Profile of crack users and factors related to criminality at the detoxication ward at Hospital Psiquiátrico São Pedro, Porto Alegre, Brazil

Abstracts

INTRODUCTION: This cross-sectional study was carried out with 30 crack users admitted at the male detoxication ward at Hospital Psiquiátrico São Pedro, in Porto Alegre, Brazil, from March to December, 2007. The objective of the present study was to identify the sociodemographic and psychoactive consumption profile of crack users and presence of antisocial behavior, anxiety and depression symptoms in patients admitted at the male detoxication ward at Hospital Psiquiátrico São Pedro, in Porto Alegre, Brazil. METHOD: Thirty crack users participated in the study, and the instruments used were a 55-item sociodemographic questionnaire to evaluate psychoactive substance consumption and presence of criminal records, Mental State Mini Exam, Beck Anxiety Inventory, Beck Depression Inventory, Fagerström Test for Nicotine Dependence and Visual Analog Scales for Craving. RESULTS: The main results led to a population of Caucasian young adults, mean age of 27.3 years, underemployed or unemployed. Presence of criminal records was observed in 40% of the sample and was associated with greater craving (U = 58.00; p = 0.035), more anxiety symptoms (U = 56.50; p =0.028) and depression (U = 47.00; p = 0.009). CONCLUSIONS: Presence of criminal records was frequent for crack users and this variable was related to more anxiety, depression and craving. Studies of this kind can enhance knowledge of the study population, in order to design a more effective therapeutic plan for these patients.

Cocaine; crack; crime; men; hospitalization units; drug effects

INTRODUÇÃO: O presente estudo transversal foi realizado com usuários de crack do sexo masculino internados na Unidade de Desintoxicação do Hospital Psiquiátrico São Pedro de Porto Alegre (RS) no período de março a dezembro de 2007. O objetivo do presente estudo foi identificar o perfil sociodemográfico e de consumo de substâncias psicoativas e a presença de conduta anti-social, sintomas de ansiedade e de depressão em usuários de crack internados na Unidade de Desintoxicação do Hospital Psiquiátrico São Pedro de Porto Alegre (RS), bem como verificar fatores associados à criminalidade nessa clientela. MÉTODO: Trinta sujeitos participaram do estudo, e os instrumentos utilizados foram: questionário sociodemográfico e de avaliação do consumo de substâncias psicoativas e de antecedentes criminais com 55 questões, Mini-Exame do Estado Mental, Inventário Beck de Ansiedade, Inventário Beck de Depressão, Fagerström Test for Nicotine Dependence e Escala Analógico-Visual de Fissura. RESULTADOS: Os principais resultados apontam para uma população de adultos jovens, de cor/raça branca, com idade média de 27,3 anos e em situação de subemprego ou desemprego. A presença de antecedentes criminais foi observada em 40% da amostra e está associada a maior fissura (U = 58,00; p = 0,035), a mais sintomas de ansiedade (U = 56,50; p = 0,028) e de depressão (U = 47,00; p = 0,009). CONCLUSÕES: É freqüente a presença de antecedentes criminais em dependentes de crack e esta variável está relacionada a mais ansiedade, depressão e fissura. Estudos deste tipo permitem ampliar o conhecimento da população atendida, para delinear de forma mais efetiva o plano terapêutico para esta clientela.

Cocaína; crack; crime; homens; unidades de internação; efeitos de drogas

en_v30n2a05

ORIGINAL ARTICLE

Profile of crack users and factors related to criminality at the detoxication ward at Hospital Psiquiátrico São Pedro, Porto Alegre, Brazil^*

Cristian Fabiano Guimarães^I; Daniela Vender Vieira dos Santos^II; Rodrigo Cavalari de Freitas^III; Renata Brasil Araujo^IV

^IMSc. Residence in Mental Health, Hospital Psiquiátrico São Pedro (HPSP), Porto Alegre, RS, Brazil. Psychologist, psychiatric hospitalization.

