A qualitative study of psychological stress and coping among persons using crack cocaine | BMC Psychology

Crack cocaine is a version of cocaine which is smokable and is obtained by washing cocaine (typically hydrochloride salt) with ammonia or mixing it with sodium bicarbonate [1]. The mixture hardens into a rock-like substance (crack cocaine) that can be crushed into chunks and smoked when dried out [2]. Recently, there has been a noteworthy upsurge in cocaine use as the principal stimulant in various parts of the world, including America, Australia, and Western Europe [3]. In 2017, both coca bush cultivation and cocaine manufacturing reached unprecedented levels [3]. In the European Union (EU), 2017 also observed record-breaking levels of cocaine confiscations, signalling a surge in the availability of high-purity cocaine for over ten years [4].

Consequently, this has led to the purity of crack cocaine reducing from a high level to a moderate level. Also, it has moved from being an expensive commodity to an affordable commodity and the stimulant of choice for many individuals engaged in drug use in Western Europe [5]. Ireland stands out as one of the countries in the European Union with the highest incidence of cocaine and crack cocaine use [6, 7]. Data has indicated a visible upswing in the consumption of both powder and crack cocaine [8, 9]. Also, regarding cocaine and crack cocaine use in the European Union, Ireland ranked second [10] with prevalence rising from 3% in 2014 to 4.4% in 2019. Also, anecdotal evidence has shown an increase in crack cocaine use in Limerick. This led to the commissioning of a study to investigate crack cocaine use in Limerick [11].

Due to its addictive nature, crack cocaine use is associated with strong cravings and obsessive drug-seeking behaviours [12]. Its use has also been linked to the development of severe forms of dependence in a short time [13,14,15] leading to a worse diagnosis compared with snorted cocaine. Emotional, cognitive and neurological changes are stimulated by the extended use of crack cocaine [16]. Compared to powder cocaine, crack cocaine use has been linked to a higher number of psychiatric indicators and psychiatric comorbidities such as depression, anxiety, paranoia, psychosis, antisocial personality disorder and suicide attempts [17,18,19]. Persons who use crack cocaine are more prone to a history of academic underachievement with fewer chances of having a formal job [20]. Problems instigated by the use of crack cocaine have been linked to social isolation and conflicts with support networks. Also, crack cocaine use has been linked to social stigma which emanates from the negative perceptions created about persons who use crack cocaine [21]. Overall, crack cocaine use has a noteworthy impact on individuals’ psychological health and general well-being, necessitating the need to explore the psychological stress that occurs from its use. Psychological stress is a widespread term indicating processes that influence the inception and continuation of a variety of mental and physical conditions [22].

Prior research has identified a two-way relationship between stress and substance use behaviours which is that stress can lead to substance use and substance use can lead to stress [23,24,25]. Studies have also examined coping mechanisms used by individuals experiencing substance use disorders including those using crack cocaine [26,27,28,29]. This study contributes to existing knowledge by exploring the psychological stressors that occur from crack cocaine use and the coping mechanisms used to mitigate them. It also explores the barriers and facilitators to positive coping mechanisms. By exploring these aspects in detail, the study provides a deep understanding of the unique challenges faced by individuals using this substance. This insight will be helpful for addiction, mental health, family support and community services in developing targeted strategies to help persons who use the substances cope and overcome these psychological stressors. The study adopted a qualitative approach because some categories deviate from the coping circumplex model which is the model that underpins the study. This qualitative approach offered the advantage of uncovering context-specific categories that might not fit into the pre-determined theoretical model.

Methodology

Study design

The study is qualitative and uses a descriptive phenomenological approach [30]. This approach enabled the researchers to draw from a variety of viewpoints to provide a better understanding of coping in this context. To ensure rigour in the reporting and undertaking of the research, this study followed the Standards for Reporting Qualitative Research (SRQR) [31], the consolidated criteria for reporting qualitative research (COREQ) [32] and the quality criteria of qualitative research [33].

