{"id":239337,"date":"2017-06-05T18:34:03","date_gmt":"2017-06-05T21:34:03","guid":{"rendered":"http:\/\/revistapesquisa.fapesp.br\/?p=239337\/"},"modified":"2017-07-04T19:19:45","modified_gmt":"2017-07-04T22:19:45","slug":"the-price-of-abstinence","status":"publish","type":"post","link":"https:\/\/revistapesquisa.fapesp.br\/en\/the-price-of-abstinence\/","title":{"rendered":"The price of abstinence"},"content":{"rendered":"
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L\u00c9O RAMOS<\/span><\/a> Metal pipe used to consume crack, a smoked version of cocaineL\u00c9O RAMOS<\/span><\/p><\/div>\n

In 2010, psychologist Andr\u00e9 Constantino Miguel decided to make a bold move. Selected to enter a doctoral program, he proposed to the team starting to form at the Federal University of S\u00e3o Paulo (Unifesp) that they study a motivational technique in psychology that had not yet been tested in Brazil or used with individuals dependent on crack. He had just returned from two years of study in Italy, where he had worked with people dependent on heroin, and he could not accept the fact that this strategy \u2013 contingency management, useful for reducing dependence on alcohol, tobacco and cocaine, according to studies conducted abroad \u2013 had still not been implemented in Brazil. That year, he completed his mission by publishing the results of the first study on the use of contingency management as an additional support in the treatment of crack dependency, in the journal Psychology of Addictive Behaviors<\/em>.<\/p>\n

Only recently adopted for the treatment of drug dependency, possibly owing to its controversial nature, contingency management consists of offering financial compensation whenever someone demonstrates behaviors considered desirable.<\/p>\n

This strategy, which can be used in a variety of contexts, is based on the work of American psychologist Burrhus Frederic Skinner. In experiments performed on laboratory animals, he demonstrated that the consequences of a given action can shape behavior. For example, rats that received food (consequence) when they pushed a lever (action) tend to repeat the action. In the 1960s, other psychologists adapted contingency management techniques for the treatment of chemical dependence, in which the goal to be achieved is usually abstinence or compliance with the treatment plan.<\/p>\n

Someone with a drug dependency who can manage for a period of time not to consume the drug that was holding him hostage receives a reward, usually financial in nature. If he stays clean, he receives vouchers, tickets to concerts, movies or the theater and even cash. It is a simple way to encourage someone to repeat a behavior.<\/p>\n

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L\u00c9O RAMOS<\/span><\/a> Specialized attention: people dependent on crack in a detox ward at Cratod…L\u00c9O RAMOS<\/span><\/p><\/div>\n

Miguel discovered an opportunity to measure the effectiveness of contingency management in the day-to-day routines of individuals dependent on crack, the smoked version of cocaine, when he was invited to practice at the psychiatric specialty outpatient clinic (AME) at Vila Maria in S\u00e3o Paulo\u2019s north zone. Until then, the technique had been adopted as part of an experimental treatment to increase participation or encourage compliance with therapies for obesity and diabetes or dependency on heroin, alcohol, tobacco and cocaine that was snorted, but not crack.<\/p>\n

From August 2012 to July 2014, Miguel and other specialists invited 65 people with crack dependency sent for treatment at AME-Vila Maria to participate in an experiment. Randomly selected, 32 of them received the standard 12-week outpatient treatment. Each participant was given one individual consultation per week with a general clinician, psychologist, psychiatrist, occupational therapist or nurse and could participate in group activities to prevent relapse. These people constituted the control group and were encouraged to collect a urine specimen on Mondays, Wednesdays and Fridays and deliver it to researchers so they could test it for the presence of cocaine or marijuana metabolites.<\/p>\n

\u201cEvery time the participant received a negative screen for cocaine or crack, his abstinence was validated,\u201d says Miguel. \u201cIf the result indicated drugs had been consumed, the group celebrated compliance with the therapy and encouraged him to remain abstinent.\u201d<\/p>\n

The remaining 33 participants made up the experimental group, which, in addition to the standard treatment, were subject to contingency management. They were required to go to the AME-Vila Maria three times a week for urine testing for cocaine and marijuana and to submit to a breathalyzer test for alcohol consumption.<\/p>\n

