Prevalence of crack cocaine use and its associated factors in patients treated in a specialized outpatient service

Prevalência e fatores associados ao uso de crack em pacientes em tratamento em serviço ambulatorial especializado

Abstract

Background

Despite the advance in studies addressing the use of crack cocaine, knowledge about the characteristics of users that seek treatment in the different modalities of care for substance use disorders is important to plan the operationalization of these services.

Objective

To analyze the prevalence and factors associated with the use of crack cocaine in outpatients.

Method

Cross-sectional study consisting in the analysis of the medical records of outpatients of a chemical dependency clinic located in the south of Brazil from 1999 to 2015. The Fisher’s exact test and the Poisson regression model were used to analyze the data.

Results

Medical records from 1,253 patients were analyzed, and 1,196 (95.5%) of them contained information on the use of crack cocaine. Use of this substance was reported by 47% (95% CI [44, 50]) of the outpatients. The risk group was composed of adults aged 20-39 years, with no income, who had three or more children, did not consume alcohol or marijuana, had continuous family assistance, spontaneously looked for the service, and had already been hospitalized or assisted at a therapeutic community or psychosocial center.

Conclusion

There is great demand for the outpatient care of crack cocaine users. It is crucial that the risk factors guide treatment planning.

Keywords:
crack cocaine; drug users; outpatient care; health services; substance-related disorders

Resumo

Introdução

embora tenhamos avançado nos estudos sobre o consumo de crack, é importante o conhecimento das características dos usuários que buscam tratamento nas diferentes modalidades assistenciais para transtornos relacionados ao uso de substâncias para planejar a operacionalização desses dispositivos.

Objetivo

analisar a prevalência e os fatores associados ao uso de crack em pacientes em tratamento de modalidade clínico-ambulatorial.

Método

estudo transversal, com análise dos prontuários dos pacientes do período de 1999 a 2015 de um ambulatório de dependência química no Sul do Brasil. Para análise dos dados foi realizado o teste exato de Fisher e regressão de Poisson.

Resultados

foram analisados os prontuários de 1.253 pacientes, dos quais 1.196 (95,5%) continham informações sobre o uso de crack. O uso de crack foi relatado por 47% (IC 95% [44, 50]) dos pacientes. O grupo de risco consistiu em adultos de 20 a 39 anos, sem renda, com três ou mais filhos, que não consumiam álcool ou usavam maconha, que tinham acompanhamento familiar contínuo, que buscavam espontaneamente o serviço, que já haviam sido internados em hospital ou feito acompanhamento em comunidade terapêutica ou centro psicossocial.

Conclusão

existe uma grande demanda no atendimento ambulatorial de pacientes que usam crack. É imprescindível que os fatores de risco orientem o planejamento do tratamento.

Palavras-chave:
cocaína crack; usuários de drogas; assistência ambulatorial; serviços de saúde; transtornos relacionados ao uso de substâncias

INTRODUCTION

Crack cocaine is a drug derived from the mixture of cocaine crystals or powder with water and sodium bicarbonate (NaHCO₃). When smoked, crack cocaine produces small particles that are rapidly absorbed by the lungs, reaching a peak level shortly after use¹. Crack cocaine is a potent form of cocaine that leads to quick and impressive stimulant effects when smoked, and it became popular in the late 1980s^2,3.

An initial short-term effect of crack cocaine comes from its effects in the central nervous system (CNS), such as the raise in the availability of dopamine, which leads to euphoria and a desire to use it again. Thus, its psychoactive and addictive affects are mainly due to its role in the limbic system of the brain, a group of interconnected regions that regulates pleasure and motivation⁴. In the long term, crack cocaine use leads to physiological changes in specific parts of the CNS that regulate the capacity of experiencing pleasure⁵.

Many advances in the understanding of the neurophysiological processes underlying dependency were made after decades of investigation, such as the changes in the function of the reward system and the neuroadaptive mechanisms involved⁶. The systemic, cognitive and functional impairments of crack cocaine and cocaine dependency are clinically evident, but the neuroanatomical foundations are still not completely known⁷. The causal principles have not yet been established, as well as the pharmacological targets. Currently, drug dependency is understood as a chronic and multifactorial pathology, as it includes genetic, neurophysiological and sociocultural components⁸.

