Deep breathing in the management of craving and anxiety symptoms of crack-cocaine-dependent patients

Abstracts

INTRODUÇÃO: O objetivo deste estudo foi verificar a efetividade do relaxamento respiratório no manejo do craving e dos sintomas de ansiedade em dependentes de crack internados para tratamento em uma unidade de desintoxicação. MÉTODO: Ensaio clínico do tipo quase-experimental de análise quantitativa. A amostra foi por conveniência, sendo composta por 32 homens dependentes de cocaína (crack). Eles tinham a cocaína como a droga de escolha e haviam utilizado esta substância por última vez entre 2 e 3 semanas antes do início do tratamento, conseguindo realizar a técnica do relaxamento respiratório adequadamente do ponto de vista biomecânico. Os instrumentos aplicados foram: Cocaine Craving Questionnaire-Brief (CCQB), escala analógica visual (EAV), Inventário Beck de ansiedade (BAI) e ficha com dados sociodemográficos e referentes ao padrão de consumo de substâncias psicoativas (FDS). Foi realizada uma intervenção em grupo na qual, inicialmente, foram aplicados o CCQB, a EAV e o BAI. Depois, foram apresentadas imagens relacionadas ao uso do crack e foram reaplicados os mesmos instrumentos. A seguir, foi realizado o relaxamento respiratório durante 10 minutos e foram aplicados, pela terceira vez, os instrumentos. Após esta intervenção, foi realizada uma entrevista individual com aplicação da FDS. RESULTADOS: Os resultados desta pesquisa demonstraram uma redução dos escores do CCQB, da EAV e do BAI pelo relaxamento respiratório em uma amostra cujo perfil corresponde ao padrão geral dos usuários de crack. CONCLUSÃO: Este estudo, apesar de ter algumas limitações metodológicas, sugere que o relaxamento respiratório pode ser uma estratégia efetiva no manejo do craving e dos sintomas de ansiedade em dependentes de crack.

Cocaína crack; síndrome de abstinência a substâncias; ansiedade

Deep breathing in the management of craving and anxiety symptoms of crack-cocaine-dependent patients

Taís Cardoso de Zeni^I; Renata Brasil Araujo^II

^IPhysical education specialist. Resident, Community Mental Health, Escola de Saúde Pública, Porto Alegre, RS, Brazil

^IIPsychologist. PhD, Psychology. Hospital Psiquiátrico São Pedro, Porto Alegre, RS, Brazil

This article is a brief communication written as a result of a study conducted as the senior research project of the Integrated Residence Program in Community Mental Health, Escola de Saúde Pública, Porto Alegre, RS, Brazil, presented and assessed by a scientific examination board on January 9, 2009 at the same institution

Correspondence

ABSTRACT

INTRODUCTION: The objective of this study was to verify the effectiveness of deep breathing in the management of craving and anxiety symptoms in crack-cocaine-dependent patients hospitalized for treatment in a detoxification unit.

METHODS: This is a quasi-experimental clinical trial using a quantitative analysis. The convenience sample comprised 32 crack-cocaine-dependent males. These subjects had cocaine as their drug of choice, having used this substance between 2 and 3 weeks prior to the beginning of the treatment, and were able to adequately perform the deep breathing technique. The instruments used were: the Cocaine Craving Questionnaire-Brief (CCQB), the visual analogue scale (VAS), the Beck Anxiety Inventory (BAI), and a form containing sociodemographic information and data related to the pattern of consumption of psychoactive substances (SDF). A group intervention was conducted with the administration of the CCQB, the VAS, and the BAI. After that, images related to the use of crack-cocaine were shown to the subjects and the same instruments were administered again. Next, the participants performed the deep breathing technique for 10 minutes, and the instruments were administered one more time. Finally, an individual interview was done and the SDF was completed.

RESULTS: Our findings demonstrated a decrease in the scores on the CCQB, the VAS and the BAI after the deep breathing technique was performed in a sample whose profile represents the general pattern of crack-cocaine users.

CONCLUSION: In spite of some methodological limitations, the present study suggests that the deep breathing technique is effective in the management of craving and anxiety symptoms in crack-cocaine-dependent patients.

Keywords: Crack-cocaine, substance withdrawal syndrome, anxiety.

