ConsequenCes related to CraCk use among women and reasons for abandonment of the drug

This aim of this study is to know the consequences related to crack use among women and the reasons for the abandonment of the drug. This is a qualitative, descriptive and exploratory study with 11 women, former crack users, conducted through semi-structured interviews. The main results were the breaking of emotional ties, family and the social environment, and material losses. As for what motivated the abandonment of the drug, the highlights were motherhood, avoidance of risk areas and religious practices. Thus, it is suggested that the assistance provided by the health services must be rethought in an attempt to enhance the uniqueness of the person, considering the complexity of this phenomenon.


Introduction
In Brazil, for nearly 30 years crack has spread throughout the streets of the country, bringing with it an increasing number of members with the habit and, as a consequence, this has generated extensive debate within the social environment, not only about the cause of addiction, but also because of marginalization and crime that are connected to this practice, reflecting on urban disorder (1) .
Currently, crack can be considered the drug most associated public health problems due to rapid dependency mechanism and the intense effects caused by this substance.These issues are important due to the risky behavior (violence and sexual behaviors) that triggers conflict both for the person who uses and for society (2) .
There are some reasons identified as responsible for the consumption of crack, such as an attempt to minimize loneliness, financial difficulties and family problems, as well as the search for pleasure and happiness (3) .From this perspective, crack abuse may cause losses and damages to the subject himself, to the family and to society, related to job loss, violence, crime, family breakdown and accidents (4) .
The activities in which some crack users engage, generate a lot of damage to the individual's life; this is exacerbated by the inclusion of women in the crack usage and sale of crack scenario because woman, at times, can use their body as a material good for trading and purchasing drugs, getting into prostitution, and risking acquiring sexually transmitted diseases such as HIV/ AIDS, along with the risk of sexual violence (5)(6) .
Due to the vulnerability of women in the crack abuse context, this study is important in terms of the lack of scientific productions related to this subject, giving voice to users and exposing their experiences related to the consequences of drug use and the reasons that led them to the abandonment of the consumption.The literature suggests that, currently, if it invests in research directed to health care professionals and institutions specializing in caring for this population, then there is a gap in the attention to the crack user themselves while they are the subject (7) .
In addition, some studies that focused on the issue of crack use, emphasize the existence of a bias with respect to the health care of women who use this drug because health professionals usually tend to establish a male pattern for these women; when the reasons for consumption and its maintenance are different in both sexes, as a result hindering the continuous treatment and reduction of crack use among women.Thus, treatment aimed at women should be different, working on aspects of beauty, body care and sexual dimensions such as contraceptive use and prostitution, as well as discussions of femininity, feelings and life goals within the perspective of gender (8)(9) .
Approaches to the female individual in the context of physical vulnerability, psychologically and socially stimulate reflections in search for changes in the areas of education, health and safety.Thus, the aim of this study is to access the consequences related to the consumption of crack in women and their motivations for the abandonment of the drug.

Methodology
This present study is part of the research project "Profile of crack users and usage pattern", funded by CNPq, through Notice MCT/ CNPq 41/2010.
It is a qualitative, descriptive and exploratory study.Participants were 11 women ex-users of crack, enrolled in the Harm Reduction Program (HRP) and referred by the team of Harm Reduction Agents (HRA), being certain of the following inclusion criteria: being older than 18 years, users or ex-users of crack, having the physical and mental capability to respond to the survey instrument and the ability to accept participation in the research.
Data collection was through the Pelotas Harm Reduction Strategy (HRS) which is an organization that is currently part of the City Health Department (CHD) and is linked to the STD/ AIDS Management Program; this program is organized from the perspective of HRS.The HRS is located in the CHD at the Pelotas City Hall, it is composed of a coordinator, a nurse and six Harm Reduction Agents who perform direct assistance to users in five major municipal areas (Areal, Frigate, Zona Norte, Centro and San Gonçalo).
The data collection was conducted in January 2012 in conjunction with the HRA, through a semi-structured interview.Voice recorders were used to ensure the documentation of information and to guarantee the anonymity of the study's participants, identification of the participant was through the use of the letter E (entrevistado, or interviewee) followed by the code number of the interviewer.The interviews were conducted during HRA field work in different districts of the city of Pelotas, providing data collection in the subject's context, taking an average of 45 minutes.The results were organized through a thematic analysis (10) .
Throughout the development of the research, the provisions of Resolution 196/96 of the National Health Council (Guidelines and Standards Involving Research of Human Subjects) were respected.The project received approval from the Municipal Health Secretary of the city of Pelotas and also the Ethics Research Committee of the Federal University of Pelotas Nursing School, under Notion No. 301/2011.

