Illicit Drug Use in Seven Latin American Countries: Critical Perspectives of Families and Familiars

et al. Illicit drug use in seven latin american countries: critical perspectives of families and familiars. Rev Latino-am Enfermagem 2009 novembro-dezembro; 17(Esp.):763-9. This cross-sectional multi-centre study explored how family members and friends of illicit drug users perceived protective and risk factors, treatment facilities and policies and laws regarding illicit drug use. Family members and friends of illicit drug users were recruited in 10 urban health care outpatient units in 7 Latin American countries (Brazil, Colombia, Costa Rica, Ecuador, Guatemala, Honduras and Mexico) to complete a questionnaire. The majority of the respondents chose psycho-social factors over genetic or biological explanations as causes of drug problems. Respondents felt that families and governments were responsible for preventing drug problems. Church/religious institutions were most often mentioned in the context of accessible treatment. When asked about access to treatment facilities, the majority said that there were not enough. Shame about drug use, cost, and limited treatment options were most often cited as barriers to treatment.

This cross-sectional multi-centre study explored how family members and friends of illicit drug users perceived protective and risk factors, treatment facilities and policies and laws regarding illicit drug use.Family members and friends of illicit drug users were recruited in 10 urban health care outpatient units in 7 Latin American countries (Brazil, Colombia, Costa Rica, Ecuador, Guatemala, Honduras and Mexico) to complete a questionnaire.The majority of the respondents chose psycho-social factors over genetic or biological explanations as causes of drug problems.Respondents felt that families and governments were responsible for preventing drug problems.Church/religious institutions were most often mentioned in the context of accessible treatment.When asked about access to treatment facilities, the majority said that there were not enough.Shame about drug use, cost, and limited treatment options were most often cited as barriers to treatment.DESCRIPTORS: street drugs; substance-related disorders; risk factors; protection; family; friends; health services accessibility; Latin America; multicenter study

INTRODUCTION
Problems stemming from illicit drug use are a major concern for individual countries and international organizations.These problems affect an increasing proportion of the world population.The World Health Organization (WHO) estimates 200,000 deaths from drug abuse in the year 2000, corresponding to 0.4 per cent of all deaths worldwide (1) .
In addressing these problems, it is important to consider among others the following critical elements: protective and risk factors, preventive initiatives, treatment facilities and laws and policies.
Understanding the role of family members and friends is essential to better face the challenges related to illicit drug use, especially for effective preventive and treatment responses (2)(3) .

Protective and Risk Factors
Protective factors, as pointed out are those attributes/ characteristics of individuals or their environment/context which inhibit, reduce or lessen the probability of drug use and/or abuse (4) .Key protective factors for drug use are easy temperament, social and emotional competence, religious involvement, family attachment, low parental conflicts, effective parent-adolescent communication, wellmanaged community environment, and marriage in early adulthood (5) .On the other hand, risk factors are as those characteristics, variables, or hazards that make it more likely for an individual to develop a health problem (6) .Drug use is also associated with economic and psycho-social factors such as poverty, social inequity, high unemployment rates, difficulties in family adjustment, unhealthy occupational environment, low education level and homelessness (7) .
Drug use usually begins in adolescence (7) , when individuals may not have a clear idea of its risks.
Initially, use is limited to one substance and to specific situations.Over time, drug use tends to increase (8) .
Protective and risk factors have dimensions that influence the design of preventive programs and policies: community, school, family and the individual (8)(9) .protective factors in individuals and in their environment (9) .Prevention can be broadly categorized as risk reduction, harm reduction, demand reduction and health promotion.Individuals and communities can be placed on a risk continuum varying from no risk to high risk (9)(10)(11) .Effective prevention requires a broader health promotion approach and has to be linked to other drug control responses in order to achieve long term benefits (12) .

Treatment Facilities
Research findings indicate that maintaining therapeutic contact for extended periods of time, with individuals with alcohol and other drug problems, may promote better long-term outcomes than limited treatment contact, 'treatment as usual' (13)   .Most of the treatment facilities in Latin America follow standardized treatment principles recommended by more developed countries.The Latin American Federation of Therapeutic Communities (14) developed a model that meets the illicit drug users' needs based on the principle that the cause of the drug use problem is not the drug, but the person as the main interpreter of his or her rehabilitation.

Laws and Policies
Facing the justice system for drug use can expose users to severe criminal penalties (15) .As a result, safeguards are necessary to protect the rights of individuals in compulsory treatment or prison (16) .
Furthermore, a balance must be found between state powers to detain persons involuntarily for public health and safety reasons and the personal rights of individuals while detained for treatment or rehabilitation (17) .
Since the 1980s, significant new legislation has been enacted in Latin America for the purposes

Treatment facilities
Respondents were asked about the availability of various treatment services (Table 2).
Church groups and health care services were the most mentioned.Overall, 73.4% of the respondents indicated that there were not enough facilities in their community for illicit drug use problems, and 72.6% indicated that it was not easy to get to the facilities.
Respondents were asked about barriers to treatment.