INTRODUCTION

The difficulty in quitting the use of drugs is related to the lack of ability to resist the impulse to use the drug when feeling the craving. Craving, which is a sudden and intense desire to use a certain substance,¹ is an idiosyncratic experience including cognitive, affective, behavioral, and physiological aspects. Such irresistible desire, which is unconscious sometimes and often defeats the firm desire of keeping abstinence, may lead the drug-dependent individual to relapse and drop out from the treatment even after long periods of abstinence.²

Crack is cocaine hydrochloride processed with other substances in the form of "rocks" that can be smoked. After being smoked using a pipe, the beginning of cocaine effect (high) is almost instantaneous – within 5 or 10 seconds³–, stimulating the central nervous system, inhibiting the reuptake of dopamine, serotonin, and noradrenaline in synapses. However, such stimulating effects quickly disappear – within 5 to 10 minutes –, and the user experiences severe depression of the central nervous system; then, the individual is controlled by anxiety and craving, which lead to the compulsion for another dose. Potential abuse and dependence is much higher in the pulmonary route of administration than in other routes (oral, nasal, intravenous) because the drug effect is more intense and, at the same time, its effect lasts for a shorter period.^3,4

In the treatment of cocaine dependence, mainly in terms of craving reduction, consensus or promising results have not been reached regarding the effectiveness of psychopharmacology;⁵ therefore, a multidisciplinary and integrated approach of the user is essential, including the use of cognitive-behavioral techniques focused mainly on relapse prevention strategies.⁶ Craving is considered an important variable to be observed in the treatment of the cocaine-dependent patient and it is very important to reinforce the drug user's ability to experience craving without relapsing.³ Drug-dependent individuals need to learn how to identify and face craving, as well as the signs and stimuli associated with craving in order to develop the ability to resist this desire. During therapeutic sessions, craving can be induced and then reduced using coping techniques.²

For craving management, one of the coping techniques used in cognitive-behavioral therapy is deep breathing (DB). A study conducted with alcoholics has suggested the use of deep breathing as an effective strategy to control anxiety symptoms caused by craving.⁷ Another study involving smokers has demonstrated that deep breathing can significantly reduce craving and relieve other symptoms of tobacco abstinence.⁸

The objective of the present study is to investigate the effectiveness of DB in the management of craving and anxiety symptoms in crack-dependent patients admitted for treatment at a detoxification unit.

METHOD

This study is a quasi-experimental clinical trial using quantitative analysis. The research project was approved by the Research Ethics Committee of Hospital Psiquiátrico São Pedro (HPSP), Porto Alegre, state of Rio Grande do Sul, Brazil. All participants were asked to sign a written consent form before taking part in this study. Data were collected from May to October 2008 at the detoxification unit for male patients of HPSP during nine group sessions of psychoeducational intervention and during individual interviews done with the sample of patients selected. The data collected were analyzed using the Statistical Package for the Social Sciences (SPSS), version 12.0. Data were statistically analyzed. We carried out descriptive and frequency analyses of the demographic data, also considering data related to the pattern of use of psychoactive substances. Student's t test was used for paired samples in the inferential analysis. The significance level was set at 5%.

The instruments used were: the Beck Anxiety Inventory (BAI),^9,10 for the assessment of anxiety symptoms; the visual analogue scale (VAS),¹¹ and the Cocaine Craving Questionnaire-Brief (CCQB),¹² to check the presence of cocaine craving; and a sociodemographic data form (SDF) including data related to the pattern of use of psychoactive substances to identify the general characteristics of the sample and those factors related to drug use.

The intervention was carried out in a closed room with few environmental distractions. The group was comprised of three to six participants who voluntarily agreed to participate. The participants sat on chairs arranged in a circle around a table. First, anxiety symptoms and cocaine craving were assessed using the BAI, the VAS, and the CCQB. Next, eight pictures related to crack and its use ("rocks," pipes, cans) were shown for 1 minute. Then, the instruments (BAI, VAS, and CCQB) were administered again with the purpose of assessing induction of craving and anxiety symptoms. After that, the participants were instructed to perform the DB technique during 10 minutes while listening to soft music and remaining sitting with their eyes closed and the palm of their hands resting on their abdomen.