Theoretical framework

The coping circumplex model underpins this study by directing the exploration of coping mechanisms used to mitigate the psychological stressors specific to crack cocaine use [34]. The model assumes that persons in stressful situations face two tasks: they need to solve the problem and control their emotions [34]. These tasks are mirrored in two parallel dimensions: the problem-coping dimension and the emotional-coping dimension. The model contains eight coping styles forming a circumplex: positive emotional coping, efficiency, problem-solving, preoccupation with the problem, negative emotional coping, helplessness, problem avoidance, and hedonic disengagement [34].

The coping strategies employed by crack cocaine users align with the dimensions of Lazarus and Folkman’s (1987) model. However, the model does not take into consideration the interplay of individual, social and environmental factors in coping. As a result, the study expanded the model to include psychological stressors as well as barriers and facilitators to coping. By incorporating these adjustments, the model better captured the nuanced coping experiences of crack cocaine users in their specific local context, addressing the unique stressors and challenges they face.

The Circumplex Model was beneficial in classifying and understanding the coping mechanisms used by study participants. The model’s use of different coping styles allowed the researchers to analyze the coping behaviours used by study participants within a properly defined structure. Also, the model enabled a deeper exploration of these coping mechanisms. By grounding the study on this model, the researchers provided a structured analysis, providing insights into the strategies used in dealing with the psychological stressors specific to crack cocaine use.

Ethical considerations

To protect the dignity, rights and welfare of study participants, ethical approval was obtained from the University of Limerick Hospital group ethics committee before the commencement of the research. Also, participants’ consent was obtained at the start of the interviews and participants were informed of their ability to quit the interview at any point. As part of the consent process, a member of the research team provided details of the study to participants. The researchers determined participants’ capability to give informed consent by assessing their ability to comprehend the information provided about the study, its risks, benefits and their voluntary participation. To minimize the stress caused by sensitive topics in the interview, the interviews took place in private rooms in service settings that the participants were familiar with. These settings also had professionals such as social care workers, nurses and General practitioners whom participants were familiar with, and who they could speak to if distressed by the interviews. Also, all participants were informed of supports available locally which included GP, addiction and support care.

Participant recruitment

Study participants were recruited face-to-face through the Ana Liffey Drug Project (low threshold harm reduction service) and the Limerick Drug and Alcohol Services using gatekeepers known by participants and purposive sampling. The selection of participants was based on the inclusion criteria, participants’ perceived availability, participants’ readiness and ability to take part in the research. The inclusion criteria for research participants were people actively using crack cocaine during the study and people who were able to give informed consent. The exclusion criteria were people unable to give informed consent.

Data collection

Data was collected through 26 face-to-face in-depth semi-structured interviews. Each participant was identified by a number based on the sequence in which they were interviewed (e.g. Person 1). No relationship was established with participants before the study commencement. The interview guide was designed by the researchers in collaboration with a local steering group of stakeholders made up of a general practitioner, a nurse, social care workers, a psychologist and a representative from UISCE (a national advocacy group for people who use substances). The inclusion of this representative ensured that the voices and perspectives of individuals impacted by crack cocaine were considered in the study design (see supplementary materials for interview guide). The inclusion of professionals and not persons who use crack cocaine or their family members in the local steering group was informed by the need for specialised knowledge in the field of crack cocaine use and mental health. Due to their expertise, the professionals in the steering group ensured that the research was informed by evidence-based practices and clinical viewpoints. The interview guide was piloted and updated at the early stages of the data collection process. Researchers used data saturation to determine the sample size for this study. To reach data saturation, data collection continued to the point where there was no new information emerging from the data. This point was determined by transcribing as the data was gathered, assessing the volume of answers to each question in the interview guide and agreement from the steering group that the initial coding of the data suggested that the data answered the research questions. The sample size after data saturation was 21. Interviews were audio recorded and each interview lasted between 10 and 60 min.

