Pierre Kopp

Julie Costa

DRUGS, INTERNATIONAL Taniele Rui

Tendances Drogues, enjeux internationaux

Keywords: Drugs, international challenges Drugs Drugs, international challenges Crack markets, open scenes and public responses

CRACK COCAINE IN BRAZIL OPEN SCENES AND PUBLIC RESPONSES

In the 2000s, Brazil was confronted with the expansion of crack cocaine use, particularly among disadvantaged groups in its main urban centres. Being the subject of high political and media visibility, the issue of crack cocaine has overwhelmed the country's social and political agenda. This issue of Drugs, International Challenges provides an overview of the Brazilian context, in its territorial and socio-historical context. It presents the evolution of crack cocaine use and trafficking in terms of their emergence as a social problem and as an issue for local and a national public action. It then shows how the spectrum of public responses in this area has fuelled intense public debate, marked by contrasting political and therapeutic proposals.

In the 2000s, Brazil was confronted with the expansion of crack cocaine use -a different product from the crack cocaine in France (see box p. 2)-particularly among disadvantaged groups in the main urban centres [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF]. This situation is closely linked to the high availability of cocaine, in a context where the country is both a production and transit area for this psychostimulant (UNODC, 2023). Against a backdrop of extreme poverty and structural violence, crack cocaine use has risen to the top of the social and political agenda in Brazil's major cities, sparking intense debate marked by contrasting political and therapeutic proposals [START_REF] Rui | Nas tramas do crack: Etnografia da abjeção[END_REF][START_REF] Souza | Crack e exclusão social. Brasília[END_REF]. This issue of Drugs, International Challenges analyses the territorial and socio-historical evolution of crack cocaine markets in Brazil. It begins by looking at the country's place in international cocaine trafficking, and how the product became an integral part of Brazilian organised crime within the national drugs markets. It then provides an overview of the supply and use of crack cocaine in the country, and finally traces the development of public responses to the problem.

On the South American cocaine routes

Strategic geopolitics

In its latest report (UNODC, 2023), the United Nations Office on Drugs and Crime highlights the central role played by Brazil in cocaine trafficking. In close proximity to the countries that produce this psychostimulant (Colombia, Peru, and Bolivia), the country has become one of the most important intercontinental transport hubs, thanks to a complex network of air, road, river, and sea routes. Various cocaine products are brought to Brazil from production centres in the Andes and Paraguay via the country's open continental borders, which are difficult to monitor (UNODC, 2023). For example, the region bordering coca-producing countries alone stretched for 8 062km (5 010 miles), more than twice as long as the border between the United States and Mexico (3 145km/1 955 miles), which is largely covered by tropical forest [START_REF] Cde | Covid-19 e tráfico de drogas no Brasil : a adaptação do crime organizado e a atuação das forças policiais na pandemia. Brasília, Centro[END_REF]. Once in Brazil, some of the cocaine reaches the export hubs, including international airports and major Atlantic ports such as Santos, in the State of São Paulo. Despite the growing interconnectedness of this logistics network, the state has for years been the main point of departure for overseas shipments of all types.

The main hub to Europe

Most of the cocaine leaving Brazil is destined for Europe, which, with an estimated 5.2 million users in 2020, is the world's second biggest consumer of the drug 1 (UNODC, 2022, 2023). In addition, its commercial links, due in particular to its linguistic proximity to Portuguese-speaking countries such as Mozambique, Angola, and Cape Verde, favour connections with the African continent, the western part of which constitutes a bounce zone towards Europe. During the period 2015-2021, Brazil accounted for 70% of the cocaine seized in Africa. An example of the scale of these latest movements: in March 2022, a tonne of cocaine was seized in Santos in two containers bound for Belgium and Ivory Coast (UNODC, 2023).

