Mortality rate among crack/cocaine-dependent patients: A 12-year prospective cohort study conducted in Brazil

Oxytocin Receptor Exon III Methylation in the Umbilical Cord Blood of Newborns With Prenatal Exposure to Crack Cocaine

BACKGROUND

Prenatal cocaine exposure (PCE) is associated with behavioral, cognitive, and social consequences in children that might persist into later development. However, there are still few data concerning epigenetic mechanisms associated with the effects of gestational cocaine exposure, particularly in human newborns.

AIMS

We investigated the effects of PCE on DNA methylation patterns of the Oxytocin Receptor (OXTR) gene in the umbilical cord blood (UCB). The relationship between UCB DNA methylation levels and the severity of the mother's cocaine use during pregnancy was also evaluated.

METHODS

In this cross-sectional study, 28 UCB samples of newborns with a history of crack cocaine exposure in utero and 30 UCB samples of non-exposed newborns (NEC) were compared for DNA methylation levels at two genomic loci located in exon III of the OXTR gene (OXTR1 and OXTR2) through pyrosequencing. Maternal psychopathology was investigated using the Mini International Neuropsychiatric Interview, and substance use characteristics and addiction severity were assessed using the Smoking and Substance Involvement Screening Test (ASSIST).

RESULTS

No differences between newborns with a history of PCE and NEC were observed in OXTR1 or OXTR2 DNA methylation levels. However, regression analyses showed that maternal addiction severity for crack cocaine use predicted OXTR1 DNA methylation in newborns.

CONCLUSION

These data suggest that OXTR methylation levels in the UCB of children are affected by the severity of maternal crack cocaine usage. Larger studies are likely to detect specific changes in DNA methylation relevant to the consequences of PCE.

Oral changes in cocaine abusers: an integrative review

•

Integrative review aiming to detect oral changes in cocaine abusers.

•

The main oral changes, methods of diagnosis and treatment were identified.

•

Good anamnesis and qualified health professionals are necessary.

Introduction

Cocaine is one of the most often used psychoactive drugs worldwide, being extracted from the leaves of Erytroxylus coca plant. Its abusive use can trigger several consequences for the human body, including the oral cavity.

Objective

To identify the oral disorders that are most commonly found in individuals who abuse cocaine, in addition to the main diagnostic and treatment methods.

Methods

An integrative review was carried out on the databases: LILACS, BBO, LIS, MEDLINE, SciELO, Science Direct and PubMed. The following keywords were used: “Cocaína”, “Boca”, “Palato” and “Odontologia”, together with their synonyms and variations in English, obtained from DeCS and MeSH. The inclusion criteria were original articles, articles in Portuguese, English and Spanish, studies involving individuals, without restriction related to the year of publication. Animal studies, literature reviews, book chapters, theses and dissertations were excluded.

Results

In total, 1373 records were identified. Of these, 22 articles were selected to comprise the review. Several oral alterations caused by cocaine abuse were found, primarily perforation of the palate, predisposition to periodontal diseases, temporomandibular disorders, bruxism, damage to oral tissues, dental caries, destructive lesions of the facial midline, xerostomia and ageusia. Among the diagnostic methods used by the professionals, anamnesis, intraoral examinations and head and neck computed tomography were the most frequently mentioned. As for treatment, in patients with palatal perforation, the reconstruction of the affected area or the use of prosthetic obturators is carried out.

Conclusion

The management of these patients is not an easy task, as many of the users do not even seek professional help. The health professionals must be able to recognize these manifestations and alterations to establish timely and accurate diagnosis and treatment planning.

Cortical thickness and subcortical volume abnormalities in male crack-cocaine users

Crack-cocaine offers a higher risk of abuse than intranasal and intravenous use of cocaine. Yet, current treatments remain disappointing and our understanding of the mechanism of crack-cocaine neurotoxicity is still incomplete. Magnetic resonance images studies on brain changes of crack-cocaine addicts show divergent data. The present study investigated gray matter (GM) abnormalities in crack-cocaine dependents (n = 18) compared to healthy controls (n = 17). MRI data was analysed using FreeSurfer and voxel-based morphometry (VBM). FreeSurfer analysis showed that CD had decreased cortical thickness (CT) in the left inferior temporal cortex (lTC), left orbitofrontal cortex (lOFC) and left rostro frontal cortex (lRFC), enlargement in left inferior lateral ventricle, and smaller GM volume in right hippocampus and right ventral diencephalon. VBM analysis showed that CD had significantly decreased GM volume in left Putamen and left nucleus accumbens. Furthermore, we found a negative correlation between duration of crack-cocaine use and lTC CT. These results provide compelling evidence for GM abnormalities in CD and also suggest that duration of crack-cocaine use may be associated with CT alterations.

