# Presentation: 164073

## Crack use in Brazil: Qualitative studies about a new public health problem

- Lisia von Diemen MD, MSc and Flavio Pechansky MD, PhD

**Notes:**
My presentation is about Crack use in Brazil: Qualitative studies about a new public health problem

## Qualitative Studies in Drug Addiction

- Journals: 2-6% of Qualitative studies
- Often are not the preferred option of research funders and policy-makers (do not produce “hard statistical data”)
- Qualitative and quantitative research are described in oppositional terms
- “Qualitative are no less informative or valuable than quantitative data, they answer different questions”
- Qualitative studies are particularly important to
- Understand drug taking
- Build  theories of addiction
- Formulate drug policies
- Hidden and hard-to-reach groups
- Identify emerging trends in drug consumption

***“******Qualitative research methods within the addictions”**** *
- (Neale J, Allen D & Coombes L, Addiction 2005)

**Notes:**
First of all, let’s take a look at what literature has to say about Qualitative studies on drug addiction. This review was published in 2005 on Addiction.
This study shows that journals have published only 2-6% of Qualitative studies, probably because they do not produce “hard statistical data”.
Besides, Qualitative and Quantitative research are described in oppositional terms, as if we had to choose between one of them and couldn’t work with them as a whole to get the best from each.
It is highlighted that “Qualitative are no less informative or valuable than Quantitative data, they answer different questions” Qualitative studies are specially important to understand drug taking; build  theories of addiction; formulate drug policies; find hidden and hard-to-reach groups, and identify emerging trends in drug consumption.

## Objectives

- To describe the quantitative data about cocaine, crack and AIDS in Brazil
- To determine questions about cocaine, crack and AIDS not answered by quantitative data
- To evaluate the contributions of qualitative studies for a better understanding of the relationship among cocaine, crack and AIDS epidemics
- To evaluate the role of qualitative studies in Brazil in:
- Identifying emerging trends in drug consumption
- Accessing hidden and hard-to-reach groups
- To speculate about the possible role of new technologies in qualitative research in drug addiction in Brazil

**Notes:**
My objectives are:
First: to describe the Quantitative data about cocaine, crack and AIDS in Brazil, 
Second: determine questions about cocaine, crack and AIDS not answered by Quantitative data
,Also, evaluate the contributions of Qualitative studies for a better understanding of the relationship among cocaine, crack and AIDS epidemics, 
And evaluate the role of Qualitative studies in Brazil so that it may be possible to identify emerging trends in drug consumption, access hidden and hard-to-reach groups and
And finally speculate about the possible role of new technologies in Qualitative research in drug addiction in Brazil.

## Quantitative view

**Notes:**
Let’s start with a Quantitative view

## Cocaine and AIDS in Brazil

- Cocaine (Nappo S, 1996)
- Widespread use of cocaine occurred at the end of the 80s
- Injected and snorted were the most common ways of use
- Almost all IDUs were cocaine injectors
- AIDS (Brazilian Ministry of Health, 2006)
- First AIDS case in Brazil: 1980

**Notes:**
Cocaine had its widespread use at the end of the 80s in Brazil and
It was most commonly injected or snorted
Another important point is that almost all IDUs were cocaine injectors, since the use of heroin is very unusual in Brazil.
When it comes to AIDS, its first case was reported in 1980 and as we can see in the graphic, AIDS also had its epidemic peak in the 90s. The number of cases per year has been stabilizing over the last ten years.

## Primary exposure categories

**Brazilian Ministry of Health, 2006**

**Notes:**
However, the primary (praimeri) exposure categories are suffering important changes. As in other parts of the world, the IDUs and the homosexuals were most infected in the beginning and nowadays both are decreasing while heterosexual infection is becoming the most important exposure category. 