An organised crime with deep roots

Brazil's growing involvement in the international cocaine trade has taken place against a backdrop of the development of other illicit markets -arms, stolen cars, gambling, rackets, kidnapping etc.-contributing to the structuring of numerous criminal groups, such as the Primeiro Comando da Capital (PCC) in São Paulo and the Comando Vermelho (CV) in Rio de Janeiro [START_REF] Cde | Covid-19 e tráfico de drogas no Brasil : a adaptação do crime organizado e a atuação das forças policiais na pandemia. Brasília, Centro[END_REF], who are currently fighting for control of these markets, particularly the cocaine market. These criminal groups, which emerged in the early 1990s and are rooted both in prison complexes and in the urban outskirts, particularly in the Brazilian favelas, have played a major role in fuelling local drugs markets, while maintaining complex and ambiguous relationships with Government stakeholders (Arias and Grisaffi, 2021;[START_REF] Feltran | The entangled city: Crime as urban fabric in São Paulo[END_REF]. Indeed, since the 1990s, recurring political scandals involving provincial and federal MPs, as well as judges and police officers, have demonstrated their infiltration on the various institutional spheres of power [START_REF] Labrousse | Dictionnaire géopolitique des drogues. La drogue dans 134 pays : productions, trafics, conflits, usages[END_REF].

Similarly, while these factions have relied on principles of solidarity and "respect" among their members, they have been the instigators in particular violent urban conflicts, whether in the context of territorial rivalries with competing groups or armed clashes with police forces [START_REF] Cde | Covid-19 e tráfico de drogas no Brasil : a adaptação do crime organizado e a atuação das forças policiais na pandemia. Brasília, Centro[END_REF][START_REF] Feltran | The entangled city: Crime as urban fabric in São Paulo[END_REF]. At the same time, these factions are undergoing a process of internationalisation with the development of groups abroad, such as in Paraguay, Bolivia, and Peru, from where they oversee part of the cocaine production process and organise its transport to Brazil. Beyond Latin America, the PCC, the most powerful group in the national crime landscape, appears to have established strong business links in Mozambique, where a notorious Brazilian trafficker was arrested in 2020. This group is also establishing itself as the main contact in Brazil for European criminal groups such as the 'Ndrangheta (UNODC, 2023). Other Brazilian figures not linked to the PCC or CV are also playing an increasing role in Europe, as demonstrated by the arrest of Sérgio Roberto de Carvalho, "The Brazilian Escobar", in Budapest in June 2022 2 .

1. These estimates include Western, Central, Eastern, and South-Eastern Europe (UNODC, 2022). With average purity still rising, the quantities of this drug intercepted in 2021 reached 300 tonnes, a new record which confirms the expansion of European markets over the last few years (EMCDDA and Europol, 2023). 2. "Alleged drug kingpin arrested in Hungary", Interpol, 22/06/2023. Available on: https://www.interpol.int/News-and-Events/News/2022/Alleged-drugkingpin-arrested-in-Hungary (Accessed: 30/05/2023).

Domestic markets and small-scale laboratories

Brazil is not only a transit area for cocaine intended for international markets. The country has also become a major source of cocaine consumption, with an estimated 1.5 million users in 2016 (UNODC, 2021). While the use of cocaine hydrochloride (powder) remains an economic and symbolic marker of the middle and upper classes, the use

Crack Cocaine in Brazil

While in North America and Europe the product known as crack cocaine refers to cocaine base obtained by processing cocaine hydrochloride, in Brazil the name crack cocaine refers to a different product, obtained directly from the dried coca paste and/or cocaine base (UNODC, 2021). It takes the form of small stones with a solid, non-friable consistency. It is mainly intended to be smoked in ad hoc or improvised pipes using cans and cups. It can also be consumed in cigarettes, mixed with tobacco or cannabis herb. Crack cocaine has a strong stimulant potential, and its effects are both quick and short-lived when inhaled. The scientific literature associated this drug with compulsive use and with an addiction defined as "psychological". Its use can lead to somatic complications of a cardiac, neurological, and respiratory nature, as well as various types of oral and finger infections.