White matter deficits in cocaine use disorder: convergent evidence from in vivo diffusion tensor imaging and ex vivo proteomic analysis

White matter (WM) abnormalities in patients with cocaine use disorder (CUD) have been studied; however, the reported effects on the human brain are heterogenous and most results have been obtained from male participants. In addition, biological data supporting the imaging findings and revealing possible mechanisms underlying the neurotoxic effects of chronic cocaine use (CU) on WM are largely restricted to animal studies. To evaluate the neurotoxic effects of CU in the WM, we performed an in vivo diffusion tensor imaging assessment of male and female cocaine users (n = 75) and healthy controls (HC) (n = 58). Moreover, we performed an ex vivo large-scale proteomic analysis using liquid chromatography-tandem mass spectrometry in postmortem brains of patients with CUD (n = 8) and HC (n = 12). Compared with the HC, the CUD group showed significant reductions in global fractional anisotropy (FA) (p < 0.001), and an increase in global mean (MD) and radial diffusion (RD) (both p < 0.001). The results revealed that FA, RD, and MD alterations in the CUD group were widespread along the major WM tracts, after analysis using the tract-based special statistics approach. Global FA was negatively associated with years of CU (p = 0.0421) and female sex (p < 0.001), but not with years of alcohol or nicotine use. Concerning the fibers connecting the left to the right prefrontal cortex, Brodmann area 9 (BA9), the CUD group presented lower FA (p = 0.006) and higher RD (p < 0.001) values compared with the HC group. A negative association between the duration of CU in life and FA values in this tract was also observed (p = 0.019). Proteomics analyses in BA9 found 11 proteins differentially expressed between cocaine users and controls. Among these, were proteins related to myelination and neuroinflammation. In summary, we demonstrate convergent evidence from in vivo diffusion tensor imaging and ex vivo proteomics analysis of WM disruption in CUD.

All-cause and cause-specific mortality among people with regular or problematic cocaine use: a systematic review and meta-analysis

AIMS

To estimate pooled all-cause and cause-specific mortality risk for people with regular or problematic cocaine use.

METHODS

Systematic review and meta-analysis of prospective or retrospective cohort studies or clinical trials (n ≥30) of people with regular or problematic cocaine use with data on all-cause or cause-specific mortality. Of 2808 papers, 28 were eligible and reported on 21 cohorts, with a total 170 019 individuals. Cohorts identified based on acute care for drug poisoning or other severe health presentation were excluded. Title/abstract screening was conducted by one reviewer; a second reviewer independently checked 10% of excluded studies. Two reviewers conducted full-text screening. Data were extracted by one reviewer and checked by a second. A customized review-specific study reporting quality/risk of bias tool was used. Data on crude mortality rates (CMR) and standardized mortality ratios were extracted for both all-cause and cause-specific mortality. Standardized mortality ratios were imputed where not provided by the author using extracted data and information from the Global Burden of Disease Study 2017. Data were pooled using a random-effects model.

RESULTS

The pooled all-cause crude mortality rate was 1.24 per 100 person-years [95% confidence interval (CI) = 0.86, 1.78; n = 16 cohorts], but with considerable heterogeneity (I²  = 98.8%). The pooled all-cause standardized mortality ratio (SMR) was 6.13 (95% CI = 4.15, 9.05; n = 16 cohorts). Suicide (SMR = 6.26, 95% CI = 2.84, 13.80), accidental injury (SMR = 6.36, 95% CI = 4.18, 9.68), homicide (SMR = 9.38, 95% CI 3.45-25.48) and AIDS-related mortality (SMR = 23.12, 95% CI = 11.30, 47.31) were all elevated compared with age and sex peers in the general population.

CONCLUSIONS

There are elevated rates of mortality among people with regular or problematic cocaine use for traumatic deaths and deaths attributable to infectious disease.

[The use of "virado" as a harm reduction strategy among crack users in the State of Pernambuco, Brazil]

The aim of the study is to discuss the use of crack in the form of "virado" as a harm reduction strategy in Pernambuco, Brazil. This is a cross-sectional study with a qualitative approach in which semi-structured interviews were conducted regarding aspects related to the culture of crack use with 39 crack users between March and August 2016. Participants were recruited using saturation criteria and data were analyzed through content analysis. Respondents discussed the use of "virado" and compared its effects in relation to crack, addressing improvement in interpersonal relationships, libido, and non-compulsive drug use, which can all be understood as harm reduction strategies. On the other hand, equipment sharing for the use of "virado" was identified as a high-risk practice with regards to the transmission of infectious diseases. Knowing about the culture of crack use in different contexts is essential in order to plan and develop health care actions.

Violence and substance use in sexual minorities: Data from the Second Brazilian National Alcohol and Drugs Survey (II BNADS)

OBJECTIVE

To describe the prevalence of substance use and the associations between adverse early life experiences, sexual behaviour and violence in sexual minority (SM) individuals.

METHODS

The Brazilian National Alcohol and Drugs Survey is a probabilistic household survey performed in 2012, collecting data from 4067 Brazilians aged 14 years and older.

RESULTS

3.4% of the sample declared themselves as sexual minorities, 53.8% female, 66.5% single, mean age of 29.5 years (standard deviation 16.0 years). A high prevalence of alcohol dependence (15.2%) and binge drinking (22.2%) was identified in the SM group. Respondents were more likely to use crack cocaine and hallucinogens, to have been involved in child prostitution, child sexual abuse and to report suicidal ideation in the previous year. Respondents were also more likely to engage in unprotected sex compared to non-sexual minorities. Nearly one-third referred to having suffered homophobic discrimination in their lives. Respondents also reported higher rates of domestic violence (18.9%) and urban violence (18%) among the SM.