## Crack use in Brazil

- First reports in the 90s – São Paulo
*“**Increase in the search for treatment by crack users in two outpatient clinics at the city of São Paulo in the years from 90 to 93” *(Perri et al, 1997)

**São Paulo**

**Porto Alegre**

**Notes:**
At the same time, crack started being used in São Paulo in the 90s and later had spread (spréd)to other parts of the country. The first Quantitative report in São Paulo was only seen in 97 related to an increase in the search for treatment by crack users in outpatient clinics between 90 and 93. We can see in the graphic a progressive (progressive) decrease (dicrise) through the years in cocaine injection and an increase in crack use

## São Paulo – AIDS infection

- Bastos, 2001

**Notes:**
We can see in the graphic that when crack started being used in sp, a decrease in new AIDS cases among IDUs was identified.

## Crack use in Brazil

- National survey 2001 – crack use (Carlini, 2002)
- Lifetime: 0.4%
- Last year: ?
- Last month: ?
- Public health problem in many states in Brazil
- Same process that occurred in São Paulo occurred in other parts of the country
- Crack being introduced in the drug scene
- Reduction in proportion  of infection by drug injection

**Notes:**
What Quantitative studies show about crack use in Brazil nowadays?
National survey conducted in 2001 showed a lifetime crack use prevalence of 0.4% and last year and last month use were not possible to estimate because the number of people reporting this was too low. This is happening at the same time that the crack use in Brazil is becoming a public health issue in many states. 
Although we used São Paulo as a reference, this has happened in other parts of the country as well, meaning that the introduction of crack in the drug scene was  followed by a reduction in proportion of infection by drug injection

## Questions not answered by Quantitative studies

- Why is HIV infection decreasing among IDUs?
- Effectiveness of Harm Reduction Programs?
- Reduction in the number of IDUs?
**Death?**
**Stopped using?**
**Changed to another drug?**
- Why is crack use increasing?
- What is the impact of the crack epidemic?

**Notes:**
So among the questions not answered by Quantitative studies are;
 Why is HIV infection decreasing among IDUs? Because of the effectiveness of Harm Reduction Programs? Because of a reduction in the number of IDUs? If so, is it related to death? or because they stopped using it? Or because they changed to another drug?
Other questions are: Why is crack use increasing? And what is the impact of the crack epidemic?

## Qualitative view

**Notes:**
On this matter the Qualitative studies can come as an aid for a better understanding

## First Qualitative study – Sao Paulo

- 25 crack users or former users (snowball technique)
- Characteristics of users
- young (<20 years), poor men, low schooling
- Drug characteristics
- Reduced time lag between first use and dependence
- Trafficking strategies
- High availability *“**Nowadays you don’t find other drugs for sale, just crack. I didn’t want to use, but it was the only drug available”*
- “Marketing” about the drug: *“It’s less aggressive because it’s smoked, not injected, it has less HIV infection risk”*

**Crack use in Sao Paulo city: an emergent phenomenon? **
- Nappo SA et al. Rev. ABP-APAL; 16(2):75-83, 1994

**Notes:**
As crack started in SP the first study was conducted there with 25 crack users or former users. The snowball technique was applied and the study was able to show important characteristics connected to crack use such as young age;low schooling and poverty as well as a reduced time lag between first use and dependence.
Another important issue is trafficking strategies of  crack introduction in the drug scene highlighting the high availability and a client said: “Nowadays you don’t find other drugs for sale, just crack. I didn’t want to use, but it was the only drug available”
....” and the marketing about the drug as another client said: “It’s less aggressive because it’s smoked, not injected, it has less HIV infection risk”

## Porto Alegre

- Developed because we tried to conduct a clinical trial with IDUs in 2004 and we only found a small sample
- 19 key-informant interviews using focus groups were conducted
- Sudden increase in the prevalence of crack use, beginning in 2001
- Number of injection drug users had declined dramatically in recent years
**High mortality among IDUs (some had never heard of AIDS or HIV)**
**Declining quality of street cocaine **
**Shift from cocaine injection to crack smoking **
- Fear of HIV and AIDS
- Quality of cocaine (cutting of cocaine with adulterants)
- Price ($2 each small rock)

