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The case of chronic clonazepam use in Rio de Janeiro through the voices of users. Its logo is emblazoned on everyday objects and the drug itself is the topic of online communities and featured on television programs. Using the snowball technique, we collected an unintentional sample of 20 subjects over 18 years of age who lived in Rio de Janeiro and who had been using the drug continuously for at least 12 months. Researchers presented the project to their social contacts, sending them emails in which they invited them to indicate people who fitted the inclusion criteria. The users customized, negotiated, and legitimized their use of clonazepam, from how much and how often they took it to their habits of sharing it. Keywords: Psychotropic drugs, Mental health, Benzodiazepines, Clonazepam. The attribution of meaning to the use of prescribed substances based on the accounts of their users is the main subject of interest in this article. The abuse of illicit substances has long featured in humanities and health science research. Unlike other classes of medicines, psychotropic substances — especially depressants, like benzodiazepines and opioids, and stimulants, like amphetamine and its derivatives — have introduced into the debate certain concepts like tolerance, dependence, addiction, specificities about their consumption, negotiated use, sharing between users, acquisition or obtainment strategies, dosage regulation, and frequency of use. In Brazil, the consumption of psychotropic drugs and the ways they are used have become the target of increasing research interest, especially the rational use of psychiatric drugs in different cities around the country Noto et al. There are some key interfaces between groups, communities, and individuals that need to be considered when it comes to prescribed substances. Another key factor is the rising number of psychiatric diagnoses and the rise in the off-label use of psychotropic drugs, together with the power the drug industry exerts over the institutions engaged in the production of knowledge Angell, In Brazil, for instance, studies that have investigated the increasing vulnerability of socially underprivileged groups and how this impacts their health and their access to health services have compared users of the public health service, which is supposed to be universal, comprehensive, and equitable, with users of private health services that have health insurance to map out differences between populations, contexts, regions, states, communities, and social, economic and cultural aspects. While such mapping may fall outside the scope of this work, what we plan to do here is to show how processes such as medicalization, pharmaceuticalization, biomedicalization, overdiagnosis, and overprescribing — depending on what approach the researcher takes — only make sense if considered on a case-by-case basis, taking local realities into account. The case in question — the consumption of clonazepam by a sample of users from the state of Rio de Janeiro — seems to us a suitable way of reflecting on the social dynamics in which we live, as well as the values, contradictions, and ultimately the perceptions about health and disease at stake. There are few studies that have used qualitative approaches to address the problematic use of prescribed substances in Brazil, specifically based on the accounts of chronic benzodiazepine users. Although it is important for users to be aware of the pros and cons of the long-term use of benzodiazepines, this study steers clear of any moralizing or stigmatizing bias towards such users or their usage habits. It is important, from a qualitative perspective, to go beyond the scope of the concept of rational use Cohen et al. Benzodiazepines first hit the world market in the s, but it was only in the following decade that their use really took off as they started to replace barbiturates, being perceived as safer, with fewer side effects, and offering a higher margin between the therapeutically effective dose and toxicity Charney et al. However, some researchers have found that their continuous use could generate tolerance and abstinence syndrome Charney et al. In Brazil, data on benzodiazepine sales, prescriptions, and consumption patterns are limited. However, key improvements of the Brazilian health regulatory agency, ANVISA, mostly introduced in the last decade, have afforded the development of an important dataset on the prescription patterns of benzodiazepines in Brazil. Although this map provides retail data on a very short period of time, what is interesting is that the pattern of sales of clonazepam was extremely homogeneous across different regions of the country. Brazil has widely varying levels of quality of life, human development indices, and demographics in its different regions, states, and municipalities. It has been the subject of light entertainment shows on TV, included in the lyrics of pop songs, and has appeared in countless memes that have gone viral