According to the United Nations Office on Drugs and Crime (UNODC), the crack cocaine circulating Brazil's main markets is either manufactured locally or imported from the Andean countries in the form on one-kilo blocks (UNODC, 2021). In addition to crack cocaine, other forms of coca derivatives are available on the South American illicit consumer markets. These drugs are made from the two main intermediate products obtained during the cocaine hydrochloride manufacturing process: coca paste and cocaine base. Coca paste is extracted from the leaves of the coca bush. Once purified, it yields the cocaine base, which can then be converted into cocaine hydrochloride. This "spectrum of drugs" is mainly consumed in South America, where it accounts for a large proportion of the domestic cocaine market (UNODC, 2023), and circulates under a variety of street names: pasta basica de cocaína, PBC, pasta, basuco, merla, mescla, zuca, pitillo, paco. of crack cocaine has spread primarily among the poorer population of urban centres, where pedra3 was more widely available and sold at a low unit price of around one euro, or even less for split doses4 . The cocaine and crack cocaine markets in particular are also closely linked with the Brazilian informal economy [START_REF] Rui | Nas tramas do crack: Etnografia da abjeção[END_REF], with its trading and credit sales systems, which are factors in the build-up of debt and the violent settling of scores within national drug markets [START_REF] Daudelin | Mercados de drogas, guerra e paz no Recife[END_REF]. The rise in the consumption of various coca derivatives has also encouraged the emergence of laboratories, some of which focus on domestic markets. Although the extent of this phenomenon is poorly documented (UNODC, 2023), the media routinely report police operations in urban and rural areas involving the dismantling of laboratories throughout the country, such as in Bahia where, in February 2023, three small-scale cocaine and crack cocaine manufacturing laboratories were found by the local public security services5 .

Crack cocaine in Brazil: a history of poverty and urban conflict The beginnings and the territorial expansion (1990-2000)

While the precise circumstances surrounding the introduction of crack cocaine in Brazil remain unknown6 , accounts suggest that the drug appeared at the end of the 1980s in the south-east of the country, on the outskirts of São Paulo, particularly in the working-class district of São Mateus where it quickly became an established part of the drug consumption and trafficking scene among the youngest and most impoverished sections of the population [START_REF] Uchôa | Crack: o caminho das pedras[END_REF]. The political and social context of the time is important in understanding the phenomenon. Institutionally, the military dictatorship came to an end and democracy and civil liberties were formally Cracolândia, São Paulo. Touz Dias, 2022.

June 2023

Drugs, international challenges

Crack cocaine in Brazil: markets, open scenes and public responses 4 restored, while economically, the Brazilian economy opened up to neoliberal globalisation, resulting in rising unemployment and social inequality [START_REF] Dedecca | Les années 1990 : stabilité et inégalité de la société brésilienne[END_REF]. These changes provided fertile ground for the growth of illegal markets and for the criminal groups that control them, and have fuelled the growth in violent crime. The homicide rate rose from 11.69 per 100 000 inhabitants in 1980 to 27.35 in 2000, these figures closely correlate with the growth of drug trafficking and the structuring of criminal networks competing for markets and territories [START_REF] Feltran | Variações nas taxas de homicídios no Brasil: Uma explicação centrada nos conflitos faccionais[END_REF].

Growing urban visibility and high media profile (2000-2010)

The second half of the 2000s was an important turning point in the history of crack cocaine as a social problem in Brazil [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF]. In urban centres, the period was marked by an increase in the number of vulnerable consumers with serious physical and psychological problems, leading to the emergence and spread of open drug scenes. In the heart of the country's largest metropolis, in São Paulo, the Cracolândia was not only the main place where this drug became a permanent feature in the public sphere, but also the main local area for the controversies associated with the care of people who consumed it. Since then, the Cracolândia has been largely invested in by journalists, researchers, and secular and religious institutions. Albeit exceptional, it became then a major revelation and mirror of what has become the "crack cocaine problem" in Brazil. Between fascination and aversion, the symbolic centrality of this setting is all more important given that the term Cracolândia soon extended beyond its geographical boundaries to refer to any gathering of drug users.

The late 2000s saw the height of a particular sensationalist political and media approach to the subject of crack cocaine, presented as a social 'scourge' at the heart of an 'epidemic' unprecedented in national history. Combined with stigmatising representations of the drug and its users, this approach to the problem was all the more vigorous in that it was a poorly documented phenomenon. For a long time, scientific studies and epidemiological data have remained localised, incomplete, and scattered, with no systematic survey conducted before 2012 on a representative sample of the population [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF]. While it was acknowledged that the country was facing real social and health problems linked to the use of crack cocaine, subsequent research will provide a more detailed picture of the situation and help deconstruct some of the myths that had been perpetuated until then.

