Telephone counseling for young Brazilian cocaine and/or crack users. Who are these users? 夽,夽夽

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www.jped.com.br

ORIGINAL ARTICLE

Telephone counseling for young Brazilian cocaine and/or crack users. Who are these users? ^夽,夽夽

Nadia K. Bisch

^∗

, Taís de C. Moreira, Mariana C. Benchaya, Dan R. Pozza,

Larissa C.N. de Freitas, Michelle S. Farias, Maristela Ferigolo, Helena M.T. Barros

UniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFCSPA),PortoAlegre,RS,Brazil

Received24April2017;accepted12December2017 Availableonline9March2018

KEYWORDS

Telephonecounseling;

Drugaddiction;

Youth;

Teenagers;

Cocaine;

Crack

Abstract

Objective: Todescribetheusers’drugabusecharacteristics,problematicbehaviorsassociated with addiction,the motivationofteenagers andyoung adultstoquitcocaineand/or crack abuse,andthencomparethesecharacteristics.

Methods: Across-sectionstudywasconductedwith2390cocaine/crackusers(teenagersfrom 14to19yearsofage,andyoungadultsfrom20to24yearsofage);1471wereyoungadults and919wereteenagerswhohadcalledaphonecounselingservicebetweenJanuary2006and December2013.Semi-structuredinterviewswereperformedviaphonecalls.Thequestionnaires included sociodemographicinformation; assessmentofthe characteristicsof cocaine/crack abuse;assessmentoftheproblematicbehaviors;also,theContemplationLadderwasusedto evaluatethestagesofreadinesstoceasesubstanceabuse.

Results: Participantsreportedusingcocaine(48.2%),crackandothersmokingforms(36.7%)and combinedconsumptionofbothdrugs (15%).Youngadultsweremorepronetousingcrackor crackassociatedwithcocaine(OR=1.9;CI95%=1.05---1.57)andtheywereexposedtosubstance abuseforlongerthantwoyears(OR=3.45;CI95%=2.84---4.18),whencomparedtoteenagers.

Ontheotherhand,theyshowedhigherreadinesstoquit.

Conclusion: Data shows important differences in drug abuse characteristics, problematic behaviorsandmotivationtoceasesubstanceabusebetweenteenagerandyoungadultcocaine and/orcrackusers.Behaviorsdisplayedbyyoungadultsinvolvegreaterphysical,mentaland socialhealthdamages.Theseﬁndingsreinforcetheimportanceofpublicpolicytoactonpre- ventionandpromotinghealth,toincreaseprotectionfactorsamongteenagersandlowerrisks andlossesduringadultlife.

by-nc-nd/4.0/).

夽 Pleasecitethisarticleas:BischNK,MoreiraTC,BenchayaMC,PozzaDR,FreitasLC,FariasMS,etal.Telephonecounselingforyoung Braziliancocaineand/orcrackusers.Whoaretheseusers?JPediatr(RioJ).2019;95:209---16.

夽夽Studylinkedto‘‘Ligue132’’(‘‘Call132’’)phoneservice,UniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFCSPA),Porto Alegre,RS,Brazil.

∗Correspondingauthor.

E-mail:nkrubs@gmail.com(N.K.Bisch).

https://doi.org/10.1016/j.jped.2017.12.016

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PALAVRAS-CHAVE Aconselhamento telefônico;

Dependência química;

Jovens;

Adolescentes;

Cocaína;

Crack

Aconselhamentotelefônicoparajovensbrasileirosusuáriosdecocaínae/oucrack.

Quemsãoestesusuários?

Resumo

Objetivo: Descreverascaracterísticasdeconsumo,comportamentosproblemáticosassociados aousoemotivac¸ãoparacessaroconsumoentreadolescentesejovensusuáriosdecocaínae/ou crackecompararessascaracterísticas.

