Reasons to crack consumption relapse. Users’ perspective

Objective: The objective of this study was to raise the reasons pointed out by the crack users as triggers for the drug consumption relapse and consequently offer some sort of help, which might come to the aid of those users. Methods: The present study is a qualitative study, using in-depth interviews and criteria-based sampling, following 42 crack cocaine users. Point of theoretical saturation was used to define the sample size. Data were analyzed using the content analysis technique. Results: The analysis of the content from the respondents’ speeches resulted in different reasons pointed as triggers of relapse, those ones being clustered in categories. User Related Reason (UR), Drug Related Reason (DR), Environment Related Reason (ER). Conclusions: Relapse is a common phenomenon among crack users, considering the reasons that lead to its occurrence are the same from people’s daily routine, making its management very tough. Interpersonal relationship problems and the consequent frustration have been the most mentioned reasons as relapse triggers, causing a rupture in the paradigm in which the causes would be focused on the drug. The possibility that the user gets to know and recognize their emotional vulnerabilities and weaknesses could be of great help in relapse prevention.


INTRODUCTION
Crack, introduced in São Paulo in the early 1990s 1 , when the first drug seizure happened in the city², keeps on defying the user and the professionals involved with their care.Although the low prevalence in population studies in Brazil, around 1%, its consumption is responsible for about 70% of cocaine hospital stays 3 .
The seriousness of this situation caused by the abusive crack use reaches bigger proportions, when the Brazilian crack user's profile identified by Pesquisa Nacional sobre o Uso de Crack (Crack Use National Research) sponsored by Senad 4 (Secretaria de Políticas sobre Drogas do Ministério da Justiça) is taken into consideration.The study shows that this user is a young man, non-white, low-educated, living in the street, unemployed and without family bonds, that is, an extremely socially vulnerable group 4 .
Treatments have been offered to drug users by the public and/or private healthcare system in attempt to either reduce or cease the crack consumption, however, the efficacy is limited 5 .Although they may produce a reduction in the severity of psychosocial problems related to crack consumption, a meaningful percentage of users restart the drug abuse in a relatively short time just after the treatment 6 .This relapse process, as defined by Marlatt and Gordon 7 , is the return to the drug problematic consumption condition, the one presented before the treatment, crack consumers seem to be particularly inclined to this dynamics 8,9 .
Authors make a distinction between lapse and relapse, giving the first one the following definition: use of substances in low quantity and for shorter periods, not following the previous baseline 10 .Some studies have showed that the user's pathway is marked by alternation of abstinence, lapses and relapses to the initial dysfunctional baseline 11,12 .
A study which took place in Porto Alegre with teenagers with crack cocaine abstinence has found high rates of relapse in this population: 65.9% relapsed in the first month and 86.4% in the third month 9 .Other authors point out even higher relapse percentages reaching the first six months the percentage of 80% 13 or even 90% 6 .
However, there is lack of studies, which deeply investigate the subject, having as source the crack user's point of view.
The objective of this study was to raise the reasons pointed out by the crack users as triggers for the drug consumption relapse and consequently offer some sort of help, which might come to the aid of those users.
For decades, researchers have focused on investigation of pharmacotherapies for the treatment of crack cocaine use disorders, with no success.So far, there are no approved effective pharmacotherapies for the treatment of psychostimulant abuse 17 , what emphasizes that the alternative approach applied to the present study is extremely important.

METHODS
Qualitative Research has been used to identify the reasons, claimed by the users, which interfered with relapse, considering in this case the users' opinion, values and beliefs 18 .