across different social media. More than an agglomerate of molecules that affects the central nervous system, clonazepam has infiltrated popular culture, becoming something of a fetish, an object of desire and social distinction — which could actually seem paradoxical given how inexpensive it is in Brazil. The theoretical references we will draw upon come from the anthropology of medicines. As argued by van der Geest and Whyte , medicines are things, and as things, they have a sort of concreteness, a quality of being tangible, and they are believed to contain the power of healing in themselves. As such, pharmaceutical efficacy is regarded as a multivalent concept that involves different dimensions, ranging from individual biology to sociocultural dynamics. Recognizing that drugs are concrete material objects with concrete biomolecular effects does not prevent them from also being analyzed as complex social phenomena embedded in the web of individual and collective meanings and interactions. The concreteness of medicines grants them a metonymic function that enables medical expertise the knowledge embodied symbolically in the physician to be incorporated into the pills, the drops, or whatever form it is that the medical substance takes. This concreteness allows their users to appropriate their uses and effects beyond the descriptions made of them in the discourses of those authorized to speak in their name, such as biomedical discourse. It is, then, easy for there to be an overlapping of meanings in medicines in general and in psychotropic drugs in particular if we consider their action on the central nervous system and their capacity to affect moods, behaviors, and perceptions of self and the world. In this superimposition of meanings, medicines become forms of merchandise imbued with healing powers that can be acquired like any consumer good, forming an intersection between the commercial and the magical, the sacred and the profane. These interwoven meanings often fail to take into account the potentially harmful effects of the inappropriate use of medicines, especially benzodiazepines, as if they were the source of benefits alone. As Cohen et al. Without doubt, the transformation from a magic object capable of healing, preventing, or altering states of consciousness into accessible merchandise does not come about without some form of coherent ritual within the cosmology of biomedicine, involving the need, to some extent, to conform to the wisdom and rites of western medicine consultations, diagnoses, prescriptions, etc. The main point for the subject at hand is the fact that the factors that influence the trajectory of a drug do not just have to do with doctors and patients; they also have to do with the removal of a drug from the market, its approval for sale over the counter, the appearance of new therapeutic indications, the public and private exchange of information about the drug and its use, what is published or broadcast in the mass media, and what information is passed on and shared amongst users through different channels, with social media playing a particular part in this process. We collected an unintentional sample using the snowball technique. During the sampling process, there were no specific criteria, such as gender or educational level, although these variables will be important elements in further analysis. The inclusion criteria were: subjects over 18 years of age, who may be receiving psychiatric treatment or not, and who have been using the drug continuously for at least 12 months and are still using it at the time of the interview, not necessarily on a regular basis. After receiving each indication of a long-term user interested in collaborating, the members of the research group contacted these users by email or phone to arrange a time to conduct the interview. By the end of , 20 clonazepam users who fitted the research criteria had been interviewed: 13 in and seven in Four declined to participate after being contacted by phone, email, or text message. None of the subjects is related to any of the researchers. The users were enrolled on the study and given an in-depth, semi-structured interview by qualified interviewers. This paper presents the analysis of the first 20 interviews of the intended total of The study, the consent forms, and all the other documents were approved by the research ethics committee registered under CAAE Below is a brief description of the research subjects and a few of their socio-demographic details. Table 1 demonstrates how pervasive in terms of education, age-group, and household income Rivotril is, being used by everyone from people who failed to complete their primary education to those with advanced academic degrees, different age groups, and different incomes. Only five of them were under 50 years of age; nine were married, three were divorced, five were single, and two were widowed. Their income range was wide, spanning from two to 20 times the minimum wage. In the data analysis, the interview transcripts were read