Data analysis

The Clarke and Braun 6-step method for thematic analysis was applied in the data analysis process [35]. This enabled the systematic recognition and analysis of patterns in the data while maintaining a focus on the individual’s lived experiences. Sundler et al. (2019) have backed the use of qualitative thematic analysis in descriptive phenomenology, highlighting the appropriateness of thematic analysis in exploring a phenomenon in depth and capturing participant’s individual experiences effectively [36]. After the transcription of the interview recordings using Microsoft Word, researchers read through the transcribed file to gain a deep understanding of the data. NVivo was used for the coding and analysis of transcribed files. The coding process was iterated three times. The coding and analysis process combined both a theory-driven and data-driven approach. While the preliminary coding and analysis were informed by the circumplex model, the incorporation of new codes and themes outside the model establishes the data-driven aspect of the analysis. The first step in the coding process was the assignment of predefined codes to the parts of the data that captured key ideas and concepts within the predefined codes. This allowed for a structured and theory-driven analysis of the data. These predefined codes were based on concepts linked to the circumplex model. Because the study was undertaken in Ireland and focused on a specific city and a specific substance, the researchers aimed to provide insights into the unique experiences and context of the population. As a result, in situations where concepts outside the predefined codes arose that were crucial for capturing the full range of insights from the data, these were adopted as new codes.

After the coding process, thematic analysis was used to analyse how recurring patterns or topics within the coded data emerged as key themes [35]. The data analysis was done by a member of the research team (Y.D) who was closely involved in the data collection. At significant points in the analysis process, another member of the research team (D.K) reviewed the codes and themes and met with Y.D. to discuss them. This served as an independent check to ensure that the researcher’s contact with study participants, her experience of working with persons with substance use disorder and her assumptions did not influence the data analysis. It also served as a check to ensure that the analysis was a reflection of the data and the circumplex model. The final step involved organising the themes into a logical framework which provides a complete understanding of the psychological stressors and coping strategies of crack cocaine use (see Fig. 1). Overall, the circumplex model influenced the data analysis process by serving as a structure for classifying and understanding the coping strategies used by individuals using crack cocaine. The researchers’ ability to analyze and interpret the coping mechanisms within this theoretical framework was achieved by aligning the coping strategies identified in the interviews with the concepts of the model.

Findings

Participant profile

Study participants were current crack cocaine users. Most participants were unemployed. Most respondents had some form of education ranging from primary to tertiary (see Table 1 for further details).

Overview of themes and subthemes

The study established diverse themes which were informed by the study data and the coping circumplex model. The themes “Psychological Stressors” and “Barriers to Positive Coping, “Facilitators to Positive Coping” as well as the subthemes under them were all informed by the study data. The theme “Coping Mechanisms” and all the subthemes under it except the subtheme “Substance Use” (under emotional coping) were informed by the circumplex model.

Psychological stressors

Cravings

The cravings that come from crack cocaine were labelled as psychological because it is believed that the body does not need crack. However, the brain makes people believe that they do. Participants further explained that this constant craving harms their psychological well-being because they are unable to focus on anything apart from how to sustain their crack cocaine use. This occurrence shows the complex interplay between substance use and mental processes. The constant cravings associated with crack cocaine use can be regarded as a stressor due to the mental and psychological burdens it inflicts on individuals. This burden can intensify feelings of powerlessness and aggravate substance use. By probing profoundly into the individual experiences of participants, a deeper understanding can be obtained of how these cravings serve as an incentive for diverse coping mechanisms, both positive and negative. Additionally, merging insights from the circumplex model can serve as a means of exploring how people cope with these intense cravings.

Person 5 who has been using crack cocaine for 3 years and is unemployed recounts her experience.

………… I wake up thinking about it and I dream about it. I mean, it’s constant. My head is clogged up just over crack. My whole life. I can’t focus on anything else, but the crack is all I think of every day……………….

Financial burden

As the sensation obtained from crack cocaine is brief, persons who use it devote all their resources to it with the hopes of maintaining their use. Most participants were unemployed and had limited money, thus, their fundamental needs were ignored. They also participated in vices and acquired huge debts which when not paid led to intimidation of themselves or their families. These habits show the deep grasp of crack cocaine use in which the quest for immediate satisfaction supersedes the desire for longstanding financial stability and well-being. The sequence of neglecting fundamental needs due to crack cocaine use prolongs a sequence of deprivation and intensifies the socio-economic challenges faced by persons with crack cocaine dependence. Also, the helplessness as a result of this financial lack makes individuals prone to exploitation and manipulation, resulting in further marginalisation and social seclusion. The interaction between financial lack, substance dependence and coercive behaviours highlights the complex challenges faced by persons using crack cocaine.

