Abstract

Crack cocaine has been a major public health problem in Brazil due to the individual and social harms and risks deriving from its use. This article aims to assess the characteristics of drug scenes in the capital and Midwest of Santa Catarina state. The project used the Time-Location Sampling. Between January and June 2011, 41 crack cocaine scenes were mapped in capital of Santa Catarina, whereas 33 were mapped in the Midwest of that state. Such scenes were randomly selected to be observed, as well as their days and shifts (time periods/day) for in-depth observation. Overall, 98 scenes/shifts were observed in the capital and 62 in the Midwest. First-hand reports were logged as field notes into notebooks. Analyses of the empirical material were based on Bardin's content analysis, and findings were compared and contrasted with Brazilian and international literature. Most crack cocaine users were adult males. In the capital, a substantial fraction of the users lived in the streets, but in both settings most interviewees have used multiple substances. In the Midwest, most scenes occurred at night, whereas in the capital scenes occurred in all shifts. Risk practices associated with the use of crack cocaine were: association of multiple drugs, prostitution, pipe sharing and sexual favors in exchange for the substance.

Key words
Crack cocaine; Drug-related harms; Qualitative studies

Introduction

Crack cocaine results from the conversion of cocaine hydrochloride by the addition of alkaline substances and is consumed as smoked stone. Cocaine crosses the blood-brain barrier and penetrates the Central Nervous System in 10-15 min when inhaled and 3-5 minutes when injected, and its effects persist for 45 and 20 min, respectively, according to the modality of use. Self-administration of cocaine under the smoked mode produces its effects instantaneously (10-15s) and duration of pleasurable sensation for approximately 5 minutes, that is, this form of use substantially reduces the onset time of drug action. However, as the resulting sensation has a short duration, it makes the intervals between the episodes of use of the substance small and contributes that this mode of use is more closely associated with dependence when compared to inhaled or injected cocaine¹1. Carlini EA, Nappo SA, Galduróz JCF, Noto AR. Drogas Psicotrópicas – o que são, como agem. Rev Imesc. 2001; 3:9-35.. A recent Brazilian study identified a new modality of use of crack cocaine, the virado, in which the crack cocaine stone is transformed into powder by the addition of boric acid, and it is used in an aspirated way. Thus, according to users, the effect of crack cocaine is longer and there are lower levels of craving and paranoia²2. Nappo SA, Sanchez ZM, Rameh R, Almeida R, Uchôa R. Virado: a new method of crack consumption in Brazil. Am J Addict 2012; 21(6):574-575..

There are reports that crack cocaine use began in the US in the 1980s in vulnerable, impoverished communities made up of individuals on the margins of the formal labor market, ethnic and linguistic minorities, among others³3. Smart RG. Crack cocaine use: a review of prevalence and adverse effects. Am J Drug Alcohol Abuse 1991; 17(1):13-26.. In Brazil, studies have indicated that the drug has been available since 1991 in the city of Sao Paulo⁴4. Nappo SA, Galduróz JC, Noto AR. Crack use in São Paulo. Subst Use Misuse 1996; 31:565-579..

The easy access (due to its greater portability and the capillarity of the retail market) and its lower cost, when compared to powder cocaine, have influenced the spread of its use, mainly among the poorest and most vulnerable social layers⁵5. Jorge MSB, Quinderé PHD, Yasui S, Albuquerque RA. Ritual de consumo do crack: aspectos socioantropológicos e repercussões para a saúde dos usuários. Cien Saude Colet 2013; 18(10):2909-2918.. Due to the short duration of its effect, several stones are usually used throughout the day, according to a repeated consumption pattern in brief intervals of time. Thus, although the unit cost of a crack stone is relatively low, the total amount spent throughout the day may become significant. Therefore, the low unit cost and the presentation in the “stone” format favor its portability and the capillarity of its distribution chains, but do not necessarily reduce the aggregate expenses.

The National Survey on Drug Use and Health estimated that by 2013, 24.6 million of Americans (~ 9.4% of the population) aged 12 years or older had used some illicit drug in the month prior to the survey, and that 1.5 million people had used cocaine (including crack cocaine). It is important to note that, in the year of the study, 601 thousand people had started using cocaine and 58 thousand had had started using crack. The analysis of the incidence of crack use indicates that the number of users varied between 209 thousand and 353 thousand, from 2002 to 2008, with a subsequent reduction to 95 thousand users in 2009. Since then, the number of people who started using crack remained stable⁶6. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Rockville: Substance Abuse and Mental Health Services Administration; 2014.. The reasons behind this significant decline remain open and are subject of debate in the US.