^IIPsychiatrist. Specialist in Labor Medicine.

^IIIResident in Collective Mental Health. Physical educator for chemical dependants.

^IVPhD. Psychologist, Unidade de Internação por Dependência Química Jurandy Barcelos, HPSP. Professor, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA), Porto Alegre, RS, Brazil.

^{Correspondence}

ABSTRACT

INTRODUCTION: This cross-sectional study was carried out with 30 crack users admitted at the male detoxication ward at Hospital Psiquiátrico São Pedro, in Porto Alegre, Brazil, from March to December, 2007. The objective of the present study was to identify the sociodemographic and psychoactive consumption profile of crack users and presence of antisocial behavior, anxiety and depression symptoms in patients admitted at the male detoxication ward at Hospital Psiquiátrico São Pedro, in Porto Alegre, Brazil.

METHOD: Thirty crack users participated in the study, and the instruments used were a 55-item sociodemographic questionnaire to evaluate psychoactive substance consumption and presence of criminal records, Mental State Mini Exam, Beck Anxiety Inventory, Beck Depression Inventory, Fagerström Test for Nicotine Dependence and Visual Analog Scales for Craving.

RESULTS: The main results led to a population of Caucasian young adults, mean age of 27.3 years, underemployed or unemployed. Presence of criminal records was observed in 40% of the sample and was associated with greater craving (U = 58.00; p = 0.035), more anxiety symptoms (U = 56.50; p =0.028) and depression (U = 47.00; p = 0.009).

CONCLUSION: Presence of criminal records was frequent for crack users and this variable was related to more anxiety, depression and craving. Studies of this kind can enhance knowledge of the study population, in order to design a more effective therapeutic plan for these patients.

Keywords: Cocaine, crack, crime, men, hospitalization units, drug effects.

INTRODUCTION

Chemical dependence has become a major public health problem and has challenged health professionals to understand the profile of users of psychoactive substances, due to the difficulties of management and approach to this problem.

In Brazil there is a current concern for the study of the profile of crack users accessing health services.¹ Cross-sectional studies focusing on this population are important, since there has been an increase in seek for treatment of crack users in varied modalities, including hospitalization for crack detoxication. Ferri et al.,² Parry et al.,³ Schifano et al,⁴ and Borini et al.⁵ observed a high prevalence of psychiatric hospitalizations following crack use either with or without association with other drugs. Laranjeira⁶ and Rassi⁷ showed that 46% of crack users did not improve or remained in the same situation after 1 year of hospital stay; 10% of users followed after hospitalization at a detoxication ward died and 7% were arrested, which suggests the need of deepening the knowledge on this population to contribute efficaciously to increase abstinence rates of this drug.

In this sense, Ferreira Filho et al.,¹ based on a study conducted on the sociodemographic profile of cocaine dependents admitted to psychiatric hospitals in the metropolitan area of São Paulo, concluded that crack users are more exposed to violent situations, which suggests more vulnerability and increase in risk factors for the health of this population. For that reason, Ribeiro et al.⁸ state that these individuals have a higher risk of death than the general population, and one of the main causes is homicide. The same authors⁸ suggest that further studies should analyze sociodemographic data of crack users considering history of drug use, as well as cultural and economic influences of users, with the aim of determining future prognoses and build new strategies for the approach of such a severe social problem.

Watkins et al.⁹ claimed that there is likely to be one or more mental disorders in alcohol and crack users, depression and anxiety being the most prevalent. In this sense, identifying existence of these disorders significantly contributes to a good treatment prognosis. Herrero et al¹⁰ and Falck et al.,¹¹ based on a prevalence study on cocaine users and using Beck Depression Inventory (BDI)¹² as a screening instrument for depression, concluded that the population using alcohol or cocaine was more likely to have moderate to severe depression.

