MAIN PSYCHIATRIC DISORDERS IN CRACK-COCAINE USERS TREATED

IN PSYCHOSOCIAL ATTENTION CENTERS FOR ALCOHOL AND DRUGS

(CAPsAD) IN RECIFE CITY

Antonio Gomes de Castro Neto

Post graduation Program in Pharmaceutical Sciences. Federal University of
Pernambuco, Postgraduate Centre of Health Sciences Building, Avenida dos
Engenheiros, no number, 2nd Floor, Cidade Universitária, Recife, PE, Brazil, 50740-600.
E-mail: litaree@yahoo.com. Tel.: +55 81 91457531
*Corresponding author

Diego César Nunes da Silva

Departament ______. Federal University of São Francisco Valley, Centre ______,
Avenida ______, number, Cidade Universitária, Petrolina, PE, Brazil, 50000-50. E-
mail: diego.bio.cesar@bol.com.br

Beate Saegesser Santos

Departament of Pharmaceutical Sciences. Federal University of Pernambuco, Centre of
Health Sciences, Avenida Artur de Sá, no number, Cidade Universitária, Recife, PE,
Brazil, 50740-520. E-mail: beate_santos@yahoo.com.br

ABSTRACT

Crack-cocaine is the main form of consumption of cocaine in Brazil. Brazilian

Northeast region has the highest crack-cocaine consumption in the country. Crack-
cocaine provides more intense effects compare to cocaine powder and can cause more
chemical dependence. Psychosocial Attention Centers for Alcohol and Drugs
(CAPsAD) are public health services which promotes treatment for drug dependence.
Normally drug use, mainly crack-cocaine users, can develop mental disorders. This
study evaluates main mental disorders in crack-cocaine dependents in treatment at
CAPsAD of Recife city consulting research database “Between rocks and shots: user
profiles, consumption strategies, and social impact of crack-cocaine”. There was 885
patients in treatment due use of crack-cocaine, with mean age 29.8±9.4 years. The mean
age of drug use was 6.1±4.6 years. Most of patients are males (80.3%), 1st-9th grade
incomplete (45.6%), Unemployed and/or seek for job (52%) and use drug daily
(56.4%). Cocaine chemical dependence are more significant correlative when use
associated of crack-cocaine and other drugs such medications and hallucinogens (p =
0.01). Social aspects should also be taken into account because they are often the drug
use triggers and also the reason to keep using.

Keywords: Crack-cocaine. Psychiatric disorders. Drug association.

INTRODUCTION

Brazil is the second largest cocaine consumer market in the world, accounting

for 20% of world drug consumption. Crack-cocaine is the consumed form of cocaine

most performance in the country.1,2 The Brazilian Northeast region has the highest crack

consumption in the country with 39% (148.000) of its users. 2 The use of crack-cocaine

has become more popular over the past 15 years especially for its lower price and its

most intense effects when compared to cocaine powder.3

Chemical dependence is a consequence of a pathologic relationship between the

individual and the psychoactive substance. The beginning of the consumption can be for

many reasons, which probably persist after the dependence installed. However the

diagnostics for its private psychologists and physics symptoms can enforce the

consumption behavior, it could transform the main damage of use.4 Crack-cocaine

dependence causes seriously public health problems, associated with significant

economic and social problems and increase the morbid and mortality index. 5 In the

abuse and dependence of psychoactive substance, psychiatric comorbid occurrence is

frequent and indicates no favorable prognostics for dependence treatment. 6 Additional

disorder occurrence could modify the symptomatology, compromise prognostic,

diagnosis, treatment or both.7 The psychiatric clinics recognize disorders co-occurrence

due to substances use and mental disorders. Psychoactive substance abuse is the most

frequently disorder in mental disorder patients, been of fundamental importance the

correct diagnosis of involved pathologies.8,9

The theme of complexity related to the use of psychoactive substances is

reflected in the associated terminology, which seems to change every time professional

and government committees meet to discuss the issue. One of the difficulties is how to

name disorders made by substances that change brain function. In Brazil, to classify
disorders resulting from substance use, are adopted concepts of major international

acceptance of the International Classification of Diseases and Related Health Problems

(ICD-10).10

The question of abuse of drugs has been treated predominantly in the biomedical

perspective, centered on the disease and the cure. However, social, psychological,

economic and political implications are evident and should be considered in the overall

understanding of the problem. Society culturally isolates drug users causing that many

of them do not share the expectation and desire for abstinence with health professionals

and do not even seek treatment because they do not feel accepted in their differences.11