CONCLUSION

The findings reinforce that violence directed at individuals in the Brazilian SM community begins early in life and persists into adulthood when compared to non-sexual minorities. This population is also more exposed to substance use disorders.

Sex-based differences in multidimensional clinical assessments of early-abstinence crack cocaine users

Crack cocaine use disorder (CUD) has been related to sex differences. This work aimed to compare the severity of drug use and the severity of other negative related outcomes in males and females with CUD. A total of 1344 inpatients (798 males and 546 females) with crack cocaine use disorder (CUD) were evaluated by a detailed multidimensional clinical assessment, including addiction severity and trauma exposure. Linear regression predicted higher drug use severity (β = 0.273, p < 0.001) and more problems in domains related to childcare issues (β = 0.321), criminal involvement (β = 0.108), work-related problems (β = 0.281) and social support impairments (β = 0.142) for females, all with p < 0.001. Alcohol problems were predicted to be higher in males (β = -0.206, P < 0.001). Females had higher rates of other mental disorders, particularly trauma and stress-related disorders (OR: 3.206, CI: 2.22, 4.61). Important sex differences also emerged in trauma history and HIV infection prevalence. CUD has a more severe clinical presentation among females facing early abstinence. Sex differences in the CUD course indicate the need for consideration of sex-specific interventions and research.

Markers for Severity of Problems in Interpersonal Relationships of Crack Cocaine Users from a Brazilian Multicenter Study

Crack cocaine users frequently report difficulties regarding having healthy and rewarding relationships. Factors other than the use of crack cocaine itself may be at play when it comes to being able to develop healthier connections with partners, adult relatives and close friends. To verify which factors, including demographics, substance abuse related factors and psychiatric comorbidities could be markers for a higher severity of problems in interpersonal relationships of crack cocaine users seeking for treatment. This was a cross-sectional study, conducted between April 2011 and November 2012. Participants were 407 crack cocaine users seeking treatment in specialized public facilities of six Brazilian capitals. The relationship of severity of problems in the family/social area and the prevalence of psychiatric disorders, exposure to stressful events, substance use related factors and practice of illicit activities were explored through multivariate analyses. Number of days using crack cocaine in the last 30 days, age of first time using alcohol and feeling its effects, a diagnosis of alcohol abuse, posttraumatic stress disorder, antisocial personality disorder and attention-deficit/hyperactivity disorder were significantly associated with a higher severity of problems in interpersonal relationships with partners, adult relatives and friends. Problems in interpersonal relationships are strongly related to specific psychiatric comorbidities and the frequency of crack cocaine use. Factors identified by this study can make the paths to recovery more challenging. These results support psychosocial interventions that focus in the improvement of interpersonal relationships of crack cocaine users.

Grief in a biography of losses: Meaning-making in hard drug users' grief narratives on drug-related death

The focus in grief theories has been increasingly shifting toward questions of meaning. In this study, we draw on the meaning-reconstruction model of grief for studying the unique case of hard drug users who have experienced a drug-related death. The social context of hard drug use, as well as the death and grief circumstances, is problematic and stigmatized. Grief narratives of 10 respondents were analyzed according to the principles of grounded theory. We identified four main themes: (1) the inhibition of emotion by drugs leading to fragmented grief reactions, (2) social exclusion and notions of disenfranchized grief, (3) the acceptance of death, and (4) meaningfulness in a "biography of losses." Connecting these results with the literature on meaning, we find that meaning-making is a multidimensional and layered process, where some layers result in meanings made while others do not. Finally, this study emphasizes the importance of social and emotional aspects of grieving, as well as the ambiguity of the notion of successful meaning-making in relation to grief.

The effect of religiosity during childhood and adolescence on drug consumption patterns in adults addicted to crack cocaine

BACKGROUND

Although many studies suggest that religiosity is a protective factor against drug use, there is little information on its effect on drug consumption patterns of those who do use drugs.AimsWe aimed to examine if there is any relationship between religiosity during childhood and adolescence, and drug consumption in adult crack users.

METHOD

We performed a cross-sectional study of adults addicted to crack cocaine. Logistic regression analysis was used to estimate the odds ratio for the association between religious history in the age groups 8-11, 12-14 and 15-17 years and outcome variables.

RESULTS

From a total of 531 respondents, religious involvement during childhood and adolescence was correlated to less frequent onset of drug consumption before 18 years (odds ratio 0.95, 95% CI 0.92-0.98) and less craving (odds ratio 0.95, 95% CI 0.91-0.99), mainly between the ages of 15 and 17 years.

CONCLUSIONS

Religiosity provides some protection against drug consumption patterns in crack cocaine addicts.Declaration of interestNone.

