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USE OF CRACK AND OTHER DRUGS AMONG CHILDREN AND ADOLESCENTS AND ITS IMPACT ON THE FAMILY ENVIRONMENT: AN INTEGRATIVE LITERATURE REVIEW1 1 Article taken from the dissertation - Meanings and experiences of parents and responsible caregivers on children using crack and other drugs: a phenomenological approach, presented to the Programa de Pós-Graduação em Ciências da Saúde: Saúde da Criança e do Adolescente, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), 2014.

USO DE CRACK Y OTRAS DROGAS POR NIÑOS Y ADOLESCENTES Y SU IMPACTO EN EL AMBIENTE FAMILIAR: UNA REVISIÓN INTEGRATIVA DE LITERATURA

ABSTRACT

Drugs abuse is a complex phenomenon with many causes, and it affects children and adolescents. The objective of this research was to seek scientific evidence that contributes to the understanding of the existing relation between the use of crack and other drugs by children and adolescents and the family. The method used was the integrative review. The bases analyzed were: MEDLINE, LILACS, Cochrane, BDENF and IBECS. Descriptors: cocaine, crack, family and family relationships. Three categories were evidenced: Family environment as a protector and/or facilitator for the use of crack and other drugs by children and adolescents; Lack of knowledge and the repercussions of the use of crack and other drugs by children and adolescents in the family environment; Networks to support the family and coping with the use of crack and other drugs. The family environment has a protective function against the use of drugs, but the issue of drugs has to be faced and addressed. It is also necessary to strengthen the social networks and discuss prevention themes.

DESCRIPTORS:
Crack cocaine; Family; Family relations.

RESUMEN

El abuso de drogas es un fenómeno complejo, multifactorial y afecta a niños y adolescentes. Este trabajo tuvo como objetivo la búsqueda de evidencia científica para la comprensión de la relación entre el consumo de crack y otras drogas por niños y adolescentes y la familia. La metodología utilizada ha sido la revisión integrativa. Las bases analizadas fueron: MEDLINE, LILACS, Cochrane, BDENF e IBECS. Los descriptores utilizados fueron: cocaína, crack, familia y relaciones familiares. Se encontraron tres categorías: El ambiente familiar como un elemento de protección o de mayor facilidad para el uso de crack y otras drogas; La ignorancia y las repercusiones del uso de crack y otras drogas en el ambiente familiar; Las redes de apoyo a las familias y al enfrentamiento al consumo de drogas. El ambiente familiar es un factor de protección para el consumo de drogas, sin embargo se debe abordar el tema del consumo de drogas, fortalecer las redes sociales y abordar la prevención.

DESCRIPTORES:
Cocaína crack; Família; Relaciones familiares.

RESUMO

O uso abusivo de drogas é um fenômeno complexo, multicausal e afeta crianças e adolescentes. O objetivo da pesquisa foi buscar evidências científicas que contribuam para a compreensão da relação existente entre o uso de crack e outras drogas por crianças e adolescentes e a família. Como metodologia foi utilizada a revisão integrativa. Bases analisadas: MEDLINE, LILACS, Cochrane, BDENF e IBECS. Descritores: cocaína crack, família e relações familiares. Três categorias foram evidenciadas: O ambiente familiar como elemento protetor e/ou facilitador do uso de crack e outras drogas entre crianças e adolescentes; O desconhecimento e as repercussões do uso de crack e outras drogas entre crianças e adolescentes no ambiente familiar; As redes de apoio à família e ao enfrentamento do uso de crack e outras drogas. O ambiente familiar é fator protetor para o uso de drogas, mas deve se trabalhar o tema drogas, fortalecer redes sociais e abordar temas de prevenção.

DESCRITORES:
Cocaína crack; Família; Relações familiares

INTRODUCTION

The contemporary reality has raised new challenges in the approach and debates on certain themes. This context is due to the fact that the objects of intervention are complex, which requires effort to avoid reductionist simplifications. One example are drugs, a prominent and comprehensive problem. Abuse and/or dependence has turned into a great challenge for society, because of its individual and collective consequences, directly affecting people's well-being and quality of life.11. Ministério da Saúde (BR). Portaria nº 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Brasília (DF): MS; 2005.-22. Ministério da Justiça (BR). Secretaria Nacional de Políticas sobre Drogas. Relatório brasileiro sobre drogas. Brasília (DF): MJ; 2009.

Drug consumption and its implications are diverse, and therefore need to be discussed and understood in health, economics, education, planning, social service, development, among others. Due to its severity and range, coping actions need to take place beyond the health area. Different sectors need to engage, which face the problems of urban violence, social disparities, the violation of rights, inequalities in the access to education, work, leisure and culture. Based on this articulation, coping can be more effective and problem-solving.11. Ministério da Saúde (BR). Portaria nº 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Brasília (DF): MS; 2005.-22. Ministério da Justiça (BR). Secretaria Nacional de Políticas sobre Drogas. Relatório brasileiro sobre drogas. Brasília (DF): MJ; 2009.