There is currently, in Brazil, a concern in studying the profile of the crack user

population that accesses health services. Cross-sectional studies that are directed to this

clientele are important as they observe the increased demand for treatment of crack

users in their various modalities, including hospitalization for detoxification of this

substance. Studies have found a high prevalence of admissions to psychiatric hospitals

motivated by crack use with or without association with other drugs.12,13,14

Assistance to drug users in the Unified Health System (SUS) has the

Psychosocial Attention Centers for Alcohol and Drugs (CAPsAD) as a reference. 11 The

CAPsAD ensure the provision of specialized care close to where the users live but there

have been reported problems of access and stigmatization evidence in connection with

CAPsAD.15 A higher number of drug users, greater social visibility and higher demand

on health services lead to need for expansion of this field of study. Action planning in

this area depends on greater ownership of data about crack-cocaine users’ population

seeking treatment in public health system. Solving studies of services must be preceded

by the recognition profile of the population that will reach services. Any selectivity

endanger the principle of universality that governs the SUS.16

 This study aims to identify the main mental disorders associated with crack-

cocaine users who seek treatment in CAPsAD in Recife city.

METHOD

The research database “Between rocks and shots: user profiles, consumption

strategies, and social impact of crack cocaine” was consulted to establish the areas of

crack cocaine consumption in the city of Recife.17 This research included a survey of

drug users and medical records who were in care at Psychosocial Attention Centers for

Alcohol and Drugs (CAPsAD), between July 2010 and June 2011. These drug user

treatment and rehabilitation centers are maintained by the government, with public free

access. A protocol containing 38 questions was filled based on medical charts data of

1,957 patients that seek treatment during the study period.

Only records relating crack-cocaine dependent patients were selected. The

parameters used for analysis were: age, gender, educational level, work condition,

duration and frequency of drug use, diagnosed psychiatric disorders as ICD-10 and

main drugs used in combination.

Significance test were used to evaluate correlation between the independent

variables, confidence interval 95% and significant correlations considered when p <

0.05. Cluster analysis performed to establish correlations between main drugs used in

combination with crack-cocaine happen when multiple drug use and correlations

between diagnosed psychiatric disorders and when there was more than one disorder per

patient. Some data were not filled in database. When these situations occurred, the

database was marked as IGN (unknown). This is mainly because patient records are not

completed filled and could compromise more accurate analysis.

RESULTS

Of the 1,957 patients that seek treatment 885 (45%) were due to use of crack-

cocaine. The mean duration of drug use is 6.1±4.6 years with a minimum use of 1 year

and a maximum use of 32 years. Table 1 shows the socio-economic characteristics of

patients.

Table 1 – Socio-economic data of crack-cocaine patients in CAPsAD.

Variables Participants
Age (SD) 29.8 (9.4)
Gender
Masculine (%) 711 (80.3)
Feminine (%) 174 (19.7)
Education level
Unlettered (%) 25 (2.8)
Only read and/or write (%) 20 (2.3)
1st-9th grade complete (%) 199 (22.7)
1st-9th grade incomplete (%) 402 (45.6)
10th-12th grade (%) 153 (17.3)
> 12th grade (%) 16 (1.8)
IGN (%) 67 (7.5)
Work condition
Student (%) 34 (3.9)
Formal job (%) 95 (10.8)
Informal job (%) 129 (14.6)
Unemployed and/or seeking for job (%) 458 (52)
Retired (%) 23 (2.6)
IGN (%) 81 (9.2)
Other (%) 61 (6.9)
Frequence of use
Daily (%) 499 (56.4)
Weekly (%) 129 (14.6)
Eventualy (%) 35 (3.9)
Abstinence (%) 75 (8.5)
IGN (%) 147 (16.6)
SD = standard deviation; IGN = unknown.

The mean age of patients was 29.8±9.4 years; 80.3% are male; 45.6% had not

completed the 1st-9th grade; and 52% was unemployed and/or seeking for job. There are

significant correlation between 1st-9th grade incomplete education level with 27.8 years

age (p = 0.04), unemployed and/or seeking for job work condition (p = 0.01) and male

gender (p = 0.001). Unemployed and/or seeking for job work condition and 30.07 years
age also shows significant correlation (p = 0.03). Table 2 shows the main psychiatric

disorders diagnosed in users using ICD-10 criteria.