Considering its magnitude and its harm to the users, their families and their communities, the use of crack cocaine represents one of the most important public health problems worldwide⁹. According to data released by the Federal University of São Paulo (Unifesp) for the 2^nd National Report on Alcohol and Drugs, Brazil occupies the second position in the global ranking of consumption of cocaine and derivatives, only behind the United States of America¹⁰. A study conducted in Brazilian capital cities estimated a prevalence of 0.81% of regular crack cocaine users¹¹. As a consequence, there has been an increase in the number of people that seek treatment to crack cocaine dependency^12,13. Thus, crack cocaine has become a serious public health problem, demanding effort from health services to provide an effective treatment for this chemical dependency¹⁴.

Data on crack cocaine use and dependency are diverse, indicating a need for acknowledging the different types of users, since different characteristics demand multiple health resources to complement the search for integral assistance. The identification of cultural, economic and social aspects associated with crack cocaine users exposes the magnitude of the matter and highlights the challenge of health professionals to find suitable ways to intervene in this reality, mainly through the formulation of prevention, treatment and health promotion public policies¹⁵.

The scientific production addressing crack cocaine consumption has increased since the 1990s, with many studies conducted by various national and international authors, with special focus on the epidemiological profile of users, the pattern of consumption, and its effects in the organism^16-19. However, from the paradigm of the psychiatric reform, which acknowledges the relevance of epidemiological data while considering the plurality associated with drug use, we understand that there is a need to contextualize the problem and discuss it in light of the new tendencies of care, which involve community services, and of the everyday practice of health professionals.

Despite the advance in epidemiological studies on crack cocaine use, knowledge about the characteristics of users that seek treatment in the different modalities of care for substance use disorders is important to rethink and problematize the operationalization of these services. In this context, aiming to contribute with the advance in knowledge, especially in the area of the public health, this study aimed to analyze the prevalence of crack cocaine use and its associated factors in outpatients.

METHOD

Design and population

This is a cross-sectional study that used data from medical records of the Regional Center for Studies and Prevention of Chemical Dependents (CENPRE). This is the Regional Referral Center (CRR) of the Federal University of Rio Grande (FURG), intended for the prevention, research and outpatient treatment of chemical dependency on psychoactive substances. Approximately 35 patients are admitted at CENPRE every week. Following admission, assistance is performed immediately, the next appointments are scheduled, and a medical record is initiated.

All patients admitted at CENPRE from 1999 (when the service was implemented) to 2015, who have provided written informed consent, were included in this study. In addition, only patients whose medical records contained information on current crack cocaine use or not were included. The exclusion criteria were not having signed a an Informed Consent Form (ICF) and/or missing information on crack use in the medical record. Analysis of the medical records and data tabulation were performed by two undergraduate students of the health sciences, medicine and psychology course under the supervision of an epidemiology professor.

This study was submitted for evaluation and approved the Research Ethics Committee of the FURG under protocol no. 194/2015. Resolution 466/2012 on research involving human beings was respected throughout this study.

Outcomes

The outcome of this study consisted of information on current crack cocaine use. To this end, the following groups of variables were analyzed: 1) sociodemographic (sex, age, level of education, profession, income, marital status, number of children); 2) use of drugs throughout life (age when started using drugs, use of other drugs other than crack cocaine, such as alcohol, tobacco, marijuana, and cocaine); 3) variables associated with treatment (family assistance, reason for admission, medical referral, abstinence episodes in the beginning of the treatment, previous treatments, psychiatric and psychological treatment, hospital admission, treatment in a therapeutic community, treatment in Alcoholics Anonymous (AA), treatment at a Psychosocial Support Center (CAPS), time under treatment, time until start of the treatment).

Data collection and analysis

Data were obtained from the CENPRE medical record of each patient. The records contained information on clinical data and those associated with the sociodemographic profiles of the patients. The records were digitized by two independent typists using the Epi-Data 3.1 software. The variables were presented as absolute and relative frequencies. A 95% confidence interval (95% CI) was considered for the outcomes. The Fisher’s exact test was used to compare proportions. Multivariate analysis was performed using the Poisson regression model. The variables in each table were adjusted for the variables within the same table and for variables from upper-level tables. The adjusted model was performed with control of the variables in Table 1 for the other variables in Table 1, variables in Table 2 for the ones in Tables 1 and 2, and variables in Table 3 for those in Tables 1, 2, and 3. Statistical significance was set at 5% (p<0.05) for the two-tailed tests. The data were processed using the Stata 15.1 statistical software.