The drugs phenomenon is complex and multicausal, without territorial, social or age limits, significantly affecting children and adolescents. The use of crack and other drugs is direct and indirectly related with a range of health problems in the population, such as: traffic accidents, aggressions, clinical depressions and disorders of conducts, besides sexual risk behavior and the use of injectable drugs, which are associated with the transmission of HIV.22. Ministério da Justiça (BR). Secretaria Nacional de Políticas sobre Drogas. Relatório brasileiro sobre drogas. Brasília (DF): MJ; 2009.

3. Secretaria de Estado de Saúde (MG). Secretaria de Assistência a Saúde. Atenção em Saúde Mental. Belo Horizonte (MG); SES; 2006.
-44. Ministério da Saúde (BR). Secretaria Executiva, Coordenação Nacional de DST/AIDS. A Política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília (DF): MS; 2003.

What drug consumption among children and adolescents is concerned, the growing early use of socially accepted drugs should be highlighted, such as alcohol and tobacco, and the use of design drugs and crack. The growth of crack consumption is one of the great challenges today to put in practice a broader care policy for drug consumption problems in Brazil.

The use of crack in the country was initially detected by professionals who worked in the damage reduction policy with injectable drugs users at the start of the 1990's. This policy highlighted the need to address the problems deriving from the drug, but without an immediate perspective of suspending the use, aiming to seek strategies to formulate practices that reduce the damage the drug causes, such as suicide, overdose, disease transmission, among others.11. Ministério da Saúde (BR). Portaria nº 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Brasília (DF): MS; 2005.,55. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Vínculo familiar de usuários de crack atendidos em uma unidade de emergência psiquiátrica. Rev Latino-Am Enfermagem. 2011 Set-Out; 19(5):1-8.-66. Guimarães CF, Santos DVV, Rodrigo RC, Araujo RB. Perfil do usuário de crack e fatores relacionados à criminalidade em unidade de internação para desintoxicação no Hospital Psiquiátrico São Pedro de Porto Alegre (RS). Rev Psiquiatr Rio Gd Sul. 2008 Mai-Ago; 30(2):101-8.

The individual consequences associated with drug abuse are known, but the social impact cannot be measured. This context has contributed to strengthen the stigma and difficulties in the different care sectors involved in clinical care for drug addiction in order to constitute and articulate an efficient care network.77. Barros MA, Pillon SC. Programa saúde da família: desafios e potencialidades frente ao uso de drogas. Rev Eletrônica Enferm [Internet]. 2006 Dez [cited 2014 Jan 17]; 8(1):144-9. Available from: http://www.revistas.ufg.br/fen/article/view/932/1129.
http://www.revistas.ufg.br/fen/article/v...

The mental health policy proposes efficient actions coherent with the development of a care network and includes the creation of new devices to address problems related to alcohol and other drugs, which help to establish a network to give answers that are more in line with the actual needs of the population and with the principles of comprehensive, interdisciplinary and community-based psychosocial care. Examples of actions in this sense are: the creation of the Family Health Support Centers - Mode 3, giving priority to users of crack, alcohol and other drugs; the Emergency Plan for Treatment Access and Prevention in Alcohol and other Drugs in the Unified Health System, the Integrated Plan for Coping with Crack and other Drugs, all of which are in conformity with the Ministry of Health Policy for Integral Care to Users of Alcohol and other Drugs, in force since 2004.11. Ministério da Saúde (BR). Portaria nº 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Brasília (DF): MS; 2005.-22. Ministério da Justiça (BR). Secretaria Nacional de Políticas sobre Drogas. Relatório brasileiro sobre drogas. Brasília (DF): MJ; 2009.

The phenomenon of drugs use and abuse affects society, requiring rapid, efficient and humane intervention modalities that do not blame the user and welcome the families affected by the problem, in view of the damage reduction perspective.

When a family is confronted with the use of crack and other drugs at its heart, particularly children and adolescents, it faces situations that are not simple to solve. In some cases, the parents do not have clear and objective information on the theme, or are drugs users too. Therefore, they need treatment themselves, which hampers the approach and increases the complexity of the problem in question.88. Campos MLG, Ferriani MGC. Uso de drogas entre crianças de 6 a 7 anos de uma escola primária de Celaya, Guanajuato, México. Rev Latino-Am Enfermagem. 2008 Mai-Jun; 16(esp):523-8.