Laws and policies
Respondents were asked about consequences of national laws and policies regarding illicit drugs.A higher score indicates greater disagreement with the proposed consequences.The rank order of responses was: decrease drug access opportunity (3.18), favor users' social reintegration (3.03), favor users' treatment and recovery (3.00), ensure public safety (2.97), benefit society (2.94), protect the drug user (2.87), respect human rights (2.86), punish drug dealers (2.54),punish drug user (2.47), and increase criminal behavior (2.11).Respondents were asked why drug users should be arrested.A higher score indicates greater disagreement with the use of arrest in particular situations.The rank order of responses was: using illicit drugs (2.44), buying illicit drugs (2.17), carrying small amounts of illicit drugs (1.99), violent behavior (1.46), selling illicit drugs (1.31), and trafficking illicit drugs (1.22).Respondents were asked if various institutions respected the rights of people with drug problems.A higher score indicated greater disagreement.The health system had the lowest score (2.21) and police the highest (2.59).

Respondents feeling stigmatized
Respondents were asked about feeling stigmatized because of a family member's or friend's drug problem.More than half of the respondents indicated that they had experienced various types of stigma due to drug use by a family member or friend.
Table 3 shows the percentages of people who responded affirmatively to the corresponding questions.Most of the situations are related with their social relationships and the difficulties to communicate issues regarding their familiars using illegal drugs.

DISCUSSION
According to the literature, this is the first multi-centric study to gather information and describe illicit drug users' family and friends' perspectives from seven Latin American countries regarding protective and risk factors, preventive initiatives, availability of services and existing policies and laws pertaining to illicit drug use.Even though it is not an objective of this study, it is relevant to remark that there was little variation across study sites in terms of the results.
Some key themes emerged from the results.
For example, respondents' views reflect the reality that there are many complex risk and protective factors in different domains (individual, family, peer, school and community/societal) and they interact among each other.This assumption is in line with recent scientific evidence regarding addictions (2)(3)(4)(5) .The or their own impressions of government or the j u s t i c e s y s t e m .T h i s i s a c u r r e n t a r e a o f international debate (15)(16)(17) and Latin America needs to achieve progress in identifying what works best in this region.
However, when asked about access to treatment facilities, the majority said that there were not enough.The most common barriers for people getting to treatment included shame about drug use, cost and not enough treatment options.In terms of services alternatives, church groups were mentioned most often, followed by general hospital and health care clinics.It is important to contrast these views with the current existent addiction treatment services in each location as well as the role that churches may have in Latin America in treatment and recovery support.
Finally, it is necessary to remark that most of the respondents indicated that they had experienced various types of stigma because of drug use by a family member or friend.Those seeking or in treatment for illegal drug issues are frequently and disproportionately marginalized (18) .

STUDY LIMITATIONS
Among the limitations of this study are: (1)   The characteristics of the sample, considering the Silva J, Ventura CAA, Vargens OMC, Loyola CMD, Eslava Albarracín DG, Diaz J, et al.Illicit drug use in seven latin american countries: critical perspectives of families and familiars.Rev Latino-am Enfermagem 2009 novembro-dezembro; 17(Esp.):763-9.
of protecting the population from drug use, of stimulating preventive initiatives and of establishing treatment programs.The Organization of American States (OAS), through the Inter-American Drug Abuse Control Commission (CICAD), plays an important role in the Americas, providing guidelines for anti-drugs cooperation in the hemisphere.The perspectives of policy makers, scientists, health care providers and drug users are not sufficient to tackle the challenges presented by illicit drug problems.The views of drug users' family and friends -who live and share the experience -are critical for the successes and failures of preventive initiatives, treatment facilities and laws and policies.Their lived and shared experience is critical for understanding the problem and for designing, following-up and evaluating services provided to the community in Latin America.The research question of this study is: "How do illicit drug users' family and friends describe protective and risk factors, preventive initiatives, treatment facilities, and policies and laws respecting illicit drug use?"Its purpose is to gather information and describe illicit drug users' family and friends' perspectives in seven Latin American countries about (i) what protective and risk factors contribute to the development of drug related problems; (ii) the availability and accessibility of preventive initiatives for illicit drug use, (iii) the availability and adequacy of existing treatment, rehabilitation, and social reintegration programs, and (iv) existing policies and laws pertaining to illicit drug use.METHODS This study was approved by the Centre for Addiction and Mental Health (CAMH) / University of Toronto (UT) Research Ethics Board, the Heath Canada Research Ethics Board and by the institutional research ethics boards of each investigator's home university.This is a multi-centre cross-sectional study utilizing both quantitative and qualitative methods.The research was carried out in 10 health care outpatient units in eight urban centers of seven Latin American countries.These urban centers were Ribeirão Preto and Rio de Janeiro (Brasil), Bogota (Colombia), San Jose (Costa Rica), Guayaquil (Ecuador), Guatemala City (Guatemala), San Pedro del Sula (Honduras) and Queretaro (Mexico).Participants The sample was composed of a subset of the population.The research involved men and women over 18 years of age, self-defined and perceived by the researcher as cognitively fit and self-identified as being personally affected by, and caring for, a family member or friend who is (or was) an illicit drug user.Excluded were people under 18 years of age, people not cognitively fit, former illicit drug users or people using illicit drug(s).Participants were recruited in ten health care outpatient units through the posting of informational fliers, distribution of brochures, and snowball technique.The snowball technique was chosen as a recruitment strategy because of the sensitive nature of illicit drug use.A sample size of 100 participants per each health care outpatient unit was chosen based on available resources per site and on a number that would ensure sufficient variation in participant characteristics and experiences.One hundred people were selected at each unit -one unit in each urban area except Rio de Janeiro, where 3 units contributed to the sample.The total sample (N) was 1008.Data Collection and Analysis Quantitative data was collected by closedended survey questionnaires answered by all participants including information on: demographic information and data on participants' knowledge about risk and protective factors, prevention initiatives, treatment facilities, policies and laws.The survey included also questions regarding stigma experienced by the family and friends of illicit drug users.The qualitative section collected information in more detail on these topics that could not easily be obtained through closed questions.A sub-set (n=100) of the total study sample also participated in openended, semi-structured interviews in each site.Quantitative and qualitative data was collected by the researchers, trained students, or community-based research assistants.The research teams in all seven countries followed procedures based on the study manual to ensure inter-rater reliability.Confidential interviews were scheduled according to the convenience and confidentiality assurance of both participant and interviewer.To standardize data capture, an EpiData ® template was developed at CAMH and distributed to each site for data entry.Upon completion of data entry, each site transferred their data file to the CICAD/ OAS office, which then merged the data into a single file and distributed it to all sites.Data were managed