Sample recruitment
Five key-informants, two psychiatrists and three psychologists, who had varied knowledge about the research theme, have been invited to an informal interview.The interviews have been recorded, transcribed and analyzed and served as basis for the script preparation used in the interview with the research participants 19 .
Some of the key-informants have also played the role of gatekeepers and helped to have access to the studied population 20 .Each gatekeeper has identified potential participants and explained the objective of the research before introducing them to the researchers.
In-depth interviews with the sample participants have been conducted 19 using a purposeful sampling, selected by criteria 18 : above 18-year-old participants, both genders, have searched the service for treatment mainly due to crack dependence, have suffered at least one relapse and, at the time of the approaching, should have left the treatment between 6 and 12 months (considering the fact relapse process occurs in the first months of treatment).
The respondents have come from three different attendance and care places dedicated to crack users: Therapeutic Community, Caps AD (Psychosocial Care Centers -Alcohol and Drugs) and Hospital Stays.The data collection lasted one year and took place in São Paulo City.
The interviews have considered the point of theoretical saturation that is a tool largely used in qualitative research to determine the size of the final study sample 18,21 , where the repetition of information has been detected and the inclusion of new participants in the sampling have been interrupted because they wouldn't contribute to the refinement of the theoretic reflection predicated on data which had been collected 22 .That point has been reached with a sample of 42 participants 21,22 .At this point, as reasons that led to relapse given by the interviewees turned out to be repetitive or redundant.

Instruments used
Semi-structured interviews have been conducted with the participants using a topic script which had been based on the information originated from interviews with the key informants 15 .Additional questions have emerged to clear specific issues during each interview allowing a rise in understanding 19,20 .The script has been composed of the following themes: socialdemographic data, drug consumption record, crack consumption record, relapse record and the reason for the triggers.The interviews have been recorded, after the respondent's permission and lasted an average of 70 minutes.The social class has been assessed by ABEP 23 (Brazilian Association of Research Companies) scale and the dependence by DSM V 24 (Diagnostic And Statistical Manual of Mental Disorders).

Content analysis
Each respondent was identified with an alphanumeric code in which the first letter is the first initial followed by the sequential number of the interview.The interviews were transcribed and read by the researchers and after analyzed based on the guiding principles of Content Analysis proposed by Bardin 25 .Material Preparation -answers detachment and reassembly according to the topic and question creating new independent files for each script item, each one of them comprising answers which corresponded to each sample component.For this material preparation, we have counted on the help of a software dedicated to qualitative research, Nvivo 10 26 .Categorization: The interview has become a content representation in this phase, identifying the meaning core.Results treatment: The Triangulation technique has been used 18,20 on the results analysis, that is, the two author researchers created the categories independently and simultaneously, being those analysis compared in order to reach the results consistency and coherence.Finally, the conclusion has begun to give support to the explanation and conclusion generation.
Through the text, users' speeches are presented in italics, identified by its alphanumeric code.

Ethical aspects
The study protocol was approved by the Ethical Review Committee of the Unifesp (CAEE nº 2451.0.000162-11) and Ethics Council in Research from Prefeitura de São Paulo (CEP/ SMS no.039/12).Oral informed consent was obtained from each participant at the beginning of the initial interview and anonymity of participants was maintained.

What they understand by relapse
At first, the participants knowledge has been evaluated in relation to the understanding of relapse idea.
We have noticed some difficulty in obtaining a more objective definition.They have used an indirect way to conceptualize it, that is, through the circumstances in which the relapse took place.Even without a concrete definition, the discourse has allowed the researchers infer the understanding that the sample had in relation to relapse and moreover, conclude that it was aligned with the literature meaning.The speeches have showed that during the outbreak of a strong desire for the drug, the respondents had used it, indicating a return to an initial pattern.
It is the uncontrolled desire to use it.There isn't self-control.When I come to myself, I am already smoking.Then I think, "no, I won't do this."... It is like an internal struggle.But there is something stronger that says 'go, go, take it, you want it!(F21).
On the other hand, a big part of the respondents hasn't agreed with the existence of lapse when it comes to crack.They considered relapse any return to the drug, regardless the time and duration of consumption, the consumed level and the arisen consequences, demonstrating some kind of inflexibility when distinguishing those concepts.
Lapse, relapse?They mean the same thing.I have never seen somebody using it only once and that's all.I have experience with the drug and in these 11 years of consumption I've never seen this lapse you're talking about.Moreover, if you come back using it, it doesn't matter if it is once, twice or a hundred times, everything is relapse.(J16)

Reasons that lead to relapse
The analysis of the content from the respondents' speeches resulted in different reasons pointed as triggers of relapse, those ones being clustered in categories.Table 1 shows these reasons, disposed according to the decreasing quotation order and combined in big categories: User Related Reasons (UR), Drug Related Reasons (DR), Environment Related Reasons (ER).