In Europe, it is estimated that 80 million adults (25% of the population) had already experienced illicit drugs in their lifetime, with cannabis being the most frequently consumed substance (75.1 million), followed by cocaine (14.9 million). In relation to the main drug among users who started drug treatment for the first time, cocaine was indicated by 25 thousand (16%) of users and crack by 6 thousand (0.26%) of them. Among European crack users, more than half lived in the United Kingdom (3,500 users) and the others in Spain, France and the Netherlands (2,200 users)⁷7. Observatorio Europeo de las Drogas y las Toxicomanías. Informe Europeo sobre Drogas 2015: Tendencias y novedades. Luxemburgo: Oficina de Publicaciones de la Unión Europea, 2015..

In Brazil, the most complete study on crack use was a national survey conducted by ICICT/Fiocruz in partnership with the National Secretariat for Drug Policy. At the time of the research conception, there was a wide mobilization of the media and health organizations around the theme mainly due to the presence of scenes of drug use in public places (“open scenes”), some of them with an expressive contingent of users, the so-called cracolandias (cracklands – pejorative term, but in common use)⁸8. Bastos FI, Bertoni N, organizadores. Pesquisa Nacional sobre o uso de crack: quem são os usuários de crack e/ou similares do Brasil? quantos são nas capitais brasileiras? Rio de Janeiro: Fiocruz; 2014.. These sites are mostly spaces that congregate individuals interacting in precarious sanitary conditions, with high exposure of sale and use of crack, where their users mostly have weakened health, hampered by the use of this substance and other contaminant elements, and diseases associated to the consumption and superimposed by it, such as various infectious diseases⁹9. Krawczyk N, Filho CL, Bastos FI. The interplay between drug-use behaviors, settings, and access to care: a qualitative study exploring attitudes and experiences of crack cocaine users in Rio de Janeiro and São Paulo, Brazil. Harm Reduct J. 2015; 6:12-24..

The survey revealed that a large proportion of people using the drug in open scenes live on the street, earning money preferentially through sporadic work, prostitution and drug trafficking. Thefts and robberies are also mentioned as additional sources of income, necessary for the acquisition of the drug. Among the habits potentially associated with risks and damages underlined by the research is the sharing of pipes and the concomitant use of multiple drugs⁸8. Bastos FI, Bertoni N, organizadores. Pesquisa Nacional sobre o uso de crack: quem são os usuários de crack e/ou similares do Brasil? quantos são nas capitais brasileiras? Rio de Janeiro: Fiocruz; 2014.. The situation of living in streets has been an important factor to motivate drug use. A study of 2,807 street children and adolescents in Brazilian capitals identified that 24.5% had used cocaine in life, and 12.6% (5.5% of crack cocaine) had used it in the previous month. Most of these started using these substances after being living in streets¹⁰10. Noto RA, Galduróz JCF, Nappo SA, Fonseca AM, Carlini CMA, Moura YG, Carlini EA. Levantamento Nacional sobre o Uso de Drogas entre Crianças e Adolescentes em Situação de Rua nas 27 Capitais Brasileiras – 2003. Brasília: CEBRID; 2003..

In Canada an ethnographic study conducted in 2011 in a safer smoking room (SSR) showed that homelessness and poverty restrict access to private or secure space in which crack users could use the drug, which leads them to smoke the substance in public spaces. In public spaces users are exposed to social and physical violence and repressive policing. In the SSRs there were successful actions to reduce harm by discouraging the sharing of paraphernalia for the use of crack cocaine within the facility and as an opportunity to reinforce public health messages¹¹11. McNeil R, Kerr T, Lampkin H, Small W. Int J Drug Policy [periódico na Internet]. 2015 [acessado 2016 Out 02]; 26(7):645-652. Disponível em: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4468019/
https://www.ncbi.nlm.nih.gov/pmc/article... .

The identification of vulnerabilities, practices and behaviors associated with the use of crack cocaine and other drugs is essential to formulate strategies that allow extending the care to this population through integrated public policies of prevention and eventual handling and treatment of the use, abuse and dependence to crack and other substances.