Métodos: Realizou-se um estudotransversal, com2.390 usuários de cocaína/crack(adolescentes:14---19anosejovens:20---24anos)sendo1471jovense919adolescentes,queligaram paraumserviçodeaconselhamentotelefônicoentrejaneirode2006edezembrode2013.Foram realizadasentrevistassemiestruturadasportelefone.Osquestionáriosincluíraminformações sociodemográficas;avaliaçãodascaracterísticasdoconsumodecocaína/crack;avaliaçãodos comportamentosproblemáticoseescaladeContemplaçãoLadderparaavaliarosestágiosde motivação.

Resultados: Osparticipantesrelataramusodecocaína(48,2%),crackeoutrasformasfumadas (36,7%)eusoassociadodeambasasformas(15%).Osjovensfaziammaiorusodecrackoucrack associadoàcocaína(OR=1,19;IC95%=1,05-1,57)eestavamexpostosaousodadrogahavia maisde2anos(OR=3,45;IC95%=2,84-4,18)quandocomparadosaosadolescentes.Poroutro lado,mostraram-semaismotivadosparacessaroconsumo.

Conclusão: Osdadosmostraramhaverimportantesdiferençasnascaracterísticasdeconsumo, comportamentosproblemáticosemotivaçãoparacessaroconsumoentreadolescentesejovens usuáriosdecocaínae/oucrack.Osjovensapresentaramcomportamentosqueenvolvemmaiores prejuízosparaasaúdefísica,mentaleaspectossociais.Essesachadosreforçamaimportância deaçõesdepolíticaspúblicasdeprevençãoepromoçãodesaúdeparaaumentarosfatoresde proteçãoentreosadolescentesereduzirriscoseprejuízosparaavidaadulta.

´

eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/

by-nc-nd/4.0/).

Introduction

The 2015 World Drug Report showed that while cocaine/crack use has stabilized in the rest of the world,therehasbeenanincreaseinconsumptioninSouth America.¹ By 2014, in the United States, approximately one million individuals over the age of 12 have been classiﬁedascocaineaddicts orabusers.²RegardingBrazil, the country ranks second in the cocaine trade and ﬁrst in crack consumption, accounting for 20% of the world’s consumption.³

Approximately 200,000 young Brazilians reported using intranasal cocaine in the last 12 months, and 150,000 youngindividualsusedcrackorsimilardrugsatleastonce.³ Accordingtoastudy carriedouttodescribetheproﬁleof usersof crackand/or similardrugs in Brazil,in 2012,the agegroupwithhighestprevalencewasthatof18---24years (31.32%).⁴

Adolescence/young adulthood is an evolutionary phase that brings many obstacles and can lead individuals to engageinriskyactivities,suchasdruguse.⁵Accordingtothe WorldHealth Organization (WHO), young individuals aged 10---19 years areconsidered adolescents,and between 20 and24yearsofage,asyoungadults.⁶

Itisknownthatdrugexperimentationusuallybeginsin adolescence.⁷However,atthisstageofdevelopment,when majorbodychangesoccur,especiallyinthecentralnervous system(CNS),druguse mayimpairbrainfunction,affect- ingcognitive andlearning ability.⁷ Delaying or preventing

theonsetof psychoactivesubstanceuse byyoungindivid- ualshasbeenaworldwidechallengeforthoseresponsible forpublichealthpolicies.Manystudieshaveshowntherisks relatedtodrugexperimentation,use,andabuseamongado- lescents and young adults.^8,9 Early use of cocaine and/or crack increases the risk of developing a substance use- related disorder,as wellas other mentaldisorders during adolescenceandyoungadulthood.¹⁰Understandingthepat- ternsof cocaine and/orcrack use amongadolescentsand youngadultscanassistintheplanningoftargetedandmore effectivepreventionactions,aswellasinthedevelopment ofmoreeffectivetreatmentstrategies.¹¹

The present study aimed to describe the characteris- ticsofdruguse,problembehaviorsassociatedtothisuse, andreadinesstoceaseconsumptionamongadolescentsand youngusersofcocaineand/orcrack,andtocomparethese characteristicsbetweenthetwogroups.

