware of their healthcare and social reinsertion needs. It is the municipality's responsibility to provide material and human resources so that public safety agents can carry out proximity (community) policing in the crack cocaine use scenes.

Brazil is experiencing a time of transition, in which efforts are being made to provide comprehensive care, encompassing all needs relative to healthcare, disease prevention, health promotion and citizenship. However, at the same time, repressive actions and ideas are still present, rooted in the view of crack cocaine and “crackheads” as the same problem, resulting in the exclusion and invisibility of drug users by society. Educational actions must provide adequate information about the social, healthcare and public safety issues involved when it comes to drugs and deconstruct prejudice. More research is necessary to underpin actions capable of reaching these purposes, i.e., to critically educate and inform the population, leading to greater responsibility of civil society and professionals from different areas with crack cocaine users.

Understanding the phenomenon of crack cocaine use scenes requires more studies about their social and cultural context, integrated with epidemiological and statistical data. Such studies would enable the immersion of different actors in this context, and therefore foster proximity and a trans-disciplinary approach that effectively embraces the needs of this population, which are often neglected. Healthcare and assistance policies that involve crack cocaine users must be the priority of managers, always based on the Brazilian and international scientific literature.20

CONCLUSION

Greater investment is needed in order to effectively implement the Integrated Plan for Facing Crack and Other Drugs, so that drug users can access social and healthcare facilities that strengthen their citizenship and promote reduced drug use or even abstinence. Brazilian municipalities should assess their capacity to provide comprehensive care to crack cocaine users. Intense efforts are also necessary for the field of prevention so that the population as a whole is empowered to address the theme ethically and humanely, enabling the social insertion of crack cocaine users.

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• FUNDING INFORMATION
  National Secretariat for Drug Policies Presidency of the Republic. Brazil.
• APPROVAL OF THE RESEARCH ETHICS COMMITTEE
  Approved by the Research Ethics Committee of the Sérgio Arouca National School for Public Health, under certificate of presentation for ethical appraisal no. 0073.0.031.000-11.

Publication Dates

• Publication in this collection
  29 Aug 2019
• Date of issue
  2019

History

• Received
  26 June 2017
• Accepted
  08 Feb 2018