Relatively little is known about the specific patterns and contexts of crack consumption outside the geographic axis where the main Brazilian research centers are located, because although it is a relevant public and social health problem, it is still a recent issue in most localities, and always surrounded by stigma. Almost all existing studies refer to organic problems, diseases and risk behaviors in the context of the classical health paradigm that is limited in the sense of providing integrated responses to a phenomenon that involves historical, economic, political, social, and cultural aspects¹²12. Arruda MSB, Soares CB, Adorno RCF. Revisão bibliográfica: o consumo de crack nos últimos 20 anos. Sau & Transf Soc [periódico na Internet]. 2013 [acessado 2015 nov 12]; 4(2):157-166. Disponível em: http://incubadora.periodicos.ufsc.br/index.php/saudeetransformacao/article/view/2251/2648
http://incubadora.periodicos.ufsc.br/ind... ^,1313. Moreira MR, Fernandes FMB, Ribeiro JM, Neto TLF. Uma revisão da produção científica brasileira sobre o crack – contribuições para a agenda política. Cien Saude Colet 2015; 20(4):1047-1062.. Ethnographic and anthropological studies have the potential to compensate the lack of scientific knowledge at these points¹⁴14. Singer M. Anthropology and addiction: an historical review. Addiction [periódico na Internet]. 2012 [acessado 2016 out 02]; 107:1747-1755. Disponível em: http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2012.03879.x/epdf
http://onlinelibrary.wiley.com/doi/10.11... .

The present study aims to contribute to the knowledge about the theme, especially in scenarios other than those of the great Brazilian urban centers, in which most of the studies on the theme have been carried out. Thus, the characteristics of scenes of use of crack cocaine in the Capital and Midwest region of Santa Catarina are described, compared and contrasted.

Methods

This is an exploratory study, of a qualitative nature, that integrates the national project “Profile of crack users in the 26 capitals, Federal District, 09 metropolitan regions and Brazil”, with an approach and analysis of the findings regarding the Capital (Florianopolis) and the Midwest region of Santa Catarina.

The research was approved by the Ethics Committee of the National School of Public Health Sergio Arouca (ENSP/Fiocruz).

The national survey used the Time-Location Sampling (TLS) methodology, one of the main methodological strategies used to recruit and collect information regarding participants from hidden/hard-to-reach populations. This methodology draws on the in-depth knowledge of places of interaction of the population under study and the ethnographic understanding of their characteristics and dynamics. Once this information is known, the TLS recruits participants based on random selection, anchored in temporal blocks, and draws on the conceptual formulation and empirical observation that hidden/hard-to-reach populations attend a set of places with days and times (or “shifts”), subject to identification and specification¹⁵15. Fisher Raymond H, Ick T, Grasso M, Vaudrey J, McFarland W. Resource Guide: Time Location Sampling (TLS). San Francisco: San Francisco Department of Public Health HIV Epidemiology Section, Behavioral Surveillance Unit: 2007..

Initially, from January to June 2011, information was collected from Non-Governmental Organizations and the Secretariats of Public Safety and Health of the municipalities under study with regard to the sites, days and times where crack users gathered to use the drug. At this stage, any group consisting of at least three people involving the handling, sharing and/or use of crack in an open public place was defined as “use scene”.

After mapping the use scenes, researchers randomly selected, by lot, different locations, days of week, shifts/times to visit the field teams to observe the scene. A total of 41 scenes of crack use were mapped in the Capital and 33 in the Midwest regions, totaling 74 scenes of crack use in Santa Catarina (according to the sample size previously defined, that is, according to a selection process that should not be interpreted as referring to the set of the state). A total of 67 scenes were selected for the observation due to the fact that the others were inaccessible, of which 39 were located in the Capital and 28 in the Midwest region. For the observation, a draw of the shifts was made (morning – 6 a.m. to 12 a.m., afternoon – 12 a.m. to 6 p.m., night - 6 p.m. to 12 p.m.) by scene, being drawn 98 scenes/shift in the Capital and 62 in the Midwest of Santa Catarina state. A minimum time of 30 minutes was set for the observation of scenes/shift. In spite of the existence of a “fourth shift”, corresponding to the dawning hours (12 p.m. – 6 a.m,), there was a deliberate exclusion of this potential time of observation and interview in order to protect the integrity of the teams.

The observation was carried out between December 2011 and March 2012 in the Capital and from September to November 2012 in the Midwest regions. The observed data were recorded in field diaries prepared for this purpose, being detailed information regarding the characteristics of scenes of crack use: count of crack users present in the scenes observed; presence of pregnant women, adolescents and children using crack cocaine; and the use of other drugs. The visits were carried out by a pair of observers for security reasons. The field diary was completed individually for the qualitative enhancement of the study.

