The path to crack addiction : perceptions of people under treatment

Objective: the objective of this study was to understand the meaning of the harmful use of crack by people undergoing addiction treatment. Method: qualitative approach of social research on strategic modality was used. Field observation, preparation of fi eld diary and focus groups, and data analysis through the method of interpreting meaning were carried out. Results: the results contributed to the construction of three thematic categories: “The discovery of crack and other drugs” that describes the experimentation with crack and other drugs; “The pain of the pleasure”, key category that describes the moments after crack experimentation and that, many times, turns into addiction, which leads the person into a cycle of short periods of attempts at abstinence, relapse, and relentless consumption; and “Return to normal life”. Conclusion: treating people with crack addiction must be carried out in ways that narrow the distance between these people and their families, society and health care. Descriptors: Crack Cocaine; Substance-Related Disorders; Health Vulnerability; Cocaine-Related Disorders; Nursing. RESUMO Objetivo: o objetivo foi compreender os signifi cados do uso nocivo de crack por pessoas em tratamento da dependência. Método: utilizou-se abordagem qualitativa da pesquisa social na modalidade estratégica. Foram realizados observação do campo, confecção de diário de campo e grupos focais, e análise dos dados por meio do método de interpretação de sentidos. Resultados: os resultados constituíram a construção de três categorias temáticas: “Descoberta do crack e outras drogas” que diferencia a experimentação do crack da de outras drogas; “A dor do prazer”, categoria principal que descreve o momento que sucede a experimentação do crack em que, muitas vezes, se instala a dependência, o que leva a pessoa a um ciclo de períodos curtos de tentativa de abstinência, recaída e consumo incessante; e “Retomar a vida”. Conclusão: a abordagem de pessoas em tratamento da dependência do crack deve ser realizada no sentido de reduzir a distância entre essas pessoas e a família, a sociedade e os serviços de saúde. Descritores: Cocaína Crack; Transtornos Relacionados ao Uso de Substâncias; Vulnerabilidade em Saúde; Transtornos Relacionados ao Uso de Cocaína; Enfermagem. RESUMEN Objetivo: comprender los signifi cados del uso nocivo de crack en personas tratando su dependencia. Método: se utilizó abordaje cualitativo para la investigación social, en modalidad estratégica. Fueron realizadas observación de campo, confección de diario de campo y grupos focales. Datos analizados mediante interpretación de sentidos. Resultados: se constituyeron tres categorías temáticas: “Descubrimiento del crack y otras drogas”, que diferencia la experiencia del crack de la de otras drogas; “El dolor del placer”, categoría principal que describe el momento en el que se prueba el crack y en el que, frecuentemente, se instala la dependencia, que lleva a la persona a un ciclo de cortos períodos de intento de abstinencia, recaída y consumo The path to crack addiction: perceptions of people under treatment A trajetória da dependência do crack: percepções de pessoas em tratamento El camino de la dependencia del crack: percepciones de personas en tratamiento