Person 17 who has used crack cocaine for 5 years recounts his experience.

Whatever money I have I will spend it no matter what. If I had a 1000 pounds, I will spend it like. I had 5000 pounds I spent it like. When I got a claim, a compensation claim I spent 5000 on it like.

Relationship breakdown

Study participants expressed worry about their strained relationship with their families because of their drug use. They attributed these strained relationships to their unwarranted demand for money to sustain their drug use and the intimidation their families face when they incur debts. These interactions come with emotional tolls defined by feelings of culpability and regret. This underlines the stress that crack cocaine use places on the emotional well-being of individuals using crack cocaine.

Person 10 who is unemployed and lives alone in an apartment secured through homeless services recounts her experience.

My mom is a very good part of my life…………….… but I often did get at this roaring and stuff for money off her. Arguments and afterwards I feel horrible. Scream after scream at your mother for money you know……………….

The adverse behaviours associated with the respondent’s substance use such as aggression, mood swings and isolation were highlighted as other reasons for this relationship breakdown. These behaviours are influenced by crack cocaine’s impact on the brain’s reward system and emotional regulation. Participant’s acknowledgement of their irregular and erratic behaviours echoes the impact of crack cocaine on cognitive functioning, emotional regulation and decision-making. Behaviours such as mood swings and isolation disconnect individuals from their support systems. This behaviour apart from contributing to relationship breakdown leads to a cycle of culpability, humiliation, and self-destructive patterns that strengthen the grasp of addiction.

Person 22 who has been using crack cocaine for 2 years, uses it regularly and lives in an accommodation secured through homeless services shares his experience.

The last time my mother blamed me for having a stroke and everything for the stress that I put her through and everything. And I knew I was wild, but you don’t know what you’re doing. It’s the nature of the beast. That has control over you if you don’t have control of yourself.

Participants also expressed the guilt they feel about not being able to care for their children like they wish to. Majority of participants had their children being cared for by their relatives or foster families. As a result, they did not have a strong bond with their children. Participants’ expression of guilt for their inability to perform their parental duties shows the multifaceted relationship between addiction, family dynamics and personal identity. Participants’ account highlights the sense of loss, remorse and self-blame experienced by people dealing with substance dependence, especially in the context of parental roles and responsibilities. A participant’s depiction of crack cocaine as a “white horrible crystal” echoes a sense of self-reproach for yielding to the appeal of crack cocaine at the expense of their children.

Person 6 who has been using crack cocaine on and off for 8 years recounts her experience.

Everything is gone I don’t think I can live a normal life anymore. I’m after throwing away my life and my babies for what for a bit of a white horrible crystal ***** of a thing. Look I sold my life over it. Over that dirt.

Negative emotions triggered by crack cocaine use

Positive sensations such as happiness, feeling problem-free and being energetic drew participants to crack cocaine. However, they also experience negative feelings such as paranoia, anxiety, anger, low energy, frustration, moodiness, depression and suicidal ideations. It was noted by participants that the positive feelings are usually brief whereas the negative feelings last longer and eventually harm the users’ psychological well-being. The conflicting experiences of positive and negative emotions underline the intricate relationship between the instant ecstatic effects of the substance and the long-term psychological impacts on users’ welfare. Participants’ account of the difference between the preliminary high and the consequent comedown emphasises the upheaval of emotions experienced by individuals under the influence of crack cocaine. By identifying the interaction between these positive and negative sentiments, people’s understanding can be expanded regarding the intricate psychological dynamics and the challenges faced by individuals using crack cocaine.

When you have your first smoke you see you’re mad for more. You can’t have enough in one like. Once you have one, you’re thinking oh I have to get another one now. Cos you’re in that high buzz and you just want to keep that highness. But then when you’re coming down off it then it’s not nice at all.

Coping mechanisms

Problem coping

The Circumplex Model assumes that individuals who face a stressful situation feel the need to solve the problem as a coping mechanism [34].