Socially situated consumption

The Secretaria Nacional de Políticas sobre Drogas 7 (National Secretariat for Drug Policies), far from the millions of users reported by the media and relayed by certain political leaders, reports, thanks to a national survey that is still the largest and most comprehensive on the subject, that there were 370 000 users of crack cocaine and related drugs in Brazil's state capitals in 2012, representing 0.81% of the population [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF]UNODC, 2023). It 7. Entity then responsible for drug policy within the Ministry of Justice and Public Safety. 8. Either pretos or pardos, according to the national ethnic-racial statistical categories. 9. Combining the results of various studies carried out in 2012, UNODC estimated the prevalence of regular crack cocaine use in Brazilian capitals at 1.7% of the population aged between 23 and 29. 10. Latest national study on drug use in the general population. 11. In 2020, around 92% of the cocaine seized in Brazil was in the form of hydrochloride, 5% in the form of base paste and 3% was identified as "smoked consumption products, including products called crack cocaine" (UNODC, 2023, p. 67). also highlights a very specific sociological profile of these populations. Comprising mainly young adult males (79%), 79% of whom are 'non-white' 8 , with an average age of 30, they were characterised by a high prevalence of social disaffiliation. Only 18% had a level of education equivalent to (16%) or higher than (2%) the baccalaureate (academic qualification taken at 18), while 40% were homeless and 49% had a history of incarceration [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF]. A number of subsequent studies carried out among sub-groups of users or in the general population have reiterated these findings and demonstrated the statistical marginal and socially restricted nature of crack cocaine use 9 . In 2017 10 , for example, while 0.9% of people aged between 12 and 65 said they had used powdered cocaine in the past year, only 0.3% said they had used crack cocaine or one of its substitutes in the past year and 0.1% in the past month (FIOCRUZ, 2017). Although some of the data remain incomplete and do not allow for an in-depth analysis of changes in the relevance over the last ten years, the country continues to be considered as the main crack cocaine consumer in the world, in a context where many indicators point to an increase in the domestic availability of cocaine in its various forms 11 (UNODC, 2023).

Heterogeneous territories

While the available data attest to the spread of crack cocaine throughout Brazil in the 2000s [START_REF] Bastos | Pesquisa Nacional sobre o uso de crack -Quem são os usuários de crack e/ou similares do Brasil? Quantos são nas capitais brasileiras? Rio de Janeiro[END_REF], it is also important to emphasise that not all major cities have seen the emergence of large open scenes like the Cracolândia in São Paulo. In Rio de Janeiro, for example, consumption areas have remained decentralised, and more discreet due to the small number -a few hundred -of consumers. In cities such as Brasília and Recife, in the centre or in the north-east of the country, the same is true: consumers are more scattered around shopping areas, transport hubs, or even in derelict land and buildings. These heterogeneous territorial layouts reflect not only the history and urban geography of each city, but also the different ways in which marginal populations are managed by law-enforcement services and by the fractions that dominate the different neighbourhoods and 'control' drug trafficking there. In São Paulo, for example, crack cocaine consumption and sales are tightly controlled by the PCC. The regulation of local order by this criminal organisation on the outskirts of the city has helped to make its centre a refuge for many users and dealers, who have been forced out of the outskirts of São Paulo. In Rio, the war between factions, militias and police forces has created dispersed and moving criminal scenes in and around the favelas, with daily militarised raids constantly reshaping criminal gangs and territories.

Situational and controversial public responses A highly publicised agenda

In the national political sphere, crack cocaine has emerged as a public health issue under the first presidency of Luiz Inácio Lula da Silva (Workers Party, 2003-2011). In December 2009, the Minister of Health launched a major national campaign to "alert and prevent drug use", with the aim of "debating the June 2023

Drugs, international challenges

Crack cocaine in Brazil: markets, open scenes and public responses issue and drawing up attention to the risks and consequences of drugs" 12 . In May 2010, a few months before the presidential election scheduled for October, the government finally launched the Plano Integrado de Enfrentamento ao Crack e outras Drogas (Integrated Plan to Combat Crack Cocaine and Other Drugs), the first policy in this area, with the aims of preventing use, treating and reintegrating users into society, and combating crack cocaine trafficking 13 . In this context, crack cocaine also became a central issue in the election campaign for the presidency of the Republic in 2010, which was won by the left-wing candidate and former minister for the Civil House 14 under the Lulist government, Dilma Rousseff.