Similarly, abusive use or dependence of other psychoactive substances is common in crack dependents. In this sense, Lai et al.¹³ showed that smokers are more likely to use cocaine and crack, and Parry et al.³ identified prevalence of primary and secondary use of other psychoactive substances, especially alcohol and cannabis. It should be stressed that these authors³ did not evaluate use of tobacco.

Ferreira Filho et al.¹ stressed that crack users have 57.4% more chances of being arrested, which is a quite significant fact. Compton et al.,¹⁴ in a study performed in the USA, did not observe a statistically significant association between antisocial personality disorder and use of substances, while showing an increase in chances of a correlation between use of drugs and antisocial personality disorder as there are comorbidities with other psychiatric disorders. Herrero et al.¹⁰ confirmed such trend in their study by finding a significant association between use of cocaine/crack and antisocial personality disorder.

Siegal et al.¹⁵ and Schifano et al.⁴ observed that crack users have problems relative to criminality. Siegal et al.¹⁵ stressed that users of that psychoactive substance that perceive its disadvantages, as well as individuals with history of previous treatment, were more likely to adhere to a new treatment, therefore showing the important role of motivation for change of addictive behavior in the therapeutic process, according to Oliveira et al.¹⁶

For being such a complex theme, this article aims at identifying the sociodemographic profile and consumption of psychoactive substances, as well as presence of antisocial behavior, anxiety and depression symptoms in crack users admitted at the Detoxication Ward (DW) at Hospital Psiquiátrico São Pedro (HPSP), in Porto Alegre, Brazil. In addition, it aims at verifying factors associated with criminality in this population.

METHOD

This is an exploratory cross-sectional study. The sample was comprised of 30 male individuals admitted at the DW Jurandy Barcellos of HPSP in Porto Alegre (male ward).

Inclusion criteria were all crack users admitted from March to December 2007 that had cognitive conditions to participate in the study (minimum of 25 points in the Mental State Mini Exam¹⁷) and that were abstinent for at least 7 days. Furthermore, the individual should meet the criteria for cocaine (crack) dependence according to the International Classification of Diseases (ICD-10).¹⁸ Exclusion criteria were individuals that had psychotic symptoms and that had schooling level below the fifth grade of elementary school, as the latter is a requirement for application of Beck scales.¹⁹

Eleven individuals were lost due to refusal in participating, besides 15 exclusions of individuals that did not meet the inclusion criteria. Data collection was performed by the researchers, and application of the questionnaires was performed individually.

The instruments were applied according to the following order:

1) Visual Analog Scale, used in many studies,^20-23 comprised of an increasing line from 0 to 10 and aimed at evaluating craving for crack use at the interview; 0 indicates none and 10 means high craving.

2) Questionnaire comprised of 55 close-ended questions, developed and previously tested in a pilot study, which aimed at evaluating four dimensions described as follows: a) demographic characteristics - age, color/race, origin; b) socioeconomic characteristics - marital status, schooling, profession and job, housing and monthly income, calculated based on the average regional minimum wage, according to the economic segment in the State of Rio Grande do Sul in November 2007, i.e., R$ 449.25; c) criminal record, motivated or not by use of crack and previous detention; d) behavior and pattern of crack use and other drugs, as well as history of previous treatments and attempts to stop using the drug; crack dependence severity was measured by the amount consumed a day.

3) Mental State Mini Exam,¹⁷ to evaluate presence of cognitive deficit.

4) BDI,¹² aimed to measure depression intensity based on the score resulting from the total sum of points, validated in Brazil.²⁴

5) Beck Anxiety Inventory (BAI),¹⁹ comprised of 21 items and aimed to measure severity of anxiety symptoms, also validated in Brazil.¹⁷

6) Fagerström Test for Nicotine Dependence (FTND), a questionnaire developed by Fagerström²⁵ and adapted by Healtherton et al.²⁶ It is an instrument comprised of six questions on smoking behavior, validated in Brazil by Carmo & Pueyo (2003),²⁷ whose score ranges between 0 and 4 - mild dependence; 5-6 - moderate dependence; and 7 - severe nicotine dependence.