User related reasons
The reasons caused by the user have been gathered together in this category, considering the emotional and behavioral features.

Difficulty in handling with the emotion
The users' discourses have showed a super dimensioned disappointment degree towards unsolved daily issues.That is, the emotional vulnerability and the little internal instrumental to support them have triggered a frustration which has only been satisfied with the drug.Interpersonal relationships, like relationship problems with close people have been claimed as the main causes.The following speech depicts this situation.
Because this is something which disturbs a person's inside and out of a sudden a certain grief you may feel, or a quarrel with someone you like, or something which goes wrong and we thought would be different, only crack to get rid of it, then the relapses happen.(F9)

Unwilling to seek support after the treatment
They believed that the ending of treatment was not promise of success and the positive treatment effect would not last for so long.The recommendation received at the treatment place was that there should be a "maintenance" of this state through some attempts like the "12 steps".
The crack user is a fragile person and if this fragility is not watched there is a risk to return to the consumption.There must be a continuity of the treatment somehow so he might feel a little bit more relieved towards the pressure he undergoes along his life.(R34) They have recognized the necessity of continued treatment, specially for those who have had relapse more than once.However, this piece of advice has not always been followed.
I don't do it, generally for lack of mood, the head is not at the right place.I don't show up at the workshop, I don't show up at the exams that we take during the appointments.This is the way it is.(H13)

Minimizing the dependence severity
At the end of the treatment the drug has returned to be object of the respondents' thoughts and for that reason they planned to use it again, ignoring the physical and psychic burden, as well as the losses they had regarding to it.The lack of this learning has made them relapsed many times.However, they feel regretful for what happened, but that feeling is totally harmless.
Because we forget the trauma and the tough situations which we have undergone.I didn't take anyone into consideration, I went out, passed by a drug stand and there I stayed and bought some crack.Then, I forgot it very fast.(M29)

Lack of willpower/weakness
Some of them have been very conservative and intolerant towards relapse and attributed the fact to some sort of weakness from the person who acted that way.We have noticed the discourse became rigid when relapse was considered unconventional behavior and therefore, it would deserve a kind of judgement.
Because it is the person's weakness of not having strong determination.Without willpower we can't do it.The anxiety for the drug comes back.While taking medication, we are abstinent.When the treatment ceases, anything can lead to relapse.(U3).

Environment Related Reasons
The reasons, which have been put together, come from the context where the user lives.Based on the "clues" from those places and the drug consumption culture from which he/ she is part of, those reasons make him/her feel tempted to come back to consume the drug again.

Resources availability
Recalling the drug pleasure might be a constant thinking in the former drug user's mind, but having money available makes the drug "closer" for some of them.The concrete possibility of obtaining the drug due to the possession of resources may conduct to relapse.

Environmental cues triggering conditioned responses
To come back to the place where they used to take drugs, to find the drug consumption friends, to pass by drug stands, to walk across people who clearly used crack are strong incentives to return to drug consumption.In addition to those reasons, there is also the lack of activities and life perspectives.
I left this place (the treatment unit), I came back to the same place I live and know everything.Where I could find money, buy drugs and there is also the reason that when I arrive at home, I don't do anything and my mind gets empty.We try to do something to fill the time and the drug turns out to be an option.(R38)

Drug use that induces crack consumption
There are some drugs that the users associate with crack to interfere with the effects produced by the drug, either to intensify the pleasure or to lessen the undesirable effects caused by the drug.According to the respondents, taking those drugs during crack abstinence leads to a relapse.Alcohol seems to be the most harmful drug in this way.
We must be very careful with alcohol.Alcohol is like a valve … Alcohol is a vehicle we take which lead us straight to crack.(L27)

Drug related reasons
The reasons, which derive from crack, have been grouped in this category, due to the pleasure, craving, compulsion and addiction effects.