through with the aim of gradually organizing the information supplied by the participants. The texts were read in depth until the saturation point was reached, using content analysis. The subject matter was organized into subsets, forming units of meaning. Although we do not have a representative sample, it is worth highlighting some of the most significant analytical points observed in the interviews so far. These uses of the drug run parallel to the prescribed regimens. The users adjust their dosage themselves, without consulting their doctor, increasing it when they feel anxious or tense and decreasing it when they feel sedated. Some share their supply of the medication with close relatives spouses, children and friends, and recommend specific dosages to other people close to them. They take their treatment into their own hands: once they have a prescription from one doctor, they can carry on for years getting other prescriptions for the same drug from other specialists, without any follow-up on the complaint that led to their being prescribed the drug in the first place. So then I share with him. Until in when I got up to four milligrams. Then after some time, nothing less than 2mg will calm you down. As they adapted to its regular use, they effected a change in their relationship with their emotional limits — emotions that might trigger a crisis or the symptoms that caused them to use the substance in the first place. After the first outbreak of the crisis and settling into regular use, they become more attuned to their own mood swings and attempt to address them, preventing potential crises, through the use of the drug. When they were asked specifically about the side effects or possible harmful effects of the chronic use of Rivotril, most of the users tended to shrug off any side effects and blame themselves for memory lapses or falls, for example. I thought that really it was just But anyway, I still took it. Then I had a fall at home and broke my leg. I mean, after a while it But I refused Like, I carry it around in my purse if anything is making me feel bad I hardly use Rivotril anymore. Although they were long-term users with between 18 months and 26 years of continuous use, although not necessarily on a regular basis during the interview period , they did not feel they were drug-dependent. So perhaps that helps me not to get dependent on Rivotril. Even though we have only dealt with a small number of subjects until now, these preliminary results indicate some issues worth investigating in the future. According to the accounts collected in our research, clonazepam seems to operate in different dimensions — sometimes as an protective object that prevents new crises from breaking out even without immediately being used , sometimes as an object of consumption, sometimes as a badge of social distinction. The risk-avoidance rhetoric found in the sample — avoiding the recurrence of unwanted symptoms — is very paradoxical: in order not to have a relapse of the kind of episode that originally triggered the use of clonazepam, the users keep taking it continuously or regularly, despite reporting that they no longer feel any of its beneficial effects. Avoiding the risk of a crisis and the immediate action of the substance were the key justifications given for chronic consumption of clonazepam by this sample of users. As Collin has noted, the chronic use of prescription substances has specific effects on identity and social interaction. On one level, being able to share the medicine and the experience of using it with others offers a place of distinction and prestige, making experienced users potentially more skilled and thus entitled to advise others in how to use the drug and, ultimately, how to self-regulate their emotions. From learning about its use and its effects, experiencing taking other psychotropic drugs, drawing comparisons between them, and detecting threatening emotions in oneself that one would rather stifle by chemical means, it is but a short road to offering the drug to others friends and family and sharing it without the oversight of a prescriber. What stands out, therefore, is a kind of management of the emotions that is also taught to the uninitiated who have not yet used the drug , between the limits of what kind of suffering is tolerable and what should not be borne. Indeed, this begs the question as to whether access to and management of drugs like clonazepam does not itself somehow end up altering socio-cultural perceptions of the limit at which chemical intervention is called for when an individual is experiencing suffering, or, to put it differently, if the frontiers of what we call tolerable suffering are not also altered by the existence of and access to this kind of medicine. Geels et al. In this sense, the prescription and use of medicines produce not just passive acceptance, but tensions and non-compliance. It is clear that the users do call on the authority of a medical practitioner to get rid of symptoms of suffering and ensure a ready supply