After this initial stage, a total of 320 field diaries were read, referring to the 160 scenes/shifts observed, and 268 field diaries were selected, corresponding to the 134 scenes/shifts in which crack use was observed (98 scenes/shift in the Capital and 36 in the Midwest region). It should be noted that only in the Midwest there was no use of crack cocaine in the observed scenes/shifts.

The qualitative evaluation was based on the methods and procedures of Bardin's content analysis¹⁶16. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011., by following the three phases of pre-analysis, material exploration and information processing. In the first stage, the organization of the material was carried out with a view to making it operational, by systematizing the initial ideas. Subsequently, the data were coded, classified and categorized. In the third and last stage, the condensation and the highlight of the information were carried out, culminating in the reflexive and critical analysis of the material.

Throughout this article, the findings regarding the empirical material collected will be systematized through tables, extracts of descriptions of the scenes and transcription of excerpts from observations recorded in the field diaries.

Results

The results are presented in two analysis categories: crack cocaine users, and scenes of crack use, described below.

Crack cocaine users

In the capital (Florianopolis), 365 users were observed in the 98 scenes/shift of crack use and 80 users in the Midwest region in the 36 scenes/shift of crack use. Although the presence of at least three people was required to characterize the place of use as a scene, during the observation period, both in the capital and in the other cities, researchers observed sites with the presence of at least one (strictly speaking, not characterized as “scenes”) and a maximum of six users (Table 1).

In most scenes in the Capital, users appeared to be street people in dirty, torn clothes, with poor hygiene, and apparent skin problems.

It is noteworthy that in one of the scenes/shift, despite help was offered to a study participant, he refused to receive health care:

In a different way, the observation of the scenes of the other cities suggests that these users, in general, had some purchasing power, wore clean clothes and in good condition; some of them reached the scenes using car or motorcycle. Apparently they used the drug after leaving work; in some scenes, users wore work clothes, and there were students with teaching materials in their hands.

In the Midwest of Santa Catarina, some scenes/shift were observed in a parking lot near a gas station, attached to a restaurant/snack bar. It was observed the use of crack by truckers and women who appeared to be sex workers.

Scenes of crack cocaine use

The characteristics of observed scenes/shifts were summarized in Table 2.

In the Midwest, it was necessary to increase the time spent observing the scenes (242 minutes, on average, versus 118 min, on average, in the capitals), as users arrived the scenes at the end of the observation shift, whereas in the Capital, when observers began the field work, crack users were already present in the scene, walking through it, interacting and using the drug. The information contained in Field Diaries about the scenes/shifts in the Midwest is more superficial, due to observation difficulties, since drug users chose places with lower less public lighting and left the scene or intimidated the team when realizing they were being observed. There were scenes in which other people (other than the drug users present at the scene) intimidated the team, as in the transcript below:

These difficulties were not seen in the Capital, as users continued using the drug even when they realized they were being observed, ignoring the presence of the observers, or they came to the observers to talk in a friendly way, which facilitated the description of the scene by the team:

The data indicate that both in the capital and in the other cities of the state, there was use of multiple drugs:

Although drug trafficking has been present both in the capital and in the Midwest of Santa Catarina, in most scenes users arrived the scenes already carrying crack and other drugs, and shared them with their peers. In the capital of Santa Catarina, the exchange of sexual favors was also identified for obtaining the drug.

Discussion

Crack cocaine users

The observation of the scenes of crack use in Santa Catarina evidenced the predominance of drug use by males, adults, not being observed the expressive presence of adolescents and pregnant women, the latter being present only in the scenes of the Capital. The higher prevalence of crack use by adults, especially among young males, was observed in several other studies and refers to the historical and social determination of the phenomenon and to the gender asymmetries present in the most distinct social phenomena in Brazil³3. Smart RG. Crack cocaine use: a review of prevalence and adverse effects. Am J Drug Alcohol Abuse 1991; 17(1):13-26.^,1717. Horta RS, Horta BL, Rosset AP, Horta CL. Perfil dos usuários de crack que buscam atendimento em Centros de Atenção Psicossocial. Cad Saude Publica 2011; 27(11):2263-2270.^,1818. Garcia EL, Zacharias DG, Winter G, Sontag J. (Re)conhecendo o perfil do usuário de crack em Santa Cruz do Sul. Barbarói 2012; 36(ed. esp.):83-95..