The pilot study, conducted to definitely test the application of all data collection instruments as to their feasibility, including the questionnaire, was performed on a restricted sample (n = 5) before starting data collection. It aimed at correcting errors and performing adjustments in the instruments or in their application, in addition to obtaining complementary information for sample planning.

This study was approved by the Ethics Committee of HPSP. To be included in the study, participants had to sign a consent form.

Collected data were organized by the software Statistical Package for the Social Sciences (SPSS), version 12.0. Data analysis consisted of descriptive and frequency statistical tests for exploratory analysis of data. Mann-Whitney test was used for inference analysis. Significance level was set in 5%.

RESULTS

Table 1 shows the sociodemographic characteristics of the sample (n = 30). Mean age was 27.3 years (SD = 6.65; 18-41). These men had mean 9.4 schooling years (SD = 2.75; 5-14), and had mean monthly income of 1.45 regional minimum wages (SD = 1.42; 0-7), which was R$ 637.94 in November 2007. Regarding the occupational characteristics of the sample, 43.3% of the individuals reported being liberal professionals, while 36.7% were unemployed and only 20% were regular employees. The most reported professions were as follows: 30% worked in general services; 16.7% in civil construction; and 13.3% in trade. The rest of the sample (40%) reported being night watchmen, driver or another job.

Mean Visual Analog Scale score to evaluate craving was 2.90 points (SD = 3.08; 0-10). According to BAI scores, 40% had minimal anxiety symptoms; 16.7% mild; 23.3% moderate; and 20% severe. According to BDI scores, 20% had minimal depression symptoms; 30% mild; 40% moderate; and 10% severe. The FTND showed that nicotine dependence was mild in 53.3%, moderate in 36.7%, and severe in 10%.

Table 2 shows the frequency of use of crack and other psychoactive substances. Interviewees consumed a daily average of 11.57 crack rocks (SD = 7.85; 1-30) during the period before being admitted for detoxication, with mean expenses of R$ 57.85/day (SD = 39.26; 5-150). Mean age of crack use onset was 23.87 years (SD = 6.47; 16-40).

Before current hospitalization, 24 individuals reported having tried at least once to quit smoking crack, accounting for 80% of all individuals. Of the total sample (n = 30), 60% of interviewees underwent some type of treatment to interrupt crack use. The most common type of treatment was hospitalization for detoxication (43.3%), followed by treatments in clinics or therapeutic farms (13.3%). In average these individuals already tried to quit using crack 3.67 times (SD = 3.96; 0-17). When the study was performed, 96.7% of the patients manifested a desire to quit smoking crack after the current hospitalization, and all of them intend to quit smoking crack at some time throughout their lives.

Data regarding criminal records were analyzed, and the results can be seen in Table 3. Of those that had criminal records (n = 12), 25% (n = 3) committed crimes motivated by use of crack alone, while 41.7% (n = 5) had both types of crime: either motivated or not by drug use. All crimes were committed after the individuals started using psychoactive substances (cocaine or crack).

Groups that had (n = 12) and did not have criminal records (n = 18) were compared as to anxiety symptoms (BAI), depression symptoms (BDI), severity of nicotine dependence (Fagerström), crack consumption pattern/day (dependence severity) and craving (Visual Analog Scale). Results can be found in Table 4. Having a criminal record, according to Mann-Whitney test, was associated with greater craving (U = 58.00; p = 0.035), more anxiety symptoms (U = 56.50; p =0.028) and depression (U = 47.00; p = 0.009). It was not associated with crack consumption pattern/dependence severity (U = 53.00; p = 0.059) neither to tobacco severity (U = 102.50; p = 0.817).