Methods

Across-sectionalstudy wasconductedwithaconvenience sample of2390 cocaine/crackusers(adolescentsbetween 14 and19 yearsof age andyoung individuals between 20 and 24 years of age), who reported using drugs associated ornotwithother substancesandcalleda counseling servicenumberaimingatseekinghelptostopthisconsump- tion.The‘‘Ligue132’’(Call132)isatelephonecounseling servicethataimstoassistusersofpsychoactivesubstances duringthe consumptioncessationprocess.Datacollection

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occurredfromJanuary2006toDecember2013,andduring thisperiod,3272young individualsandadolescentscalled theservice.Atotalof892adolescentsandadolescentswho reported being under the effect of drugs during the call wereexcluded,aswellasthosewithcognitivedifﬁculties tounderstand or respondtothetools,and thosewhodid notagreetoparticipateinthestudy.

Theusersacceptedtoparticipateinthestudythroughan informedconsentprocess,carriedoutverbally,withimplicit acceptanceafterlearningabouttheprojectobjectivesand purpose. The consent wasrequested during the ﬁrst call madebytheuser.Oralacceptancewasdulyrecordedinthe computerizedprotocols.¹²Thepresentstudywasapproved bytheEthicsandResearchCommitteeofUniversidadeFed- eraldeCiênciasdaSaúdedePortoAlegre(UFCSPA),process No.942/12.

Datacollectionwascarriedoutbyconsultants,whowere university studentsfromdifferent health areas trainedto work at the call center and to apply the intervention to theusersunderthesupervisionofhealthcareprofessionals.

Thetrainingprocessconsistedof:(a)theoreticalclassesas a continuingeducation courseon howtoapproachchem- ical dependency (40h); (b) theoretical---practical training in the call center for software familiarization (20h) and motivational interview training; and (c) continuous train- ingtomaintain thequalityof theprovidedinformation.¹³ The trainingmodel was adaptedfrom theMedical Educa- tionModelforthePreventionandTreatmentofAlcoholUse Disorders.¹⁴

Semi-structured interviews were carried out by telephone,withameandurationof50min.Thequestionnaires included: (a) the general treatment protocol, containing informationsuchasgender,age,maritalstatus,profession, familyincome,levelofschooling,andcityandstatewhere the call originated; (b) assessment of cocaine/crackconsumption, with questions that characterized the amount (grams/stones of cocaine/crack) used per occasion, frequency, and pattern of consumption. For this purpose, a questionnaire created by the World Health Organiza- tion (WHO), which has been widely adopted in Brazil, was used¹⁵; and (c) assessment of problem behaviors due to cocaine/crack use, a questionnaire created by the National Household Survey on Drug Abuse (NHSDA)¹⁶ to assess problems related to cocaine/crack use, chosen because it is utilized in drug use surveys in Brazil. This questionnaire shows six problem behaviors, according to the DSM-5. For data collection, the subjects’ consump- tionisdeﬁnedasmild(twotothreesymptoms),moderate (fourto ﬁvesymptoms), and severe (over six symptoms);

and (d) the Contemplation Ladder, used to qualitatively assessmotivation usingﬁvestatementsthat seektoiden- tifyanindividual’swillingnesstoceaseconsumptionthrough themotivationalstages(pre-contemplation,contemplation, preparation,action/maintenance).¹⁷

The univariate descriptive analysis shows sociodemographic data,cocaine and/or crack consumptionmarkers, motivationindexes,andinformationondrug-relatedprob- lembehaviorsasmean±standarderrorofthemean(SEM), whereasthequalitativedataareshown asn andpercent- ages.Inthebivariateanalyses,thechi-squaredtest, odds ratio(OR),and95%conﬁdenceinterval(95%CI)wereused for comparisons of data between adolescents and young

individualsandtodifferentiatebetweencocaineandcrack users.Tocomparethesubstanceamountsusedbetweenthe agegroups,thet-testforindependentsampleswasused.