INTRODUCTION
Drug use has always accompanied human existence and, in some contexts and situations, seen as a natural behavior, since it soothes pain and suffering and produces stimulating effects (1) .However, from the time that human beings started using drugs in a harmful way, the social, economic, and health losses began to pile up.Thus, drug use became the topic of worldwide discussion, and as a result prohibitionist policies have been taken to prevent such use and to curb its trafficking across countries (1) .
Cocaine is one type of drug that has been on the rise worldwide in the last few years, especially in Brazil.One of its forms of presentation, known as "smoked cocaine" or "crack", gives rise to the fastest and most intense addiction.It is a psychotropic and illegal drug that stimulates the central nervous system.It receives this name because it makes a cracking sound when heated.Crack is composed of the mixture of cocaine base paste with water and baking soda that, when heated, results in the formation of crystals known as crack "stones" (2) .When smoked, it causes stimulating effects in fifteen minutes approximately, maintaining it for about five minutes.These two related facts contribute to the need for the user to constantly search for the drug (3) .
The study carried out in Brazilian capitals and the Federal District (4) , shows that estimates for the regular use of crack and similar drugs were at a rate of approximately 0.81%, which would represent nearly 370,000 users, whereas the estimate for the overall number of illegal drug users (except for marijuana) was 2.28%, that translates to approximately one million users.In the capitals, crack use and/or similar drugs was estimated at 35% among illegal drug consumers (4) .
Among the consequences of crack addiction, are, physical damage related to pulmonary impairment, exposure to Acquired Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), hepatitis B and C, physical violence and mortality.Regarding the social-economic aspects, the main effects are social and family isolation, marginalization due to illicit acts such as violence, rupture of family ties, job loss or forced leave when the person is in the labor market, collective panic and chaos that compromise the quality of life, loss of hope in life, and difficulty in having access to health services (5) .
In view of the breadth of such consequences, the isolation the crack addict gets exposed to puts him in a situation of social vulnerability.This article is based on the vulnerability assumptions of Robert Castel, which sheds light on the vulnerability processes and social exclusion (6) .Individuals have their social existence marked by the interaction of two axes: labor and relational inclusion in social and family networks.In the view of the author, both interact dynamically, and the fragility of a person can be compensated for by the stability of the other (6) .
The density of social relations, along with work stability, has a direct impact on the level of an individual's interaction with society.Depending on the quality of these social and work bonds, the individual fluctuates through varied zones that present porous and dynamic borders, which Castel denominates as Integration, Vulnerability, Supporting, and Exclusion Zones (6) .
The Interaction Zone is characterized by stable social relationships and work stability.The Vulnerability Zone, which is increasingly growing in societies, introduces fragile social relationships and work instability.The Exclusion Zone is associated with exclusion or rupture from a formal work market and the lack or rupture of bonds that are the source of social support (family or society in general) (6) .
In this perspective, crack use (among other drugs) can influence and be influenced by relationships established by the user in the workplace, and in the social support network as well.In addition to the stigma associated with drug use, with its impact exposed by the media, the lack of qualified professionals for adequate treatment makes it difficult to bring this vulnerable population closer to society, to the public authorities, and to the health sector (7) .
Taking into account the relevance of the topic and aiming to offer subsidies that could contribute to the discussion and planning of preventive actions in the field of health care, the study that led to the current article had as objective the understanding of the meaning of the harmful use of crack by people undergoing addiction treatment.

Ethical aspects
This study was guided by the human research guidelines, under Resolution 466/2012 from the National Health Council.The proposal of this study was submitted for approval by the Research Committee of Hospital das Clínicas of Federal University of Goiás (HC/UFG).

Theoretical-methodological framework
Qualitative approach in social research, in strategic modality, was used (8) .The aim of the Strategic Social Research(8) is to "shed light on specific aspects of reality", without prioritizing practical solutions for the issue that it seeks to answer, which does not mean that the Strategic Social Research findings would not be capable of holding a debate on such alternatives.

Type of study
Descriptive exploratory study with a qualitative approach.
The path to crack addiction: perceptions of people under treatment Pedrosa SM, et al.

Study setting
This is a psychiatric hospital that makes up the mental health network of a Central-West Brazilian capital, which receives patients referred by the city mental health emergency care, other health units, or private demand.The mental health care network in the capital relies on a City Mental Outpatient Unit, teams from the Street Outreach Offices, therapeutic residential services, four Psychosocial Care Centers (CAPS).One of these centers is for children, and the other a mental emergency hospital responsible for meeting the demand of emergency cases in the capital and associated cities and also for regulating the patient into the city health service system.

Data source
The source of the study data was field observation, field diary, and focus groups.39 people that were undergoing treatment in the hospital for crack use addiction participated in the study and met the following inclusion criteria: must be over 18 years of age, having used crack for at least 25 days during the six months prior to data collection (9) , being capable of reading, discussing, and signing the inclusion in the study via an Informed Consent Form, not being under the effect of illegal drugs at the time of data collection and, finally, not presenting, during this stage of the study, behavior that would compromise their participation and sharing of information.

Data collecting and sorting
Data collection was conducted using three methods: field observation carried out before, during, and after observation of focus groups; field diary preparation and realization of focus groups (10) , which added up to a total of 10 groups, with nearly 4 participants on average.The focus group meetings were recorded and transcribed by the researcher herself.