**Changing patterns of cocaine use and HIV risks in the south of Brazil**
- Inciardi JA et al. J Psychoative Drugs; 38(3):305-10, 2006

**Notes:**
In POA we conducted this Qualitative stud
y because we tried to perform a clinical trial with IDUs in 2004 and we found only a small sample different from previous studies with this population.
Nineteen key informant interviews using focus groups were conducted.
There was an agreement among the participants regarding the sudden increase in the prevalence of crack use in 2001.
In relation to IDUs it was highlighted a dramatic decline in the number of users in recent years. The reasons suggested being the high mortality among IDUs (some had never heard of AIDS or HIV) the declining quality of street cocaine and the shift from cocaine injection to crack smoking. Maybe due to fear of HIV and AIDS; quality of the cocaine and low pricing

## Impact of crack use
Changed the “natural history”: snorted – injected – smoked
“They go straight to the rock, because they don’t want to inject themselves. - It is the same as injecting, and you don’t get AIDS”
Public health efforts
“There are plenty of syringes – there are more syringes than drugs on the streets”
Sex-for-crack exchanges
Common practice among poor women addicted
 High risk behavior
Condoms are rarely used
Larger number of sexual partners
“When you are on drugs you don’t care: you need it! You go to a corner, do it anywhere, and it is live, everyone is seeing it...”

- Changed the “natural history”: snorted – injected – smoked
*“**They go straight to the rock, because they don’t want to inject themselves. - It is the same as injecting, and you don’t get AIDS”*
- Public health efforts
*“**There are plenty of syringes – there are more syringes than drugs on the streets*”
- Sex-for-crack exchanges
- Common practice among poor women addicted
-  High risk behavior
**Condoms are rarely used**
**Larger number of sexual partners**
*“**When you are on drugs you don’t care: you need it! You go to a corner, do it anywhere, and it is live, everyone is seeing it...”*

**Changing patterns of cocaine use and HIV risks in the south of Brazil**
- Inciardi JA et al. J Psychoative Drugs; 38(3):305-10, 2006

**Notes:**
The impact of crack use was also investigated. The natural history has changed. Formerly the typical sequence was snorted – injected – smoked and now it jumps from snorted to smoked. A key informant said:”They go straight to the rock, because they don’t want to inject themselves.-It is the same as injecting and you don’t get AIDS.
Also, They have reported a mistake in public health efforts because they insisted on exchanging syringes when the number of IDUs was  already reduced and another informant said: “There are plenty of syringes – there are more syringes than drugs on the streets”
In addition to this there was also a new pattern on the exchanges involving drug sex and money. The sex for crack exchange became a common practice among poor women addicted, they are exposed to high risk behaviors since it usually involves not using condoms and a larger number of sexual partners due to the high drug craving leading to a constant need for money. An interviewee said When you are on drugs you don’t care: you need it! You go to a corner, do it anywhere, and it is live, everyone is seeing it...”

## Qualitative view

**Qualitative view**

**Quantitative view**

**Notes:**
We have seen that the information obtained from Quantitative and Qualitative studies are different views of the same fact. They are complementary and not oppositional as it is usually believed.

## What information did Qualitative studies add?

- AIDS cases among IDUs are decreasing,
- probably because the number of IDUs is decreasing

- IDUs are shifting from injecting cocaine to crack smoking

- Young, poor men (<20 years), low schooling, unemployed

- Elevated sexual risk behaviors – risk of HIV infection

- Elevated craving for the drug – criminality, social and family impact

**Notes:**
AIDS cases among IDUs are decreasing, 
probably because the number of IDUs is decreasing
IDUs are shifting from injecting cocaine to crack smoking
Young, poor men (<20 years), low schooling, unemployed
Elevated sexual risk behaviors –which leads to a higher risk of HIV infection
They have an Elevated craving for the drug that can be connected with criminality, social and family impact

## What has the Federal Government done about the data?

## Harm Reduction Program

- São Paulo
- Beginning in 2001 (official program)
- IDU infection decreased
- Porto Alegre
- Beginning in 1997
- Law about HR in Porto Alegre: 2000

**Heterossexual**

**IDU**

**Homossexual**

**Health Secretary, 2006**

**Bastos, 2001**

**Notes:**
Taking the harm reduction program as an example we can see that in SP the infection peak among IDUs was around 1992 but the HRP only started in 2001 when the infection was already declining. While in POA the program started in 1997 when the infection was still on the increase. However, we can not attribute the decline to the program because it happened just when crack started being used, around 2001.