Association between oral mucosal lesions and crack and cocaine addiction in men: a cross-sectional study

The aim of this cross-sectional study was to evaluate the prevalence of oral mucosal lesions (OMLs) and their association with crack/cocaine addiction in men. Clinical oral examination was performed in 161 adult male patients at the School of Dentistry of the Federal University of Bahia, Brazil. Crack/cocaine addiction was determined from the medical records, and all drug-addicted individuals used both crack and cocaine. All participants (40 crack/cocaine-addicted men and 121 non-addicted men) underwent a systematic evaluation of the lips, labial mucosa, commissures, buccal mucosa and sulcus, gingiva and alveolar ridge, tongue, floor of the mouth, and soft and hard palate by a single examiner. Bivariate and regression analyses were conducted to assess for the presence of OMLs and the association of OMLs with crack/cocaine addiction. OMLs were found in 22 participants with a significantly greater prevalence in the crack/cocaine-addicted group (25 vs. 9.9%; p = 0.01). The most prevalent types of lesions in the addicted group were traumatic ulcer and actinic cheilitis (7.5% for each) followed by fistulae associated with a retained dental root (5%). After adjusting for covariates, crack/cocaine addiction was significantly associated with OMLs (OR = 2.87; 95% CI = 1.08-7.67; p = 0.03). The prevalence of OMLs was higher in crack/cocaine-addicted individuals, and crack/cocaine addiction was significantly associated with OMLs. A public health program aimed at the early diagnosis and treatment of OMLs is vital to improving the oral health status of individuals addicted to crack/cocaine.

Active Brazilian crack cocaine users: nutritional, anthropometric, and drug use profiles

Objective:

To evaluate the nutritional status of crack users and to analyze its correlation with drug use profiles.

Methods:

Cross-sectional study with 108 crack users. Anthropometric data were assessed through body mass index (BMI) and bioimpedance (BIA) measurements. A blood test to analyze hematocrit, hemoglobin, glucose, and lipid profiles was also performed. Crack use was determined through a standardized interview.

Results:

Based on BMI and BIA, most individuals were eutrophic (about 70%). Regarding hematological parameters, we found that hemoglobin and hematocrit levels were below normal for 32.4 and 30.6% of patients, respectively. Considering normal parameters, a large part of the sample (60.2%) had low levels of HDL cholesterol and high levels of triglycerides (38%). There were no significant correlations between drug profile and nutritional variables.

Conclusion:

This is a pioneering study that examines the nutritional status of crack users. Our results showed that most crack users present normal anthropometric findings and the prevalence of underweight is low. However, blood analysis showed changes and a specific type of malnutrition.

Abortion and sex-related conditions in substance-dependent Brazilian patients

Abortion is a very sensitive issue with relevance to public health; however few clinical or population-based studies have examined induced abortion among drug users. The study aims to evaluate the prevalence of induced abortion and sex-related conditions in an inpatient drug user sample. A cross-sectional design study was conducted in an inpatient addiction treatment unit in São Paulo, Brazil, with a sample of 616 patients, aged 18-75. Sociodemographic data, sexual behavior, and dependence severity were evaluated in relation to induced abortion. Approximately 27% of patients reported having a history of abortion (themselves in the case of women or partners in the case of men). The mean age was 34.6±10.9 years old, 34.9% diagnosed with severe alcohol dependence, 33% were diagnosed with severe levels of dependence on other drugs, 69.6% were diagnosed cocaine users (inhaled and smoked), and alcohol was the drug of choice for 30.4%. Chances of having a history of abortion is greater for women than for men with a odds ratio (OR = 2.9; 95%CI: 1.75-4.76), (OR = 1.7; 95%CI: 1.09-2.75) of no condom use; (OR = 2.0; 95%CI: 1.35-3.23) of history of STI and (OR = 3.2; 95%CI: 1.29-5.73) use of morning-after pill. Drug- and alcohol-dependent patients have high-risk behaviours of sporadic use or no-condom use which contribute to unplanned pregnancy and induced abortion, making this vulnerable population a group which deserves special attention in sexual health prevention programmes and health promotion efforts for the reduction of induced abortion.

Prevalence of cocaine and derivatives in blood and urine samples of trauma patients and correlation with injury severity: a prospective observational study

PURPOSE

The abuse of cocaine and its derivatives presents a likely risk factor for injury. Trauma incurred by cocaine and derivative abusers may be more severe than that incurred by non-users.

OBJECTIVES

To ascertain the presence of cocaine and its derivatives in trauma patients and to correlate RTS (Revised Trauma Score) and ISS (Injury Severity Score) with the presence of cocaine and its derivatives in blood and urine samples.

METHODS

All trauma victims treated in an emergency unit between November 11, 2012 and September 15, 2013 were included in the study. Blood and urine samples were collected on admission to hospital. RTS and ISS scores were then compared with the presence or absence of cocaine and its derivatives in the samples. The associations between RTS < 7.84 and ISS > 16 and the independent variables were evaluated by the gross odds ratio values, determined by univariate logistic regression. Multivariate analysis was performed using multivariate logistic regression.