A multivariate analysis was performed to conﬁrm the maindifferencesbetweentheagegroups,andallvariables withp<0.20inthebivariateanalysiswereincludedinthe logisticregression analysis(sought helpbeforecallingthe service,typeofpreparation---crackorcocaine,timeofuse, frequency, dependence, drug use-related problems, and stages of change). p-Values <0.05 were considered statis- ticallysigniﬁcant.Spearman’sbivariatecorrelationanalysis wasperformed.TheanalyseswereperformedusingtheIBM SPSSStatistics19.0software.

Results

Themeanagewas22.1years(SD=1.39)amongyoungindi- vidualsand17.3years(SD=1.36)amongadolescents.When analyzing the participants’ level of schooling, in general, it was observed that most of them, both young adults andadolescents, didnot finish their studies. Only 10% of theparticipantsreportedhavingfinishedelementaryschool and20.7% hadfinishedhigh school.Among thosewhodid not finish their studies, it was observed that 62.5% of the young adults and 67.3% of the adolescents showed poor academic performance. There was a direct correla- tionbetweenschooldelayandseverityofproblemsrelated tococaine/crackuse (r=0.063; p=0.002); age of participants(r=0.238;p=0.000)andamountofcocaineconsumed (r=0.158, p=0.000), with all correlations being weak. A weak indirect correlation wasalso found between school delayandamountofcrackconsumed(r=−0.142,p=0.000).

When asked about occupation, 22.6% of the participants saidtheywerestudents(mostofthemwereadolescents), 21.1%reported beingunemployed (young adults, mostly), and 56.3% said they performed some work activity. The sociodemographic characteristics of the participants are summarizedinTable1.

When data on drug use were analyzed, participants reported using cocaine (48.2%), crack and other smoked forms (36.7%), and associated use of both forms (15%).

Cocaine/crackuseassociatedwithotherlicitorillicitdrugs wasreportedby94.5% oftheparticipants,andonly 6%of the participants used only one type. When analyzing the use associated with other drugs of abuse, 39.5% of the users reported the association withlicit drugs and 54.6%

declareduse associated withother illicit drugs (Table 2).

The associations showed signiﬁcant statistical differences betweenyoungadultsandadolescents.Youngadultswere less likely to associate illicit drugs when compared with adolescents(OR=0.61,95%CI=0.51---0.74).Theassociation betweencocaine/crackuseandwithalcoholand/ortobacco wasmorefrequent amongyoungadults,while adolescents morefrequentlyreportedassociationsofcocaine/crackwith marijuana.

In relation to the amount of drug used per occasion, youngadultsusedonaverage 8.11g(SE=0.45)ofcocaine, 14.3 crack stones (SE=0.72) and, when used concomi- tantly,6.9g(SE=0.3).Foradolescents,themeanamountof cocainewas12.1g (SE=1.1),10.1 crackstones (SE=1.18) andboth,8.3g(SE=0.83),withoutstatisticaldifferences.

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Table1 Comparisonofthesociodemographiccharacteristicsbetweenyoungadultsandadolescents^awhousedcocaine/crack.

Totaln Youngadultsn(%) Adolescentsn(%)

Gender

Male 1698 1149(67.7) 549(32.3)

Female 682 321(47.1) 361(52.9)

Education

Incompleteelementaryschool 748 405(54.1) 343(45.9)

Yearsofschooldelay --- 10.5±2.25 4.43±2.95

Completeelementaryschool 234 167(71.4) 67(28.6)

Incompletehighschool 543 263(48.4) 280(51.6)

Yearsofschool --- 7.23±1.95 2.72±1.65

Completehighschooldelay 468 374(79.9) 94(20.1)

College/university 174 126(72.4) 48(27.6)

Familyincome

Uptofourminimumwages 1922 1195(62.2) 727(37.8)

Morethanﬁveminimumwages 185 110(59.5) 75(40.5)

Maritalstatus

Single 1773 1028(58.0) 745(42.0)

Married 402 324(80.6) 78(19.4)

Occupation

Doesnotwork 1015 460(45.3) 555(54.7)

Works 1153 881(76.4) 272(23.6)

Someparticipantsdidnotanswerallquestions.

aAgeaccordingtoagegroups=adolescents(14---19years),youngadults(20---24years).