of drug prescriptions, when applicable, but they also express an interest in commenting on the benefits obtained to people close to them. However, once armed with this information, the use, dosage, and management of the drug is no longer decided upon simply in consultations with a doctor. One of the limitations of the analysis made so far is that it does not explore correlations between the findings and the sociodemographic data obtained, such as sex, age group, and level of education. As far as education is concerned, for instance, the fact that the sample stemmed from contacts made by the researchers could have resulted in the recruitment of users whose education level is above the average in Brazil, as indicated by the recruitment of just one user with middle education incomplete. More in-depth study is required, primarily to correlate the qualitative findings with the sociodemographic indicators like social class, age, ethnicity, and gender. Abraham, J. Sociology, 44 4 , Angell, M. Rio de Janeiro, Brasil: Record. Mapa Interativo de Farmacoepidemiologia. Charney, D. En Goodman Gilman, A. Clarke, A. American Sociological Review, 68 2 , Cohen, D. Medications as social phenomena. Health, London, 5 4 , Collin, J. On social plasticity: the transformative power of pharmaceuticals on health, nature and identity. Conrad, P. The medicalization of society. Gage, S. British Medical Journal, , Geels, F. Cultural enthusiasm, resistance and the societal embedding of new technologies: psychotropic drugs in the 20th century. Noto, A. Revista Brasileira de Psiquiatria, 24 2 , Olfson, M. Benzodiazepine use in the United States. JAMA Psychiatry, 72 2 , p. Ortega, F. Interface Botucatu , 17 44 , Pieters, T. Canadian Bulletin of Medical History, 24 1 , Rezende, C. The charms of medicines: metaphors and metonyms. Medical Anthropology Quarterly, 3 4 , Wieteke van Dijk, M. International Journal of Health Policy and Management, 5 11 , — Williams, S. The sociology of pharmaceuticals: progress and prospects. Sociology of health and illness, 30 6 , Zorzanelli, R. Rafaela Zorzanelli rtzorzanelli gmail. Renata de Marca. This work is licensed under Creative Commons Attribution 4. Received: 17 May Accepted: 11 October Benzodiazepines: link between the sacred and the profane The theoretical references we will draw upon come from the anthropology of medicines. Research design We collected an unintentional sample using the snowball technique. Table 1. References Abraham, J.

Drugs and Democracy in Rio de Janeiro

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Official websites use. Share sensitive information only on official, secure websites. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Despite some essential indicators, opioid-related data are limited for Brazil. Data indicate that population-level availability of prescription opioids represents only a small fraction of use in comparison to high-income countries. However, within Latin America, Brazil ranks mid-level for opioid consumption, indicating relatively moderate consumption compared to neighboring jurisdictions. Codeine remains the major opioid analgesic utilized, but stronger opioids such as oxycodone are becoming more common. Professional knowledge regarding medical opioid use and effects appears limited. National surveys indicate increases in non-medical use of prescription opioids, albeit lower than observed in North America, while illicit opioids e. Overall population-level opioid availability and corresponding levels of opioid-related harms in Brazil remain substantially lower than rates reported for North America. Since existing and acute e. The worldwide use of opioids has substantially increased post The global prevalence of non-medical opioid use among persons aged 15—64 was estimated to have increased from 0. Globally, a total of , opioid-related deaths were estimated for \[ 5 \]. The highest consumption of opioids occurs in North America e. More recently — following the implementation of system-level restrictions e. Post, and fueled by the persistently high opioid availability described, North America has experienced steep increases in population-level opioid-related harms, including opioid-related morbidity and mortality e. For example, a total of 47, opioid-related deaths occurred in the United States in , with proportionally similar rates, and a total of 4, opioid-related deaths in Canada \[ 12 — 14 \]. However, following policy restrictions and availability reductions, mortality resulting from prescribed opioids has steadily decreased. In North America, high levels of opioid-related deaths negatively impact life expectancy in the general population \[ 17 — 20 \]. While comparative data are scarce, the context of opioid use and harms in Latin America differs from that in North America \[ 21 \]. In Latin America, there are significantly lower amounts of medically prescribed opioids, especially when compared to high-income countries \[ 4 \]. However, access to effective pain treatment involving opioid pharmacotherapy is