RESULTS

Of 453 patients (83.7% male) included in the study, 28.6% presented ISS > 16 and 33.6% presented RTS < 7.84. A total of 435 samples were collected, and 86 (19.8%) provided positive samples for cocaine, 48 (11%) for crack and 69 (15.9%) for cocaethylene. Compared to other patients, drug users showed a greater probability of RTS < 7.84 (2.18 times greater) and a greater probability of ISS > 16 (1.76 times greater).

CONCLUSION

For the trauma patients included in our study, the use of cocaine and its derivatives was shown to be associated with more severe traumas, as demonstrated by their RTS and ISS scores.

Psychiatric hospitalizations in the Rio Grande do Sul State (Brazil) from 2000 to 2011

OBJECTIVE

To examine the variation in the rates of psychiatric hospitalization and the mean hospital stay time in the public health system in the state of Rio Grande do Sul, in the south of Brazil, from 2000 to 2011.

METHODS

This was an ecological study. Data were collected from DATASUS. The rates were obtained from diagnosis of admissions due to psychoactive substance use and to other causes, stratified by the gender of the patients. The data were analyzed using Poisson regression and Spearman correlation coefficient.

RESULTS

Increasing hospitalization rates were observed for women with disorders due to substance use (p < 0.001) and other causes (p < 0.001), and among men with disorders due to the use of alcohol or other drugs (p < 0.001). This elevation of the rates remained statistically significant and inversely correlated to the length of hospital stay (p < 0.001).

DISCUSSION

In a period of expansion of the local care networks for mental health, an increase in the occupancy of psychiatric beds in the state was noticed, with shorter length of stay and greater diversity of gender and causes of hospitalization.

Revisão sistemática da literatura sobre crack: análise do seu uso prejudicial nas dimensões individual e contextual

RESUMO Este artigo visa investigar como se conformam, no Brasil e internacionalmente, as abordagens ao uso prejudicial do crack e outras drogas. Foi realizada uma revisão crítica da literatura acerca do padrão de consumo do crack e os fatores a ele relacionados com busca sistemática em bases eletrônicas no período de 2010 a 2016. Foram analisados 37 artigos por autor, ano, país do estudo, metodologia; padrão de consumo de crack e fatores individuais e contextuais relativos a esse uso. Conclui-se que a abordagem ao uso de drogas deve estar focada na perspectiva da redução de danos, na promoção da autonomia e dos direitos humanos, e não na utopia de eliminação do consumo e da produção de drogas.

Mortality and virological failure among HIV-infected people who inject drugs on antiretroviral treatment in China: An observational cohort study

OBJECTIVE

HIV-infected people who inject drugs (PWID) have a disproportionally low rate of access to antiretroviral therapy (ART). We aimed to assess the impact of ART on 12-month mortality and virological failure of HIV-infected PWID in China, stratified by methadone maintenance treatment (MMT) and active drug use status.

METHODS

HIV-infected PWID who initiated ART at 29 clinics in 2011 were enrolled and followed in this prospective cohort study. Kaplan-Meier curves and log-rank tests were used to compare the survival probability. Risk factors for mortality and virological failure were evaluated by Cox proportional hazards models and logistic regression analyses.

RESULTS

A total of 1,633 participants initiated ART. At the time of initiation, 324 were on MMT, 625 were engaged in active drug use, and 684 had discontinued drug use but were not on MMT. At the 12-month follow-up, 80.3% remained on ART, 13.5% had discontinued ART, and 6.2% had died. Among the MMT group, active drug use group, and drug abstinent group, we observed all-cause mortality of 4.9%, 12.0%, and 1.5% and virological suppression of 51.9%, 41.1%, and 68.7%, respectively. Factors associated with both mortality and virological failure were drug use status, unemployment, and treatment facility type.

CONCLUSION

For HIV-infected PWID receiving ART, engagement in MMT and discontinuation of drug use were more likely to be associated with lower mortality and virological failure compared with active drug use. In order to maximize the clinical impact of ART, HIV treatment programs in China should be further integrated with MMT and social services.

Crack cocaine addiction, early life stress and accelerated cellular aging among women

BACKGROUND

Early life stress (ELS) and addiction are related to age-related diseases and telomere shortening. However, the role of telomere length (TL) in crack cocaine addiction remains unknown. The purpose of this study was to investigate the TL in a sample of crack cocaine dependent-women who reported an ELS history and in a community-based sample of elderly women as a reference group for senescence.

METHODS

This study included treatment seeking crack cocaine dependents women (n=127) and elderly women without a psychiatric diagnosis (ELD, n=49). The crack cocaine sample was divided in two groups according to their Childhood Trauma Questionnaire (CTQ) scores: presence of history of childhood abuse and neglect (CRACK-ELS) and absence of ELS history (CRACK). TL was assessed by T/S ratio obtained from peripheral blood DNA using quantitative PCR assay.

RESULTS

CRACK and CRACK-ELS subjects exhibited shortened TL in comparison to the ELD group, despite their younger age. Among crack cocaine sample, CRACK-ELS group had significantly shorter telomeres than the CRACK group. Correlation analysis within crack cocaine group indicated that TL was negatively correlated with emotional abuse scores.