Data analysis
The analysis was carried out through meaning interpretation method, which consists of "walking through comprehension (hermeneutics attitude) and critique (dialectic attitude) from data generated from a research" (11) .Among the 10 groups, one was inaudible and another conducted as a test for improving the triggering questions, and they were both excluded from the analysis of the meanings.The data analysis process took place initially by exhaustive reading of the material resulting from the transcription of the discourses of the groups and, later, identifying the key ideas expressed by the discourses of the study participants.The main ideas were then grouped in nuclei of meanings and then regrouped to form the thematic categories.The participants were represented by the letter P, followed by Arabic numeral incrementally, according to the sequence in which each discourse emerged in the audio recordings, such as, P1, P2, P3, P4, and so on.

RESULTS
Each focus group had an average of four participants, with a total of 39 participants (34 men and five women), age between 18 and 52 years and with a mean age of 32 years.More than half reported to be single 20 (54%), 17 (46%) had children and, among them, the mean was three children per person.The majority reported that, at the time of the study, they were under extremely unfavorable socioeconomic conditions from not having a fixed household, being jobless, having sold their assets, and being separated from their family or relations since they developed their drug addiction.In the detailed analysis of the discourses, elements for the construction of three thematic categories emerged: "The discovery of crack and other drugs", "The pain of the pleasure", and "The return to normal life".
In the category "The discovery of crack and other drugs", the participants described the motivation for using crack and other drugs.Such motivations revolved around curiosity, too much freedom from the parents, and relief from some disappointment in life (death of a parent or family conflicts, for instance).The first experiences with drugs were alcohol, cigarettes, and marijuana.Most often, they continued their consumption of alcohol, cigarettes and marijuana even when the participants were already addicted to crack: Curiosity.I saw a friend using it, and that called my attention, the form… the guy poking a hole in a can, all that ritual followed for consuming crack, and I kept thinking "yeah, I'm going to smoke that stuff.I want to know how it is".(P 7) In this path toward experimentation, they ended up coming across crack led by their curiosity to try it.They reported that after the first contact with crack, a change in the pattern of drug use took place, making it more frequent and incompatible with work, social and family relations, leading to a lack of control in both areas and, according to them, becoming the reason for increase in use.
In the category "The pain of the pleasure", it is noticeable that drug use becomes a cycle in which a person gets trapped.This includes short periods of attempts at quitting through treatment when immersed in regret.Such attempts are generally interrupted by some disappointment that provokes the relapse and unremitting consumption for consecutive days.The following discourse represents this regret: Thus, crack was considered as the drug that paradoxically provides pleasure and relief for suffering, but also leads to rampant consumption, unstoppable craving, job loss, sale of assets and separation from family, conflict with drug dealers and the police regardless of the purchasing power.object of this study.Hospitalization can be considered as a period of rest for some and, for others, an opportunity to maintain abstinence, even if only temporarily.
In the category "The return to normal life", it was identified that, when under the regret phase, people tend to be more motivated to seek help and, oftentimes, this occurs when they "hit bottom", as they often say.This period is characterized by issues such as lack of money, family support and a place to sleep.It is also characterized by a feeling of being gripped by a sense of desperation in not wanting to use crack anymore but not being able to quit it, because the addiction has already taken its toll.Added to this suffering is the awareness they have that the addiction causes suffering to their families, especially to their mothers, wives, and children.
As a result, they describe their desire to quit crack consumption, be included in the formal work market, go back to school, and resume family ties.At the same time, they consider abstinence as a challenge to be met with faith and the will to rebuild their families, restore their dignity through honest work and, thus, to obtain support to overcome the addiction.
One thing is that as if we were a child, start living all over again.You know, leave everything behind.Forget everything and start living again.(P11) The setbacks they face with abstinence are lack of trust by their families and society, the pleasant effects of crack, love affairs with other users, and drug use within the hospital.