Thevariableyearsofschooldelaywasexpressedasmeanandstandarddeviation.

Theothervariableswereexpressedasnumberandpercentage.

Table2 Druguseassociatedwithothersubstances:comparisonbetweenyoungadultsandadolescents^ausingcocaine/crack.

Youngadultsn(%) Adolescentsn(%)

Usedonlyonetypeofdrug 67(4.8) 63(8.0)

Druguseassociatedwithlicitsubstances 607(43.5) 245(32.2)

Alcohol 186(12.7) 84(9.2)

Tobacco 108(4.6) 64(7.0)

Alcoholandtobacco 313(21.3) 106(11.6)

Druguseassociatedwithillicitsubstances 720(51.6) 471(59.8)

Marijuana 73(5.0) 71(7.8)

Alcoholandmarijuana 114(7.8) 55(6.0)

Tobaccoandmarijuana 115(7.8) 94(10.3)

Marijuana,alcoholandtobacco 416(28.3) 246(27.0)

aAgeaccordingtoagegroups=adolescents(14---19years),youngadults(20---24years).

Thevariabledruguseassociatedwithlicitsubstancesreferstothetotalnumberofyoungadultsandadolescentswhoreportedthe concomitantuseofcocaineand/orcrackwithalcoholand/ortobacco.

Thevariabledruguseassociatedwithillicitsubstancesreferstothetotalnumberofyoungadultsandadolescentswhoreportedthe concomitantuseofcocaineand/orcrackwithmarijuana,alcoholand/ortobacco.

Crude andadjusted bivariate analyseswere performed toverifystatisticaldifferences betweenyoung adultsand adolescents regarding the consumption characteristics. It wasobservedthatmostyoungadultsandadolescentssought helpfortheﬁrsttimewhentheycalledtheservice.Young adultsusedcrackorcrackassociatedwithcocaineandhad beenusingdrugsforalongerperiodoftimewhencompared withadolescents,withastatisticallysigniﬁcantdifference.

Regardingthefrequencyofuse,groupsindicatedaweeklyor

lessthanweeklyfrequency.Inturn,althoughyoungadults had a greater probabilityof using drugs, when the motivational stagestoceaseconsumption wasassessed,itwas observedthatyoungadultsweremorelikelytobemotivated tochangethecocaine/crackusebehaviorthanadolescents (Table3).

Foramore detailedanalysis, inthe assessment of the consumptioncharacteristics,thesamplewasdifferentiated between users of crack and cocaine, comparing the age

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Table3 Characteristicsofcocaine/crackconsumption:comparisonbetweenyoungadultsandadolescents.

Total n

Youngadults n(%)

Adolescents n(%)

CrudeOR(95%CI) p AdjustedOR(95%CI) p

Hadsoughthelpbefore calling

No 1380 829(60.1) 551(39.9) 1.31(1.08---1.59) 0.003 1(0.77---1.16) 0.62

Yes 695 462(66.5) 233(33.5) 1

Typeofsubstance Crackandcrack associatedwithcocaine

1232 797(64.7) 435(35.3) 1.29(1.09---1.52) 0.001 1.29(1.05---1.57) 0.01^a

Cocaine 1148 673(58.6) 475(41.4) 1 1

Timeofexposure

Morethan2years 1396 1024(73.4) 372(26.6) 3.34(2.81---3.97) 0.000 3.45(2.84---4.18) 0.000^a

Upto2years 981 443(45.2) 538(54.8) 1 1

Frequency

Daily 998 623(61.4) 385(38.6) 0.98(0.83---1.16) 0.44 0.87(0.71---1.06) 0.17 Weeklyorlessthan

weekly

1316 813(61.8) 503(38.2) 1

Stagesofchange Notmotivatedto changebehavior

483 260(53.8) 223(46.2) 0.66(0.54---0.81) 0.000 0.72(0.57---0.91) 0.007^a

Motivatedtochange consumptionbehavior

1897 1210(63.8) 687(36.2) 1 1

a p≤0.05.