Strong wish for the drug/abstinence symptoms
The respondents have elevated the crack pleasure that seems to have left some sort of imprint on these users who still missed the drug, even after a long time of treatment.

I really feel like smoking because the feeling crack gives you when you smoke it is a paradise feeling. But only at that very moment. (D5)
In more extreme situations, the user has developed craving, a compulsive desire for the drug (addiction effects).Associated to these symptoms are intense physical changes, related to the drug abstinence which led to relapse.

Unwilling to stop taking the drug
There are respondents who stated they did not want, as a matter of fact, they never wanted to abandon the drug, so at the end of the treatment they restarted to use it.It is not exactly a relapse, but a decision to continue the drug consumption, mainly because there had never been the decision to stop it.This is a special condition in which the treatment happened by the user's contumacy and he/she planned during the internment he/she would go back to use crack after finishing the treatment.They made clear they weren't at that place of their own volition, but because somebody wanted to, which gave them the right to return to the drug consumption.
I don't want to stop, I don't have the true wish to stop.I'm here because of the cops, family quarrels, to save the marriage, anyhow, but not to treat myself.I'm not here because I want to but because somebody did so.(C15).

Having constant thoughts with crack
The drug kept dominating the user's thoughts, after concluding the treatment so recently.They start thinking about crack constantly, about its pleasure effects, forgetting the other effects that made them look for help.This situation contributes to relapse.
The thought is the main conductor.Keep imagining the pleasure it brings, we let it grow up in our minds, developing, it turns out to lead to crack.(A25)