Despite the negative impact of drugs use and considering that the factors leading to adherence or not to the consumption of drugs are influenced by the individuals' sociocultural context, it can be affirmed that the family is extremely important to monitor, maintain and solve the problem among its members. Knowledge is needed about the parents' experiences and feelings about their child(ren)'s use of crack and other drugs. This is the case in any approach, whether prevention or treatment. This strategy is fundamental as, beyond the individual therapeutic plan, support for the family members helps to overcome the anguish and doubts, so that they are empowered and encouraged to act in the social reinsertion process of their children.

The objective in this study was to seek scientific evidence that contributes to understand the existing relation between the use of crack and other drugs by children and adolescents and the consequences for the family.

METHOD

An integrative literature review was undertaken. This method permits the inclusion of relevant studies on the theme, providing theoretical foundations to improve the clinical practice and decision making. In addition, it permits a broad analysis of the scientific production, significantly contributing to the research methods and results.99. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008 Out-Dez; 17(4):758-64.

The process was developed in six phases, as recommended in the literature:1010. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005 Dec; 52(5):546-53. 1) identification of the theme and selection of the research hypothesis or question; 2) selection of studies for the research sample; 3) definition of information to be drawn from the selected studies; 4) critical analysis of studies included in the review; 5) interpretation of the results; and 6) presentation and synthesis of the knowledge evidenced.

The guiding question of the research was: what publications in the Brazilian and foreign scientific literature highlight the existing relation between the use of crack and other drugs in children and adolescents and its impact on the family?

In the selection of the manuscripts, the research portal of the Virtual Health Library (VHL) was defined. The search was undertaken in the databases of the Latin American and Caribbean Literature in Health Sciences (LILACS), in the Nursing Database (BDENF), in the Spanish Bibliographic Index of Health Sciences (IBECS) and in the Portal of Evidences of the Cochrane Library. In the research portal of PubMed (digital file produced by the U.S. National Library of Medicine), studies were selected in the database of the Medical Literature Analysis and Retrieval System Online (MEDLINE). According to the research objective, the descriptors cocaine crack, family and family relationships were chosen from the DeCS (Descriptors in Health Sciences) of BVS.

In the survey of the articles on the research portal of BVS, three descriptors were crossed, using Boolean logic in the search field. The strategy used was (MH: D02.145.074.722.388.250$ OR "Cocaína Crack" OR "Crack Cocaine") AND (MH: F01.829.263$ OR Família OR Familia OR Family OR MH: F01.829.263.370$ OR "Relações Familiares" OR "Relaciones Familiares" OR "Family Relations").

In the survey of scientific studies in MEDLINE, via PubMed, the descriptors used were Crack Cocaine, Family and Family Relations, broadening the search of the terms in the title and resumo/abstract. The strategy used in the search field was ("Crack Cocaine"[Mesh]) AND ("Family"[Mesh]) OR "Family Relations"[Mesh]) OR ("Crack Cocaine" OR crack[Title/Abstract]) AND (Family OR "Family Relations"[Title/Abstract]).

The inclusion criteria used were: articles that picture the issue about the use of crack and other drugs among children and adolescents and its impacts for the family and the family relations; and the period between 1960 and July 2013. Children and adolescents were considered as the age range between zero and 19 years, according to the definition of the World Health Organization.1111. Organización Mundial de la Salud. La salud de los jóvenes: um reto y uma esperanza. Genebra (CH): OMS; 1995. Repeated articles were counted in the database with the largest number of references. No restrictions were raised in the selection as to the language and publication period.

To strengthen this review, the selected articles were also classified according to the evidence level, adopting seven levels.1212. Melnyk BM, Fineout-Overholt E. Making the case for evidence-based practice. In: Melnyk BM, Fineout-Overholt E, organizadores. Evidence-based practice in nursing and healthcare: A guide to best practice. 2nd ed. Philadelphia (US): Lippincott Williams & Wilkins; 2005. p. 3-24. Level I contains the evidence from a systematic review or meta-analysis of all controlled randomized clinical trials or originating in guidelines based on systematic reviews of randomized controlled clinical trials. Level II contains the evidence from at least one randomized controlled and well-designed clinical trial. At level III, the evidence comes from a controlled study without randomization. Level IV relates to studies deriving from a well-designed case-control or cohort study. Level V concentrates the studies from a systematic review of qualitative and descriptive studies. Level VI contains the evidence from a single descriptive or qualitative study. Finally, at level VII, the evidence from expert opinions and/or expert committee reports stands out.1212. Melnyk BM, Fineout-Overholt E. Making the case for evidence-based practice. In: Melnyk BM, Fineout-Overholt E, organizadores. Evidence-based practice in nursing and healthcare: A guide to best practice. 2nd ed. Philadelphia (US): Lippincott Williams & Wilkins; 2005. p. 3-24.-1313. Pedersoli CE, Dalri MCB, Silveira RCPC, Chianca TCM, Cyrillo RMZ, Galvão CM. O uso da máscara laríngea pelo enfermeiro na ressuscitação cardiopulmonar: revisão integrativa da literatura. Texto Contexto Enferm. 2011 Abr-Jun; 20(2):376-83.

