Intergenerational Approach of Crack Users by Using Genograms

Results: It was evidenced that the consumption of alcohol, tobacco and marijuana is a reality since the generation of grandparents, highlighting the consumption of alcohol by woman with a progressive increase on the following generations. Cocaine, crack, and other drugs emerge from the generation of parents. On the horizontal line, drug use is a common practice among brothers. Family ties vary among “close”, “hostile” and “broken” between father and mother; “close” with mothers, and “broken” or “distant” with fathers. The present drug use across all the generations reaffirms historical trends as a social practice described in different cultures for decades.


Introduction
Drugs have been addressed by various points of view and in different contexts, ranging from user to combat actions by the public and social spheres.They search for the link between the beginning, the standard and the consequences of consumption.However, studies that portray the intergenerational history of drug use are still necessary to know the characteristics and behaviors of the family and its influence through generations.
Among illegal drugs, crack is the most important.The consumption of this substance is considered a public health problem for its intense popularity, rapid spread in the most marginalized layers, consequences to the health of users and its social, political, legal, religious and economic repercussions [1][2][3][4][5][6].
Against the magnitude of this problem, the family is seen as the primary socializing institution of the individual, since it is through blood ties that traditions, teachings, values, beliefs and morals that can contribute to the formation of protective mechanisms are carried on.These elements may impose limits, respect, and provide feelings of belonging, considered essential for the development of the individual [7], or contribute as a risk factor for experimentation and drug abuse, when that consumer is already a intergenerational reality, as well as the presence of conflict, criminalities and family violence [8][9].
Moreover, it is understood that family is as an essential element in the social reintegration of a drug user.In this sense, it is necessary to know family and make it active in this process, especially in support for coping with abstinence and restructuring social networks and bonds [10,11].
One way to understand and integrate the family in nursing care is rethinking the family in terms of composing, people relationships and perpetuation of values.Therefore, the genogram has been an effective and capable tool to demonstrate the internal and external family structures, and the relations of its members [12].This tool is the graphic representation of qualitative information on the family dynamics and is able to demonstrate family balance/ unbalance.
The genograms can be very useful for nurses, doctors, social workers and other health professionals, as they can make a survey on family history in search not only of disease patterns, but also behavioral patterns that may present recurrently in the investigation of the family tree [13].In this context, the objective of this study is to analyze drug use among crack users generations.

Methodology
This is a descriptive and qualitative approach, developed in the Psychosocial Care Center for alcohol and other drugs users (CAPSad) in Teresina, Piaui, Brazil, with 10 crack users, chosen intentionally, of both sexes and 18 years.In this study, each user is called the "index case" and is identified by the ordinal number from 1 to 10, referring to the order of application of the interviews.
This method stands out for finishing a concern in studying the specific sequences of an interpersonal behavior.When working with small samples, qualitative studies are concerned with the singularities in the analysis of each family group in particular [14].
Data production was carried out from May to June 2014, through interviews with semi-structured script about drug use by grandparents, parents, siblings, partners and children, death of some of these members, characteristics of the relations established between them and with whom the index case resides.The interviews lasted about 25 minutes and the produced data was recorded in a MP3 device.
Data were obtained on interviews conducted in private atmosphere, then transcribed and analyzed for the construction of genograms.This tool consists on a schematic map constituted by symbols, shapes and lines.The information gathered in the genogram may include genetic, medical, social, behavioral, relational and cultural aspects that denote the family structure and configuration, giving evidence of its functioning and dynamics [14].
The genogram was chosen as a tool for the intergenerational analysis of drug use because it is a scientific instrument for data collection, specifically when addressing family.It becomes very useful in situations when there is presence of patients with mental health problems, such as drug use [14,16].
Participants signed a Term of Consent, under the Resolution 466/2012 of the National Health Council.The study was approved by the Ethics Committee of the Federal University of Piauí under CAAE 30609014.7.0000.5214number.

