The Brazilian ‘Cracolândia’ open drug scene and the challenge of implementing a comprehensive and effective drug policy

Open air drug scenes represent very substantial challenges to health and law enforcement professionals around the world, especially in LAMI countries. Crack-cocaine users have gathered for 25 years in Cracolândia (São Paulo, Brazil), one of the world's largest open drug scenes. Several initiatives have provided treatment, employment and accommodation, but the Cracolândia problem is complex and impact has been limited, highlighting the need for a multi-dimensional perspective and multi-agency response Open-air drug scenes represent very substantial challenges to health and law enforcement professionals around the world, especially in low- and middle-income (LAMI) countries. Brazil has the largest crack cocaine market in the world: 1 million Brazilians have used the drug during the past 12 months 1. There are 370 000 regular users living in the 26 state capitals and Federal District 2, and approximately 80% of them use drugs in public places 2. In São Paulo, the largest metropolitan region in Brazil (20.3 million inhabitants), there are several drug scenes with different degrees of visibility. ‘Cracolândia’ (Crackland) is the oldest (1989) and most densely populated, with 500 residents and more than 2000 regular visitors 3, 4. It is located in the city centre of São Paulo by the main railway station (Luz Station). Cracolândia's economy and organization are controlled mainly by local drug trafficking and activities linked to drug use, such as unlicensed bars, the sale of stolen objects and prostitution. There is a lack of policing-specific strategies, and an absence of community involvement. Unemployment and social deprivation also contribute to the open and free use of drugs in this area 4, 5. In May 2013, the Government of São Paulo State launched a programme to deal with this drug scene. The State Programme Recomeço (Restart) 6 installed tents and mobile offices inside Cracolândia with a team of nurses, social workers and 80 community health agents. A family planning programme was also established. Inside the drug zone, an 11-floor building was renovated offering a shower, a bathroom, a barber-shop and a sports centre, as well a variety of work-shops and training opportunities. A detoxification unit and a housing centre will also be available within this building. All these services are connected to the Reference Center for Alcohol, Tobacco and Other Drugs (CRATOD), an addiction treatment centre located at a short distance from Cracolândia. CRATOD offers two services: an out-patient unit (CAPS-AD) able to treat 400 users and offer 3500 monthly appointments, and an emergency care facility with 40 beds. Patients can be transferred to detoxification clinics (1173 beds), or to therapeutic communities (1703 places) if required. These places are financed through public funds 5, 6. In order to facilitate drug users’ access to justice, a cooperation agreement with the Judiciary System allowed CRATOD to have a judge, a public prosecutor, a public defender and volunteer lawyers, all based within its facilities 5. Since the beginning of the programme, 2168 drug users from Cracolândia received treatment under State supervision 6. In April 2014, the Municipality Programme De Braços Abertos (With Open Arms) was launched in attempt to deal with Cracolândia's homelessness and unemployment. The programme removed shacks from the streets and offered 453 drug users accommodation in local hotels and employment as street sweepers 7. Outreach workers and access to two out-patient units (CAPS-AD) in the area were also made available. As part of a separate initiative, the State Military Police and the Metropolitan Civil Guard established a presence with bases within Cracolândia. All initiatives described above took place during a 2-year period (2013–15) and helped to reduce Cracolândia's population by a third. However, the great majority of drug users remains firmly based in the area, despite the offer of treatment, employment and accommodation. Cracolândia still attracts drug trafficking, homeless people, former convicts and individuals unable to integrate mainstream society. This leaves an environment where violence and crime still often take place and hampers community development 8, 9. Initiatives organized by local community activists and religious organizations have had little impact. The limited effect of initiatives in significantly improving the situation of open drug markets has also been seen in other countries 10-12. However, Cracolândia presents additional challenges when compared to open-air heroin consumption scenes. Differently from some European countries, where open drug scenes began with gatherings for drug consumption and political activism 8, 12, Cracolândia was formed by people living on the fringes of society, mainly illiterate and with high rates of criminality 2, 13, 14. Additionally, the efficacy of harm reduction initiatives for crack cocaine users (crack-pipes distribution, cocoa butter, smoking rooms) has a less robust evidence base than that for heroin users (needle-exchange programme, opioid substitution therapy, injecting rooms) 15. There is a lack of agreement on the efficacy of low-threshold actions for crack cocaine users 15. Conflicts of ideology are prominent, and take precedence over evidence-based discussions on how to deal with open-air drug markets 16. The emphasis on drug users’ health and public order, as well as proposals of partnerships involving law enforcement, social and health services 17, 18, can be seen by some parts of Brazilian society as processes of ‘social cleansing’ and a ‘threat against addicts’ rights’. Detoxification units and, especially, therapeutic communities, can also be seen as a ‘return to lunatic asylums’. There is an underlying belief that psychiatric disorders, including drug addiction, can be resolved solely with social inclusion 3, 16. The alternative view is that, while social inclusion is clearly a fundamental part of the solution, the importance of treatment should not be neglected. There is no housing system designed specifically to assist psychoactive substance abusers. What is required is a combination of policies, in order to reduce supply and increase treatment availability and social and housing support. These have been seen to help other countries to deal successfully with existing open drug markets and prevent new ones from forming 8, 11, 12, 19. As well as increasing drug users’ access to health care and promoting their social inclusion, it is also important to prioritize the quality of life of the urban space, increase security and revitalize suburbs 17. International comparison reveals that three aspects are dangerously absent in Brazilian drug policy on open-air drug scenes: (i) the recognition that open-air drug scenes are particularly problematic, therefore formal guidelines and comprehensive interventions are needed to improve the wellbeing of drug users and also of the wider community; (ii) the establishment and support of organizations responsible for understanding the needs and particularities of the open-air drug markets, as well as searching for solutions, with full involvement of representatives of users, health care, social care, justice and public security and government; and (iii) the development of an integrated action plan with attainable targets and involving health care, social services and police agents. These point to the most constructive way forward in Cracolândia and in other comparable open-air drug scenes internationally. JS has worked with a range of types of governmental and non-governmental organisations and has also worked with pharmaceutical companies to seek to identify new or improved treatments from whom he and his employer have received honoraria, travel costs and/or consultancy payments (none known to be related to treatment of crack addiction). A fuller account of his interests is at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx. JS is supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London.