Problem avoidance

Study participants highlighted that keeping busy helps to stay away from crack cocaine. Some participants expressed the importance of employment as a way of keeping busy and their desire to work. According to the Circumplex Model, problem avoidance involves not thinking about the problem, reducing attempts to solve the problem, stalling tasks or giving up efforts to attain a goal [34]. This behaviour is evident among participants who instead of getting help for their substance use, distract themselves with keeping busy as a way of staying away from crack cocaine.

Many of the participants were unemployed and had little to no social lives due to relationship breakdowns and drug use behaviours such as isolation. They were not involved in any meaningful activities to keep them busy. Their substance use had taken away their sources of livelihood, dreams and aspirations. As a result, their lives were mostly centred around their drug use and ways to sustain it. Also, many of the services available to them were focused on harm reduction, healthcare, treatment and social services such as housing. There were limited services which provided them with activities to keep them busy during the day.

As a result, keeping busy for them entailed staying indoors and being involved in household chores which was not sustainable in the long term. Some participants also expressed the importance of employment as a way of keeping busy and their desire to work. Participants’ emphasis on the essence of staying engaged exhibits their recognition that structure, drive and routine can reduce the appeal of substance use. Also, their involvement in household chores to keep busy emphasises the therapeutic worth of routine tasks and productive hobbies. The coping mechanism used by participants mirrors a real-world, independent approach to dealing with substance use and sustaining mental health.

Person 10 who has been using crack cocaine for three years narrates how she has the desire to work but lost a job opportunity because of her drug use.

……I always kind of wanted to work…. And then I was talking to a woman….………… And she said that she would get me a job because I wanted something to do and eventually this job came up for me and she was just very disappointed that I didn’t start……… I never turned up because I was coming down off crack cocaine………….

Problem solving

Problem solving as defined by the Circumplex Model involves vigorous cognitive and behavioural efforts to solve a problem such as recognising several opinions regarding the problem, making attempts to comprehend the situation, forecasting the course of events, selecting the most suitable resolutions, planning and executing plans as well as taking constant action to solve the problem [34]. These behaviours were manifest in participants taking action, forecasting the sequence of events and seeking help regarding their substance use.

Person 26 acknowledged her need for help and had taken steps to get this help through support groups, key workers and addiction services. This participant has been using crack cocaine for a year, lives with her parents has been open to her close friends and family about her drug use due to her awareness of the importance of social support. The participant’s hands-on style in looking for help illustrates an important step towards well-being. Admitting the need for support and actively seeking this help shows a readiness to tackle their challenges to achieve positive change. It also reflects a positive approach to coping with crack cocaine use. Through having a collective mindset, individuals can use the services of professionals and loved ones to pilot the difficulties of addiction, gain resilience and achieve sustainable recovery and well-being.

….I need a bit of help. I know I need a bit of help. You can’t do it on your own. Meetings and things like that…….

Person 17 who has been using crack cocaine for 5 years, uses it in small doses and has been in and out of treatment in the past but ended up relapsing also narrates the role his environment has played in this. This participant had taken time to understand his experience and was making use of this knowledge to ensure that it didn’t reoccur. While he was interested in seeking help, he also had preferences about where he could get this help as some environments gave him flashbacks which led to cravings and increased risk of relapsing. Generally, the participant’s account highlights the importance of environmental mindfulness, trigger identification and positive coping mechanisms in dealing with the cravings associated with crack cocaine use.

…. Cos, I get cravings and I get flashbacks when I go to use the toilet cos, I used to use inside the toilet bathrooms. If I go to the bathroom, I get cravings when I’m clean……

Emotional coping

The Circumplex Model assumes that individuals who face stressful situations feel the need to regulate their emotions as a coping mechanism [34].

Negative emotional coping

The behaviours described in the analysis are in line with the concept of negative emotional coping in the Circumplex Model which involves self-criticism, concentrating on negative aspects of a situation and concentrating on negative emotions when dealing with a problem [34]. For instance, participants’ focus on negative emotions such as anger, loneliness and depression led them to adapt poorly to their substance use.

