ApproAching the world of young drug users : A quAlitAtive study in nicArAguA

This study aims to approach the world of young addicts in a Western city of Nicaragua to explore and better understand their reality. This a qualitative, descriptive, cross-sectional study, using a detailed interview technique, anonymous and voluntary directed toward young drug users. It was found that only illegal drugs are considered as drugs and that curiosity and easy access are factors facilitating the use; drug use is something natural in the context of their lives, the drug offers the possibility of transgressing social norms; drug combinations occur for economic reasons and the need to search for new sensations; the user acknowledges the problems that develop in the family and the community as a result of the presence of drugs with emphasis on the violence, personal powerlessness and conventional helplessness were identified as factors present at the idea of quitting.

Se observó que solamente las drogas ilícitas son consideradas drogas; la curiosidad y el acceso son factores facilitadores del uso; el uso de drogas es algo natural en su contexto

Introduction
The use of psychoactive drugs is a widespread global problem , either through the diseases related to the use of alcohol, tobacco and other drug or by the social consequences of its abuse or the trafficking of illegal drugs (1) .
The use of technology and communication have shifted the traditional and regulated use of drugs, with a clear cultural significance; moreover, they imposed new consumption patterns characterized by drugs and methods increasingly potent and affordable (2) .
The use of drugs became a global phenomenon; according to the United Nations in 2000, it is almost impossible to find a country that is not affected by it, although the characteristics and consumption may vary from nation to nation (3) .
Drugs are a serious public health problem worldwide, by directly or indirectly affecting people regardless of race, religion or social status, it is usually manifested in the populations of almost every country in the world, harming the economy and jeopardizing the security.Starting in the sixties, drug use has become an international concern, especially in the developed countries, because of its impact on the public health, the economy, the legal systems, and family relations, among others; also it has serious implications on violence, crime, and international terrorism (4) .
The World Drug Report 2010, launched by the United Nations Office on Drugs and Crime (UNODC) shows that between 155 and 250 million people worldwide have used drugs in 2008 and that marijuana remains the number one drug consumed in the world.And the number of ecstasy users ranges between 10.5 and 25.8 million.It is estimated that the world population is around 6 billion and 600 million people; therefore, more than 3 % of the population turn to drugs.According to the report, the cultivation of coca and opium decreased in the Andean countries and Afghanistan in 2009, but cocaine use remained stable in Europe and the USA, and increased in the developing countries.Marijuana smokers formed the largest group of illegal drug users in the world, ranging from 129 and 190 million people (5) .
The use of psychoactive drugs follows a progressive trend with regard to its magnitude and the damages to society caused by the indiscriminate use (6) .
There were two studies on drug abuse performed in Ontario (Canada) from 1977-2011; the first surveyed students in grades 7 through 12 and the other surveyed adults in the general population.The results showed that tobacco and alcohol are routinely used and that Cannabis is the illicit drug of choice for both groups (7)(8) .
It is noteworthy the new consumption patterns of the adolescents, which sustained a high prevalence of drug use in recent years.As a result of their evolutionary features, such as, the search for personal identity and independence, moving away from family values and emphasizing their need for acceptance by their peer groups, adolescents find themselves in a situation of vulnerability that facilitates the initiation of risk behaviors as drug use (9) .
Like everywhere else, in Nicaragua the drug use has influenced social relations, bringing negative consequences to human life.There are few studies on the prevalence of drug use in Nicaragua.The national police note that 3.5 per thousand inhabitants currently consume some type of illegal drug.According to data from 2003, in Nicaragua, marijuana is the most used drug, among students ages 12 to 20, followed by cocaine, solvents, and inhalants.There was an increased prevalence of amphetamine use within this population.Tobacco and alcohol, have a high percentage of consumption, half of the students have tried it at least once (10) .
The drug problem is associated with several factors, transforming the dependence on a very complex issue, which requires knowledge and understanding to be able to provide appropriate and effective intervention.
Given the consumption situation and the immediate need to provide prevention and intervention programs directed to young users of psychoactive drugs; the research presented here aims at an approach to the world of young drug users from a westerly region of Nicaragua to explore and achieve a better understanding of their reality.

Type of Study
This is a qualitative study of an exploratory nature.A qualitative approach was used to achieve the objective of the study, because this approach seeks the subjectivity and the symbolism of subjects and situations (11) .
The exploratory aspect allows the researcher to approach the world of the participants and their concerns, and it is used to explore issues that provide obstacles for future research (12) .

Location and Sample
In a city located in the westerly part of the country, five sectors were chosen for the confirmed higher usage of drugs.Prior to the structured interviews, the participants were offered the options of locations where they would feel comfortable and safe and could answer the questions without interruptions; some chose the place they eat, others the place they hang out, still others chose an office, or a place at home.