Losses/damages related to crack use
There are many reasons that lead people to consume drugs, however, the literature points out various reasons at different times to justify the practice.In the early 90s, the main reason for drug use was the pursuit of pleasure.However, over the years, pleasure, coupled with compulsion and dependency on drugs, was the main way of dealing with family problems and personal difficulties (11) .Therefore, there is a loss of relational ties to the family and the social environment, as well as pawning their things and changes in their appearance, due to lack of body care and feeding; these were some of the factors reported by women related to damage or loss due to crack use, as explained in the following statement.The statements of crack users show the disruption of affective family ties and causes property damage due to loss of sense of reality, because of the drug abuse, they are subject to the emergence of losses in their lives.
The determined crack user believes this is the most effective way to deal with everyday adversities.However, to experience the reality of the compulsion, which leads to comprehensive drug use and dependence, they are faced with an ambiguous path: on one side the pleasure and on the other, the loss or damage, affecting their social relationships and health (2,7) .

Motivations for crack abandonment
Pregnancy and maternity Some of the women interviewed said they had crack withdrawal for a few months and even years.The main reason reported for the abandonment of the drug was the fear of losing their children due to disruptions in their lives caused by crack use.Caring for and educating their children, culturally, is part of the female role.A parent who is a drug user that is taking care of their child is seen by society as irresponsible and selfish, subjected to biased looks daily; yet, women who consume crack are doubly stigmatized and end up feeling guilty for their addiction, causing low self-esteem and anxiety symptoms that contribute to the onset of paranoia regarding the loss of their children, as quoted in the reports this is highlighted as the trigger for crack abandonment.
[...] One day I stopped to think, no, I have two daughters, so I am going to stop, so I stopped.Since that day gave me the strength for this, I traveled with my daughter to the child protection agency and that's where I started to say that I would not want more [...] it has been two years that I do not smoke (E9).
In addition to having children, pregnancy is another triggering element for crack abstinence among the women interviewed Pregnancy triggers guilt in women drug users, since the tasks involving motherhood are seen by society as exclusively the responsibility of the mother, and the concern of harming their baby due to crack use, generates feelings of distress.

I can stop, I stopped because I got pregnant with my daughter, so all that time I was not smoking [...] My daughter was 2 years old, I got pregnant and all that time I was not smoking, but after six months I went back (E6). [...] I used, I smoked about 2 or 3 times and found out I was pregnant, it has been 6 years now, then I did not want to smoke anymore [...] (E11). [...] I was pregnant with her inside of me and I smoked, I smoked until the last day of pregnancy and instead I stopped when she was born, never again, I stopped for free and spontaneous psychological pressure because of the kids and the advice that was given at the hospital [...] A year ago today I stopped (E5).
Noticing changes in their body, feeling the baby move, breastfeeding and having a greater knowledge about the risks that crack use can bring to the fetus, such as: prematurity, low birth weight, cognitive delay, predisposition to mental disorders and even fetal death (12)(13) , these things cause many women to gain courage and decide to stop their consumption.
Studies of pregnant women who use crack and other drugs have shown that users who have continued consumption during pregnancy have low self-esteem, anxiety and depression compared with those who stopped using during pregnancy (14) .
As shown previously, motherhood can be considered an important motivational tool for the abandonment or reduction in the use of crack among women, upsetting the cultural context of women's role in caring for their children.