OR,oddsratio;CI,conﬁdenceinterval.

groups.Amongcrackusers,youngadultswerenearlythree times more likely to have been consuming the substance formorethantwoyearswhencomparedwithadolescents (OR=2.84, 95% CI=2.16---3.73). Likewise, it wasobserved that among cocaine users, young adults were four times morelikely tohave been usingthedrug longerthan adolescents(OR=4.38;95%CI=3.30---5.82).Dataonmotivation werealsomaintainedamongyoung adultswhowerecrack users(OR=0.63,95%CI=0.45---0.88);however,therewasno signiﬁcantdifferencebetweenyoungadultsandadolescents whowerecocaineusers.

Whenassessingtheseverityofproblembehaviorsdueto cocaine/crackuse,1131users(47.8%)metthecriteriafor moderateuse and811users(34.3%) forsevere use.When assessingproblembehaviorsrelatedtodruguseinthelast 12months,youngadultsweremorelikelytocravethedrug, toincreasethefrequencyofuseortheamountofthedrug, andlosecontrolovertheuse(OR=1.42,p=0.008;OR=1.43, p=0.009;andOR=2.22,p=0.000,respectively),asshown inTable4.Whenanalyzingtheassociationsbetweenprob- lembehaviorsrelatedtouseinthelast12months,itwas observedthatamongyoungadults,thelossofcontrolwas associatedwithastrongdesiretousecocaineand/orcrack (p=0.000), increased frequency of use (p=0.003), tolerance to substance effects (p=0.01), exposure tophysical risks(p=0.005),andpersonalproblemsrelatedtothesub- stanceuse(p=0.000).Foradolescents,lossofcontrolwas associatedwithastrongdesiretousecocaineand/orcrack (p=0.04) andpersonal problems relatedto thesubstance use(p=0.003).

Discussion

The results demonstrate that there are important differ- encesintheconsumptioncharacteristics,problembehaviors relatedto the use, and motivationto cease consumption amongyoungadultsandadolescentswhousecocaine/crack.

Youngadultsweremorelikelytousecrack, tohave been using drugs for a longer period, and to have more problem behaviors related to consumption, while adolescents weremorelikelytouseotherillicitdrugsandtohaveless motivationtochange theproblem behavior.Furthermore, anassociation wasfound between levelsof schoolingand severityofproblemswithcocaineandcrackuse.

Thedatashowedthatmostoftheyoungadultsandado- lescentsdidnotcompletetheirstudies.Itisknownthatdrug useisstronglyrelatedtopooracademicperformance,and thecontinuityofuseisassociatedwithpoorschoolresults, oftenleadingtoschoolabandonment.Epidemiologicalstud- ieshaveshown ahighassociation betweenschooldropout ratesandmentalhealthproblems,^18,19illicitactivities,¹⁹and aparticularlyincreasedriskforproblemsrelatedtotheuse ofalcohol, cigarettes, marijuanaand other illicit drugs.²⁰ Schooldelay wasassociatedwiththeseverityofproblems relatedto the consumption and amount of usedcocaine, aswellasage;thatis,theoldertheuser,thegreaterthe schooldelay,themoreproblemswithconsumption,andthe greatertheamountofcocaineused.

In thepresent study,young adultswere more likelyto usecrackoracombinationofcrackandcocaine,andmore likelytohavebeenusingthedrugformorethantwoyears.

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BischNKetal.

Table4 Characteristicsofproblembehaviorsrelatedtococaine/crackuse:comparisonbetweenyoungadultsandadolescents.