Table 1
Distribution of the sociodemographic variables according to the prevalence of crack cocaine users under outpatient care at CENPRE, Rio Grande, Rio Grande do Sul, 2015

Variable	N	Prevalence %	Crude analysis (95%CI)	Adjusted analysis (95%CI)
Sex	1,194		p=0.06	p=0.07
Male	957	45.7	1.00	1.00
Female	237	52.3	1.15 (1.00; 1.32)	0.60 (0.34; 1.06)
Age (years)	1,186		p<0.01	p<0.01
10-19	208	43.8	1.00	1.00
20-29	397	63.7	1.46 (1.23; 1.73)	2.08 (0.98; 4.38)
30-39	316	54.4	1.24 (1.04; 1.50)	2.00 (0.93; 4.31)
≥40	265	15.9	0.36 (0.26; 0.50)	0.52 (0.18; 1.45)
Level of education	646		p=0.43	p=0.65
Up to primary school	419	24.2	1.00	1.00
Middle or high school	227	22.0	0.89 (0.66; 1.19)	1.10 (0.74;1.62)
Occupation	730		p=0.02	p=0.77
Self-employed	148	31.8	1.00	1.00
Employed	162	31.5	0.99 (0.71; 1.38)	0.87 (0.47; 1.60)
Unemployed	209	38.8	1.22 (0.91; 1.63)	0.72 (0.37; 1.38)
Student	67	22.4	0.71 (0.43; 1.17)	1.06 (0.36; 3.06)
Others	144	22.9	0.72 (0.49; 1.06)	0.97 (0.55; 1.70)
Income	475		p<0.01	p=0.02
With no income	137	32.9	1.00	1.00
Up to one minimum wage	93	10.8	0.33 (0.17; 0.62)	0.32 (0.14; 0.74)
One to two times the minimum wage	125	24.0	0.73 (0.49; 1.08)	0.57 (0.31; 1.05)
Three times or more the minimum wage	120	10.8	0.33 (0.19; 0.58)	0.29 (0.12; 0.68)
Civil status	761		p=0.01	p=0.27
Single	308	25.3	1.00	1.00
Married / stable union	318	36.2	1.43 (1.12; 1.82)	0.77 (0.50; 1.18)
Separated, divorced, widowed	135	34.1	1.35 (0.99; 1.82)	0.58 (0.27; 1.23)
Number of children	797		p<0.01	p=0.11
0	242	19.4	1.00	1.00
1	221	41.1	2.17 (1.61; 2.92)	1.64 (0.98; 2.76)
2	154	42.9	2.21 (1.61; 3.02)	1.69 (0.95; 2.98)
≥3	180	37.2	1.92 (1.39; 2.64)	2.01 (1.12; 3.63)

• N: number of individuals; CI: confidence interval

Table 2
Distribution of the variables related to the treatment according to the prevalence of crack users under outpatient care at CENPRE, Rio Grande, Rio Grande do Sul, 2015