In this context, it is important to understand that the crack use can be associated with traumatic situations and psychiatric disorders, being a risk factor for suicide attempts. Younger crack users, usually have high prevalence of comorbidities, such as depression, generalized anxiety, and antisocial personality disorder. These disorders can both be facilitators of the experimental use of the drug, as well as of its continued and eventually dependent use¹⁹19. Narvaez JCM, Jansen K, Pinheiro RT, Kapczinski F, Silva RA, Pechansky F, Magalhães PV. Psychiatric and substance-use comorbidities associated with lifetime crack cocaine use in young adults in the general population. Compr Psychiatry 2014; 55(6):1369-1376.. Among the events and motivations associated with crack use, we can highlight social vulnerability, influence of friendship networks, curiosity, seek for pleasure and previous/concomitant use of other illicit drugs and alcohol²⁰20. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaucha Enferm 2013; 34(1):140-146..

Despite the limited presence of pregnant women on the scenes observed, the crack cocaine use by this population group is especially worrying, since the drug poses risks to both the woman's and the fetus's health, and since this population, like other marginalized populations, interacts little or never with the health services. The literature shows that when pregnant crack users are compared to non-users, the former are at higher risk of suicide, consume alcohol and tobacco more frequently, have a higher prevalence of antisocial personality disorder, high rates of different infectious diseases and low/zero frequency to prenatal services. Most pregnant users of crack have no fixed partner and some of the partners are also crack users or use other substances, making it more likely that the custody of that child after birth will be assumed by a family member, either due to psychosocial or family problems, or by judicial determination²¹21. Zavaschi MLS, Mardini V, Cunha GB, Costa SHAM, Guarienti F, Pianca TG, Pechansky F, Rohde LAP, Kapczinski F, Cereser K, Szobot CM. Socio-demographic and clinical characteristics of pregnant and puerperal crackcocaine using women: preliminary data. Arch Clin Psychiatry 2014; 41(5):121-123.. These problems are challenges to be faced by comprehensive health and social care policies sensitive to the demands of this population.

In a national survey in which the present study is inserted, it was found that, in the sample referring to the set of scenes evaluated throughout Brazil, more than half of the crack users reported having become pregnant after beginning the drug use, and that the use of condoms in vaginal intercourse by men and women users of crack cocaine was not a common practice⁸8. Bastos FI, Bertoni N, organizadores. Pesquisa Nacional sobre o uso de crack: quem são os usuários de crack e/ou similares do Brasil? quantos são nas capitais brasileiras? Rio de Janeiro: Fiocruz; 2014.. One of the strategies for acquiring drugs is prostitution. The risks of this practice include undesired pregnancy, which can lead to abortion/attempted abortion, and the acquisition/transmission of sexually transmitted infections/diseases (STIs/STDs), given the inconsistent use of condoms. Usually, the craving for the drug overlaps with the care needed for a safe sexual relationship²²22. Ribeiro LA, Sanchez ZM, Nappo SA. Estratégias desenvolvidas por usuários de crack para lidar com os riscos decorrentes do consumo da droga. J Bras Psiquiatr 2010; 59(3):210-218..

It is the responsibility of the health professionals, obviously respecting users' individuality, to raise awareness about the prevention of STIs/STDs, responsible maternity and paternity, and, specifically with pregnant women, to highlight the importance of prenatal care and issues that address the health and safety of women and the fetus.

An important counterpoint perceived in the open public scenes of Florianopolis, unlike the cities studied in the Midwest region, was the prevalence of crack users who presented characteristics of people living in streets and with a greater impairment of their health status, which leads us to think that the health of these users is deteriorated not only due to the use of the drug, but due to the damages and risks to which a person in a street situation is exposed in their daily lives. On the other hand, in the other cities, there was a great diversity of characteristics in the population that frequented the local scenes, being the majority composed of users that seemed to have some purchasing power, students and workers in general, besides the presence of truckers and sex workers. These quite different characteristics suggest that a fraction of these users of the Midwest of Santa Catarina are able to use crack in a way that is compatible with the maintenance of their regular activities, which should be the object of detailed analyzes of their trajectories and daily life.