According to the biomechanical aspect, the DB technique consists in practicing breathing control using the diaphragm muscles during three different phases:

I. Inhaling through the nostrils, distending the diaphragm, expanding the abdomen, and counting three times;

II. Holding the air inside the lungs while counting three times;

III. Slowly exhaling through the mouth, contracting the diaphragm and the abdomen while counting six times.

After performing the DB technique, the participants completed the BAI, the VAS, and the CCQB for the third time to assess reduction of craving and anxiety symptoms. At the end of the intervention, the patients were informed that the relaxing technique causes a feeling of well-being, and that when someone is relaxed, it is less probable that he/she will act impulsively;² highlighting the fact that this technique may be useful for crack-dependent individuals regarding the management of craving and anxiety symptoms.

With the purpose of defining the profile of the sample selected and checking whether the patients met any additional exclusion criterion, we carried out individual interviews – during which the SDF was completed – with those participants who were able to adequately perform the DB technique considering the biomechanical requirements.

This was a convenience sample comprising 32 male patients diagnosed as crack-cocaine-dependent patients according to the ICD-10.¹³ These patients had crack as their drug of choice and had used this substance for the last time between 2 and 3 weeks before the beginning of the treatment. They were able to adequately perform the DB technique during the session considering biomechanical aspects. Those individuals with diagnostic hypotheses of mental retardation and/or who had psychotic symptoms were excluded from the present study.

RESULTS

Our sample included male patients whose mean age was 24.63 years (standard deviation = 4.64; 18-40). Most of them (72.7%) lived in the metropolitan area of Porto Alegre. The mean monthly income reported by the patients was R$ 606.56 (standard deviation = 313.04; 0-1,200.00), approximately 1.26 minimum salaries. These crack-dependent individuals (100%) were also addicted to tobacco (100%), marijuana (93.9%), alcohol (57.6%), and solvents (24.2%). With regard to the use of crack, these patients consumed an average of 67.76 rocks per week, which would result in approximately 271 rocks per month. Table 1 shows the alterations, according to Student's t test for paired samples, in craving means before and after the pictures were displayed and craving and anxiety means before and after DB.

DISCUSSION

Our sample had a prevalence of crack consumption among young adults who had low income, used multiple drugs or had a history of consumption of other psychoactive substances – mainly alcohol, tobacco, and marijuana –, which is in agreement with other studies related to the profile of crack users.^14-17

During group psychoeducational intervention, there was a significant induction of craving evidenced by the scores on the CCQB and the VAS after the pictures related to the use of crack were shown. Some participants denied craving induction due to the pictures, which might be explained both by the difficulty in acknowledging craving and by the fear of reporting craving and, as a consequence, causing the postponement of discharge from treatment. Other patients reported they did not experience craving due to the pictures because they were in a protected and restraining environment, where the access to the drug was difficult. Some participants reported that craving induction was more strongly influenced by the participants' testimonials and behavior, which changed while the pictures were being shown, when they could identify the use of typical jargon and gestures.

After performing the DB technique, there was a decrease in the anxiety symptoms, which were investigated using the BAI, as well as a significant reduction of craving, which was measured using the CCQB and the VAS. These results showed an overlapping of anxiety symptoms and craving, suggesting the presence of the same underlying mechanisms in both phenomena, which is in agreement with findings of other studies conducted with chemical dependents,^7,18 and the simultaneous manifestation of hyperventilation, anxiety, and craving.¹⁹ Since the breathing pattern of anxious people tends to present hyperventilation, which, on its turn, leads to physiological symptoms caused by a significant increase in blood oxygenation – dizziness, paresthesia, chocking, and tachycardia –,²⁰ DB can be a powerful technique to control anxiety because it may cause a feeling of self-control, reducing the vulnerability to hyperventilation.²¹ In spite of the fact that the mechanisms that reduce craving and anxiety symptoms are not widely known, DB may be a strategy recommended for crack-dependent individuals with the purpose of providing a decrease in craving thanks to the anxiolytic effects inherent to DB and the partial mimesis of the characteristics of crack use: when it mimics the act of smoking by means of controlled diaphragmatic breathing, DB induces a sensory-motor experience that reduces craving.⁸

The intervention conducted in the present study made it possible to experience the DB technique as a relapse prevention strategy that can be taught in a clinical environment and administered whenever and everywhere. If it becomes a habit and is adequately performed, DB can contribute to increase the crack-dependent individuals' feeling of self-effectiveness because it improves their ability to deal with anxiety and craving – main factors of abusive behavior.⁷

The present study has some methodological limitations that make it impossible to conclude that the reduction of craving and anxiety symptoms was caused only by the DB technique. The use of soft music and the time during which DB was performed (10 minutes) may have had an influence in the lowering of the scores of the variables. In order to definitively demonstrate the effectiveness of DB in the management of craving and anxiety symptoms, it would be necessary to conduct a study involving a larger sample, shorter time of DB (5 minutes), as well as to compare the scores with a control group. It would be also recommended to check the administration of the technique outside the protected environment of the hospital, that is, during risk situations faced by crack-dependent individuals at their daily routine, with the purpose of checking the long-term effects of DB.