Variable	N	Prevalence %	Crude analysis (95% CI)	Adjusted analysis (95% CI)
Family assistance	1,148		p<0.01	p=0.12
Initial interview	296	29.4	1.00	1.00
Continuous assistance	240	31.7	1.08 (0.83; 1.39)	1.28 (0.73; 2.26)
Not performed	612	59.8	2.04 (1.09; 2.46)	0.59 (0.29; 1.23)
Reason for seeking treatment	1,156		p<0.01	p=0.50
Knowledge about chemical dependency	978	48.4	1.00	1.00
Others	178	35.4	0.73 (0.59; 0.90)	1.61 (0.40; 6.42)
Referral	740		p<0.01	p<0.01
Spontaneous	313	39.0	1.00	1.00
Other persons	427	23.2	0.59 (0.48; 0.74)	0.13 (0.06; 0.30)
Abstinence in the beginning of treatment	948		p=0.93	p=0.16
No	516	46.1	1.00	1.00
Yes	432	45.8	0.99 (0.87; 1.14)	0.72 (0.45; 1.15)
Previous treatment	748		p<0.01	p=0.88
No	259	27.0	1.00	1.00
Yes	525	44.8	1.66 (1.33; 2.07)	0.95 (0.45; 1.97)
Psychiatric treatment	741		p<0.01	p=0.70
No	666	39.5	1.00	1.00
Yes	75	21.3	0.54 (0.35; 0.84)	1.20 (0.48; 3.00)
Psychological treatment	735		p=0.43	p=0.27
No	714	37.7	1.00	1.00
Yes	21	28.6	0.76 (0.38; 1.50)	1.68 (0.67; 4.22)
Hospital admission	750		p<0.01	p=0.48
No	476	31.9	1.00	1.00
Yes	274	48.9	1.53 (1.28; 1.83)	1.16 (0.78; 1.72)
Therapeutic community	748		p<0.01	p<0.01
No	572	31.1	1.00	1.00
Yes	176	61.9	1.99 (1.68; 2.36)	2.91 (1.40; 6.05)
CAPS	737		p=0.03	p<0.01
No	656	36.4	1.00	1.00
Yes	81	48.2	1.32 (1.03; 1.69)	2.73 (1.51; 4.93)
Time until start treatment	885		p<0.01	p=0.68
≤5 years	164	40.2	1.00	1.00
6-10 years	151	55.6	1.38 (1.09; 1.75)	0.77 (0.13; 4.62)
11-20 years	273	56.4	1.40 (1.13; 1.74)	1.03 (0.15; 7.08)
21-30 years	186	37.1	0.92 (0.71; 1.20)	1.12 (0.14; 8.77)
>30 years	111	10.8	0.27 (0.15; 0.77)	0.27 (0.01; 5.25)
Permanence time	1,195		p<0.01	p=0.88
<1 month	759	57.3	1.00	1.00
1-6 months	318	32.4	0.57 (0.48; 0.67)	0.92 (0.54; 1.59)
>6 months	118	20.3	0.36 (0.25; 0.51)	1.10 (0.52; 2.35)

• N: number of individuals; CI: confidence interval

Table 3
Distribution of the variables related to the use of drugs according to the prevalence of crack users under outpatient care at CENPRE, Rio Grande, Rio Grande do Sul, 2015

Variable	N	Prevalence	Crude analysis (95% CI)	Adjusted analysis (95% CI)
Age when started using drugs	889		p=0.16	p=0.81
≤12 years	224	47.3	1.00	1.00
13-17 years	541	43.4	0.92 (0.78; 1.09)	1.26 (0.63; 2.53)
≥18 years	124	36.3	0.77 (0.59; 1.01)	1.18 (0.30; 4.57)
Current alcohol consumption	1,047		p<0.01	p=0.16
No	402	58.0	1.00	1.00
Yes	645	27.9	0.48 (0.42; 0.56)	0.66 (0.37; 1.19)
Tobacco	1,053		p=0.79	p=0.05
No	533	39.8	1.00	1.00
Yes	520	40.6	1.02 (0.88; 1.18)	1.81 (1.00; 3.27)
Marijuana	1,078		p<0.01	p<0.01
No	557	33.8	1.00	1.00
Yes	521	49.1	1.46 (1.26; 1.68)	2.35 (1.31; 4.22)
Cocaine	1,073		p<0.01	p=0.10
No	575	36.9	1.00	1.00
Yes	498	45.7	1.26 (1.09; 1.45)	0.64 (0.38; 1.08)

• N: number of individuals; CI: confidence interval

RESULTS

Patient characteristics and recruitment

Medical records from 1,253 patients were analyzed, and 1,196 (95.5%) of them contained information on current use of crack cocaine. From these, 80.2% were male and 60.1% were aged 20-39 years. Concerning marital status, 41.8% of the patients were married or in a stable relationship and 69.6% had children. With respect to level of education, nearly two thirds (64.8%) had up to eight years of regular education. Regarding profession and income, 28.6% were unemployed and 28.8% did not have an income.

From 1999 to 2007, the prevalence of patients that used crack cocaine was 6%. There was a significant raise in the number of users from 2008 to 2010, when a prevalence rate of 76.6% was observed. From 2011 to 2014, this rate reduced to 50.6%. Knowledge about chemical dependency was the most reported reason for seeking treatment (84.6%), and 42.3% sought the service spontaneously. Nearly two thirds (70.2%) of the patients had undergone previous treatment, 36.5% had already been hospitalized, 23.5% had attended a therapeutic community, 11% had been treated at a CAPS, 10.1% had had psychiatric assistance, and only 2.9% had undergone psychological treatment. For more than half of the patients (64.4%), it took more than 11 years to seek professional care. Concerning time under the service, 63.3% were followed up for up to a month.