Based on the publications selected in the search and in strict compliance with the inclusion criteria presented, the studies were preselected when in compliance with the study proposal. Thus, the relevance of the title and abstract was verified with a view to the future assessment of the full version.

The data were collected with the help of a proposed and validated tool1414. Ursi ES, Galvão CM. Prevenção de lesões de pele no perioperatório: revisão integrativa da literatura. Ribeirão Preto (SP): Rev Latino-Am Enfermagem. 2006 Jan-Fev; 14(1):124-31. and adapted to the research objective. The tool contains information on the identification of the research, the host institution, the methodological characteristics, the assessment of the methodological rigor and the description of the results found.

RESULTS AND DISCUSSION

A flowchart (Figure 1) was elaborated to present the bibliographic survey, the research strategies and the number of studies included in the review.

Figure 1
Flowchart of bibliographic research. Belo Horizonte, Minas Gerais, 2014

After surveying and defining the publications used to elaborate the study, a summary was elaborated to understand the profile of the selected evidence, containing the year of publication, journal, title of the study and language, database and evidence level, as illustrated in Table 1.

Table 1
Description of studies included in integrative review. Belo Horizonte, Minas Gerais, 2014

As verified, 69.6% of the selected articles were published in journals indexed in MEDLINE, 21.7% in LILACS, 4.3% in BDENF and 4.3% in IBECS. What the year of publication is concerned, 39.1% of the studies were published in the 1990's, 21.7% between 2000 and 2010 and 39.1% in the period between 2011 and September 2013. Concerning the language, the largest number of studies was published in English (65.2%), followed by Portuguese (26%) and Spanish (8.6%).

In the analysis of the evidence level, it was verified that 8.7% of the studies belong to level II, 30.4% to level III and 8.7% to level V. Most studies selected (52.4% was classified at level VI, highlighting studies that used qualitative methods.

After reading and analyzing the selected studies, the assessment and description of the theme were organized and presented in three categories: The family environment as a protector and/or facilitator of the use of crack and other drugs among children and adolescents; Lack of knowledge and the repercussions of the use of crack and other drugs among children and adolescents in the family context; and The networks for family support and for coping with the use of crack and other drugs.

The family environment as a protector and/or facilitator of the use of crack and other drugs among children and adolescents

Protecting the family is a relevant factor in preventing the use of crack and other drugs. The results presented in studies 2, 3, 8 and 9 evidence that these elements are identified as strong influences in reducing the number of users. Among the non-users, the availability of information and the protective family structure are factors to distance the youth from the problem. The information on the consequences of drug use and the affective bonds between parents and children, guaranteed by feelings of complicity and respect, are important elements to refuse the drug.1616. Seleghim MR, Inoue KC, Santos JAT, Oliveira MLF. Aspectos da estrutura familiar de jovens usuários de crack: um estudo do genograma. Cienc Cuid Saude. 2011; 10(4):795-812.-1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.-2323. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Family ties of crack cocaine users cared for in a psychiatric emergency department. Rev Latino-Am Enfermagem. 2011 Oct; 19(5):1163-70.

It was also highlighted that the strengthening of bonds, the creation of rules and the prescription of clear and coherent limits, besides the monitoring, supervision and support for young people in their decisions and attitudes, are fundamental in these individuals' process of growth and emotional maturing. Talking on the theme should be common practice in the family routine (3, 8).1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.

Another aspect, present in studies 2, 3, 8, 19, is the family's protection concerning the treatment of the children and adolescents dependent on crack and other drugs. The therapeutic process to recover chemical addicts includes multiple aspects. Initial measures are actions that stimulate the users to contact the care services. It was verified that addicts' search for treatment is directly related with the support the relatives offer. The family and social networks facilitate the treatment compliance, in view of the patients' low motivation and monitoring difficulties during the maintenance period of abstinence. In that sense, the articulation with the family and social environment is fundamental for the success of the treatment, rehabilitation and social reinsertion.1616. Seleghim MR, Inoue KC, Santos JAT, Oliveira MLF. Aspectos da estrutura familiar de jovens usuários de crack: um estudo do genograma. Cienc Cuid Saude. 2011; 10(4):795-812.-1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.-2323. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Family ties of crack cocaine users cared for in a psychiatric emergency department. Rev Latino-Am Enfermagem. 2011 Oct; 19(5):1163-70.