## In what manner qualitative studies could help government detect problems in an earlier fashion? 

**Could new technologies help in this process?**

- I’m late! I’m late! I’m late

**Notes:**
As the rabbit in “Alice in Wonderland” the government is always late. What can be done to change this?
In what way qualitative studies could help government detect problems earlier? 
Could new technologies help in this process?

## How could the time lag be reduced?

- Gathering qualitative and quantitative data
- Stimulating qualitative data collection
- Generates a less expensive alternative (Brazil)
- Allows to reach hidden populations
- Detects the trend before the fact

**Notes:**
How could the time lag be reduced?
Mainly, Gathering Qualitative and Quantitative data
And Stimulating Qualitative data collection which 
Generates a less expensive alternative, at least in Brazil
It makes possible to Reach hidden populations
 and to Detect the trend before the fact

## How could the time lag be reduced? (cont...)

- Including key informants
- Clinicians, epidemiologists, and other experts
- To obtain sentinel data  already done in many countries:
- USA (Cicero T, 1999)
- Canada (Popova S, 2006)
- Australia  (Degenhardt L, 2005)
- Network of key informants can be obtained through internet
- Systematic questions by e-mail
- Inform immediately about a new substance of abuse or an abuse of a prescribed drug
- Internet surveillance
- Information between drug users (chats, personal webpages, sites)

**Notes:**
Other options are to include key informants which is already used to obtain sentinel data in many countries, such as USA, canada and australia.
A network of key informants can be obtained through systematic questions by e-mail and a request to inform immediately about a new substance of abuse or an abuse of a prescribed drug.
Internet surveillance can also be used to find information about new trends on chats, personal webpages and sites.

## Primary exposure categories

**Other causes**

**Government measures**
-  Condom distribution in public health system
-  Media campaigns to use condoms
-  Harm reduction programs - IDUs

**Notes:**
As we have seen before, the AIDS epidemic is changing its pattern, there is an increasing infection through heterosexual practices and a declining in infections through IDUs and homosexual practices. But, what is the government doing to deal with this new trend?
Condom distribution in public health system 
Media campaingns to use condoms
And despite all the available data about the reduction in drug injection, they are still investing and conducting harm reduction programs focused on IDUs.

## Issues qualitative studies might answer

- Why is AIDS infection increasing among heterosexuals and women?
- Considering that the information about AIDS is widespread, why are these people getting infected?
**Condoms unavailable**
**Do not feel at risk**
**Can not decide about condom use because they are “on drugs”, and**
**“****Trust the sexual partner”**
- What proportion of this infection is associated with other drugs of abuse (cocaine, crack, alcohol)?

**Notes:**
Qualitative studies could help the planning of public policies through the answers of some questions like:
Why is AIDS infection increasing among heterosexuals and women?
Considering that the information about AIDS is widespread, why are these people getting infected?
Is it because Condoms are unavailable?
Because they Do not feel at risk?
Because they Can not decide about condom use since they are “on drugs”, or
Simply because they “Trust the sexual partner”
And 
What proportion of this infection is associated with other drugs of abuse?

## The proposal is to use qualitative studies to change from a distorted reality to a more precise one

**The proposal is to use qualitative studies to change from a distorted reality to a more precise one**

## Federal University of Rio Grande do Sul

**2350/2201F** **Ramiro Barcelos Street Porto Alegre, Brazil**
**(55-51) 3330-5813, cpad.fm@terra.com.br**