Sample
The sample consisted of 10 youth drug users from five neighborhoods that were characterized by a high consumption of drugs.After the arrival and a brief reconnaissance of one of these neighborhoods, a youth was approached and after his acknowledgment of drug use and informed consent to participate in the research, a detailed interview followed.Once the interview process was concluded, the subject indicated another youth that he recognized as a drug user; thus, following the snowball technique to acquire subjects.The snowball is the sampling technique where the subjects of the study indicate other individuals, which in turn indicate somebody else who are also included in the sample (13) .

Data Collection
Data were collected using a detailed questionnaire that it was used during the interview.A pilot test was performed prior to the interviews, using similar subjects from different neighborhoods, i.e., to adjust the interview guide according to the observations from the pilot test, changes that validated the final instalment.
After a brief evaluation of the environment, the interviewer casually approached a young drug user, initiating the first contact for an interview.In this first contact, the interviewee explained the objective of the research and what it entails and extended an invitation to participate, and presented the informed consent; with the subject´s agreement a date and place for the interview were agreed upon.The interviews were conducted at different places: office, home and/ or street.The duration of the interviews varied, since it gave importance to the development of the story presented during the interview.

Ethical Considerations
This research was approved by the protocol No. 19 of 06/24/2010, from the Ethics Committee for Biomedical Research (CEIB) FWA 00004523/IRB0003342, from the School of Medical Sciences of the National Autonomous University of Nicaragua.UNAN-León.All participants signed an informed consent.

Data Analysis
The interviews were transcribed in its entirety and a content analysis was performed; content analysis is a technique used to formulate, from certain data, reproducible and valid inference that can be applied to their context (14) .
So we tried to organize the information so as to contribute meanings to specific passages in the context of the data in its entirety.From the data encoding, emerged 8 categories that are described in the results.

Results
The results showed drug use through the multiple relationships of the youth with himself, his family, and his community, involved by the social and economic context of drug use.

The drug concept
When discussing drugs, despite knowing the differences between legal and illegal drugs, the youth considers only illegal drugs in his speech, even when they speak about the mixing of drugs they do not include alcohol and tobacco.Therefore, it is noticed a decreased significance of the risks and damages associated with legal drugs while the illegal ones become more attractive because of the associated lawlessness, and a sense of transgression.
The literature shows that the drug users generally do not consider legal drugs as drugs and the explanation is related to the historical, cultural construction of the social imaginary of drugs.Alcohol and tobacco are consumed freely and drugs, as socially conceived, is a bit forbidden and discriminated by the users of the legal psychoactive drugs (15) .

The approach to drugs
The data collected in the interviews indicate that the curiosity is a major cause for the entry into the world of drugs.Respondents report that the curiosity usually arises from the comments made by other users, which induces the desire to try it.

[...] The curiosity, only to try it and see the reactions "" I saw a friend smoking and asked how it felt [...]. S.1 [...] a teenager´s mischief, to see what happened and see if it was true what they said [...] S.2
In this regard, the access to the drugs is presented as an important factor to satisfy the desire to use it.The participants reported easy access to get drugs and generally the only hindrance was of the financial order.Moreover, they mentioned that in their neighborhood, it is very common to find several youths who use drugs and that they gather together in small groups on street corners or houses to consume drugs.

It's easy, just sometimes what is missing is the moolah [...] S. 10
In this category was evident the individual and social characters that support the drug use.If, on one hand, the youth meets the internal need of curiosity and the desire to sample, the other finds in the company of his peers condition of equality that favors consumption.

The conscious and natural use
The study results implied that the youths prior to start using the drug already had knowledge of the different types of drugs, their effects, and the complications related to their use.This is evident by the fact that they identify the drug as something usually close to them or in their families, i.e., the use of drugs is an everyday occurrence.
Furthermore, when speaking of the effects of drugs, they know how to distinguish between the physical effects produced by the drug and the effects while consuming it, that's how they speak of the highs and of the bad effects and consequences.However, the knowledge and verification of the negative effects related to drug use does not prevent the youth from starting and continue using drugs.The transgressive effect of the drug Some reports show drug use as a way of transgressing the law.In this sense, the police are seen as a repressive force.

[...] The police discriminates and persecutes me, the drug gives me strength and I run, I'm stronger [...] S.1 S.6 [...] when the police chased me for doing drugs, I ran and they could not catch me. [...] S.6
The user's speech leads to the idea that drugs represent a kind of empowerment that ensures protection in the face of repression.