Study 13,2727. Wu Y, Stanton BF, Galbraith J, Kaljee L, Cottrell L, Li X, et al, Burns JM. Sustaining and broadening intervention impact: a longitudinal randomized trial of 3 adolescent risk reduction approaches. Pediatrics. 2003 Jan; 111(1):32-8. a randomized controlled study (evidence level II), supported the fact that interventions involving children and adolescents, articulated with the family, offer additional protection against the involvement in risk behaviors, such as the use of drugs, in comparison with interventions that only target adolescents. In another randomized study (12),2626. Furr-Holden CD, Ialongo NS, Anthony JC, Petras H, Kellam SG. Developmentally inspired drug prevention: middle school outcomes in a school-based randomized prevention trial. Drug Alcohol Depend. 2004 Feb; 73(2):149-58. a new aspect was evidenced as a consistent protection factor against drug use. That is the intervention centered in the classroom, in close partnership with the family, which can offer protection against the early use of illegal drugs, such as cocaine, heroine, crack and other drugs.

As opposed to the points highlighted earlier, drug use can start early, as from the child and adolescent's exposure to situations of conflict and violence in the family or in contact with significant others, including friends. Conflicting or weakened family relationship with antecedents turn these individuals into a vulnerable group for consumption and with difficulties in terms of treatment compliance, in accordance with article 12.2626. Furr-Holden CD, Ialongo NS, Anthony JC, Petras H, Kellam SG. Developmentally inspired drug prevention: middle school outcomes in a school-based randomized prevention trial. Drug Alcohol Depend. 2004 Feb; 73(2):149-58.

Studies 2, 8, 14, 20, 23 demonstrate that the drug use by parents and other relatives influences children and adolescents to use and abuse drugs. The intergenerational transmission of behavioral patterns is frequent in the scientific literature. Parents who use a drug serve as a model for children to experiment and keep up the use.1616. Seleghim MR, Inoue KC, Santos JAT, Oliveira MLF. Aspectos da estrutura familiar de jovens usuários de crack: um estudo do genograma. Cienc Cuid Saude. 2011; 10(4):795-812.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.,2828. Boyd CJ, Holmes C. Women who smoke crack and their family substance abuse problems. Health Care Women Int. 2002 Sep-Nov; 23(6-7):576-86.,3434. Caudill BD, Hoffman JA, Hubbard RL, Flynn PM, Luckey JW. Parental history of substance abuse as a risk factor in predicting crack smokers substance use, illegal activities, and psychiatric status. Am J Drug Alcohol Abuse. 1994 Aug; 20(3):341-54.,3737. Wallace BC. Crack cocaine smokers as adult children of alcoholics: the dysfunctional family link. J Subst Abuse Treat. 1990; 7(2):89-100. Study 9 was intended to get to know the family bond of crack users attended at a psychiatric emergency service in the South of Brazil, in the city of Maringá, Paraná. The results found in the participants' reports evidence that their families contain one or more members who used legal and/or illegal drugs.2323. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Family ties of crack cocaine users cared for in a psychiatric emergency department. Rev Latino-Am Enfermagem. 2011 Oct; 19(5):1163-70.

In view of the relatives' influence in the early onset and in treatment difficulties, studies 2, 8, 15, 18 highlight the importance of knowing the structure and relations among the family members, as well as to identify the relatives that use some kind of drug. Alcohol and tobacco are the drugs the relatives use more commonly, as their use is considered a widely accepted sociocultural phenomenon in some cultures.1616. Seleghim MR, Inoue KC, Santos JAT, Oliveira MLF. Aspectos da estrutura familiar de jovens usuários de crack: um estudo do genograma. Cienc Cuid Saude. 2011; 10(4):795-812.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.,2929. Johnson BD, Dunlap E, Maher L. Nurturing for careers in drug use and crime: conduct norms for children and juveniles in crack-using households. Subst Use Misuse. 1998 Jun; 33(7):1511-46.,3232. Kandel DB, Davies M. High school students who use crack and other drugs. Arch Gen Psychiatry. 1996 Jan; 53(1):71-80. Identifying the risk factors in the children and adolescents is an important task, as the intervention should concentrate on these individuals' interactions with the environment they are inserted in and with the behavior of other family members, a relevant fact in the planning and elaboration of protection strategies, according to the results highlighted in studies 10 and 11.2424. Kliewer W, Murrelle L. Risk and protective factors for adolescent substance use: findings from a study in selected Central American countries. J Adolesc Health. 2007 May; 40(5):448-55.-2525. Van Der MS, Nappo SA. From the first drug to crack: the sequence of drugs taken in a group of users in the city of São Paulo. Subst Use Misuse. 2007 Jul; 42(1):177-88.

Therefore, understanding the family environment and its relation with the consumption of crack and other drugs among children and adolescents is fundamental, as the family context should be considered an environment that acts as a protective and risk factor.