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L\u00c9O RAMOS<\/span><\/a> …where they also receive dental careL\u00c9O RAMOS<\/span><\/p><\/div>\n

Each time a participant presented a urine sample that was clean for cocaine, he received compensation in the form of a voucher. The voucher for the first negative screen was worth R$5, and the vouchers increased in value by R$2 for each subsequent screen that was clean, up to a maximum amount of R$15 per test. Participants received an additional R$2 if, in addition to abstaining from cocaine use, they had refrained from consuming alcohol. Participants with three negative screens for cocaine in one week received an additional R$20 in the form of a bonus. They were also awarded R$10 if the three urine tests that week were negative for marijuana use. As such, any participant who remained clean for the 12-week period would receive R$942.<\/p>\n

In the case of relapse \u2013 which is common in the treatment of chemical dependency \u2013 the participant would not lose the money he had earned. Instead, with the first positive result, he would receive nothing and the amount of the reward would go back down to the initial amount of R$5 for the next negative screen.<\/p>\n

Of the 33 individuals enrolled in the voucher group, 7 (21.2%) did not use crack over the 12 weeks of the study, according to results reported by researchers in the journal Psychology of Addictive Behaviors<\/em>. No one in the control group remained abstinent over the entire course of the study \u2013 only one (3%) remained abstinent from consuming crack for eight weeks, while 9 (27%) of participants who received the financial reward remained abstinent for two months. Those who received the vouchers, in general, also consumed less alcohol and marijuana.<\/p>\n

\u201cAs they grew in their capacity to remain abstinent and bought into the idea of accumulating the rewards to gain higher levels of compensation, some participants used the vouchers to buy basic goods for their mother or a gift for a child,\u201d says Miguel.<\/p>\n

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Zanone Fraissat \/ Folhapress <\/span><\/a> Consumers and sellers of crack on Alameda Dino Bueno, in downtown S\u00e3o Paulo, where rocks of crack are purchased for amounts ranging from R$5 to R$10Zanone Fraissat \/ Folhapress <\/span><\/p><\/div>\n

According to psychologist Clarice Madruga, a professor at the Center for Research on Alcohol and Drugs (Uniad) at Unifesp and coauthor of the study, the willingness to collect more rewards by extending abstinent behaviors indicates that these participants began to tolerate delayed gratification, an ability they had lost when they became dependent. \u201cThe consumption of crack and other drugs gives an immediate reward, which may be a fleeting sense of wellbeing or relief to which the body becomes accustomed,\u201d she explains. \u201cNew conditioning is needed to extend the period of delayed gratification.\u201d<\/p>\n

Six months after the experiment\u2019s completion, researchers offered people in the control group the possibility of working with the contingency management approach. Yet again, around 20% completed the treatment without consuming crack.<\/p>\n

Although only a small percentage managed to stay off crack, Miguel points out that this happened under real-life circumstances involving risks that are not in play when subjects are hospitalized. \u201cThese people managed to do this even in the eye of the storm, with their rocks of crack alongside them,\u201d emphasizes the researcher, who conducted the study under the supervision of psychiatrist Ronaldo Laranjeira, a specialist in the treatment of alcohol and drug dependency and professor at Unifesp.<\/p>\n

The effectiveness of contingency management at different stages of treatment for chemical dependency is recognized today by the National Institute on Drug Abuse (NIDA) in the United States, one of the world\u2019s premier centers for the study of substance abuse, which recommends its use. \u201cRecently, I was at a meeting at NIDA, and no one questions the effectiveness of this technique anymore. It has been adopted in more than 60% of centers for the treatment of alcohol and drug dependency in the United States,\u201d says Laranjeira. \u201cThe current debate is about how to implement it properly.\u201d<\/p>\n

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L\u00c9O RAMOS<\/span><\/a> Cooking workshop helps to create connections with people who have not yet entered treatment and to train clients of the Helv\u00e9tia Unit under the Recome\u00e7o<\/em> programL\u00c9O RAMOS<\/span><\/p><\/div>\n