Results
The index cases of this study were crack users, young adults with low education and unemployed who reported the drug use by grandparents, parents and siblings.This information allowed the graphic construction of genograms for three generations (Figure 1).
In the analysis of genograms, it is observed, in the generation of grandparents, the death of 16 men and 14 women.Regarding to the history of drug abuse, were mentioned alcohol, tobacco and marijuana.
In the parents' generation of the index cases, there is the death of both parents and the mother's.The relationship between fathers and mothers was considered "close", "broken" and "close-hostile."As for the drugs in the current generation history, it was quoted alcohol consumption by four fathers and four mothers, marijuana and tobacco both by two parents.Solvent, crack, cocaine and other drugs were cited as consumed by only one parent.
It is observed in genograms, for the brothers, the representation of 39 brothers and no deaths.As for the history of drug use among the brothers, there is the presence of alcohol, crack, solvents, marijuana and other drugs.Of the 39 siblings, eight only consume alcohol.Crack use is found in seven brothers.Solvents were also reported by five brothers.There was also reference the use of marijuana by two brothers.
The relationship between parent and child is represented by the relationship line "distant", "broken" and "close".The relationship between mother and child is represented by "close" in six index cases, "distant" in two index cases, "close-hostile" (in an index case and "hostile" in an index case.
In the house representation in the genograms show that the mother is present in four of them.The representation shows that an index case live only with the mother, another with mother and son and the other two live with their mothers and all