CONCLUSIONS

These results support previous findings associating telomere shortening with both ELS and drug addiction. This study suggests new evidence of a distinct biological phenotype for drug-dependent women with ELS. The results support the biological senescence hypothesis underpinning ELS experience.

Cross-cultural adaptation of the drug-taking confidence questionnaire drug version for use in Brazil

BACKGROUND

The Drug-Taking Confidence Questionnaire evaluates a drug user's confidence in his or her ability to resist the urge to consume psychoactive substances in high-risk situations. This study's objective was to develop a cross-cultural adaptation of the eight-item version of the Drug-Taking Confidence Questionnaire (DTCQ-8) for all drugs except alcohol and to verify its content validity and reliability in a pre-test stage.

METHODS

The following steps were taken: (1) implementation of the translation protocol and transcultural adaptation, (2) validation of the adapted content, and (3) assessment of reliability. Nine experts participated in the process of adaptation, and the trial's sample comprised 40 drug users in treatment at a Psychosocial Care Center for Alcohol and Other Drugs (CAPSad).

RESULTS

The average indices of semantic agreement (0.989; 0.989; 1.00), idiomatic (0.967), experiential (0.956), conceptual (0.978) and content validity with respect to language clarity (0.972), practice relevance (0.958), theoretical relevance (0.958) and theoretical dimension (1.00) showed that the adaption was successful. The mean total score of the DTCQ-8 version for other drugs was 477.00 + 234.27-SD, and 57.5 % of the users were classified as having moderate self-efficacy to resist the urge to use drugs in high-risk situations. The Cronbach's alpha coefficient was 0.889 for the complete instrument and 0.863-0.890 between items.

CONCLUSIONS

The DTCQ-8 version for other drugs proved to be easy to use and understand, and its process of adaptation was satisfactory for use in the Brazilian context. In this sample, the questionnaire was adequate to measure users' self-efficacy to resist the urge to consume these substances in high-risk situations.

Comportamento violento entre usuários de crack

<p>Considerando a relevância do uso abusivo de crack na atualidade brasileira e sua relação com a violência, este estudo propõe-se a analisar a associação entre comportamento violento —delitivo, auto e hetero<br />agressivo— entre os usuários de crack e variáveis sociodemográficas e de uso de drogas. Realizado estudo quantitativo, transversal, com amostra de conveniência, com 72 homens usuários de crack em tratamento nas Comunidades Terapêuticas de seis cidades da região Oeste<br />do Estado de Minas Gerais (Brasil). Os dados foram analisados estatisticamente no Statistical Package for<br />the Social Sciences Versão 17.0, utilizando-se teste qui-quadrado para verificação de diferenças estatisticamente<br />significantes. Os resultados apontam associação do tráfico com número de pedras consumidas e de tratamentos realizados; de prisão ou detenção com baixa escolaridade,<br />ser solteiro e idade de início do uso de droga ilícita; de tentativa de suicídio com o tempo máximo de<br />abstinência e de heteroagressão com idade de início do uso de droga ilícita e frequência diária do uso de crack. O uso de crack pode contribuir para o desenvolvimento de comportamento violento —delitivo, auto e heteroagressivo.</p>

Factors that lead to the use of crack cocaine in combination with marijuana in Brazil: a qualitative study

Background

In Brazil, crack cocaine use remains a healthcare challenge due to the rapid onset of its pleasurable effects, its ability to induce craving and addiction, and the fact that it is easily accessible. Delayed action on the part of the Brazilian Government in addressing the drug problem has led users to develop their own strategies for surviving the effects of crack cocaine use, particularly the drug craving and psychosis. In this context, users have sought the benefits of combining crack cocaine with marijuana. Our aim was to identify the reasons why users combine crack cocaine with marijuana and the health implications of doing so.

Methods

The present study is a qualitative study, using in-depth interviews and criteria-based sampling, following 27 crack cocaine users who combined its use with marijuana. Participants were recruited using the snowball sampling technique, and the point of theoretical saturation was used to define the sample size. Data were analyzed using the content analysis technique.

Results

The interviewees reported that the combination of crack cocaine use with marijuana provided “protection” (reduced undesirable effects, improved sleep and appetite, reduced craving for crack cocaine, and allowed the patients to recover some quality of life).

Conclusions

Combined use of cannabis as a strategy to reduce the effects of crack exhibited several significant advantages, particularly an improved quality of life, which “protected” users from the violence typical of the crack culture.

Crack use is considered a serious public health problem in Brazil, and there are few solution strategies. Within that limited context, the combination of cannabis and crack deserves more thorough clinical investigation to assess its potential use as a strategy to reduce the damage associated with crack use.