DISCUSSION
Based on the participant discourses, it became clear that drug addiction issues, especially related to crack (even with its specific aspects), are influenced by complex matters that might have not been a subject of serious discussion at the macro level in society, remaining restricted to public security, public health, and moral concepts.
The early contact with drugs identified in the first category of this study, "The discovery of crack and other drugs", demonstrates the situation of vulnerability that the participants were immersed in, even before being introduced to crack.Children and adolescents tend to be more susceptible to trying drugs since they are experiencing an initial stage of social interaction and the gradual breaking up of the family's inner circle.Experiences in a dysfunctional family such as situations of violence and drug use can have an impact on the behavior of the people included in this study, an observation which is supported by other studies (12) .Likewise, disadvantageous social-economic status was noted among most of psychoactive drug users (13) .However, it is important to emphasize that this finding should not be considered the rule, since addiction is present in all social classes.
Regarding family dynamics, a study conducted with ninth grade students in Brazil showed a deficit in the monitoring that parents exercise on their children (14) , a situation that contributes to the increased vulnerability of this group.
Among the participants in this study, some participants expressed the desire to kill the father or the spouse, reported physical abuse by family members, or having experienced serious aggressions committed by the father or the mother.Abuse and violence have an impact on the harmful use and addiction to psychoactive substances, including crack (2) .
The family is part of the primary social experience and it is in a family that the human being first socializes and learns relational behavior in getting along better with family members and, later, with neighbors and friends (6) .Therefore, relational support starts with the family that provides an opportunity for the formation of independent ties without the need for any intermediation for its organization or setting up.However, according to the participants, the family support experienced by them was not adequate in most cases.Consequently, when primary sociability is not able to play its role in supporting and forming a child or adolescent, in the sense of offering examples for tackling problems without the need of medication, violence, alcohol or other drugs, the children can also adopt attitudes similar to their parents, resorting to such practices in the future.
At this point, it must be understood that, behind vulnerable children, there are families that, oftentimes, have also already experienced situations of vulnerability, and that this is a cycle that needs to be stopped by strengthening family ties.Blaming the family is not part of the issue (15) .
The results showed that there was also a failure in secondary sociability, in other words, that developed by the State through policies, actions, and services offered to society.This takes into account the fact that, among the participants, the lack of support by the heath team and state institutions also contributes to the path towards crack use and addiction.Thus, due to poor socio-economic conditions and lack of educational opportunities and work activities throughout their lives, these people became vulnerable to the harmful use and addiction to crack and other drugs.
In relation to experimenting with crack, only two participants reported being influenced by family members, namely the father who was addicted to inhaled cocaine.However, in another study (16) , 48.3% of the interviewees reported having already consumed crack with some family member, whereas this possibility is higher among those who had a horizontal kinship relationship, such as with siblings and spouses, rather than with parents.However, drug consumption accompanied by the spouse was reported more frequently.
The second category, "The pain of the pleasure", showed that crack use takes the person into a routine of searching for the drug.and creates a different pattern of use, which, in some cases, leads to addiction.Addiction can present some predisposing factors, such as antisocial personality disorder, attention deficit/hyperactivity disorder, and dependence on alcohol, marijuana, amphetamine, hypnotics, and opioids (17)(18) .
In this study, the participants mentioned that the change in their drug use pattern, after experimenting with crack, led to significant losses in their lives, to the extent that the use, previously controllable and compatible with work and family and social relations, assumed a different level and led to financial and relational losses that, according to them, in turn became the reason for the increasingly constant use.
When crack addiction becomes a deep seated habit, the participants of this study described a cycle of use as was cited in another study (19) .It was a cycle in which people swung from a state of total abstinence, while they were in some health institution, to a total surrender to the drug, without having The path to crack addiction: perceptions of people under treatment Pedrosa SM, et al.
access to effective treatment that, according to the authors, was marked by relapse and sporadic use.
The illegal actions became frequent among crack addicts who ended up assuming the designation of "tramp", which according to Castel (6) , is used as a term referring to those outside the law and assistance.Thus, at the same time that they cannot count on relational and occupational support, they also do not follow the laws of the institutions that provide the support.In the territory of crack addiction, the laws are different and the line of illegality, which they have already crossed, tends to have its own borders increasingly blurred.
It is important to point out that the very consumption and the resulting behavioral consequences limit the possibility of the users in seeking to strengthen their participation in the labor world and getting involved in substantial social relationships that could become a source of support, thus worsening the situation of social vulnerability already experienced by them.
In the context of crack use, the participants described their involvement with drug trafficking and their feelings of outrage toward drug dealers and the police.With the former there is no friendship, since they aim exclusively to profit and ignore those who cannot afford to buy the drug.As for the latter, there is no friendship either because the actions of the public security agents were described by the participants as coercive and, sometimes, unfair to crack addicts, who fearing retaliation from the drug dealer, do not provide information on the locations of the "crackhouses" and, consequently, end up being treated with violence by the police, a situation already shown in another study (20) .
However, the study participants considered crack use incompatible with drug trafficking in relation to the drug dealer, since the extremely addicting characteristics of this drug put them in constant risk of "never-ending" debts.As for the experience reported by those who got involved with drug trafficking, although there was an improvement in their purchasing power, since it is a very profitable activity, the assets gained were also quickly lost in obtaining the drug.
The fight against drug trafficking is the battleground for the National Policy on Drugs (21) , in an effort to promote supply reduction.However, who are the drug dealers?In this study, it became clear that the participants who reported involvement with drug trafficking, and even profiting from it, ended up losing their gains to obtain crack and secure their addiction.
