Background
Crack, the smokable form of cocaine, is a potent stimulant of the central nervous system and carries with it a high potential for user addiction. In general, crack cocaine use occurs over a prolonged period of time [
1], and cessation of use results in physical, psychological or financial exhaustion [
2,
3].
Cocaine presents inherent risks to users, such as neurological and psychiatric impairments [
4] (e.g., depression and psychosis symptoms [
5,
6]) and death through overdose [
7].
Although it is not identified among the most heavily consumed illicit drugs from Brazilian statistical data (only 0.7% of the population has used it during their lifetime) [
8], crack deserves attention due to the risks associated with the pattern of compulsive use surrounding it. Users frequently become involved in violent and illegal activities, such as theft, assault, trafficking [
2,
3] and risky sexual activities to obtain money or drugs [
9‐
11], all of which cause social and public health problems.
The sharing of drug paraphernalia and sexual promiscuity lead to an increase in sexually transmitted diseases in addition to other diseases resulting from respiratory damage (e.g., tuberculosis) [
12,
13]. Furthermore, the lifestyle adopted by users, which is often permeated by illegal activities, makes them especially vulnerable to external causes of death [
10]. In a five-year follow-up study with crack users, Ribeiro et al. showed that 18% of the sample died during the follow-up period. The authors reported that this rate is seven times greater than the general mortality rate in São Paulo during the same period and noted that 56.6% of these deaths were homicides [
14].
Such facts demonstrate how destructive the culture of crack consumption can be. Due to social marginalization, violence related to trafficking, conflicts with the police and organic and social psychological problems associated with the drug, crack has become one of the most devastating drugs [
2,
3,
10].
However, there is evidence that some users manage to stay alive and active while using crack cocaine for many years, despite the list of adversities and risks involved with this behavior. Dias et al. [
15] followed crack users for 12 years and reported that deaths declined considerably during the last seven years of follow-up. They saw stabilization in deaths over time, which suggests that users learned protection strategies [
15].
In a nine-year American study following crack users, Falck et al. also noted some adaptation to the crack culture [
1]. They emphasized that 64% of the sample maintained unaltered use of crack for nearly a decade (i.e., use without periods of abstinence for more than six months in duration).
However, there is still a serious and important lack of understanding with regard to the practices and social dynamics related to crack consumption [
16], especially among long-term users [
1]. Therefore, there is a need to explore and describe in detail the strategies that seem to support this long-term crack use [
2].
Trying to understand the practices and social dynamics related to crack consumption among long-term users is novel and very timely because there is a dearth of research concerning long-term users of illicit drugs, especially non-treatment populations. Such understanding may substantially subsidize the policies directed to this population.
Therefore, the objective of this study was to identify, from the perspective of the user, the risks to which users are subjected. This study then sought to explore strategies and tactics employed by users to overcome these risks and increase the chances for survival within this context.
Discussion
Given the high mortality rate among the population of crack users [
14,
15] and, paradoxically, the long-term consumption for most users who remain alive [
1], the question arises: "How are some users able to survive this culture and continue using for decades?"
This type of question had not been explored previously in literature through the vision of crack users. Despite this, some reports have shown that changes in the crack culture may have contributed, in some cases, to an increase in the life expectancy of consumers. In the early 1990s, it was estimated that a crack consumer would live for just a few years [
3,
26]. Today, it is common to find users with more than five years of consumption history [
14]. An example of this finding is the sample in this study, which demonstrated a surprisingly high average time of crack use (11.5 years). This finding parallels a U.S. study that also showed the continuing use of crack for years and even decades [
1].
The results of this study confirm the hypothesis that crack users "adapt" to the drug culture and some of the risks it generates. The latter, which are well-perceived by users, are confirmed by their detailed reports.
Apparently, some strategies and tactics are effective for maintaining and improving the dynamics of users' lives. In particular, effective strategies enable the user to recognize situations of greatest risk, generally, those arising from the illegality of the drug and its psychological effects, and to learn to deal with them. Because these strategies were born inside the crack culture itself and were developed by the consumers themselves, they seem to have been more easily absorbed by the culture. In a study conducted in Canada, Boyd et al. [
27] concluded that measures of harm reduction are more effective when passed through the practices of current users and their associates. In the same way, Sherman et al. [
28] showed the importance of peer diffusion of prevention information among drug injectors, facilitating the accessibility and reducing the stigma.
Death arose as the inherent risk in crack use that was most feared by users. Avoidance of this risk allowed the maintenance of addiction for many years. Most of the cited survival strategies were aimed at circumventing possible death and maintaining use in conditions that satisfied the dependence of the respondent.
Ribeiro et al. [
14] presented homicide as the leading cause of death among crack users. Along this line, issues related to the illegality of the drug (e.g., trafficking and police) were emphasized in the present study. Haasen and Krausz [
29] also claimed that crack-related homicides were directly related to the risks posed by the illicit drug market. Strategies described to facilitate dealer-user relations, which are underdeveloped relative to the risks to which they are intended, often seem to prevent serious injuries. Not challenging the dealer on apparently simple rules (e.g., not trying to negotiate price, paying debts, not causing problems around the
"bocada" to arouse the attention of the police, choosing an appropriate place of purchase or soliciting the drug through a delivery service) can prevent the death of the user.
Additionally, regarding the illegality of the drug, the literature and the present data show that the treatment of this population by the police is not cordial [
30]. The most useful strategy reported by users in this context was to admit use to the police if approached. This strategy led to a decrease in violence, as the police are more lenient with simple drug users than with those suspected of being dealers. This attitude is based upon a change in drug laws in the country, which decriminalized the behavior of users to dispense with the need for consumers caught with drugs to be taken to the police station (Law 11343/2006) [
31]. Ensuring placement in the 'user' rather than the 'dealer' category was noted as a beneficial strategy to avoid police violence or punishment.
