Female crack cocaine users under treatment at therapeutic communities in southern Brazil: characteristics, pattern of consumption, and psychiatric comorbidities

de crack. Abstract Objective: To explore and describe sociodemographic characteristics, crack consumption patterns, and psychiatric comorbidities of female crack users receiving treatment at therapeutic communities. Methods: This was a cross-sectional, descriptive, quantitative study. Forty-six women who abstained from crack use were assessed using a sociodemographic questionnaire, the Mini- Mental State Examination (MMSE), the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and a profile of crack use questionnaire. Descriptive statistical analyses were conducted. Results: Participants had a mean age of 31.02 years (standard deviation [SD] = 7.73), most were single (76.1%), white (67.4%) and had complete or incomplete elementary education (43.5%). Before treatment, 65.2% of the women reported using crack every day; 46.3% smoked between 10 to 30 crack rocks per week. Mean treatment time was 63.56 days (SD = 75.85), with a mean of 80.41 days of abstinence (SD = 74.52) and 3.37 previous treatments (SD = 5.49). Mean age upon crack use initiation was 22.61 years (SD = 8.06), and the most frequent motivation to start using crack was curiosity (78.3%). The mean lifetime duration of crack use was 82.26 months (SD = 74.76), and the physical complications most frequently reported were weight loss (93.5%), followed by sleep problems (87%). In this study, the most prevalent psychiatric diagnoses were major depressive episode (60.87%), followed by post-traumatic stress disorder (52.17%) and generalized anxiety disorder (13.07%). Conclusions: Overall, a pattern of high consumption of crack was observed. The results show a high frequency of mood and anxiety disorders, with the highest frequencies found for major depressive episode and post-traumatic stress disorder.


Introduction
The use of crack cocaine (crack), a form of cocaine that is smoked, is an outspread phenomenon that mobilizes societies, public authorities, and public health services. Worldwide, it is estimated that around 18.2 million people make use of cocaine, with a noticeable increase of almost 7%. 1 The Americas are the biggest market, and Brazil is assumed to be the second greatest consumer market for cocaine worldwide, second only to the United States. 2  (powder cocaine, crack cocaine, merla, or oxi). It was also estimated that 1 in every 100 adults smoked crack in that same year, at a total of 1 million Brazilians. 3 These epidemiological estimates lay out the burden of cocaine and crack consumption on users, their families, Brazilian society, and public health services.
Crack is a powerful stimulant, which activates the brain's reward system and causes deleterious consequences to all areas of the user's life. 4,5 People who use crack are frequently exposed to a variety of risk factors associated with low quality of life and potentially life threating situations. 6,7 Therefore, crack use leads to a marginalized life that increases the number of clinical conditions, including psychiatric comorbidities. 8 Studies have sought to identify the characteristics of this population to propose effective treatment and prevention programs. 9,10 However, while the consumption of crack has increased in the female population, the bulk of those studies focus on male users. Thus, there is still much to learn about the specificities of female crack users. Researchers have identified differences between men and women regarding their drug use patterns, the consequences to their health and psychosocial life. 11 Some studies showed that women experience a rapid progression from the beginning of drug use to the onset of drug-related problems as compared to men. 12 Regarding treatment for substance use disorders, the demand for crack use treatment is increasing, 13 and women have been seeking more help at public facilities. A 14-year cross-sectional study with Brazilian women evidenced that the rate of women looking for treatment because of crack use increased from 2.8% in 1997 to 67.8% in 2010, indicating a significant increase in the consumption of crack among women. 14 It is also important to consider evidence suggesting that women must overcome many barriers to enter treatment, and therefore have less opportunities for treatment associated with drug use. 15 Those barriers are mainly associated with social stigma, concerns about childcare, lack of awareness of the range of treatment options, economic factors, and the time needed to get treatment. 16 The pattern of crack use, regarding frequency and quantity, is associated with the severity of health and social consequences, such as HIV risk behaviors, violence, legal problems, and unemployment. 10,17,18 Another important aspect is the use of crack use concurrent with other psychiatric problems and other drugs. [19][20][21] The symptoms of certain psychiatric disorders can act as risk factors for addictive behavior and may result in negative outcomes, jeopardizing treatment maintenance. 22,23 Despite the increase in drug use, little information is available on female crack cocaine users in Brazil. Moreover, Brazilian studies are mostly focused on white male and female populations. [17][18][19][20] Therefore, the purpose of this study was to describe sociodemographic characteristics, crack consumption patterns, and psychiatric comorbidities present in female crack users receiving treatment at therapeutic communities in the metropolitan area of Porto Alegre, southern Brazil.

Sample and design
This was a cross-sectional, descriptive study. It

Sociodemographic questionnaire
This instrument was developed by the research team for the specific purpose of this study, to obtain information on age, education, marital status, profession, socioeconomic status, initiation of drug use, and days of treatment.

Mini-Mental State Examination (MMSE) 24
This screening instrument provides information on cognitive parameters. Items are divided into seven categories, each one designed to assess specific aspects: temporal orientation, spatial orientation, attention and calculation, recollection, language, and motor skills.
It took approximately 10 minutes for the examiner to apply the test. Scores ranged from 0 to 30 points.
Women who scored < 18 points were excluded. 24

Structured Clinical Interview for DSM Axis I Disorders (SCID-I)
This instrument is widely used to assess axis I psychiatric disorders according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). The purpose was to identify crack dependence and other axis I psychiatric disorders.

Profile of crack use 25
Detailed information about crack cocaine use was obtained using a questionnaire developed by the Center for Drug and Alcohol Research (CPAD) of Hospital de Clínicas de Porto Alegre, 25 but not yet validated (entitled the Profile of the Crack User). This scale is comprised of 27 questions about the intensity, impact, and evolution of crack use.

Ethics and research procedures
This study was carried out in accordance with the recommendations of the Brazilian National Health

Statistical analysis
Descriptive analyses were performed using the to obtain money to buy the drug, including engaging in undesired sexual relationships (58.7%) and getting involved with drug trafficking activities (54.3%).
In regard to axis I psychiatric comorbidities, 70.0% presented at least one additional diagnosis. In fact, 56.5% had attempted suicide at least once, and 63.0% were using psychiatric medication during the current treatment. The frequencies and percentages of psychiatric disorders are displayed in Table 3.