In relation to drug use, most individuals (86.1%) started using drugs before the age of 18. Alcohol consumption was the most prevalent variable (61.6%), followed by use of tobacco (49.9%), marijuana (48.3%) and cocaine (46.4%).

Crack cocaine history of the surveyed participants

Current use of crack cocaine was reported by 47% (95% CI [44, 50]) of the patients, with those aged 20-29 years (63.7%) considered as of greater risk. Absence of income (32.9%) was significantly associated with the use of crack cocaine, and was one of the variables with the strongest association with the risk group. Having three or more children was another risk factor for crack cocaine use (37.2%). A significantly higher prevalence was observed among unemployed (38.8%) and married (36.2%) individuals. After performing the adjusted analysis for confounding factors, age and income maintained their association with the risk group, whereas occupation, marital status, and number of children lost their significant association. There were no statistically significant differences regarding sex and level of education (Table 1).

Use of crack cocaine and characteristics associated with treatment

Among the variables associated with treatment, current use of crack cocaine presented significantly higher association in patients that did not have family assistance (59.8%) compared with those who sought treatment as a result of knowledge about chemical dependency (48.4%) and with those who spontaneously sought the outpatient service (39%). Among the patients who had been previously treated for chemical dependency (44.8%), current use of crack cocaine presented higher association in patients who had previously undergone psychiatric treatment (21.3%), had been hospitalized (48.9%), had attended a therapeutic community (61.9%), and had been treated at a CAPS (48.2%). Current use of crack cocaine was also higher in patients that took from 6 to 20 years to seek treatment (55.6 and 56.4%, respectively) and among those who remained up to one month under treatment (57.3%). Associations with spontaneously seeking the service and treatment at psychosocial support centers (CAPS) were maintained after the adjusted analysis was conducted (Table 2).

Use of crack cocaine in relation to use of other drugs

Regarding association of current use of crack cocaine with the use of other drugs (Table 3), higher prevalence rates of crack cocaine use were observed among users of marijuana (49.1%) and cocaine (45.7%) compared with patients who did not use these substances (33.8 and 36.9%, respectively). It is worth mentioning that the use of crack cocaine was higher in the group that did not currently consume alcohol (58%). After the adjusted analysis for confounding factors, the use of marijuana was still associated with the use of crack cocaine (Table 3), although current alcohol and cocaine consumption were no longer associated. Tobacco use, which was not associated in crude analysis, gained association after adjustment.

DISCUSSION

This study analyzed the prevalence of current use of crack cocaine and its associated factors in patients under outpatient treatment. The results showed that there is a great demand of crack cocaine users for treatment in the outpatient modality. Factors associated with current use of crack cocaine were also identified, and young adults aged 20-39 years, with no income, who consumed marijuana and tobacco were characterized as risk groups. In addition, some factors involved in the treatment were also associated to risk factors: patients who spontaneously sought the service and who previously attended a therapeutic community or were assisted at a CAPS. Altogether, the results suggest that there is great demand of crack cocaine users in this model of service, and the risk associated factors must be considered while planning health care actions, seeking improvement of the service offered.

The prevalence of crack cocaine users undergoing treatment in this study (47%) is similar to those observed in other studies. A previous study that evaluated the demand of crack cocaine users under treatment at the Psychosocial Support Center - Alcohol and Drugs (CAPS AD) - a service with similar characteristics that also offers multi-professional outpatient care, found a similar prevalence rate (45%)²⁰. Whereas the prevalence of psychiatric hospitalization was 21.6%²¹ and attendance of therapeutic communities was 92.3%²². Our data showed that there is great demand from patients who used crack cocaine for outpatient clinical care, which indicates that these care services are a good reference for patients - in supplementation for treatment with hospitalization and therapeutic residency regimen, but that require adequately trained professionals to offer an effective treatment.