REFERENCES

• 1. Araujo RB, Oliveira MS, Moraes JF, Pedroso RS, Port F, de Castro MG. Validation of the Brazilian version of Questionnaire of Smoking Urges-Brief. Rev Psiquiatr Clin. 2007;34(4):166-75.
• 2. Beck A, Newman C, Wright F. Terapia cognitiva de las drogodependencias. Barcelona: Ediciones Paidos Iberica; 2000.
• 3. Seibel SD, Toscano Jr A. Dependência de drogas. São Paulo: Atheneu; 2001.
• ⁴
  World Health Organization. Neuroscience of psychoactive substance use and dependence. Geneva: WHO; 2004.
• 5. Focchi GR, Leite MC, Scivoletto S. Utilização do agonista dopaminérgico pergolida no tratamento da "fissura" por cocaína. Rev Bras Psiquiatr. 2005;23(4):188-94.
• 6. Marlatt AG, Gordon JR. Prevenção de recaída. Porto Alegre: Artes Médicas; 1993.
• 7. Almeida SC, Araújo RB. Avaliação da efetividade do relaxamento na variação dos sintomas da ansiedade e da fissura em pacientes em tratamento de alcoolismo. Bol Saude. 2005;19(2):135-42.
• 8. McClernon FJ, Westman EC, Rose JE. The effects of controlled deep breathing on smoking withdrawal symptoms in dependent smokers. Addict Behav. 2004;29(4):765-72.
• 9. Beck AT, Steer RA. Beck anxiety inventory manual. San Antonio: Psychological Corporation; 1993.
• 10. Cunha JA. Manual da versão em português das escalas Beck. São Paulo: Casa do Psicólogo; 2001.
• 11. Dols M, van den Hout M, Kindt M, Willems B. The urge to smoke depends on the expectation of smoking. Addiction. 2002;97(1):87-93.
• 12. Sussner BD, Smelson DA, Rodrigues S, Kline A, Losonczy M, Ziedonis D. The validity and reliability of a brief measure of cocaine craving. Drug Alcohol Depend. 2006;83(3):233-7.
• ¹³
  Organização Mundial da Saúde. Classificação de transtornos mentais e de comportamento da CID-10: descrições clínicas e diretrizes diagnósticas. Porto Alegre: Artes Médicas; 1993.
• 14. Ferreira Filho OF, Turchi MD, Laranjeira R, Castelo A. Perfil sociodemográfico e de padrões de uso entre dependentes de cocaína hospitalizados. Rev Saude Publica. 2003;37(6):751-9.
• 15. Duailibi LB, Ribeiro M, Laranjeira R. Perfil dos usuários de cocaína e crack no Brasil. Cad Saude Publica. 2008;24(Supl 4):S545-57.
• 16. Nappo SA, Galduróz JC, Raymundo M, Carlini EA. Changes in cocaine use as viewed by key informants: a qualitative study carried out in 1994 and 1999 in Sao Paulo, Brazil. J Psychoactive Drugs. 2001;33(3):241-53.
• 17. Ferri CP. Cocaína: padrão de consumo e fatores associados à procura de tratamento [dissertação]. São Paulo: Universidade Federal de São Paulo; 1999.
• 18. Swift RM, Stout RL. The relationship between craving, anxiety, and other symptoms in opioid withdrawal. J Subst Abuse. 1992;4(1):19-26.
• 19. Roelofs S. Hyperventilation, anxiety, craving for alcohol: a subacute alcohol withdrawal syndrome. Alcohol. 1985;2(3):501-5.
• 20. Ito LM. Terapia cognitivo-comportamental para transtornos psiquiátricos. Porto Alegre: Artmed; 1998.
• 21. Valença AM, Falcão R, Freire RC, Nascimento I, Nascentes R, Zin WA, et al. The relationship between the severity of asthma and comorbidites with anxiety and depressive disorders. Rev Bras Psiquiatr. 2006;28(3):206-8.

Publication Dates

• Publication in this collection
  18 Mar 2010
• Date of issue
  2009