limited or insufficient in most Latin American countries \[ 23 , 25 — 27 \]. Similarly, the prevalence of non-medical opioid use in South America was estimated to be 0. In the specific Latin American context, Brazil features a relatively low prevalence of opioid use and harms, especially when compared to high-prevalence settings like North America. However, this situation does not compromise the need and utility of comprehensively examining related indicators, especially in the spirit of comparative study. Rather, and given that opioids offer both medical e. In this particular context, Brazil represents the most populous country while still being representative of the opioid context in Latin America, and so overall offers a unique case study in regard to opioid use, harms, and regulations \[ 4 , 23 \]. Furthermore, Brazil features distinctly high levels of other psychoactive substance use e. First, we developed basic search terms e. The focus was on original studies or other publications, in English or Portuguese, originating from Brazil that included relevant data towards the scope of the present overview as defined, for the time period from to Second, we manually scanned related bibliographies and conducted Internet-based searches e. All data and indicator materials of relevance were extracted, thematically and topically structured and organized, and subsequently narratively summarized and presented. Given the specific and combined data search and identification approach, the present overview is non-systematic while comprehensive and narrative in nature; hence, also no formal review reporting system e. These intraregional indications for population-level opioid use in Latin America are reflected by other data. Longitudinal data from insurance claims showed that 2. Opioid analgesics use was reported by 2. Studies surveying specific disease-related populations reported comparatively higher prevalence of opioid use. Opioids were predominantly used in combination formulations e. The prevalence of medical opioid use in the general population was significantly higher among people aged 60 years or older 0. Only medical physicians and dental surgeons are permitted to prescribe scheduled opioids, based on a special registration from the local health surveillance service. Further, pharmacists are not allowed to accept emergency telephone prescriptions for opioids or to correct technical errors e. Dispensing entities i. Currently, opioids scheduled and available for outpatient use in Brazil include codeine, morphine, tramadol, methadone, buprenorphine, oxycodone, and fentanyl \[ 44 \]. Codeine and morphine are included in the national list of essential medicines used within the public health system and, so consequently, make up the majority of opioid prescriptions dispensed \[ 45 \]. These variations significantly correlated with socioeconomic status e. Results from national household surveys and suggest that among Brazilians aged 12—65 years there was an increase in non-medical opioid analgesic use, defined as non-prescribed use. Corresponding rates increased from 1. In , the annual prevalence of non-medical opioid use 1. In addition, the national survey found that male sex prevalence ratio: 0. A national survey among college students from Brazilian state capital cities reported prevalence of non-medical non-prescribed opioid use, with findings as follows: 5. When comparing results by sex, women showed significantly higher prevalence of lifetime use 6. In addition, a separate national survey conducted among high-school students in Brazilian state capital cities estimated the prevalence of lifetime non-medical non-prescribed opioid use at 0. When considering opioid dependence DSM-IV criteria , the national household survey reported a 0. These estimates were higher not statistically tested among respondents aged 25—34 years 0. It was estimated that about 30, Brazilians aged 12—65 years were receiving treatment mainly psychosocial or psychiatric for opioid-related use problems in \[ 51 \]. Other than in North or Central American regions, the use of heroin or other illicit opioids is uncommon in Brazil, and data are correspondingly scarce. National household surveys have estimated the prevalence of lifetime heroin use of 0. The study highlighted the use of psychostimulants without explicitly noting heroin \[ 60 \]. Heroin use in these sub-locales occurs mostly by inhalation and smoking similar to the use of crack-cocaine instead of injecting. However, with the high cost and limited access of heroin, this practice is uncommon \[ 63 , 64 \]. These occurrences are irregular and are thought to be mostly from West African importation and then distributed to end-users by African migrants and asylum seekers \[ 64 \]. Otherwise, there are virtually no indications of recurring opioid use in Brazilian drug use scenes. Similarly, mortality data are scarce and limited in specificity. Data from the Mortality Information System SIM , run by the Health Surveillance Secretariat of Ministry of Health, shows 