Lack of knowledge and the repercussions of the use of crack and other drugs among children and adolescents in the family context

The consequences of drug use emerge in a wide range of spheres of human life and affect the lives of the family members in different aspects. Part of the population does not have access to information on the theme, resulting in a vicious cycle.

The results described in studies 3 and 5 evidence that the families only gained knowledge on the theme drugs after one of their children passed through an inpatient service for treatment; others presented insufficient knowledge, deriving from media resources. The lack of knowledge on the use of drugs impeded the relatives' actions to prevent, identify and/or treat their addicted members. Despite the harmful consequences of crack and other drugs, the families reported that they did not know that their relatives were taking drugs.1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,1919. Vargas L, Alberto F. Consumo de alcohol y sustancias adictivas en población escolar de 7 centros educativos municipio de Managua, Septiembre-Octubre del 2011[dissertação]. Managua (NI): Universidad Nacional Autónoma de Nicaragua. Centro de Investigaciones y Estudios de la Salud. Escuela de Salud Pública de Nicaragua; 2012.

Knowledge on issues related to the prevention and treatment of drug use is important. In study 10,2424. Kliewer W, Murrelle L. Risk and protective factors for adolescent substance use: findings from a study in selected Central American countries. J Adolesc Health. 2007 May; 40(5):448-55. it is verified that approaches at the family level can be executed to reduce the negative interaction standards as well as to increase positive interactions among the members. This involvement is intended to develop skills that facilitate conflict solving and communication, besides strengthening a healthy and harmonious environment. Through this type of intervention, the family can get additional benefits that reduce the involvement with aspects of deviant behavior, such as the use of crack and other drugs among children and adolescents.

Besides lack of knowledge, another issue intensely discussed in the studies assessed derived from the debate on the repercussion of drug use in the family group. This panorama is mainly permeated by aspects of violence, of risk for the personal and family members' lives in view of drug traffic, besides the consequences for the intra-family relationship.

Study 6,2020. Rodrigues DS, Backes DS, Freitas HMB, Zamberlan C. Gelhen MH, Colomé JS. Conhecimentos produzidos acerca do crack: uma incursão nas dissertações e teses brasileiras. Ciênc Saúde Coletiva. 2012 May; 17(5):1247-58. which was intended to analyze the contributions of the knowledge produced about crack in Brazilian Master's and Doctoral programs evidenced that the main difficulties the parents faced after they discover their child's drugs use were aggressiveness, robbery and theft. They reported that the most frequent thoughts were fear of their child's death and imprisonment.

Concerning the repercussion of drugs use, in studies 3, 9, 21, negative events were identified, such as conflicts and fights in the family context of the users of crack and other drugs, characterized by reports of physical, verbal and/or psychological aggression. Another important issue refers to the family's repressive attitudes towards the use of crack and other drugs, such as home imprisonment, as they feel powerless in view of the problem.1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,2323. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Family ties of crack cocaine users cared for in a psychiatric emergency department. Rev Latino-Am Enfermagem. 2011 Oct; 19(5):1163-70.,3535. Minkler M, Roe KM, Price M. The physical and emotional health of grandmothers raising grandchildren in the crack cocaine epidemic. Gerontologist. 1992 Dec; 32(6):752-61.

This turbulent environment directly influences the growth and development of these children and adolescents. Studies 15 and 22 reveal that the behavior and the family environment, with its standards and conducts towards the use of crack and other drugs, can contribute for its members to turn into young people and adults with antisocial behavior, delinquents, drug users, prostitutes, with a high risk of getting into criminal life and with few chances of becoming adults resilient to the adversities of life.2929. Johnson BD, Dunlap E, Maher L. Nurturing for careers in drug use and crime: conduct norms for children and juveniles in crack-using households. Subst Use Misuse. 1998 Jun; 33(7):1511-46.,3636. Dunlap E, Johnson BD. The setting for the crack era: macro forces, micro consequences (1960-1992). J Psychoactive Drugs. 1992 Oct-Dec; 24(4):307-21.

The family members' quality of life can also be subject to immeasurable consequences. Study 41818. Moreira TC, Figueiró LR, Fernandes S, Justo FM, Dias IR, Barros HMT, Ferigolo M. Quality of life of users of psychoactive substances, relatives, and non-users assessed using the WHOQOL-BREF. Ciênc Saúde Coletiva. 2013 jul; 18(7):1953-62. assessed the quality of life among drug users and their relatives in comparison to non-users, using a validated questionnaire to assess the score. The results demonstrated that the quality of life of family members and users is directly affected. Article 62020. Rodrigues DS, Backes DS, Freitas HMB, Zamberlan C. Gelhen MH, Colomé JS. Conhecimentos produzidos acerca do crack: uma incursão nas dissertações e teses brasileiras. Ciênc Saúde Coletiva. 2012 May; 17(5):1247-58. highlighted reports of individuals who affirmed that their quality of life dropped by 100% when one of their children was identified as a user of crack and other drugs.