An ambitious plan marked by therapeutic controversies

During its first four-year term (2011-2014), around €1.8 billion will be allocated to structuring and implementing the national plan now known as Crack, é possivel vencer or CEPV (Crack cocaine, it's possible to beat it), a major symbolic 12. Minister of Health press release 18/12/2009 (CNS, 2009). 13. "Integrated plan to combat crack cocaine and other drugs", see Decree no. 7 179, 20 May 2010. Available on: https://www2.camara.leg.br/legin/ fed/decret/2010/decreto-7179-20-maio-2010-606392-publicacaooriginal-127199-pe.html (Accessed 05/06/2023). 14. The highest position in the Brazilian government. 15. The CAPS-AD is a hybrid of the French CSAPA (specialised drug treatment centres) and CAARUD (harm reduction facilities). 16. Governed by law 10216/2001, the reform is essentially based on the gradual closure of asylums and the of outpatient treatment services for people with mental health problems. 17. In 2016, 82% of Brazilian TCs were linked to churches and religious organisations, particularly Evangelicals (40%) and Catholic (27%). 18. Justified by the shortage of public services for drug users, public funding of TCs was a common practice in various states and municipalities even before CEPV was set up. For a long time, these appeared as the most accessible addiction treatments, if not the only ones, available in Brazil (Ipea, 2017). milestone in political and institutional terms. Following in the conceptual and operational footsteps of its precursor, the CEPV was structured around the pillars of "prevention, support, and authority", with the aim of funding a wide range of initiatives, drawing on both government department and partners at a regional and city level. Intersectoral, this threeyear plan mobilised various ministries, such as Education and Development and Fight against Hunger, reiterating the framing of crack cocaine as a multidimensional social problem [START_REF] Mattos | Crack e políticas públicas : análise sobre a formação da agenda do programa "Crack, é possível vencer[END_REF]. In terms of health, the CEPV budget was used to fund harm reduction programs and therapeutic communities, while beds were made available in general and psychiatric hospitals. At the same time, the security aspect of the plan was aimed at strengthening municipal, military and federal police forces in terms of manpower and equipment, in order to preserve urban law and order and to strengthen repressive measures on trafficking and organised crime on a national scale (Confederação Nacional de Municípios, 2014).

While this plan helped to make crack cocaine a matter of public interest and a state priority, it also helped to rekindle controversy over the policies to be adopted towards drugusing populations. One of the most striking of these is undoubtedly the controversy surrounding the effectiveness of therapeutic communities (TC) and the place given to the psychosocial approach of the Redes de Atenção Psicossocial 15 (Psychosocial Care Networks), based on the harm reduction paradigm and Brazilian psychiatric reform 16 [START_REF] Rui | Therapeutic communities in Brazil. Brooklyn, Social Science Research Council[END_REF]. Structured around three main pillars -the requirement of abstinence as a condition of care, the prolonged hospitalisation of patients and estrangement from their family and community environment, and the use of religious/spiritual symbols and rituals as a therapeutic resource 17 -these TCs are commonly accused of human rights violations. Many professionals in the health and social treatment sector ended up opposing their public funding, provided for by the CEVP 18 (Ipea, 2017). This mobilisation led to stricter supervision and regulation of TCs, without, however, hindering them. In 2016, there were more than 2 000 facilities in the sector.

Conflicting local arenas

Given the decentralised nature of Brazil's drug policy, this national debate has also found its way in the states that make up the Federation. The State of São Paulo, whose eponymous capital is home to the Cracolândia, is a good example of the opposition to the plan. While the São Paulo state government, through the Recomeço (2013-today), prioritised funding for places in therapeutic communities, initiatives more focused on harm reduction were put in place between 2013 and 2016 by left-wing mayor Fernando Haddad. His De Braços Abertos program offered, among other things, care services (outreach services, outpatient treatment, etc.) and social support (shelter, integration projects, etc.) to drug users in Cracolândia. Despite positive evaluations [START_REF] Rui | Pesquisa preliminar de avaliação do Programa 'De Braços Abertos[END_REF] scene was set up, accompanied by a weakening of its lowthreshold health and social care assistance structures and an increase in the precariousness of its beneficiaries. Lastly, a number or urban renewal projects promoted by the municipality have contributed to the dispersal of some of the users from Cracolândia, who, despite successive moves, remain in the centre of São Paulo [START_REF] Fernández | Policing, covid-19 and people who use drugs: Surviving the police in Cracolândia[END_REF].