The globalization of addiction research: capacity-building mechanisms and selected examples

Over the past decade, the amount and variety of addiction research around the world has increased substantially. Researchers in Australia, Canada, United Kingdom, United States, and western Europe have significantly contributed to knowledge about addiction and its treatment. However, the nature and context of substance use disorders and the populations using drugs are far more diverse than is reflected in studies done in Western cultures. To stimulate new research from a diverse set of cultural perspectives, the National Institute on Drug Abuse (NIDA) has promoted the development of addiction research capacity and skills around the world for over 25 years. This review will describe the programs NIDA has developed to sponsor international research and research fellows and will provide some examples of the work NIDA has supported. NIDA fellowships have allowed 496 individuals from 96 countries to be trained in addiction research. The United Arab Emirates and Saudi Arabia have recently developed funding to support addiction research to study, with advice from NIDA, the substance use disorder problems that affect their societies. Examples from Malaysia, Tanzania, Brazil, Russian Federation, Ukraine, Republic of Georgia, Iceland, China, and Vietnam are used to illustrate research being conducted with NIDA support. Health services research, collaboratively funded by the U.S. National Institutes of Health and Department of State, addresses a range of addiction service development questions in low- and middle-income countries. Findings have expanded the understanding of addiction and its treatment, and are enhancing the ability of practitioners and policy makers to address substance use disorders.

The impact of drug use patterns on mortality among polysubstance users in a Canadian setting: a prospective cohort study

Background

Illicit drug use is a well-established risk factor for morbidity and mortality. However, few studies have examined the impact of different drug use patterns on mortality among polysubstance using populations. This study aimed to identify drug-specific patterns of mortality among a cohort of polysubstance using persons who inject drugs (PWIDs).

Methods

PWIDs in Vancouver, Canada were prospectively followed between May 1996 and December 2011. Participants were linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariate Cox proportional hazards regression to investigate the relationships between drug use patterns (daily alcohol use, heroin injection and non-injection use, cocaine injection, amphetamine injection and non-injection use, crack smoking and speedball injecting) and time to all-cause mortality.

Results

2330 individuals were followed for a median of 61 months (inter-quartile range: 33 – 112). In total, 466 (19.1%) individuals died for an incidence density of 3.1 (95% confidence interval [CI]: 2.8 – 3.4) deaths per 100 person-years. In multivariate analyses, after adjusting for HIV infection and other potential confounders, only daily cocaine injection remained independently associated with all-cause mortality (adjusted hazard ratio [AHR] = 1.36, 95% CI: 1.06 – 1.76).

Conclusions

Although heroin injecting is traditionally viewed as carrying the highest risk of mortality, in this setting, only daily cocaine injecting was associated with all-cause mortality. These findings highlight the urgent need to identify novel treatments and harm reduction strategies for cocaine injectors.

Violent and sexual behaviors and lifetime use of crack cocaine: a population-based study in Brazil

OBJECTIVE

To estimate the prevalence of lifetime use of crack cocaine and to assess associations with violent and sexual behaviors in young adults selected from the general population of Pelotas, Southern Brazil.

METHODS

This cross-sectional population-based study included 1,560 participants aged 18-24 years. The use of alcohol and other substances, including crack cocaine, was assessed using the alcohol, smoking and substance involvement screening test. Other variables included violent behaviors, firearm possession, and sexual risk behaviors. The frequency of antisocial personality disorder was also investigated. Associations were analyzed using a crude model and models adjusted for sex, social class, and the use of snorted cocaine.

RESULTS

Lifetime prevalence of crack cocaine use was 2.51 %, and it was higher among males and individuals coming from more vulnerable social classes (D or E). In the final multivariate models, lifetime use of crack cocaine was associated with episodes of aggression and firearm possession, as well as with a higher chance of not having used condom in the last sexual intercourse. In less conservative models, crack cocaine use was associated with other violent and sexual risk behaviors.

DISCUSSION

The strong association observed between lifetime use of crack cocaine and different violent and sexual risk behaviors underscores relevant characteristics of people who use crack cocaine. Improving our understanding of possible causal chains leading to such associations should be a priority in future studies.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil

Background

Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil.

Methods

N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.

Results

The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.

Conclusions

The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.

Key drug use, health and socio-economic characteristics of young crack users in two Brazilian cities

BACKGROUND

Crack use constitutes a major problem in cities across Brazil. While existing data suggest that crack use is generally concentrated among disenfranchised young people with extensive health problems and crime involvement, extensive data gaps exist. To address this issue, this study aimed to assess key characteristics of young crack users in two Brazilian cities.

METHODS

N=160 regular and young adult (ages 18-24) crack users were recruited by community-based methods in the cities of Rio de Janeiro (Southeast) and Salvador (Northeast). Assessments included an interviewer-administered questionnaire on key social, drug use, health and service use characteristics, as well as serological testing of HBV, HCV and HIV status, and were conducted anonymously between November 2010 and June 2011. Participants provided informed consent and received transportation vouchers following assessment completion. The study was approved by institutional ethics review boards.

RESULTS

The majority of participants were: male, with less than high school education, unstably housed (Rio only); gained income from legal or illegal work; arrested by police in past year (Salvador only); had numerous daily crack use episodes and shared paraphernalia (Salvador only); co-used alcohol, tobacco, cannabis and cocaine; had no injection history; rated physical and mental health as 'fair' or lower (Salvador only); had unprotected sex; were never HIV tested; were not HIV, HBV or HCV positive; and did not use existing social or health services, but desired access to crack user specific services.