This family relationship, which should be mediated by kindness and bonds of affection, is ruptured by the drug. The family relation becomes dominated by ignorance, fear and concern, changing the relations of trust, respect, freedom and quality of life.

The support networks for the family and for coping with the use of crack and other drugs

The family feels passive and impotent in view of the aggressive effects of crack and other drugs. A feeling of resignation to the treatment exists, which becomes distant from reality. In that sense, it is important to know what the literature appoints as strategies to cope with the problem.

The therapeutic process of drug addicts involves multiple aspects, taking months to years to abstain from the drug. This approach includes pharmacological aspects, basic principles of the disease, prevention of relapse, psycho-educational and social aspects, family engagement in individual and family therapy, self-help groups, search for alternative activities, care from health professionals in inpatient treatment and in therapeutic communities (5, 8, 17).1919. Vargas L, Alberto F. Consumo de alcohol y sustancias adictivas en población escolar de 7 centros educativos municipio de Managua, Septiembre-Octubre del 2011[dissertação]. Managua (NI): Universidad Nacional Autónoma de Nicaragua. Centro de Investigaciones y Estudios de la Salud. Escuela de Salud Pública de Nicaragua; 2012.,2222. Gabatz RIB, Schmidt AL, Terra MG, Padoin SMM, Silva AA, Lacchini AJB. Percepção dos usuários de crack em relação ao uso e tratamento. Rev Gaúcha Enferm. 2013 Mar; 34(1):140-6.,3131. Roe KM, Minkler M, Saunders F, Thomson GE. Health of grandmothers raising children of the crack cocaine epidemic. Med Care. 1996 Nov; 34(11):1072-84.

When the participation of the health sector in this process is assessed, articles 1, 2, 3, 5, 7 and 17 reveal that the health teams are not prepared to work with the theme chemical addiction. Some factors can be associated with this situation, such as the lack of material and human resources for training and the constitution of work and support groups, besides the professionals' distrust in the users' rehabilitation.1515. Barbosa de Pinho L, Ramos Oliveira I, Cardozo Gonzales RI, Harter J. Consumo de crack: repercusiones en la estructura y en la dinámica de las relaciones familiares. Enferm Glob. 2012 Jan; 11(25):139-49.,1818. Moreira TC, Figueiró LR, Fernandes S, Justo FM, Dias IR, Barros HMT, Ferigolo M. Quality of life of users of psychoactive substances, relatives, and non-users assessed using the WHOQOL-BREF. Ciênc Saúde Coletiva. 2013 jul; 18(7):1953-62.

This context hampers the implementation of actions intended to support the family of drug addicts. The use of basic health services and of the Psychosocial Support Network (PSN) is constructed and strengthened, with emphasis on the medication treatment. This form of isolated care does not respond to the demands deriving from the users' hazardous consumption and the impact it causes in the family context.

Studies 3, 5 and 16 appoint an important factor: the coping with the use of crack and other drugs should be based on the incorporation and integration of other actors beyond the health sector, as the problem comprises social, psychological, economic, safety and health aspects. The organization and functioning of the strategies should be guided by the users and the family's needs. The treatment should be focused on resources that permit the expansion of the life prospects and the strengthening of the family and social bonds.1717. Seleghim MR, Oliveira MLF. Influência do ambiente familiar no consumo de crack em usuários. Acta Paul. Enferm. 2013; 26(3):263-8.,1919. Vargas L, Alberto F. Consumo de alcohol y sustancias adictivas en población escolar de 7 centros educativos municipio de Managua, Septiembre-Octubre del 2011[dissertação]. Managua (NI): Universidad Nacional Autónoma de Nicaragua. Centro de Investigaciones y Estudios de la Salud. Escuela de Salud Pública de Nicaragua; 2012.,3030. Dunlap E, Johnson BD. gaining access to hidden populations: strategies for gaining cooperation of drug sellers/dealers and their families in ethnographic research. Drugs Soc. 1998 Oct; 14(1-2):127-49.

The family should not neglect the support for the addict, who also needs treatment. The professionals involved in care should get to know the family's world better and make possible new strategies and routes for people to live together, through appropriate treatment, in accordance with the discussion in studies 1, 7 and 17.1515. Barbosa de Pinho L, Ramos Oliveira I, Cardozo Gonzales RI, Harter J. Consumo de crack: repercusiones en la estructura y en la dinámica de las relaciones familiares. Enferm Glob. 2012 Jan; 11(25):139-49.,2121. Monteiro CFS, Araújo TME, Sousa CMM, Carvalho e Martins MC, Lima e Silva LL. Adolescentes e o uso de drogas ilícitas: um estudo transversal. Rev Enferm UERJ. 2012 jul-set; 20(3):344-8.,3131. Roe KM, Minkler M, Saunders F, Thomson GE. Health of grandmothers raising children of the crack cocaine epidemic. Med Care. 1996 Nov; 34(11):1072-84.