Distancing from risk areas
In this section, women list some strategies they used to stay away from crack, the call them removal of "risk areas".People who are abstinent from drugs create strategies to keep their distance.In the testimonies, one can see that women seek to distance themselves from what they call "risk areas," such as, the removal of friends who used the drug, avoiding places where they used to consume crack, going out with a small amount of money, and avoiding other drugs which may trigger the desire to use crack as, for example, alcohol.
The decision to discontinue crack use is influenced by several factors, including: drug cravings, the emotional state of the subject, the implementation of treatment and some environmental stimuli.However, some studies show that there is a tendency of individuals to employ strategies to regulate their consumption and even stop using crack, such as: removal of the social context in which the drug was consumed, structuring daily activities and leisure, diverting attention and thoughts to other practices and moderation in the consumption of other substances, which act as "triggers" for crack use (1)(2) .
A person's relapse to crack use can be triggered by various reasons, including: alcohol use, feeling emotions (anger, sadness, joy), having cash on hand, seeing other crack users and feeling alone.The individual's exposure to environmental factors previously associated with the drug produces a strongly conditioned response that encourages the individual to use crack.In this sense, we see the importance of evaluating these situations in the treatment of individuals who use crack and other drugs (15) .
Regulating the practices associated with crack use in order to reduce its use or even cease it altogether, results in a cumulative experience of the drug and the damage associated with its consumption.

Religious practice
The belief in a higher being or involvement in any religion was also cited as a reason for the abandonment of crack use.Sometimes it makes me want to use and I think about all that I went through and it now gives me the will, then I say to my God "Lord I will not need that" [...] If I'm looking for a God so powerful then why will he let me fall [...] that abstinence, that desire, I came trembling, sweating inside, but at the same time I thought my God, I'm looking for you, if I am chosen, then you will not let this happen to me and that went well so you know, it's amazing the sense of peace, a very good thing (E2).
The study of women using religious practice or belief in a higher being to stay away from crack was identified in some of the testimonies as being fundamentally important.This result corroborates a study in which the authors identified that religious adherence favors the decrease in consumption of drug users, when this is desired (16) .In another study that was transversal exploratory, which had 223 college students at the Bahia Adventist Colleges, they identified that 79.8% of students said they believed that religious beliefs helped in withdrawal from drugs, and 90.4% believed that the religious factor contributes to abandonment or reduction of drug use (17) .
By engaging in religious practices, people adhere to a set of values, symbols and social practices, influencing their thoughts and behaviors about the acceptance or refusal of alcohol and other drugs (17) .

Final Considerations
The main factors related to the damage of drug use as identified by the women in the study were the severance of family ties (especially children and husbands) as well as society, and the loss of material goods.The interviewees highlighted the following factors which led to the abandonment of crack use: pregnancy, removal from "risk areas" and religious practice.
In this sense, it is believed that the behaviors and actions presented by crack users cause weakness within family and social relationships, which explains the break in existing ties.
The identification of the main risks related to crack use, can help with the development of strategies to address these issues and help society and health professionals understand the complex phenomenon that is crack use; culture and social implications, seem to be the key for the survival of those who wish to continue their addiction or enter treatment.
Therefore, understanding the significance of their experience from the perspective of crack users, knowing the implications of the losses associated with crack and the reasons for the abandonment of the drug may be an effective coping strategy for the daily difficulties experienced by these women.It is in this direction that care provided by health services must be rethought in an attempt to enhance the uniqueness of the person, considering the complexity of this phenomenon.
[...] I lost my children, I lost my husband, I lost the shame in my face, I lost everything, I lost my family [...] I was sleeping on the street, I ate trash, I stole, trafficked, I did everything that I should not [...] I lost my appearance, my beauty, that I was pretty, I had long curly hair, my voice changed, my health, dignity, my children, my house, the man that I loved [...] (E3).
[...] there came a time that we started to sell things [...] the Family Welfare card for the children was chosen [...] attempted to sell the stove, refrigerator [...] I did not let them go outside because I used the crack, but wanted them in front of my eyes because I had the feeling that if they left something would happen [...] often times they slept hungry, crying from hunger, but the drug had [...] (E11).
[...] Sometimes there are risk areas that I turn and I run away, you know?Risk areas are where we went to use [...] I try to always walk around with little money, to leave this money with my family, as I am an addict, I do not risk it [...] if I see a friend of the previous lifestyle, I try to divert my path [...] I do not drink alcohol, it will open up the door to use crack, it will give me the desire, so I have to know myself (E3).
[...] I am not going to treat the user differently, it is just that, well, he is at his house and I am in mine, those people use drugs and I do not want them to use in my house, so my friends are totally different, they are other friendships [...] I cannot be testing myself, it has been six months that I do not get a fix [...] I will be in the house of a user, I will get there and get a pipe and it gives me the desire [...] (E7).
[...] I am going on Tuesdays, without fail, on Thursdays aswell without fail and also to seek spiritual help [...]You have to grab onto God to get out of this, I was with God (E3).