Mixing drugs
Users report the use of various drugs and relate those practices to the economic availability, the dependency and the curiosity to try new sensations.
The economic reason for mixing drugs is related to the financial status of the user.In this case, the price one can afford is the determinant of which drug will be used at one time, or another.In other cases the scarcity of a specific drug causes the user to consume any drug available, this is due to the situation of dependency since it can no longer control the desire to be under the influence of any psychoactive drug.Finally, the curiosity to try new sensations leads to the use of various drugs.Thus, the users always seem to be looking for a different high.The majority mentions that marijuana is the primary drug used to mix with other drugs such as crack and alcohol.The consequences to family and community In speaking of the consequences of drug use, users are aware of the problems they cause to their families, and they especially highlight the violent situations surrounding the drug consumption.They are aware that the community is also affected by their drug use.This situation which is configured in relation to the transportation indicates that the user´s behavior under the influence of the drug results in the loss of an important service (transport) to the community.
Also with respect to the community, there is a perception among them that crimes whose basis comes from the consumption of drugs increased greatly, especially because when they do not have the means to get the drug, they are forced to commit a crime in order to feed their habits.

S.7
Inability to quit the habit According to the respondents once they started taking drugs it is very difficult to stop, it became an addiction and they cannot live without them.When confronted with legal or family issues, they think about quitting and even quit for a while; only to relapse sometime later.In this sense, the environment emerges as a reinforcer of the use and abuse of drugs; it is very hard to quit the habit without leaving the environment that favors it.

The absence of formal support for the user
The respondents mentioned the absence of services to help them deal with their addictions; there was only a small number of public institutions and a few private individuals that sporadically worked with them; some identified clergymen or church members who, in the past tried to help them; however, their approach was purely religious with a moralistic point of view that did not help them in the least.None of the respondents were aware of the existence of any structured rehabilitation program that offered long term personalized attention in the treatment of drug addiction.Morales-Alfaro JR, Herrera A, Zanetti ACG, Gherardi-Donato ECS.

Conclusions
The research granted access to the world of the young drug addict in a Western city of Nicaragua.It was found that only illegal drugs are considered drugs and that curiosity and easy access are factors facilitating the use; drug use is something natural in the context of their lives, the drug offers the ability of committing social transgressions; drug combinations occur for economic reasons and the need to search for new sensations; the user acknowledges the issues affecting the family and the community as a result of the presence of drugs with emphasis on the violence; personal powerlessness and conventional helplessness were identified as factors present in the idea of stopping using drugs.
There is a relationship in which the individual and the collective enjoyment overlap the outcome generated by the use of drugs.In their social context, the drug helps them to belong.Therefore, it is sensible to seek an intervention that can create a system that produces collective pleasure to be able to introduce other forms of emotional well-being, disinhibition, relaxation and enjoyment.
[...] because just one type of drug is not enough and they say... I'm not happy with this one and I am going to try another one, then he tries one and another and soon ends up mixing [...] S.4 [...] I want to know what kind of high each type of drug gives and to see how it feels when they are mixed [...] [...] S.6 [...] Alcohol and marijuana [...] S1. [...] marijuana with powder (cocaine) as the day goes by only two types [...] S.2 [...] The combination (marijuana and stone) [...] S. 4 [...] To my family on the reactions I may have under the influence, I can be difficult, cause problems; they may fear the possibility that under the influence I can steal [...] S. 5 [...] it affects my loved ones, if one day I´m in a robbery and get shot, and my family is at home without knowing, that worries them [...] S. 6 [...] it greatly affects my family, who always sees me using, there are robberies; we give bad examples.They are afraid that we're going to rob them [...].S.7

[
...] The taxis don´t come here, when we call them, because they are robbed and stoned [...] S.1 S.2 [...] It affects the community, at least in the fact that taxi drivers do not enter the neighborhood and maybe, there is someone sick in need of a cab and let´s say it is eight in the evening and nobody comes to visit the neighborhood because they are afraid [...] S.2 [...]There are a lot of crimes and many younger users, a lot of them steal to support their habits since they do not work [...] S.2 [...] If I don´t have money to buy the drug, I grab a knife and rob somebody, my most serious offense was a stabbing [...].
[...] It is hard to quit it, it is an addiction; one day the person quits and the next day is back to it [...] S.1 [...] it is very hard, because when you smoke you want to keep on smoking even more.I quit for a month and then started again [...] S.3.
[...] the acquaintances from the neighborhood provide them, the gang, and since I did not join them, and started smoking [...] S.1.[...] being in the group with the same users [...] S.5 [...] If you belong to a group, then it will be every day at every half hour [...] S.5 I´m aware of; there was a gentleman who promoted parties, sports, and carnivals at the CISA (Center for Care and Assistance in Health), currently there is none [...] S. 1 [...] yes, but not continuously, some visiting church youth saying that this is bad and that what we should do is to accept Christ, and college students who pay us some attention [...].[...] S.6