Unfortunately, sectorial or institutional actions are observed today, which hardly contribute to the management of this phenomenon. The efficacy of public policies is jeopardized as new data appointed the growing consumption of crack and other drugs and difficulties in the treatment and rehabilitation of the users and family members who deal with the problem daily. Therefore, reflecting on this panorama is fundamental: intersectoral articulation should be encouraged (public safety, education, health, work, among others) to permit and facilitate the elaboration of efficient and effective public prevention and treatment policies.

Another important aspect related to the support network for the family of users of crack and other drugs is religion. This factor can be observed in the results of studies 1, 2, 5, 9 and 10. In certain situations, religiosity and the development of spirituality are related to the consumption of drugs or not, as well as with the recovery of drug addicts. Besides the protective aspect, faith strongly figures as a strength capable of raising hope among family members for the son or daughter's recovery.1515. Barbosa de Pinho L, Ramos Oliveira I, Cardozo Gonzales RI, Harter J. Consumo de crack: repercusiones en la estructura y en la dinámica de las relaciones familiares. Enferm Glob. 2012 Jan; 11(25):139-49.-1616. Seleghim MR, Inoue KC, Santos JAT, Oliveira MLF. Aspectos da estrutura familiar de jovens usuários de crack: um estudo do genograma. Cienc Cuid Saude. 2011; 10(4):795-812.,1919. Vargas L, Alberto F. Consumo de alcohol y sustancias adictivas en población escolar de 7 centros educativos municipio de Managua, Septiembre-Octubre del 2011[dissertação]. Managua (NI): Universidad Nacional Autónoma de Nicaragua. Centro de Investigaciones y Estudios de la Salud. Escuela de Salud Pública de Nicaragua; 2012.,2323. Seleghim MR, Marangoni SR, Marcon SS, Oliveira MLF. Family ties of crack cocaine users cared for in a psychiatric emergency department. Rev Latino-Am Enfermagem. 2011 Oct; 19(5):1163-70.-2424. Kliewer W, Murrelle L. Risk and protective factors for adolescent substance use: findings from a study in selected Central American countries. J Adolesc Health. 2007 May; 40(5):448-55.

Study 11515. Barbosa de Pinho L, Ramos Oliveira I, Cardozo Gonzales RI, Harter J. Consumo de crack: repercusiones en la estructura y en la dinámica de las relaciones familiares. Enferm Glob. 2012 Jan; 11(25):139-49. explored the existing relation between religiosity and drug use. People who attend church tend to feel protected, and families of users see the encouragement of religious practice as an attempt to support the family relations and as a form of recovery. The support network religion constructs offers a safe environment that favors the establishment of bonds and affective relations between the individual and the community, including new people who can be of help in the process of social reinsertion and life.

In this context, it is fundamental to evidence and qualify the support network. The magnitude and interface of the problem are big. Therefore, the articulation of devices that can contribute and ally with the family in this coping is essential. Specific public policies need to be elaborated for the prevention and treatment of drug use in the family context, which consider not only other aspects, but also the range of configurations the families express.

FINAL CONSIDERATIONS

The use of crack and other drugs among children and adolescents is a public health problem with a great impact in the family group. This environment exerts important influence in the risk behavior of people in this family group, and also figures as a protective element at all ages. The positive factor related to protection should not be ignored, but addressed to prevent drug consumption among children and adolescents whose parents serve as a reference.

Associated with this issue, the parents and responsible caregivers should be attentive to and informed on the drug phenomenon, as the subject's empowerment on the problem is relevant to cope with it. Therefore, inserting and preparing the families to work and dialogue on the aspects of health promotion, drug use prevention and the recovery of addicts is important, in view of the magnitude and dimensions of the problem. This articulation is fundamental to maintain the balance in the family environment, even if great difficulties come up.

It is necessary to constitute support networks that articulate individual and family needs. Stimulating the articulation of the public power's activities, such as health, education, social service and public safety, is a route that can strengthen the support and care network related to drugs use. This organization, associated with other initiatives from the civil society, has the ability and strength to promote the families' quality of life, as well as a better future for chemically addicted children and youth.

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    Article taken from the dissertation - Meanings and experiences of parents and responsible caregivers on children using crack and other drugs: a phenomenological approach, presented to the Programa de Pós-Graduação em Ciências da Saúde: Saúde da Criança e do Adolescente, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), 2014.

Publication Dates

  • Publication in this collection
    2016

History

  • Received
    01 Apr 2015
  • Accepted
    11 Nov 2015
Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
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