Controlled use is characterized by intermittent use in which, through strategies of self-control and permanent negotiation between social actors and various contexts, the user combines the use of the drug with preexisting social activities (family, studies and work), not allowing that the need for the substance dictates the pace of their life, that is, with less individual and social implications²³23. Oliveira LG, Nappo SA. Caracterização da cultura de crack em São Paulo: padrão de uso controlado. Rev Saude Publica 2008; 42(4):664-671..

In a study with crack users in Sao Paulo, controlled use was identified among users who have already undergone compulsive use. As a rule, this transition occurred after years of consumption, when the individual became aware of the negative implications of the continued use of crack, turning to controlled use or even abstinence²³23. Oliveira LG, Nappo SA. Caracterização da cultura de crack em São Paulo: padrão de uso controlado. Rev Saude Publica 2008; 42(4):664-671.. The opposite can also occur, that is, the individual can initiate the use of the substance in a controlled way, and, after a certain time of use, compulsive patterns of consumption emerge, eventually leading to clinical dependence.

Regardless of the perceived characteristics of crack users accessing the use scenes and their us-age patterns, there is no doubt that all, although in varying degrees, are exposed to situations of risk and, therefore, they need a close look of the managers of public policies and of those who implement them in the day-to-day work of the use contexts.

The difficulty access of these users to social and health services is a central barrier to the establishment of the link between this population and public institutions. A research carried out with this population in the cities of Rio de Janeiro and Salvador indicated that, despite the great majority of respondents claiming to have strong interest and acknowledging the need for care in health services and social assistance, a small minority effectively accessed these devices. Factors underlying this discrepancy included the lack of trained professionals to deal with their specific needs, bureaucratic barriers and social stigma²⁴24. Santos Cruz M, Andrade T, Bastos FI, Leal E, Bertoni N, Lipman L, Burnett C, Fischer B. Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil. BMC Health Serv Res 2013; 13:536..

Crack cocaine use scenes

This study identified a greater number of users in the scenes of the Capital when compared to the Midwest region and found that these scenes crack use are different from those usually carried by the media, according to the models of cracolandias of Sao Paulo and Rio de Janeiro.

From the dissemination of the use and sale of crack in the national territory, the term cracolandia was generalized to other Brazilian cities, designating places where there are groups of dozens and even hundreds of people using crack in public spaces²³23. Oliveira LG, Nappo SA. Caracterização da cultura de crack em São Paulo: padrão de uso controlado. Rev Saude Publica 2008; 42(4):664-671., which draws the attention of the population to this fact, amplified by the media. To understand some of the genesis and uses of this word and the associated preconceptions, it is necessary to summarize its historical context.

The term arose in Sao Paulo, when the city was in a process of devaluation of its central region due to the degradation of urban services and infrastructure and the large number of abandoned houses, some of them being invaded by people in situation of social vulnerability. As many streets were empty after business hours and on weekends, the region started to be concentration space for sex workers, street dwellers, drug traffickers and a large number of drug users, mainly crack cocaine, and then became known as Cracolandia²⁵25. Raupp L, Adorno RCF. Circuitos de uso de crack na região central da cidade de São Paulo (SP, Brasil). Cien Saude Colet 2011; 16(5):2613-2622..

There was priority of policies for repression and containment of users, with the central reference being hospitalization, which was sometimes compulsory, against the proposals for de-hospitalization of the Movement for Psychiatric Reform²⁶26. Romanini M, Roso A. Mídia e Crack: Promovendo Saúde ou Reforçando Relações de Dominação? Psicol. cienc. prof. 2012; 32(1):82-97..

In practice, there has been emphasis on a hygienist practice to exclude crack users from the city and society, without considering the complex biopsychosocial demands of this population. The popularization of the term Cracolandia reflects lack of knowledge regarding the historical, economic, urban and social processes of urban and social degradation of Brazilian cities, focusing exclusively on the users and the drug itself²⁷27. Frúgoli Junior H, Cavalcanti M. Territorialidades da(s) cracolândia(s)em São Paulo e no Rio de Janeiro. Anuário Antropológico 2013; 2:73-97.. The discourses regarding crack use presuppose a linear association of the drug with dependence, marginality and crime, secondary to the dimension of prevention, care and health promotion.

In the Capital and the Midwest of Santa Catarina, crack use was present every day of the week, but in the Midwest it was intense during the night shift, while in the Capital this use was intense at all times of the day. In this study authors identified some situations that expose the crack user to risks and that deserve the attention from public managers: association of multiple drugs, prostitution, pipe sharing and sexual favors in exchange for the drug.