DISCUSSION
The reasons which lead to relapse are recognized situations, included in the respondents' daily routine, that is, nothing which has been reported by the respondents is close to deviance, associating relapse to exceptional situations 6,11,27,28 .This verification make us believe that relapse is a very common process, almost inevitable and of difficult management, by both drug user and professional involved with their recovery, because the reasons which originate it are hard to control due to the fact they are very common 27,29 .
The analysis of the sample characteristics illustrate it is similar to the one considered by Senad's study 4 , only dissenting from the big presence of white respondents.
Among the relapse triggers pointed out by this sample, includes the respondent's inability to handle with their feelings.Identified in this study as a user associated reason, it has risen as the most cited of all.This finding is impressive, even in an intentional sampling, when taking into account that the crack effects are defined as harmful and therefore, more probable to conduct to relapse 30,31 , given the reason that many authors attribute craving as the main reason for relapsing 32,33 .In this study, the desire for the drug, expressed by constant thoughts about its use or even by unpleasant effects the user develops in the absence of crack have also been considered as reasons why the user doesn't carry on the abstinence, however it doesn't feature as a relapse key process.The knowledge the users have obtained about crack along almost 30 years of the drug in Brazil has allowed them to develop strategies to deal with some of the unpleasant drug effects, specially craving, as explained by other authors 15,16 .They have concluded that, although it is very simple, for example, replacing the crack compulsion for other compulsive situations (physical exercise) bring huge benefits to the user 15.16 .It could be a possible explanation to that fact.
On the other hand, the daily life challenges are perceived as exaggeration, especially when interpersonal relationships are involved, something that the participants from the study have pointed out.The incapability which the crack cocaine users have to stand frustration, the relapse can be understood as an answer to the fact they don't confront those situations 6,34  frustrated, which contributes even more to the consumption maintenance.
Still according to the findings from this study, the interaction with drug user friends may affect the abstinence process.This result is similar to the ones found in other studies, which suggest the peers are considered an important factor of relapse triggering, just as the drug availability.Both conditions might lead to pleasure experience memories along the drug interaction 35,36 .The external clues, as defined by some authors, conduct the user to crack consumption return.Tiffany 37 considers the fact that the repetitive use of the drug makes the user develops clues connecting them to the consumption (smell, pictures etc.).Other authors state that when the users are exposed to these instigators related to drug use, a strong desire to take the drug is prompted.Bruehl et al. 38 and Stalcup et al. 39 credit those clues to an increase in craving for the drug and as a consequence, a relapse.Nevertheless, the answer for those instigators is difficult to be interrupted because it occurs regardless the user's will.Yet, the respondents have related that keeping the same previous habits when they used to take the drug, for example: to visit the same places, to pass by near a drug stand are habits, which may contribute to relapse.If we consider the respondents' characteristics from this study who are marked by the social vulnerability they are exposed to 4 , it becomes hard to believe they will be able to change the previous life scenario.
The ability abuse drugs have to disturb the behavior in order to search for another abuse drug is common 40 .Gonçalves and Nappo 41 give support to this statement in the crack and marijuana association's study.Other researchers state that the access to one of the drugs (either cocaine or alcohol) during polyusers' abstinence increase the self-report of craving for both cocaine and alcohol 42 .This crossed reactivity among abuse drugs explains the crack craving provoked by alcohol, if it causes abstinence it may lead to relapse 40 .This scenario is explained by classical Pavlovian conditioning, widely accepted as having an important role in relapse 43 .The Pavlovian theory considers that stimulus/responses combined with the drug administration (and subsequent pharmacological effects of crack cocaine) become conditioned stimuli.These stimuli then increase motivation for drug-taking, elicit or occasion behavior making drug-taking and drug-seeking more probable 44 .As a way to reach a more stable abstinence, the adherence to social support programs after the treatment, like self-help resources seem to be of big relevance as raised by the participants.Siegal et al. 12 claim that the social support after the treatment is decisive for abstinence maintenance, considering it more important than the dependence gravity or the treatment duration.Still about this topic, but not clearly mentioned, family is an essential social nucleus, which may act in this abstinence process, having influence on either accelerating or blocking the relapse, according to the family atmosphere.Families with more co-operating and friendly relationships, in which the members are aware of their roles, may develop a very conducive environment for the user's rehabilitation 35,36 .The contrary, as identified throughout the speeches, family dispute problems are causes for relapse 45 .
Another point that must be considered in this study -a possible research limitation -is the fact the participants had just finished the treatment, what can explain the rigidity in the relapse process evaluation.There might possibly be a contamination in their speeches with the discourse repeated in some treatment places, especially those with a religious bias.The statement of the inexistence of lapse or even the intolerant manner to judge the user as "weak" or "reluctant" when having a relapse are examples of intransigence.

CONCLUSIONS
Relapse is a common phenomenon among crack users, considering the reasons that lead to its occurrence are the same from people's daily routine, making its management very tough.Among the most important findings of this study is the fact that interpersonal relationship problems and the consequent frustration have been the most mentioned reasons as relapse triggers, causing a rupture in the paradigm in which the causes would be focused on the drug.We still infer in this study that the possibility that the user gets to know and recognize their emotional vulnerabilities and weaknesses could be of great help in relapse prevention.

LIMITATION OF THE STUDY
The work is based on a qualitative research, so the authors recommend wariness with the data extrapolation to other contexts.Although the authors haven't perceived any interference of the treatments in connection with the reasons which lead to relapse cited by the interviewees, we do not exclude the possibility that this interference may happen in studies of such kind.The sample is predominantly consisted of men (fact which is in accordance with the profile of the Brazilian crack user) which does not allow us to assert that the reasons of relapse, cited in the manuscript, would be the same for women.

INDIVIDUAL CONTRIBUTIONS
RCRA managed data collection, conducted preliminary data analysis and drafted the manuscript.SAN conducted the final data analysis, revised the manuscript, designed the research questions and was responsible for general coordination.Both authors read and approved the final manuscript.

Table 1 .
Main reasons pointed out by the crack users as triggers for the drug consumption relapse J Bras Psiquiatr.2018;67(3):194-200 Albuquerque RCR, Nappo SA 27Rigotto and Gomes27have warned about this situation, which may cause a vicious circle, regarding the person's inclination after relapse is to feel failed,