Effective results, but contrasted and below requirements

Even though they were subject to political and therapeutic controversies, these early years of Brazilian public action produced effective results, particularly in terms of public health. Firstly, putting the issue of crack cocaine on the agenda has made a major contribution to building, expanding, and sustaining support systems for drug users in the 26 states and cities, ranging from harm reduction initiatives to residential facilities. For example, in 2011 alone, the year in which the CEPV was set up, 139 TCs were created (Ipea, 2017). Similarly, between 2010 and 2014, 151 new alcohol and drug psychosocial CAPS-AD centres were set up, an increase of around 80% (SAPS, 2022). However, progress has remained very partial and uneven across the country. Among other shortcomings, only 53.5% of the resources initially allocated by the CEPV was spent, and no more than a hundred major Brazilian cities were involved (Confederação Nacional de Municípios, 2014). The scope of the actions formulated by the government thus turned out to be much more limited and concentrated than expected, far removed from the real needs of the areas and users affected by crack cocaine use.

The conservative turn in times of crises

Dilma Rousseff's second term in office (2015)(2016), which was marked by major institutional tensions, pushed the issue of crack cocaine into the background, highlighting the highly 19. Now organised into federations, national organisations, and a Parliamentary Executive Front within the Federal Congress [START_REF] Rui | Therapeutic communities in Brazil. Brooklyn, Social Science Research Council[END_REF] 20. Brazilian government press release, 15/04/2021 Available on: https://www.gov.br/pt-br/noticias/justica-e-seguranca/2021/04/dois-anos-demuitas-conquistas (Accessed 30/05/2023). 21. In particular through the Programa Nacional de Segurança nas Fronteiras e Divisas (VIGIA).

short-term nature of Brazil's drug policy. The parliamentary coup d'état that overthrew the president in 2016 and, above all, the arrival of Jair Bolsonaro (Liberal Party, 2018-2022), who was strongly committed to public safety issues among his electorate, has finally marked a political turning point in this decade.

Major changes were made to drug policy under the pretext of the difficult economic situation. Annual direct expenditure in this sector fell from around €558 million in 2014 to €100 million in 2018 (Ipea, 2021), while the distribution of resources was characterised by a major redistribution in favour of the Ministry of Justice at the expense of the Ministry of Health. This fundamental shift was accompanied by changes to the regulatory framework in 2019. On the health plan, priority was given to therapeutic communities, which were more institutionally organised 19 and have become the main means of combating addiction under the Bolsonaro administration, while harm reduction is tending to disappear from official guidelines. Between 2018 and 2019, the number of government-funded places in TCs rose from 2 900 to almost 11 000 20 . Finally, compulsory hospitalisations took an important place in these new directives, which were essentially rooted in the prohibitionist paradigm, the other aspect of which was the development of strategic actions against transnational organised crime in the country's borders and neighbouring regions 21 (CdE, 2021). Drug busts, particularly of cocaine products, have also increased significantly: having never exceeded 50 tonnes before 2018, busts of this psychostimulant exceeded 100 tonnes in 2019 (ibidem). At the beginning of 2020, the Covid-19 pandemic and the subsequent socio-economic crisis further accelerated the disruption of national policy by contributing to the weakening of safety and drug-related issues on the political agenda, including at municipal level where drug policy has been overshadowed for some years.

Conclusion

Brazil and its criminal networks have gradually established themselves as major players in the cocaine supply chain thanks to their strategic position in South America, between the main producers' countries of this psychostimulant and their international consumers markets. The country is heavily supplied with cocaine by flows that pass through it, and at the same time a domestic market has emerged, partly focused on the supply of crack cocaine. Particularly visible from the 2000s onwards, this cocaine derivative has been the focus of considerable political and media attention, centred on open scenes and the most vulnerable groups of consumers. Far from a consensus on how to treat users, the political and therapeutic proposals put forward have been governed by the political environment and the economic situation. After reaching the top of the political agenda during the first term of the Rousseff government, the issue of crack cocaine disappeared from the national spotlight, without any noticeable positive change having taken place in the landscape of drug use and trafficking in the various regions and urban criminal areas.

The institutional and socio-economic shifts that affected Brazil from 2016 onwards, with the arrival of the far-right in power, caused the debate in favour of a more progressive drug policy to recede before disappearing, against a backdrop of the Covid-19 pandemic. However, Lula's re-election in 2022 seemed to mark a new turning point in this socio-historical context. As soon as it was sworn in, the government held hearings with representatives and partners of the Brazilian Platform on Drug Policy, a network with a strong commitment to citizen engagement and reform in the field. Similarly, the new national secretary for human rights visited Cracolândia, accompanied by associations involved in harm reduction and in the anti-racist movement. This panorama suggests not only the return of the issue of drugs and crack cocaine to the federal government's agenda, but also the political recomposition in the field of the key players in this area, two major challenges that Lula will have to face in the context of a divided country undergoing numerous economic and social upheavals.