Totaln Youngadultsn(%) Adolescentsn(%) CrudeOR(95%CI) p AdjustedOR(95%CI) p

Severeuse 811 535(66.0) 276(34.0) 1.77(1.39---2.25) 0.000 0.93(0.40---2.13) 0.87

Moderateuse 1131 699(61.8) 432(38.2) 1.39(1.11---1.74) 0.002 0.95(0.77---1.16) 0.62

Milduse 425 222(52.2) 203(47.8) 1

Problemsrelatedtodruguse Strongdesiretousecocaine

Yes 1874 1191(63.6) 683(36.4) 1.47(1.21---1.79) 0.000 1.42(1.09---1.85) 0.008^a

No

Increasedfrequencyandamountofuse

Yes 1928 1219(63.2) 709(36.8) 1.43(1.16---1.76) 0.001 1.43(1.09---1.87) 0.009^a

No 1

Tolerance

Yes 1638 1025(62.6) 613(37.4) 1.14(0.95---1.36) 0.14 1(0.81---1.36) 0.71

No

Physicalriskundertheeffectofcocaine

Yes 1686 1057(62.7) 629(37.3) 1.17(0.98---1.40) 0.08 1.14(0.89---1.46) 0.28

No

Personalproblemsrelatedtouse

Yes 1831 1149(62.8) 682(37.2) 1.21(1.00---1.48) 0.030 1.15(0.89---1.47) 0.27

No

Lossofcontrolrelatedtouse

Yes 2182 1375(63.3) 807(37.0) 2.02(1.51---2.71) 0.000 2.22(1.56---3.16) 0.000^a

No 1

a p≤0.05.

OR,oddsratio;CI,conﬁdenceinterval.

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It can be hypothesized that these young adults started usingcrackafter theirexperienceswithcocaineandmar- ijuanaduringadolescence.Astudythataimedtoassessthe sociodemographicproﬁleandpatternofcocaineuseamong hospitalizeddrugusersfoundsimilarresults.Amongthe440 interviewed patients, 29.8% were cocaine addicts, 38.4%

werecrack addicts and 31.8%usedboth forms of cocaine (inhaledandsmoked).²¹Anotherstudythatsoughttoinves- tigate the prevalence of cocaine use and dependence in Brazilandpossibleassociationswithsociodemographicfac- tors showedthat45% ofthe sample startedusing cocaine beforetheageof18years.²²Astudythatinvestigatedthe useofotherdrugsofabusein20crackusersidentiﬁedthat substanceconsumptionhadbegunwithlicitdrugs(alcohol andtobacco),progressingtootherillicitdrugs,suchasmar- ijuanaandcocaine.Cocainewasthethirdmostcommonly useddrug,whereascrackwasthelastdrugtobeusedinhalf oftheassessedcases.²³ Theliteraturehaspointedoutthat theprogressionofuseusuallyoccursinadolescence,with the experimental use of licit drugs (alcohol and tobacco) andthen progressingtotheuseof illicitdrugs (marijuana andinhaledcocaine).²⁴

The results ofthe presentstudy indicated thatadoles- centsshowedahigherriskforassociationswithotherillicit drugs and that almost 100% used more than one drug. A studyamongcocaineandcrackuserswhosoughttreatment showeda25%prevalenceofdependenceononesubstance, 32.6%dependenceontwo,and22.4%dependenceonthree drugs.²⁵ These ﬁndings reinforce theurgency of interventions,sinceitisknownthatthelongerthetimeofexposure toasubstance,thegreaterthedamagetothedevelopment ofyoungindividuals.²⁶

The findings of this study did not show significant differences between age groups regarding the severity of problemsrelatedtosubstanceuse,i.e.,bothgroupsshowed moderate to severe problems related to cocaine and/or crackuse.Theassociationbetweenearlyuseandincreased riskfor psychiatricillnesseshasbeen demonstratedin the literature.²⁴ Anotherimportantfindingwastheassociation of problem behaviors related to cocaine/crack use. Sta- tistically significant associations were observed in all six assessed behaviors among young adults,which raises the questionabouttheseverityoftheabuse.Althoughadoles- cents reportedproblembehaviors, theydid notshow loss of control associatedwith frequency of use, tolerance to effects, and exposure to physical risks. This finding may be explained by the fact that they had been exposed to the substance for a shorter period, when compared with young adults. However, it is important to emphasize the importance of early interventions aiming toprevent drug use,aswellaspreventingtheprogressionofexperimenta- tiontoother drugsthat representsgreater risksregarding druguse-relatedproblemsandseverityrelatedtofrequent consumption.Community-andschool-basedpreventionpro- grams and specific health care strategies for adolescents and young adults can contribute toa healthier psychoso- cialdevelopment, preventingmore severe losses in adult life.²⁷