The risk group concerning age included patients from 20 to 29 years old, and younger crack cocaine users showed higher prevalence for seeking treatment. This result corroborates that a previous report on crack cocaine users undergoing treatment at a CAPS, which observed that 42.5% of the users were young and aged <35 years²³. This indicates how much dependency and health problems related to the use of crack cocaine affect young adults. This treatment-seeking behavior can be explained by the large number of complications triggered by crack cocaine in the organism, increasing mortality among users aged <30 years²⁴.

Absence of income was one of the risk factors with higher association with current use of crack cocaine. This aspect draws attention to the fact that crack cocaine is more widespread among socially vulnerable populations²⁵, corroborating the result observed in our analysis. These associated characteristics are similar to those of young adults with low level of education who are mostly unemployed or not formally employed^26-29. It is essential that policies and services provide this population with access to prevention and treatment, as well as plan strategies of inclusion into social and work market programs.

Concerning the variables related to treatment, spontaneously seeking for treatment was strongly associated with crack cocaine use. This result corroborates findings from the national research on crack cocaine, which showed that 78.9% of crack cocaine users reported a will to undergo treatment¹¹. This can be related to the perception of the health and social hazards associated with crack cocaine use and the fear of harming family relations³⁰.

Association between therapeutic community attendance or treatment at CAPS and crack cocaine use indicates both the demand of the patients for treatment and the low persistence in previous treatments^31,32. Moreover, having different services involved in care offer points to the need of a network operation to better understand the case and, consequently, improve the therapeutic planning and the possibility of sustained assistance.

Concerning the permanence time of crack cocaine users in the services, the results reveal a worrisome scenario, since 57.3% of the patients that persisted in treatment for less than one month were crack cocaine users. This finding corroborates the results of an previous study on the assessment of treatment drop out³¹. Crack cocaine users showed the highest probability of quitting compared with users of other drugs, with twice the chance for giving up treatment³¹. It is important to mention that low adherence indexes were not only found in this study, but also in other national and international reports^32-35.

As in other studies, crack cocaine use showed a high association with the use of other drugs such as marijuana^23,36. Our findings agree with these results,, which show that crack cocaine users reported greater use of marijuana and tobacco compared with patients with dependency on other substances. The use of these substances may be associated with the reduction of symptoms related to crack cocaine use and as a management strategy for abstinence symptoms. There are studies in which patients report that the use of marijuana decreases the craving symptoms and produces changes in their behavior that help them deal with symptoms related to the use of crack cocaine^37,38. The use of multiple substances is a common occurrence among crack cocaine users, with crack cocaine reported as the substance associated with greater losses in different domains^35,39.

This study has some limitations. It was performed only through analysis of medical records, which does not permit evaluation of the diagnoses of comorbidities. Our sample included outpatients from a single service that is a part of the public health system and did not allow us to include patients who might have sought care in other services. Finally, the cross-sectional approach did not allow us to evaluate whether the associated factors are the cause or the consequence of crack cocaine use. In this sense, it is important that new investigations be carried out, including different populations and with methodological designs that can complement the knowledge on crack cocaine use and demands.

In conclusion, our results suggest that there is great demand from crack cocaine users for outpatient care, since half of the patients used crack cocaine. Our data also allow us to conclude that crack cocaine users under outpatient care show fewer social and health hazards. The goal of our study was to advance in the identification of the prevalence of crack cocaine use and its associated factors aiming to offer a foundation for the planning of services and measures directed to this population. Identifying the characteristics of service users is extremely important for the organization of spaces and care teams, as well as for the preparation of treatment plans. Currently, the importance of outpatient care is emphasized, which allows greater integration with society during treatment, and it is understandable that these services have a physical structure and professional structure different from other care devices. Identification of the demands enables the service to properly plan strategies that seek to meet the needs of these patients, as well as allowing us to evaluate when there is a need to refer these patients to other care services.

It is imperative that the risk factors guide the planning of the treatment to offer measures that serve the young adult population, a familiar approach to the patients, and that include social reinsertion related to income generation and the return to the work market, as well as strategies for increasing adherence. This attention is important to guarantee a treatment that considers the individual as a whole, in addition to clinical individuals, providing a better intervention. Thus, reducing the complications resulting from the use of crack cocaine and providing a better quality of life for the service users.

• Study carried out at Universidade Federal do Rio Grande (FURG) – Rio Grande (RS), Brasil.
• Financial support: none.

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Publication Dates

• Publication in this collection
  10 Dec 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  26 Mar 2019
• Accepted
  20 July 2020