Table 2 – Psychiatric disorders data of crack-cocaine patients in CAPsAD.

Participants
Psychiatric disorders Only one mental More than one Total
disorder mental disorder
Chemical dependence 623 140 763
Mood disorders 0 12 12
Schizophrenias 1 23 24
Neurotic disorders 0 5 5
Personality disorders 0 3 3
Others* 25 107 132
*Depression; Bipolar disorder; Persistent mood disorder; Psychotic disorders; Delusional
disorders; Nonorganic psychosis unspecified.

For the 885 crack-cocaine patients, 763 are chemical dependence of cocaine or

other drug. All psychiatric disorders were significantly correlated to each one (p <

0.04), except neurotic disorders with mood disorders (p = 0.1). It was established a

relationship between socio-economic data and psychiatric disorders, where gender, age,

education level, work condition are significant correlated with all psychiatric disorders

(p < 0.05), except age with chemical dependence (p = 0.08) and neurotic disorders (p =

0.07). Gender and personality disorders also show low significant correlation (p = 0.06),

although majority of personality disorders were diagnosed in women (66,7%). Table 3

shows the main drugs used in combination with crack-cocaine.

Table 3 – Crack-cocaine use and main drugs used in combination with crack cocaine in
patients in CAPsAD.
Substance Participants
Crack (only) 64
Crack + Alcohol 45
Crack + Tobacco 24
Crack + Marijuana 65
Crack + Cocaine 6
Crack + Inhalants 2
Crack + Alcohol + Tobacco 32
Crack + Alcohol + Marijuana 85
Crack + Alcohol + Inhalants 5
Crack + Tobacco + Marijuana 63
Crack + Tobacco + Cocaine 1
 Crack + Marijuana + Cocaine 10
Crack + Alcohol + Tobacco + Marijuana 183
Crack + Alcohol + Marijuana + Cocaine + Amphetamines 7
Crack + Alcohol + Tobacco + Marijuana + Benzodiazepines 18
Crack + Alcohol + Tobacco + Marijuana + Cocaine + Amphetamines + Others 2
Crack + Alcohol + Tobacco + Marijuana + Cocaine + Benzodiazepines + Others 4
Crack + Alcohol + Marijuana + Cocaine + Amphetamines + Benzodiazepines + 1
Others*
*Medical drugs; Hallucinogens.

Regarding crack-cocaine use, 64 patients used only the drug and all the others

patients used at least one drug in combination with crack-cocaine. Most part of patients

(183) used in combination crack-cocaine, alcohol, tobacco and marijuana. It was not

found crack-cocaine, cocaine and alcohol used in combination. Figure 1a shows the

cluster analysis correlating drugs used in combination with crack-cocaine and Figure 2b

shows the cluster analysis correlating psychiatric disorders.

Figure 1 – Cluster analysis correlating drugs used in combination with crack-cocaine

(a) and psychiatric disorders (b).
T r e e D ia g r a m f o r 8 V a r ia b le s T r e e D ia g r a m f o r 6 V a r ia b le s
S in g le L in k a g e S in g le L in k a g e
E u c lid e a n d is t a n c e s E u c lid e a n d is t a n c e s

A lc o h o l
C h e m ic a l d e p e n d e n c e

M a r iju a n a
M o o d d is o r d e r s
T obacco

A m p h e t a m in e s N e u r o t ic d is o r d e r s

B e n z o d ia z e p in e s P e r s o n a lit y d is o r d e r s

O th e rs
S c h iz o p h r e n ia s
C o c a in e

O th ers
I n h a la n t s

2 4 6 8 10 12 14 16 18 20 22 0 5 10 15 20 25 30
(a) L in k a g e D is t a n c e (b) L in k a g e D is t a n c e

The use of alcohol is significant correlated with amphetamines (p = 0.04),

benzodiazepines (p = 0.03) and cocaine (p = 0.03). The use of tobacco is significant

correlated with amphetamines (p = 0.01), benzodiazepines (p = 0.01) and cocaine (p =

0.04). Table 4 shows the correlation between mental disorders and use of substance in

combination with crack-cocaine.