A
higher score indicates greater perception of this as a barrier.The rank order of responses was: Perceived stigma about drug use (3.16),Cost (3.08), not enough treatment options (2.98), not enough specific medication (2.88), long waiting lists (2.84), lack of specialized professionals (2.83), limited working / opening hours (2.77), distance (2.73) and lack of transportation (2.54).
respondents chose psycho-social factors such as curiosity, poor self-esteem, loneliness or seeking pleasure to explain addictions, over genetic or biological reasons.W i t h r e g a r d t o t h e r e s p o n s i b i l i t y f o rpreventing illicit drug problems, the respondents tended to attribute greater responsibility to families and governments over religious institutions or private companies.This may stem from their own experiences with families and friend rather than the lack of recognition of the need for a policy r e s p o n s e f r o m t h e s o c i e ty.H o w e ve r, t h e respondents had mixed opinions about the value of national laws and policies.They generally were more supportive of arrests for trafficking illicit drugs, selling illicit drugs and violent behavior than for using or buying illicit drugs.These perceptions might be related with a variety of factors such as the real weaknesses of laws and policies, issues related with implementation and enforcement, and This novel cross-sectional multi-centre study explored how family members and friends of illicit drug users perceived protective and risk factors, treatment facilities and policies and laws respecting illicit drug use in Latin America.It provided a meaningful perspective for better understanding of the drug phenomenon in the region.It also highlighted some health promotion and prevention based alternatives for addressing the main challenges.The indispensable role of families and friends in innovative and culturally relevant strategic responses to the challenges was made apparent.Future research is needed in terms of this research subject for Latin America.

Table 1 -
Rev Latino-am Enfermagem 2009 novembro-dezembro; 17(Esp.):763-9www.eerp.usp.br/rlaeIllicit drug use in seven latin american countries... Silva J, Ventura CAA, Vargens OMC, Loyola CMD, Eslava Albarracín DG, Diaz J, et al. and statistically analyzed using the Statistical Package for the Social Sciences (SPSS ® Version for Windows).Frequency of risk factors identified by illicit Protective and risk factors, Preventive initiatives, Treatment facilities, Laws and policies and Respondents feeling stigmatized.For each theme the results for the merged data (N=1008) are noted.The results are a combination of percentages and average scores on a four point (1 to four) scale.(17.4%),child(15.3%), and other (12%).In contrast to the sex of the respondents -most were female -the majority of the illicit drug users were male (81.2%).Their average age was 27.9 years and they lived with other relatives (57.7%), with a spouse or partner (22.8%), or alone (15.1%).Respondents identified the

Table 2 -
Availability of treatment services according to illicit drug users' family and friends

Table 3 -
Perceived stigma related situations -by Illicit drug use in seven latin american countries...SilvaJ, Ventura CAA, Vargens OMC, Loyola CMD, Eslava Albarracín DG, Diaz J, et al.Rev Latino-am Enfermagem 2009 novembro-dezembro; 17(Esp.):763-9www.eerp.usp.br/rlaesampling method (e.g., no random selection) and size does not allow to generalize the results at the country or Regional levels neither to compare accurately the results among countries.(2) The results presented here are based on self-reports and are thus subject to the various kinds of error associated with this approach, including the possibility of social desirability and recall biases.(3) Some potential weaknesses in terms of the validity of the applied measurement instrument (questionnaire).