Discussion
In intergenerational analysis of crack users, drug use is a reality since the generation of grandparents.In the current generation, alcohol, tobacco and marijuana appear as the most consumed drugs, especially by men, and only alcohol by women.Because it is from the generation of grandparents and young adults are the index cases, the grandparents should be in a more advanced age, a reality that demands specific care for this life stage, including habits and attention to alcohol and other drugs consumption.Therefore, anxious to know life habits in the elderly population three municipalities of Minas Gerais, in a sample of 611 respondents, 12.3% reported drinking alcohol, and tobacco, 23.1% [17].
This practice of drug consumption in old age should be discouraged, because the physiological changes that accompany the aging process influence drug concentrations and the metabolism, so that the interaction of other drugs with alcohol can impair the functional capacity and psychomotor and cognitive ability -which increases the risk of accidents, injuries, isolation and finally institutionalization [18].
Moreover, the harmful use of alcohol by parents leads to family illness as a whole and leads to risky behavior in different directions and the consequences of records is not only the incidence of illness, injury or other health conditions but, above all, the burden of disease and death [19].
In intergenerational analysis carried on this study, it was observed that in the parents' generation of the index cases there is a change in the profile of grandparents to parents regarding to gender and its relation to alcohol consumption.It is noted that the number of women who consume this substance is equal to that of men.Although this study is not directed to represent the frequency of use, it's possible to check in the Brazilian data that already exists trend of increasing this rate, especially among women.These data are presented in the Second Report of the National Drug and Alcohol Survey (Lenad) as the increase in men drinkers and women from 2006 to 2012 and whose frequency is more significant among the surveyed women, which rose from 27% in 2006 to 38% in 2012 [20].
In a gender perspective, experimentation by women is usually motivated by a partner or other family members.This can be understood when it seeks to know the initiation and maintenance of drug use in this universe and that has been shown that it can be linked to the need to follow the partner as well as personal dissatisfaction, social isolation and even the presence of depressive symptoms [21].
Although studies reinforce the discussion of gender differences, in relation to the pattern of drug use, however, it is evident that between men and women is occurring a gap narrowing on the pattern of alcohol consumption among genders [22].
The increase of women in the context of alcohol should be viewed with concern by health professionals, because the women are who seek health care and also are responsible for the care of the whole family at home.Therefore, when they are submerged in the perverse world of drugs, it causes significant impact on the family context and health of all members of the group.
Still in the second generation, the parents, in addition to alcohol, tobacco and marijuana, there is the consumption of cocaine, crack and other drugs, setting multiuse.Crack consumption already is on this generation, which may be associated with some risk factors, such as the multiuse of substances [23,24], the experience in hostile social environments and families whose use of the substance already has its landing.
Family is socially an intrinsic institution for the construction and social development of a human being.In this perspective, the experience of healthy family relationships, in which there is value for sharing responsibilities and strengthening family affection, is considered as a protective factor for the use of drugs [25].
A survey in Colombia reinforces that demonstrations of affection are considered protective factors that are related to drug use and need to be reinforced in the everyday life in all families.That is, family is a "two-way street": Firstly, the fragility of these emotional bonds is a risk factor for drug use; secondly, establishing strengthened and healthy relationships protect people and make them less vulnerable to drug use [26].
In the horizontal line of the index cases, drug use is common practice among the brothers, jutting out alcohol, crack and solvents.In this generation, excepts a distinct genogram, in which information is not recorded use of substances by previous generations, only the index case itself.This may be related to the existence of close relations between members of the generations by setting up structured families.Conversely, when there is the presence of consumption between generations, reinforcing evidence that there is a causal link between the consumption in the family and its continuity on future generations.Therefore, parents who use any drugs can serve as an example for use also by children.This trigger is called intergenerational transmission of behaviors [27].
The study also shows that, although there is a close bond between father and mother of the index cases, there are conflicting relationships and even breakups.These links can lead to risky behavior, since in an unstructured family, hostile, marked by the presence of quarrels, separation of spouses, lack of communication, breaking of the relational ties, conflicts and violence can affect the lives of individuals, particularly during the adolescence, being a predictor for drug experimentation [27].
The conflicting relations between crack users and family members can be driven by user behavior inside the house, which tends to make constant thefts, leading often to problems with the police.Thus, family members also tend to distance themselves from the user due to the stress experienced routinely.Another distance factor may be associated with hospitalizations since the institutions of treatment, in general, are located away from the family home, which makes family visits occasional, or even infeasible [28].
In the analysis of the relationship between fatherson and mother-child it is observed that most of the index cases refer to a close relationship with his mother and broken or distant with his father.This configuration in the relational dynamics contributes as a way to identify family risk factors for drug use.Aiming to such identification, a study conducted in Brazil, in the Drug and Alcohol Research Center at the Hospital of Porto Alegre shows that crack users perceive the father as controller and without affection.This perception contributes to the gap between family members and affects the formation of less resilient people in front of the adversities of life, making them more vulnerable to find the crack a way to overcome [29,30].
The reference to the consumption of alcohol, crack and other drugs in all generations of this study reaffirms historical trends of the presence of drugs as a social practice described in different cultures and decades.This fact is strongly linked to environmental factors involving economic development, culture, availability and the level of effectiveness of public addressing policies [19], and family history of drug use.
It is recognized that the crack is a new drug that has emerged since the late 1980s, not only in Brazil, but also in other Latin American countries [31].As a relatively new product, of low cost and easy acquisition, crack has led to a change in drug use pattern, observed across generations genograms in this study.
Although the study presents new and relevant data on the consumption of this drug, derived from a methodological driving sustained by the literature, there are still limited and this refers to the bias of memory, since the information was collected based on what was reported at the time of the interview, so there may be differences in the accuracy or completeness of "recovered memories" by study participants about events or experiences of the past.[32]

Conclusion
The present study shows that there is an intergenerational relationship of drug use in crack users families.Noteworthy is the consumption by women in the generation of grandparents and with progressive increase in subsequent generations.Similarly, in the horizontal line of the respondents index cases, involvement with drugs is a striking reality.
Also stands out in the study, the presence of conflicting relations, distant and broken, which favors family breakdown and may contribute to increase the consumption, including future generations.
This study contributes to the advancement of scientific knowledge, presenting a different view, not only covering the crack user, but also analyzing the relation of this phenomenon between the generations.This view can be inserted in nursing practices associated with the drug addiction care in different contexts this practice.
Although the produced knowledge represents advances to approach the crack users, it is recognized that, as it is related to data obtained from the speech of the participants, the reliability of these data may be limited against the bias of memory and expose the family to a socially stigmatized phenomenon.