Not speaking about and not dealing with emotions was highlighted as a way of coping by Person 7 who has experienced traumatic events such as the loss of family. When asked why she doesn’t like to reveal how she truly feels, she could not point out her reasons and acknowledged that it was not the best way of coping. The participant’s acknowledgement highlights an increasing responsiveness to the restrictions of emotional repression as a long-term coping mechanism. Individuals may start to discover better mechanisms for processing emotions and tackling underlying psychological challenges associated with substance use and trauma when they distinguish the difference between outward entrances and internal agony. Overall, this account highlights the importance of dealing with psychological well-being and trauma-informed care in addiction services. By recognising the influence of negative sentiments, relationship dynamics and past experiences on substance use behaviours, individuals can work towards developing more adaptive coping mechanisms and emotional resilience.

“Just like if somebody is on crack, don’t do what I do. Don’t put up the wall and say Oh yeah, I’m okay when really I’m dying inside. You know I feel like crying, but it’s just like put that front, think it’s a coping mechanism.

Some study participants cope with the depression associated with their crack cocaine use by causing harm to themselves. This helps them to distract themselves from the negative emotions they feel, suggesting a deep level of emotional suffering. Using self-harm as a retort to control negative emotions and express internal struggles that cannot be expressed through words alone may serve as a short-term relief. However, this relief is exceeded by the risk of physical injury, emotional trauma and the continuation of a harmful sequence of coping.

Person 9 who has used crack cocaine for 3 years and has a history of self-harm narrates how she copes.

When I get depressed, and I see blood, I kind of calm down myself. And I want to cut myself all the time.

Isolation from people and services was also used to mitigate depression. During periods of isolation, participants’ substance use increased and their tendency to access services decreased, which augments poor mental health. Participant’s engagement in substance use during periods of isolation paints a picture of loneliness, disconnection and emotional pain which further engrain the individual in a sequence of maladaptive coping and negative results.

Person 10 recounts her experience.

I was isolating even though COVID wasn’t there or nothing. Everything was opened I found that I kept myself at home a lot. I wasn’t going out. You know I’d wake up on drugs and go back in and clean up my apartment……. Just wanted to lie down all day

Substance use

Regarding the negative emotions associated with using crack cocaine, study participants coped by reusing crack cocaine or using other unprescribed drugs. Their use of this coping mechanism was to overcome the cravings and withdrawal symptoms such as paranoia and anxiety. Participants belief is that, since there are no prescribed medications that can be used for their cravings and some of their withdrawal symptoms, it is impossible to overcome them. Participants highlight the challenges met in tackling the psychological impacts of crack cocaine use and the absence of approved treatment options for dealing with cravings and withdrawal symptoms. Also, the pattern of substance use as a coping mechanism may prolong a cycle of polydrug use, tolerance development and increased risks of adverse health outcomes.

Sometimes when I use crack I just sit down, and I feel paranoid out of my head…. But when I take a few tablets though it takes that away.

Facilitators to positive coping

Social support

Most participants had very few competencies and assets to cope positively with the adverse impact of their substance use. Person 21 highlighted the significance of the support from low-threshold outreach services. This participant who has been using crack cocaine for 3 years and has never been to treatment recounts how with the right support, a plan had been put in place to help them achieve their goal of abstaining from crack cocaine. By acknowledging the importance of support from these services, the participant shows their awareness of their needs, their struggles and the importance of getting professional help in addressing their substance use. Also, the participant’s stress on the coordinated efforts between different services shows the importance of integrated care, continued support and personal treatment plans in addressing the complex needs of individuals with co-occurring substance use and mental health issues.

(Outreach service) has been helping me. I’m also an alcoholic. We were just with my GP…….We working to go to (name of treatment centre) to help me with the crack cos it’s more mental than anything. So go and get off the drink and the crack at (name of treatment centre).

Family relationships

Person 10 whose children are in foster care narrates how her desire to have a better relationship with her children and to set a good example for them, has led her to adopt better coping mechanisms. The participant’s account underlines the complex interaction between substance use, shame, guilt and the longing for family ties and positive role modelling. It also shows the mental intricacies, difficulties and incentives involved in dealing with substance use disorders within the settings of family relationships. This accentuates the potential of family relationships to inspire changes in attitudes and promote resilience in the face of addiction. The participant’s acknowledgement of the influence of their actions on their children’s feelings and general welfare highlights the cross-generational impacts of substance use and the continuing desire to restore and fortify family relationships.