DISCUSSION

The sample of this study was comprised of Caucasian (53.3%) and single (93.3%) young adults. Most (90%) have their own house, and only 30% have been homeless. Age of crack use onset in this population ranged between 16-40 years of age. These data are in disagreement with a study performed in the Metropolitan Area of São Paulo,¹ where there was prevalence of non-Caucasian crack users and higher frequency of users that had been homeless. However, studies have similar mean age group of this population, showing prevalence of drug use by young adults,^1,8,28 except for the study by Parry et al.,³ which found a higher mean (38 years) in cocaine/crack dependents in South Africa.

Initial age of crack use in this sample (23.87 years) stands out since 70% are aged 16-24 years, whereas a study conducted in São Paulo shows existence of users of this substance with mean age of 14.5 years.²⁹ To Waiselfisz,³⁰ the magnitude of homicide violence is more frequent in the age group between 15 and 24 years and advances in metropolitan regions, such as that of Porto Alegre (RS). Therefore, both adolescents and young adults represent a population exposed to risk of death from homicides, as crack use leads to robbery, violence and debts owed to drug dealers.³¹ A study on the situation of death vulnerability in adolescents³² (young adults might also be considered) from homicide in Porto Alegre (RS) showed that the main causes are revenge, participation in robberies, witness elimination and involvement with drugs (including crack).

As to professions and jobs, when the category of "liberal professional" was clustered with "unemployed," there was a percentage of 80%. That cluster was performed because the condition of "liberal professional" was no guarantee that the individual was working during the study period, as it is a category that may cause discontinuous periods of employment. In this sense, reported income (1.45 minimum wages) could be changed, considering the relevance of liberal professionals (43.3%), working with general services or in civil construction and that are submitted to variations of job opportunities in both classifications. Therefore, most crack users in this sample do not have a formal job or are unemployed, which worsens the problem of crack dependence, in agreement with some authors in the literature.^1-28

Crack use associated with alcohol was not frequent (20%). However, combined daily use of crack and tobacco (83.3%) and crack and cannabis (70%) is significant, although less than half of the individuals (46.7%) had moderate to severe nicotine dependence. Frequent and combined use of crack, alcohol, cannabis or tobacco was also observed in many studies,^3,28,33 in which involvement with drugs was characterized by the interviewees themselves.

Presence of anxiety and depression symptoms in this population was representative, as 43.3% of crack users, after 1 week of withdrawal, showed signs of moderate to severe anxiety, while 50% also had moderate to severe depressions scores. The literature shows that depression and anxiety are the most prevalent mental disorders in crack users⁹ and that presence of psychiatric comorbidity in cocaine/crack dependents is quite significant and deserves care.¹⁰ This study did not evaluate psychiatric comorbidity due to the short withdrawal time, but presence of this symptomatology should be stressed.

Importance should be given to procedures and interventions performed in detoxication wards, since this sample showed that 43.3% of the individuals (n = 30) were at least once hospitalized to treat crack dependence. In this sense, the literature shows that 46% of individuals that use this form of treatment cannot maintain withdrawal after discharge, increasing mortality and arrest rates,³⁴ as well as use of public health resources, due to the need of being readmitted to high complexity services, which shows the high potential of crack dependence.¹

Illicit acts committed by crack users are motivated by either use of drugs or not, which suggests the possibility of comorbidity with antisocial personality disorder, as indicated in the studies by Falck et al.³³ and Herrero et al.¹⁰ However, the recent study by Compton et al.¹⁴ should be stressed, suggesting a lack of correlation between drug use and antisocial personality disorder without concomitant existence of any other psychiatric comorbidity.