There are several kinds of drug dealers (22) .The profile exposed by the media and that which prevails in the social imagination is that of a fearless individual, who controls the "favelas" ("slums") and gets rich very fast; however, the author argues that the poor, Afro-descendent, economically deprived, and dweller of areas with little assistance from the State is the most common profile.These drug dealers are known as "mulas" ("mules"), "boca" ("crackhouse"), or "aviãozinhos" ("pushers") and get a small share of the drug money.
The discourses allow for the understanding of this reality, since the participants that reported involvement with drug trafficking did not have access to a large part of the money and were not drug bosses.
Continuing with the discussion on the results in the context of crack addiction, some aspects need to be emphasized because of its higher potential for vulnerability.For instance, gender, since the use of this drug by women has grown and has its own specificities, according to what the participants expressed in this and other studies (23)(24)(25) .
Women tend to take care of the family, especially their children, and they expressed more frustration by situations that exposed their children to risks because of crack addiction.In their discourses, they justified their initial use of drugs by feelings of loneliness, helplessness, immersion in family conflicts, or by the need to lose weight.All these factors show the influence of using drugs at an emotional level and the aspects related to self-image as a cause for women in using the drug.
Additionally, some factors make crack addiction among women cause more serious problems, since it is not uncommon that most are single, mothers of reproductive age, without personal income and susceptible to situations of violence and prostitution as a way to get access to the drug.Besides that, it must be taken into account that they are susceptible to high risk pregnancies with damaging effects to the baby and a high possibility of neglecting to care for their children later (26) .
The arrival at the point where they "hit bottom", as they called this situation, caused the exclusion from the family that characterized their lives at this point and despite being able to leave the hospital, some still needed to stay there because they did not have anywhere to go and did not want to live on the streets.
The situation of social exclusion that the participants found themselves in also caused them to be labeled as 'able indigent' or "capable for work but that do not work".They "are placed in a double bind: injunction of working, impossibility of working", in other words, the person experiences, externally and internally, a pressure to work but is not capable or, at least, he/she does not demonstrate interest in order to be included in the labor market (27) .They are people that neither fit the profile for receiving the kind of assistance provided to the disabled, nor the profile of those unable to work due to physical disability.or mothers of single parent families, elderly or even orphans.
The author further adds that the requirement and the simultaneous impossibility to work make it possible for these 'able indigents' to be considered as criminal and fosters the view that their attitudes justify acts of repression.Although the author refers to the situation of groups from European history in the last few centuries, it should be taken into account that the profile of most participants in this study can be identified as 'able indigent'.They are people capable of working, but they are not "employable."Their relational bonds are very compromised, because they did not have access to them since childhood, or because they lost them while they were using the drug or were addicted to it.
Finally, according to the reports in the third category, "The return to normal life", the participants wished to get out of the situation they found themselves in, and associated this The path to crack addiction: perceptions of people under treatment Pedrosa SM, et al.
return to normalcy with the need to keep themselves away from the drug.They recognized that this wish to quit the use of crack could only happen by their own will and initiatives.The participants demonstrated that they shared the concept that prevails in society, which upholds abstinence as the only path to a life considered righteous, as was observed in another study (19) .There is also the need of an approach that respects the autonomy and the will of those who seek treatment.
In this context, it is important to highlight the discussion on the stigma suffered by drug users, particularly crack users.The stigma can be defined as "a physical or social label of negative connotation or that makes the carrier of this 'label' to be considered marginalized or excluded from some social situations" (28) .Conceptions that regard the drug addict as "weak" or having "bad character" and that this problem is "unsolvable" are ideas rooted in society and, as a consequence, influence the ways health care professionals behave with them (28) and which can compromise the approach of these professionals.
It is necessary to look at a person under crack addiction treatment (who should not be called crack user or addict) as an individual capable of empowering actions, value these people, and help them to strengthen their self-esteem with regard to their families.Health, education, social assistance and public security professionals, could come up with a joint effort to help drug users.
One of the fundamental aspects for the rehabilitation of a crack addict is occupational inclusion.Among psychoactive substance addicts, the loss related to the lack of an employment relationship is often present, since it is not uncommon that they lack formal education, or that the daily use of drugs impaired them from maintaining a steady job.They are often subject to harassment from employers and coworkers (29) .
Inclusion in the work market is one of the pillars for effectively integrating these people into society (6) .For the participants in this study, work represents the path for obtaining money, recovery of their dignity, and of their value in society and in their families.Therefore, it proved to be essential for them to provide for their own support and for their families through legal and stable work, which during the harmful use of crack was one of the first aspects t to become compromised.
However, this inclusion in the work market, viewed with hope by most participants, demands joint efforts that must be supported by the social assistance network and followed closely by the family and by several health care partners.
The Assistance Zone is an attempt to replace the primary sociability and to offer, at least at a minimum, conditions for survival for those who are suffering exclusion (6) .In this study, according to the discourses of the participants, the hospital represented one of the few tools from the Assistance Zone that helped to overcome the consequences of crack addiction.
However, since drug addiction can be considered a chronic condition, relapses and difficulties in maintaining the treatment by those who experience the addiction are expected to occur (2) .
Another issue to be considered is that religion has served as an important resource for treatment against drug addiction, since faith provides better quality of life as it brings in hope.
In this respect, a person undergoing treatment for addiction begins "to rely on the help of God" (30) .