“………I meet my oldest daughter sometimes in town…. I used to be begging as well in town…………… And there was one time when she passed me, and the shame was unreal…. I haven’t never sat down since then, because I know that that really hurt me, you know and for them sure they could be in town anytime.………. “.

Barriers to positive coping

Stigmatisation

Most of the participants suffer humiliation from members of the public, persons who use other drugs, family, friends and in some cases services. Due to this, participants try to hide their crack use. This leads to them isolating themselves from support networks and services which leads to them adopting negative coping mechanisms. Participant’s hesitancy in disclosing their substance use to others highlights the inescapable fear of judgement, denunciation and social discrimination that individuals who use substances experience. Participants’ encounters with offensive remarks and public humiliation highlight the degrading impacts of stigma and the internalized distress experienced by such individuals. Furthermore, the participant’s negative emotional retorts such as feeling bad and trying to conceal their substance use mirror the psychological burden caused by stigma which can increase feelings of humiliation, culpability and worthlessness. Person 10’s accounts highlight the need for more mindfulness, compassion and destigmatization efforts in societies. This will enable a more supportive and comprehensive environment for people experiencing substance addiction.

You know they call you crackhead. As I’m on Facebook, I see a lot of things like that, so when I see things like that, and they’re making jokes of it, I’m on crack cocaine. That makes me feel terrible and I tried to hide it. People know I’m on it, so it got around so people a lot of people know you know. It is shameful

Environmental triggers

Most participants have experienced traumatic events such as sexual violence, physical abuse and the loss of a loved one. This shows the frequency of traumatic experiences among individuals with substance use disorder. These experiences served as a trigger for their substance use. Being in certain environments reminded them of these traumatic events. Identifying the link between traumatic experiences and substance use can help individuals gain knowledge of their triggers, develop coping strategies and participate in trauma-informed care methods to deal with underlying emotional issues. This process is vital in building healthier coping mechanisms.

Person 12 pinpointed how their traumatic experience led to them using crack cocaine.

To be honest look six years ago I found my father dead…………and I just went out of control because I wasn’t able to handle or deal with the situation. I was ill like at that time and couldn’t use heroin. And then I moved on to crack cocaine use. And then I went on to injecting

The high availability and easy accessibility of crack cocaine were also highlighted. Most participants reported that they started using crack due to the ease of accessing it. Also, participants described seeing people using crack cocaine as a trigger, making it difficult for them to abstain from it. Previously, getting access to crack involved going to specific places or specific people. Participants’ experiences show how the nearness and visibility of crack cocaine in their environment serve as a trigger for drug use, making abstinence from its use difficult. Participants also reported being offered crack cocaine when walking around their neighbourhood. This highlights how contact with drug-related activities can regularise substance use and underwrite the regularisation of behaviours linked to substance use. A participant in his twenties recounts his experience

Yes, that does affect it. Yeah, that does big time. Cos you can be gone out the door and you might have a tenner and say no I won’t use today but if someone throws it out in front of you, of cos you’re gonna get it like. It’s like bringing a child to the shop, they’re gonna want sweets when they see them you know so yeah it does affect big time.

Lack of information

Lack of prior knowledge about crack cocaine was also highlighted as a barrier. It was underlined that study participants became aware of crack cocaine only after taking it over time. Due to its addictive nature, it made it difficult for users to manage their use and its adverse impacts. This highlights how inadequate knowledge about crack cocaine can serve as barriers to well-informed decision-making, harm reduction methods and efficient management of drug use behaviours. This account underlines the essence of education, prevention and harm reduction efforts in tackling the inadequate information and responsiveness regarding crack cocaine use.

Person 8 who has been using crack cocaine for 9 months recounts her experience.

… Like, you only start becoming aware of it when you start taking it. So, it’s just strange. Like the way how much it would cost you and it’s only there for two minutes, and then when it’s gone you want more but then if you wait even an hour that anxiety wears off you for more….