The proﬁle of young individuals in the present study donot differ fromthat presented inthe literature (moderate to severe use, users of more than one drug, with poor school performance); however, when assessing the

readinesstomodify thebehaviors, young adults reported higher motivation, a fact that can be understood by the possibleperception of thelosses relatedtothe consumption.Adolescents, in turn, were more likely tobe in the pre-contemplationandcontemplation stages,thatis,with low motivation to change the behavior. Adolescents are stillimmatureintheirabilitytoassessrisks,considercon- sequencesand organize the cause-effect association in a temporalmanner;thisoccursbecausethebrainstructures responsibleforimpulsecontrolandtemporalperceptionare stillmaturing.²⁸ Dueto thesecharacteristics, adolescents maynotrealize the need tochange their consumption or arenotreadytomakesuchdecision.

Mostyoung adultsand adolescentssought help for the ﬁrst time by calling the telephone counseling service. It isknownthat, generally,thispopulation does notsponta- neouslyseekhelp,especiallywhentheyhavelowmotivation to change their behavior. However, anonymity and easy accessto advice devoid of prejudice and judgments may havestimulatedthemtoseekhelp.Theliteratureshowsthat telephonecontacthasbecomeanadvantageousalternative forhealthcareservices,²⁹andthesetreatmentalternatives haveproven effective forcessationand reductionofdrug use.³⁰

Thepresent studyhassome limitations.The ﬁrsttobe highlightedisthesampleselectionprocess,whichoccurred byconvenience.Thestudywascarriedoutwithuserswho hadaccesstoinformationabouttheexistenceofafreeand anonymoustelephoneserviceandwhocalledthetelephone number. It is not possible toknow howmany young indi- vidualsreceivedinformationabouttheserviceanddidnot callit.Therefore,theimpactofaselectionbiascannotbe estimated.Inturn,astheinformationaboutthetelephone servicewaswidelydisseminatedbytelevision,internet,and radioatanationallevel,itcanbeassumedthattherewasan opportunityforyoungindividualsfromeveryBrazilianregion toseekcontactthroughtheservice.

Nootherriskfactors,suchasthepresenceofcomorbidi- ties, violence, school dropout, and parental relationship, wereassessed.Thesefactorsareimportantfortheoverall understanding ofdrug use by young individuals. However, asthis study aimed to investigate the difference in consumption patterns, dependence, and motivation among adolescentsand young individuals, it is believed that the factthattheotherriskfactorswerenotinvestigatedhadno interferenceontheresults.

The ﬁndings of the present study showed important differencesinthecharacteristicsofdrugconsumption,problembehaviors,andmotivationtoceaseconsumptionamong adolescents and young adults that used cocaine and/or crack. Young adults, despite showing a lower association of cocaine and/or crack use with illicit drugs, showed a morefrequent useofcrackandhadbeen usingthesesub- stancesforalongertime,inadditiontoshowingbehaviors that involve greater damages tothe physical and mental healthinadditiontodamagesrelatedtothesocialaspects.

Regardingthemotivationtoceaseconsumption,adolescents werelessmotivatedtodosothanyoungadults.Theseﬁnd- ingsreinforcetheimportanceofseekingmoreappropriate methodologiesfor early interventions, aiming to increase protectivefactorsamongadolescentsandreduce therisks anddamagestoadultlife.

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Funding

National Secretariat of Drug Use Policies (SENAD) and Associac¸ãoMarioTannhauserdeEnsinoPesquisaeAssistên- cia(AMTEPA).

Conﬂicts of interest

Theauthorsdeclarenoconﬂictsofinterest.

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