Due to police access in this population, intervention programs should include police officers playing an educational-preventative role. In this context, Malchy et al. [
16] also suggested that policies for the "street" must be based on realistic programs for the care of this population.
In another group of reported survival strategies, the use of other psychoactive substances to reduce cravings led to a series of additional risks. The strategy of additional substance use contradicts previous reports in which users report avoiding the use of other substances [
2] because, according to the subjects in those previous reports, such a strategy would be suboptimal because it would reduce or modify the positive effects of crack [
2]. In the reports from this study, however, subjects reported that the use of other drugs, especially alcohol and marijuana, helped to alleviate the negative effects of crack use, primarily cravings, withdrawal symptoms and unwanted side effects.
In agreement with the present study, Magura and Rosenblum [
32] observed that 60% of cocaine users frequently used alcohol to relieve discomfort related to cravings and the cessation of use. The literature suggests that this association aims to alleviate discomfort, especially during periods of abstinence [
32]. In the present study, the use of alcohol was observed at various times, even simultaneously with crack, for a variety of purposes, many of which centered upon the reduction of unpleasant psychological effects.
The use of alcohol, reported as effective in minimizing the principle unpleasant psychological events (i.e., craving and paranoid symptoms), would help reduce risks related to behavioral conduct adopted in the presence of these symptoms. Thus, it is likely that this association plays a role in the survival of users while confronting these risks, but further studies are needed to examine this question in depth. This association raises concern due to its vast short- and long-term consequences, such as the development of another associated dependency. Moreover, the formation of the metabolite cocaethylene is also a concern. This product of combined ingestion, whose half-life is three times that of cocaine, apparently promotes an extension of the pleasurable effects for the user and results in significant stimulation. In addition, cocaethylene has properties that are more cardiotoxic than crack, such as increased heart rate and blood pressure, and it can increase the risk of an overdose [
33‐
35].
The consumption of marijuana along with crack as a strategy has also been associated with various outcomes. The main effect presented here was the relief of cravings. Despite the existence of reports that marijuana induces cravings and encourages the development of compulsive mixed use, several reports have attributed success to this association. Labigalini et al. [
36] reported successful experiences with crack users in which they could replace crack with marijuana over a reasonable period of time. As dependence on marijuana is much less damaging than dependence on crack, these authors suggest that this strategy be considered to reduce damage.
This association appears to be more common than originally thought. Therefore, further study with regard to both the results it can produce and its medium- and long-term disadvantages is needed.
Other strategies presented in the reports (e.g., using the drug in groups), however, were entirely harmful to the users. This strategy, which was reported by users as a way to protect against possible episodes of overdose due to the potential for immediate assistance, also potentially increases the chances of violent injury. Reports have indicated that there is considerable confusion among members using in group settings related to persecutory delusions and cravings during collective use. These events trigger physical confrontations between users. In addition, Latkin et al. suggested that the drug-use network influences behavior in relation to consumption; it increases drug use, causing greater susceptibility to overdosing and sharing of paraphernalia [
37].
With regard to episodes of overdose, little research has examined the prevalence of this event for cocaine and its derivatives. Further, neither social nor contextual factors associated with overdosing have been considered [
37]. Mesquita et al. showed that 20% of 396 exclusive cocaine users surveyed had suffered one or more episodes of this nature, with 50% of the sample knowing of one or more cases of death by overdose [
38]. The authors believe that overdose events are under-reported, probably because users do not wish to present themselves as such [
38].
In this study, a minority of the sample reported experiencing this event or witnessing or hearing news of a death due to such circumstances. A considerable portion of respondents reported having "felt sick" when smoking crack, with the reported symptoms clearly characterizing episodes of overdose. Thus, while overdose events may be underestimated, this underestimation likely occurs because such events are not identified as overdoses due to the fear of self-exposure.
Regarding HIV, this infection is more prevalent among crack users compared to the general population [
9]. The statistics describing HIV as the second most prevalent cause of death among crack users [
14] are explained by some factors related to the lifestyle of users. Apart from the vast literature on the risky sexual behavior adopted by crack users (particularly sexual activity to obtain money or drugs) [
9,
11,
39], this study has shown that users consider condom use to be optional. Thus, the use of condoms is inconsistent. This strategy protects few users and does not prevent infection and consequent death due to HIV for the majority of users. Friedman et al., in a study with long-term injection drug users, described that some injectors remain uninfected by HIV and HCV [
40]. They use personal strategies and tactics developed to stay safe [
40]. The authors also showed that multiple intentionalities are integrated to keep the user uninfected [
40].
The present study detected that inconsistent behavior among users extends to many survival strategies and the evaluation of risks. Some users exhibit a deficit in the ability to recognize or judge potential risks. This would make them unlikely to learn and adopt strategies to deal with such risks. These users may represent those most at risk for a poor prognosis (e.g., STDs or death). Therefore, it is possible to observe how prevention strategies need to be interconnected with objectives that cover different user behaviors.
This qualitative study was designed based on intentional sampling criteria; therefore, the ability to extrapolate these findings to other populations or to represent the standardized behavior of the general population of crack users remains limited.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LAR managed the data collection, conducted preliminary data analysis and drafted the manuscript. ZMS conducted the final data analysis and revised the manuscript. SAN designed the research questions and was responsible for general coordination and revised the manuscript. All authors read and approved the final manuscript.