Contingency management is not itself a treatment method. It is more of a psychological tool intended to encourage the exercise of healthy or desirable behaviors. \u201cThis technique could be used on the street as well as in clinics,\u201d says Laranjeira, who coordinates Recome\u00e7o <\/em>[New Beginnings], a program to deal with crack and other drugs begun in 2013 by the government of the state of S\u00e3o Paulo. \u201cI hope that we will soon see these changes in Cracol\u00e2ndia<\/em>.\u201d<\/p>\n

The addiction spiral \u00a0<\/strong>
\nCracol\u00e2ndia<\/em> is the name given to a few well-known blocks in the neighborhood of Campos El\u00edseos, in the central area of S\u00e3o Paulo. There, between 600 and 1,000 people, depending on the time of day, smoke crack on the street \u2013 purchased on site for between R$5 and R$10. Dirty and dressed in rags, they wander around, often shoeless and with their feet and bodies marked by wounds that do not heal (pain relievers mixed in with the drug block any feeling of pain).<\/p>\n

Weakened immunity, a result of their ongoing cocaine use, explains the high number of TB cases among these individuals. Prostitution and unsafe sexual practices in exchange for a few rocks of crack also increase the frequency of sexually-transmitted diseases like syphilis and AIDS, which are more common among people who frequent Cracol\u00e2ndia<\/em> compared with the population at large.<\/p>\n

Crack use surged in Brazil owing to use in this area in the late 1980s, before it spread across the nation. Both the snorted form of cocaine (in powder form) and its smoked form (crack) act in a similar way on the brain: their molecules indirectly increase the concentration of the neurotransmitter dopamine in areas connected to motivation and reward. The result is a sensation of extreme euphoria and wellbeing, which is fleeting nonetheless.<\/p>\n

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L\u00c9O RAMOS<\/span><\/a> Conducted twice a day, rehearsals of the percussion group Cora\u00e7\u00e3o Valente<\/em> [Brave heart], under the Recome\u00e7o<\/em> program, bring rhythm and structure to the daily life of the chemically dependentL\u00c9O RAMOS<\/span><\/p><\/div>One of the main differences between snorted and smoked cocaine is in the speed of its absorption, which influences the rapidity with which the drug reaches the brain and how long it remains active, which are determining factors in establishing dependency. When a line of cocaine is snorted, the drug is absorbed slowly through the nasal mucosa, enters into the bloodstream and is partially processed by the liver before reaching the brain. It takes a few minutes until its effects are felt, and they can last for more than 30 minutes. In the case of crack, everything moves faster and is more intense. As soon as the smoke reaches the lungs, the drug enters the bloodstream and is carried to the brain in higher concentrations. It takes effect almost immediately: there is an explosion of pleasure and euphoria that disappears in minutes and then leads to an intense depression. This is where the problems begin.<\/p>\n

In search of a feeling of wellbeing, users smoke another rock. As time passes, brain cells attempt to return to normal, reducing the amounts of dopamine available. It then becomes necessary to smoke more to attain the same result. With ongoing consumption, cocaine becomes necessary to maintain the levels of dopamine levels to which the body has become accustomed. Without the drug, many unpleasant symptoms ensue: agitation, anxiety, difficulty concentrating, angry outbursts and depression. At this moment, users are no longer smoking for pleasure but rather to avoid suffering.<\/p>\n

Young, black and poor <\/strong>
\nA national survey on drug consumption conducted in 2012 under the supervision of Clarice Madruga and Ronaldo Laranjeira estimated that 1.5% of Brazilians over the age of 14 (almost 2.2 million people) had consumed crack at least once in their lives. A smaller proportion (0.8% or 1.2 million Brazilians) had used the drug in the year prior to the survey, an indication of current consumption. This fact indicates that Brazil has one of the world\u2019s highest number of drug users. In the United States, where cocaine and crack are being replaced by synthetic drugs, current users are 0.3% of the population over the age of 12, or about 8 million people.<\/p>\n