It is observed that the crack user often makes use of and is eventually dependent on other psychotropic substances such as tobacco, alcohol and cannabis²⁰20. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaucha Enferm 2013; 34(1):140-146.. The concomitant use of psycho-active substances with different and even opposing properties may be a strategy to deal with the adverse effects of crack, such as in the concomitant use of marijuana and other cannabis, which moderate the stimulant effects of crack²⁸28. Fischer B, Kuganesan S, Gallassi A, Malcher-Lopes R, Van den Brink W, Wood E. Addressing the stimulant treatment gap: A call to investigate the therapeutic benefits potential of cannabinoids for crack-cocaine use. Int J Drug Policy 2015; 26(12):1177-1182.. There is a risk, however, of a concomitant harmful use of multiple drugs, with no evident pharmacological or psychosocial benefit²²22. Ribeiro LA, Sanchez ZM, Nappo SA. Estratégias desenvolvidas por usuários de crack para lidar com os riscos decorrentes do consumo da droga. J Bras Psiquiatr 2010; 59(3):210-218..

The crack user is exposed to a number of other dangers, including sexually transmitted infections/diseases, due to the exchange of sex for drugs/money, unprotected sex, and possible transmission through oral lesions. Study²⁹29. Guimarães RA. Comportamentos de risco para doenças sexualmente transmissíveis em usuários de crack. Rev Lat Am Enfermagem 2015; 23(4):628-634. conducted with 588 crack users identified that the reported prevalence of some STDs was 26.2%, which suggests a high risk and particular vulnerability of this population. Therefore, public policies and strategies to control and prevent diseases associated with crack use, such as harm reduction policies and health education, are crucial.

In reflecting on all the aspects raised so far in the present study, the need to address the issue of crack as a serious and complex social issue¹³13. Moreira MR, Fernandes FMB, Ribeiro JM, Neto TLF. Uma revisão da produção científica brasileira sobre o crack – contribuições para a agenda política. Cien Saude Colet 2015; 20(4):1047-1062. is highlighted, arising from a historical context in which the expansion of public security, social and health services network has not accompanied the increase of their demands, which reflects negatively in the prevention of the use of these substances, as well as in the treatment and social reintegration of its users.

In face of contemporary challenges, the Integrated Plan to Combat Crack and Other Drugs was launched in 2010 - “Crack, It's Possible to Win”, which provides for a series of actions that contemplate three axes: care, prevention and authority. The care axis consists in the expansion of the capacity of care and attention to the user and their family, including, in view of the social vulnerability that exposes individuals to drug use, the structuring of a care network with the purpose of helping users of these substances and their families in the treatment and social reintegration. The prevention axis establishes the strengthening of the protection network against the use of drugs by establishing communication actions to be carried out with the population to prevent the use of these substances through various educational devices, such as the permanent training of health professionals, social assistance, justice and public security to better address the issue in the course of their work process. The authority axis emphasizes coping with drug trafficking and ostensible policing³⁰30. Brasil. Decreto n° 7.179, de 20 de maio de 2010. Institui Plano Integrado de Enfrentamento ao Crack e outras Drogas, cria o seu Comitê Gestor, e dá outras providências. Diário Oficial da União 2010; 20 maio..

Final thoughts

It is up to the managers to carry out the existing public policies, paying attention to the diagnosis of their local reality regarding the characteristics of the territory that make the individual vulnerable to the use of drugs. It is necessary to invest in awareness and empowerment strategies of society to act in a humanized and comprehensive way on the theme “crack cocaine and other drugs”, so that everyone has the potential to develop preventive actions with ethical, resolutive and culturally appropriate approach to the reality experienced in the communities, by considering all the social and cultural aspects involved in the phenomenon, as well as in the programming of care actions and social reintegration of crack users.

The expansion of access to health care for users of these drugs must involve community health workers, Harm Reduction Programs, Family Health Strategy teams, Street Medical Offices, public security and social assistance workers, Psychosocial Care Centers, among other social actors, programs and institutions that work in a consistent and interdisciplinary manner.

As a limitation of the present study, we can highlight the time elapsed between the registration of the scenes and the field visits. Since the scenes are dynamic and have a mobile and intensely stigmatized population, the scenes in which the crack use was not observed can be justified by the fact that originally referred crack users have moved to other locations and/or started to use substances other than crack at the time of the field visit.

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