FINAL CONSIDERATIONS
The treatment offered to people under crack addiction is complex and involves an array of feelings, stigmas, and prejudices by those who approach them.In this study, as this contact was established and feelings addressed, it became possible to understand what the participants were expressing.
The participants in this study reported little support on their path to crack use.The challenge of intervening at any moment in this process can be facilitated if it is accompanied by the necessary support provided by the family, friends, employers, religion, and also the willingness of the users themselves to overcome the addiction and return to the normal life after crack.
The use of Robert Castel's framework allowed for a more dynamic and closer approach regarding the complexity that the participants of this study experienced.However, this framework deals with one of the aspects of a social problem of great complexity, so it requires further studies and different approaches, whether quantitative or qualitative, so other possibilities can be explored in health care provision to people addicted to crack.Therefore, nursing practice as part of a multidisciplinary team, must try to learn more about people who are seeking treatment for crack addiction, their anguish, their relationship with the family, the factors that make it difficult or facilitate the treatment, and provide support during the relapses.
Based on the results of this study, it is imperative to learn more about the perspective of the families of crack addicts, an aspect covered with limitation in this article, since this group did not constitute the population of this research.Therefore, there is an understanding that this gap requires specific research in future studies, taking into account that the primary relational support is fundamental for the effective construction, on a solid base, of the self-esteem and redefinition of the lives of those who are addicted to drugs, especially crack.
Another point that should be mentioned is that, even having used the group solely as a tool for data collection, the interaction provided to the participants at the time seemed to be of great benefit for them, since they expressed their feelings, oftentimes, with no strings attached, touched and comforted each other, exchanged advice and support and received and provided feedback.This interaction made possible the potential of this strategy for achieving new perspectives in treating people under crack addiction.
Finally, it is essential that nursing professionals, like other professionals, do not perpetuate the stigma imposed on people who use and are under crack addiction treatment.They should keep in mind that, behind the behavior demonstrated, there are specific contexts and fundamentals that enable health professionals in bringing down the barriers between crack addicted people and the health care services, education and social assistance, and between the interaction with their family and society as a whole, with the purpose of integrating and reintegrating these citizens deprived from their rights.