Table 4 – Correlation between mental disorder and multiple substance use.
Mental disorder Substance p-value
Chemical dependence Other 0.01

Mood disorders Alcohol 0.01

Schizophrenias Tobacco 0.01

Neurotic disorders Amphetamines 0.007

Personality disorders Amphetamines 0.005

Others Inhalants 0.02

Crack-cocaine use associated with amphetamines is significant correlated with

neurotic disorders (p = 0.007) and personality disorders (p = 0.005).

DISCUSSION

Socio-economic data of crack-cocaine users attended in Recife city CAPsAD are

similar to data found in national surveys.2,3 However the average age 29.8 (9.4) is

slightly higher compared to the national average which is between 18-24 years in

capitals.3

Studies typically show drug use in early adolescence. 17,18 The early use is

associated with several factors as a way to enter in a group 19, curiosity20 and problems

like lack of prospects21 and family breakdown.22 Continued use may trigger chemical

dependency and make the person susceptible to violence of trafficking due to

compulsive use.23,24 Nevertheless the average time of drug use being 6.1±4.6 years

shows a long survival when compared with studies showing average lifespan of people

associated with crime25 or victims of trafficking.24 With a maximum usage of 32 years

and with approximately 30% of patients with some fixed income, this may demonstrate

a use pattern which does not directly interfere in their personal and work relationships.
 Most patients have showed chemical dependence to cocaine or other drugs.

Theoretically as the cut was made in crack-cocaine users attended in CAPsAD,

everyone should introduce some kind of mental disorder. That did not happen due to

filling failures of records which compromises improved data analysis.

All psychiatric disorders were significant correlated to each one (p < 0.04),

except neurotic disorders with mood disorders (p = 0.1). The pressure of society over

the individual makes the person search for forms of relaxation and possibly seek drugs

as a mean of pleasure and end up becoming dependent. 26 Anxiety, depression or

dissociation caused by way of life associated with use of drug can lead to formation of

multiple psychiatric disorders, further hindering the treatment.27 Most of personality

disorders were diagnosed in women (66,7%). Despite men are more impulsive in

relation to women28, there is a higher proportion of women than men suffering from

personality disorder29. Use of crack-cocaine due to its excitatory effects can cause

borderline or antisocial conduct frames in women. 30,31 These situations are normally

accompanied by aggressions which can cause violence problems among users.

Multiuse is more common than isolated crack-cocaine use. Despite literature

report tobacco main use in conjunction (92%)3, in this study the main multiuse consists

of a combination of alcohol, tobacco, marijuana and crack-cocaine. Use of marijuana

and tobacco together with the crack-cocaine is reported as a way to reduce crack-

cocaine craving effects.32 Use of alcohol in conjunction with crack-cocaine is related as

a way to prolong the drug effects. 33 This pattern of use can be related to a form of

prolonging the effects of crack-cocaine while their cracking effects are reduced, which

may explain the average time of use. Although it has been reported the use in

conjunction of crack-cocaine and cocaine, it has not been reported crack-cocaine,

cocaine and alcohol use in conjunction. Possibly because this pattern of use is related to

craving.34

Other drugs use in conjunction with the crack-cocaine showed a strong

association with chemical dependence (p = 0.01). Possibly due to other drugs increasing

cocaine effects favor installation of dependence.35 The use of alcohol and crack-cocaine

together also showed a strong association with mood disorders (p = 0.01). Probably

their use together leads to formation of cocaethylene, which has a longer half-life time

compared to cocaine33 and, due to its excitatory effects, can cause manic episodes 36 or

after the use of the amount of excitatory neurotransmitters, particularly dopamine and

noradrenalin, become reduced it can also cause depression episodes. 37 The use of

tobacco and crack-cocaine has great association with schizophrenia. Probably because

they are both excitatory drugs potentially triggering schizotypal or paranoid frames.38

Data from this study showed strong associations between crack-cocaine uses

with development of psychiatric disorders, particularly when multiuse occurs. Despite

cocaine dependence be the primary disorder treated, patient who develops associated

disorder, if not properly treated, can lead to recurrence frames. Social aspects should

also be taken into account because they are often the drug use triggers and also the

reason to keep using. Public services such as CAPsAD should be easily accessible to

population and priority on governments to ensure better treatment to those who need

support and wish to leave crack-cocaine use.

ACKNOWLEDGEMENTS
 National Council of scientific and technological development (CNPq) for

financial support. Study Group on Alcohol and other Drugs (GEAD) for database

consult.

DISCLOSURE

The authors report no conflicts of interest.

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