Also in 2012, psychiatrist Francisco In\u00e1cio Bastos and statistician Neilane Bertoni, both of whom work at the Oswaldo Cruz Foundation (Fiocruz) in Rio de Janeiro, developed a profile of crack users. Researchers went to cracol\u00e2ndias<\/em> and interviewed 7,300 frequent users of crack distributed over every Brazilian state. They confirmed that these areas are occupied by young and poor black Brazilians: 78% were male, 85% were between 18 and 40 years old, 80% were black or brown-skinned, and 58% were in school only up to the end of middle school. Four out of of ten lived on the street, 65% supported themselves, 10% committed thefts or robberies and 7% engaged in prostitution to get drugs, which they had been using for some time (on average for 6.5 years) and consuming in large quantities (13 rocks a day).<\/p>\n

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L\u00c9O RAMOS<\/span><\/a> Under the De Bra\u00e7os Abertos<\/em> program, the painting, sewing and bicycle repair workshops serve as a space for occupational apprenticeships, and participants earn about R$15 per day for their workL\u00c9O RAMOS<\/span><\/p><\/div>\n

Two programs in the city of S\u00e3o Paulo \u2013 Recome\u00e7o<\/em>, run by the state government, and De Bra\u00e7os Abertos<\/em> [With Open Arms], run by the city government \u2013 attempt to help users stop their crack use. Established in 2013, the state program opened the Recome\u00e7o<\/em> Helv\u00e9tia Unit in mid-2014, as one of the pillars of its outreach work, where researchers intend to adopt the contingency management approach soon. Located in an 11-story building at 55 Alameda Helv\u00e9tia, the unit offers users access to a social center where they can shower, get their hair cut, have their injured feet cared for, work out and participate in therapeutic cooking and music groups. There is a detox ward on two floors with 21 beds for people who agree to try to quit crack during a hospitalization period. Anyone who is successful at breaking the crack habit can compete for one of 30 spots in one of the supervised apartments located in the same building, and the only requirement for residency is that they remain drug-free. This system of supervision follows a model already adopted in England and the United States, the goal of which is to jumpstart a social reintegration process so that these individuals earn some income and a place to live outside of the crack-infested area.<\/p>\n

Before arrival at the Helv\u00e9tia Unit, individuals from Cracol\u00e2ndia<\/em> that accept treatment are directed to the Referral Center for Tobacco, Alcohol and Other Drugs (Cratod), facing the Parque da Luz, some 900 meters away. As a center focused on the highly complex, psychosocial dynamics involved with alcohol and drug abuse, Cratod offers therapy groups, dental care, referrals to therapeutic communities and hospitalization. Between April and June 2016, Cratod served about 2,600 crack users referred for different kinds of treatment: 42% for outpatient treatment; 14% for therapeutic communities; and 39% for inpatient detox. \u201cOur centers strive to help the patient navigate the first 90 days of abstinence,\u201d says psychiatrist Marcelo Ribeiro, a professor at Unifesp and Cratod\u2019s technical director.<\/p>\n

Food and shelter <\/strong>
\nHelv\u00e9tia street, facing the Recome\u00e7o<\/em> building, is home to one of the units of the De Bra\u00e7os Abertos<\/em> program, opened in early 2014 by the City of S\u00e3o Paulo. Underneath a large metal roof installed over a tract of city land, crack users have access to a bathroom, food and a rest area. It is an entryway, of a sort, for services based exclusively on the principle of harm reduction, which requires nothing in exchange from those who accept the invitation, not even abstinence. \u201cHarm reduction is based on the idea that most people who have a drug problem aren\u2019t able to abstain from using them,\u201d says psychiatrist Leon Garcia, a doctor at the Psychiatry Institute at the University of S\u00e3o Paulo (IPq-USP) and one of the coordinators of health services for the De Bra\u00e7os Abertos<\/em> program.<\/p>\n

In the treatment of chemical dependency, the harm reduction strategy consists of slowly replacing very toxic drugs with less toxic drugs. In the case of crack, however, there is no effective substitute. According to Garcia, this is the reason that De Bra\u00e7os Abertos<\/em> is counting on offering food, safety and shelter to help those who are dependent to get out of the world of drugs \u2013 the Recome\u00e7o<\/em> program, in turn, adopted harm reduction to prevent unintended pregnancies by offering birth control implants.<\/p>\n