Presence of criminal records was also associated with more symptoms of anxiety, depression and craving, which is in agreement with results from other studies indicating that use of cocaine/crack is followed by symptoms as impatience, irritability, paranoia and violent behavior. The latter can be explained by an impairment in executive functions and by release of norephinephrine, which may trigger reactions of fight and escape when the individual thinks he is in danger (both due to paranoia and to more intense carving).³⁵

An interesting finding was the fact that presence of criminal records was not associated with crack consumption pattern/dependence severity, which seems to be in disagreement with the literature.³⁶

However, this study did not aim at evaluating presence of comorbidity, which is why crack or cocaine withdrawal time in each offense was not evaluated, which would be essential to exclude the possibility of a disorder induced by use of substance.^10-18

Although this study does not intend to evaluate psychiatric comorbidity, it should be considered when developing a diagnostic hypothesis of a crack dependent, as reviews in scientific databases on psychoactive substances and criminality reveal an association between both.³⁵ This suggests an important public health problem nowadays,³⁷ based on the need of new hospitalizations for crack detoxication and increase in vulnerability regarding violence.

Only two of the men who reported having criminal records had not been in prison, which shows higher marginality in this population, according to the study by Ferreira Filho et al.¹ Among those who reported having been imprisoned, half was arrested only once, and half remained up to 30 days in prison, indicating a minor sentence. This finding differs from the trend seen in the USA by the Drug Enforcement Administration (DEA), which consists of a department that is part of the American justice system, where sentences for crack users have been higher than for other drugs.³⁸

It is interesting to see that 40% of individuals who had been arrested reported use of some type of drug in prison, especially tobacco and cannabis. According to the reports, crack use in prison was not much prevalent, opposed to what was found by Ferreira Filho et al.¹ However, it should be considered that studies evaluating use of psychoactive substances in prison may be biased, since awareness of the illegality of consuming illicit drugs at a penitentiary institution, followed by fear of any punishment, can cause the individual to hide the truth. Such difficulty for this type of sample has been discussed in a study on drug consumption in prisons.³⁹

To end this discussion, one of the main limiting factors of this study was small sample size, which prevented generalization of data. In addition, the types of crimes were not evaluated, which included drug trafficking. It should also be considered that, although the researchers have been prepared to apply research instruments, some reported data may not reflect the informer's reality, due to the difficulties suggested by Ferreira Filho et al.¹ and to the hospital setting.

CONCLUSIONS

Based on the collected data, it can be concluded that the current crack users admitted to the DW of HPSP de Porto Alegre come from the metropolitan area of Porto Alegre and coastal region of the State of RS, comprised of young adults in productive stage and that are mostly out of the formal job market or are unemployed.

It is worth stressing that 80% of crack users reported onset of substance use between 16-26 years, suggesting the need of approaching this problem since adolescence, as it is a group that currently has the highest mortality rates from external causes in Brazil, among them homicides. Therefore, these individuals are exposed to varied risk situations and social vulnerability, which indicates a serious public health problem and contributes to increase in violence.

Presence of depression and anxiety symptoms was significant in the sample, as well as use of tobacco and cannabis combined with crack. Presence of criminal records for crack users was also frequent, and this variable was related to more anxiety and depression symptoms, and more intense craving. The investigated profile challenges high complexity services, such as detoxication wards, to evaluate in detail possible psychiatric comorbidities and associations with licit and illicit drugs.

Finally, in addition to being an important estimate of the inpatients at the DW of HPSP de Porto Alegre, this research suggests an investment in follow-up studies on users at detoxication wards after discharge. This should be performed in order to increase, evaluate and qualify actions provided by public health services in different levels of attention, as well as studies exploring in detail the association with criminality in this population.

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39. Carvalho ML, Valente JG, Assis SG, Vasconcelos AGGV. Modelo preditivo do uso de cocaína em prisões do Estado do Rio de Janeiro Rev Saude Publica. 2005;39(5):824-31. en_v30n2a05

Received March 25, 2008.

Accepted September 1, 2008.

*

Financial support: Treasury of the State of Rio Grande do Sul, no. 0006, activity no. 2485, rubric no. 3390363619, according to Agreement of Scholarship Grant and Acceptance between State Health Department and Public Health School of the State of Rio Grande do Sul.

Publication Dates

• Publication in this collection
  13 Jan 2009
• Date of issue
  Aug 2008

History

• Accepted
  01 Sept 2008
• Received
  25 Mar 2008