CONCLUSION

Crack users in the two Brazilian sites featured extensive socio-economic marginalization, crack and poly-drug use as well as sexual risk behaviours, and compromised health status. Social and health service utilization are low, yet needs are high. There is an urgent need for further research and for targeted interventions for crack use in Brazil.

Mortality in a cohort of young primary cocaine users: controlling the effect of the riskiest drug-use behaviors

BACKGROUND

Published studies indicate that primary cocaine users (PCUs) have a mortality rate 4-8 times higher than their age-sex peers in the general population. Most PCUs are primary intranasal cocaine users, never-injectors and never-opioid users (PICUNINOs) and are usually underrepresented in cohort mortality studies. The aim is to estimate excess mortality in all PCUs and in the subgroups of never-opioid users and PICUNINOs in Spain.

METHODS

714 PCUs aged 18-30 were street-recruited in 2004-2006 in Spain and followed until 2010 to ascertain vital status. Drug use was self-reported at baseline and 1-2years later. Mortality was compared with that of the general population using standardized mortality ratios (SMRs).

RESULTS

SMRs were 4.7 (95% CI: 2.4-9.0), 2.5 (95%CI: 0.8-7.8) and 3.1 (95% CI: 1.0-9.6), respectively, among all participants, never-opioid users and PICUNINOS when using only baseline data on drug use, and 1.2 (95% CI: 0.2-8.5) and 1.4 (95% CI: 0.2-9.9) among the latter two subgroups, when using baseline plus follow-up data.

CONCLUSION

Short-term mortality in young Spanish PCUs is 5 times higher than in the general population. This excess mortality may largely be explained by a history of opioid use or the risk of starting such use.

Influência do ambiente familiar no consumo de crack em usuários

OBJETIVOS: Analisar a influência do ambiente familiar no consumo de crack em usuários habituais ou dependentes. MÉTODOS: Pesquisa qualitativa, realizada com 15 familiares de usuários de crack em tratamento em um serviço especializado, por meio de entrevista semiestruturada. Os dados foram analisados de acordo com conteúdo temático e organizados em categorias. RESULTADOS: Dentre os fatores de influência, verificou-se a deficiência de suporte parental, a superproteção dos filhos, a presença de cultura implícita do uso de drogas, a existência de conflitos e violências, a desinformação e o desconhecimento sobre o uso de drogas. CONCLUSÃO: Constatou-se que as famílias apresentaram vários elementos considerados desfavoráveis no ambiente familiar, os quais atuaram como elemento facilitador ao uso crack.

Is there a crack epidemic among students in Brazil?: comments on media and public health issues

In the past year, the Brazilian Federal Government and society have reported and acted on a crack use epidemic, which has been exacerbated by the media. This study hypothesized that crack use has not increased at the rate suggested by the Brazilian media. A cross-sectional survey was carried out in 2010 usinga multistage probabilistic representative sample of Brazilian middle and high school students in the country's 27 state capitals. A total of 50,890 valid questionnaires were weighted, analyzed and results compared to the 2004 national school survey dataset. Considering lifetime and past year crack use, no change in consumption was found between 2004 and 2010. Official data in Brazil on middle and high school students does not support the assertion of a crack epidemic widely publicized by the media. Government measures to treat and prevent crack use are encouraged; however, the term epidemic has been inappropriately used to represent the static prevalence of crack consumption among students.

Validação psicométrica do Cocaine Craving Questionnaire-Brief - Versão Brasileira Adaptada para o Crack para dependentes hospitalizados

Introdução: O craving (ou fissura) é um fator muito importante no tratamento da dependência de substâncias psicotrópicas. Objetivo: Validar o Cocaine Craving Questionnaire-Brief - Versão Brasileira Adaptada para o Crack. Método: O delineamento foi experimental e seus participantes foram randomizados, em grupos: experimental, para o qual foi apresentada uma imagem de um indivíduo consumindo crack (G1), e controle (G2), para o qual não foi apresentada nenhuma imagem. A amostra foi composta por 109 sujeitos (G1 = 50 e G2 = 59) do sexo masculino, internados por causa da dependência do crack. Os instrumentos utilizados foram: Entrevista Clínica com dados sociodemográficos, CCQ-B Versão Adaptada para o Crack, Escala Analógico-Visual do Craving, Inventários Beck de Ansiedade e de Depressão e o Estímulo Visual indutor de craving para o G1. Resultados: Na análise fatorial, foram encontrados dois fatores: o fator 1, relacionado ao craving propriamente dito, e o fator 2, relacionado à percepção da falta de controle do uso do crack. Os dois fatores apresentaram variância total de 68,84%, e a correlação entre os fatores foi significativa e de baixa intensidade (r = 0,204; p = 0,041). O alfa de Cronbach do seu total de pontos foi 0,85. O instrumento no total de pontos foi correlacionado com a Escala Analógico-Visual (r = 0,515; p < 0,01). Conclusão: O CCQ-B - Versão Brasileira Adaptada para o Crack demonstrou ser, psicometricamente, satisfatório para utilização em pesquisas e em ambiente clínico.