44, deaths associated with psychoactive substance-related disorders reason unspecified from to , with 24 0. For the period to , deaths 0. However, these general and unspecific substance-categorizations render it difficult to ascertain the actual number of opioid-related poisoning deaths in Brazil. Available indicators document that population-level availability and use of prescription opioids in Brazil constitutes a small fraction compared to that of high-income countries, especially in North America i. Within Latin America, Brazil ranks in mid-field, indicating relatively moderate consumption of opioids compared to neighboring nations. It is rather unclear what the Brazilian context of opioid utilization means for the needs, practices, and outcomes related to pain care given that many countries find themselves in a major recalibration phase e. In Brazil, codeine remains the most common opioid analgesic prescribed, but prescriptions of stronger opioids such as oxycodone are becoming more common, while detailed dispensing information is lacking. Codeine products are mainly prescribed for acute health conditions, whereas non-opioid analgesics and NSAIDs are the most utilized drugs for pain-related conditions. While chronic pain is reported to be prevalent in municipal survey samples \[ 36 , 37 , 76 — 78 \], satisfaction with pain treatment is reported by few patients \[ 36 \]. The low levels of medical opioid utilization in Brazil are noteworthy given the relatively high use of other psychotropic medication e. These regulations have been justified as preventing opioid non-medical use while unduly neglecting pain care and medication needs in practice \[ 4 , 22 \]. Other factors appear relevant, including inadequate under-resourced public health policies and services for the majority of the population in a two-tiered health system, poor palliative care, and lack of specialist pain treatment training, programs, and evidence-based guidelines towards improved opioid-based medical care \[ 22 , 26 , 35 \]. Financial barriers towards procuring opioid medicines for many Brazilians have also been identified, including high cost to patients, for many of whom opioids are simply unaffordable \[ 4 , 25 , 50 \]. National surveys indicate a substantial increase in non-medical i. This involves only about 0. These observations appear to confirm that overall population-level opioid availability determines corresponding levels of opioid-related harms e. Available indicators are limited in regard to contexts of non-medical use. For instance, it is unclear why people are using prescription opioids non-medically. Additional studies are needed to investigate motives for the non-medical use of prescription opioids in Brazil. For example, higher prevalence of non-medical opioid use among women commonly observed might be related to higher prevalence of chronic pain \[ 37 , 79 \] and other self- medication use among women in general \[ 40 , 84 , 85 , 89 , 90 \]. On the other hand, opioid-related deaths in Brazil post is twice as high among men as compared to women \[ 67 \], as is also observed — albeit at higher levels — for other psychotropic drugs \[ 68 \]. The influence of sociodemographic, behavioral, or economic factors towards these divergences is unclear yet should be empirically examined. The use of illicit opioids e. This is rather different from North America or Europe, where illicit opioid drugs form a major part of the epidemiology of non-medical substance use and related harms, including mortality \[ 2 , 10 , 91 \]. While illicit substance use other than cannabis in Brazil has traditionally centered around psychostimulants e. Brazil is not part of the major global locations or paths of illicit opioid production and supply \[ 3 \]. Notably, recent sporadic heroin use has been linked with local pockets of international migration in urban settings \[ 64 \]. As sketched out by this overview, there is only limited and rather insufficient, and especially systematic and rigorous e. Essential data and outcomes are widely lacking, with largely only sporadic or local indicators available while others are entirely absent. Within available publications or sources, potential publication biases e. Therefore, since existing and acute e. Professor Fischer developed the concept for and contributed to several revisions of the paper. Maia led the data collection and writing for the paper. MSc Daldegan-Bueno provided substantial intellectual content towards drafts and contributed to several revisions of the paper. All authors approved the final version of the paper submitted. The funding sources had no involvement in the manuscript development. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Subst Abuse Treat Prev Policy. Find articles by Lucas O Maia. Find articles by Dimitri Daldegan-Bueno. Find articles by Benedikt Fischer. Accepted Jan 16; Collection date Similar articles. Add to Collections. Create a new collection. Add to an existing collection. 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