Methodology and background data

This panoramic restitution is based on the interweaving of two main sets of materials. On the one hand, based on a wide-ranging literature survey, they draw on i. official reports from national and international monitoring bodies, ii. media sources and iii. secondary data from social science studies on the subject of drugs and crack cocaine, the latter having flourished in Brazil in recent years. On the other hand, they are based on a comparison of the author's ethnographic experiences in scenes of drug use and in Brazilian facilities for the care of people in situations of addiction, i.e in the public services of the Psychosocial Care Networks (n=9) and in religiously orientated therapeutic communities (n=15).

In parallel with the observation of the respective empirical contexts, semi-directive interviews and informal exchanges were conducted with users and professionals from the health and social care sector. These studies, which here fit into our panoramic narrative, took place in particular in the metropolitan areas of São Paulo (2008-2018), Rio de Janeiro (2013-2018) and Recife (2014[START_REF] Souza | Crack e exclusão social. Brasília[END_REF], while drawing heavily on counterpart work carried out in other cities in the country.

  , the program was dismantled in 2017 following the victory of conservative candidate João Doria in the municipal elections. Since then, the new policy has led to an increase in police harassment in the historic area where the São Paulo open "Burning, convulsions, shortness of breath, tachycardia. You don't need to try crack cocaine to know its effects. Never try crack. It causes dependency and kills".

  produced by the authors using IPEA data (2021).

Stone or rock, the unit of sale for crack cocaine.

All reals-to-euros conversions are made at the average exchange rate for the reference year, according to the Brazilian Central Bank. Available on: https://www.bcb.gov.br/conversao.

"Três laboratórios de cocaína são desmontados na Bahia em 16 dias", G1, 16/12/2023. Available on: https://g1.globo.com/ba/bahia/ noticia/2023/02/16/tres-laboratorios-de-cocaina-sao-desmontados-na-bahia.ghtml (Accessed 23/04/2023).

Historical evidence suggests, however, that the smokable cocaine products available in Brazil were probably imported from the neighboring Andean producer countries, where they have been traded since at least the 1960s.


Arnaud Duport

Sonia Be ´dard

Catherine Raynauld

Martine Bordeleau

Randy Neblett

Fre ´de ´ric Balg

Herve ´devanne

Guillaume Le ´onard
email: guillaume.leonard2@usherbrooke.ca

Cross-cultural translation and psychometric validation of the French version of the Fear-Avoidance Components Scale (FACS)

Background

The Fear-Avoidance Components Scale (FACS) is a reliable and valid instrument widely used to assess fear-avoidance beliefs related to pain and disability. However, there is a scarcity of validated translations of the FACS in different cultural and linguistic contexts, including the French population. This study aimed to translate and validate the French version of the FACS (FACS-Fr/CF), examining its psychometric properties among Frenchspeaking individuals.

Methods

A cross-cultural translation process-including forward translation, backward translation, expert committee review, and pre-testing-was conducted to develop the FACS-Fr/CF. The translated version was administered to a sample of French-speaking adults (n = 55) with chronic musculoskeletal pain. Internal consistency (including confirmatory analyses of the 2 factors identified in the Serbian version), test-retest reliability and convergent validity were then assessed.

Results

The FACS-Fr/CF demonstrated high global internal consistency (α = 0.94, 95% CI: 0.91-0.96) as well as high internal consistency of the 2 factors identified in the Serbian version (α = 0.90, 95% CI: 0.86-0.94 and α = 0.90, 95% CI: 0.85-0.94, respectively). Test-retest analysis revealed a moderate (close to high) reliability (ICC = 0.89; 95% CI: 0.82-0.94 and r = 0.89; p<0.005). Convergent validity was supported by significant correlations between

Introduction

The fear-avoidance (FA) model is proposed as a possible explanation for the transition from acute to chronic pain in some patients [START_REF] Vlaeyen | Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art[END_REF][START_REF] Lethem | Outline of a Fear-Avoidance Model of exaggerated pain perception-I[END_REF]. According to this model, individuals who perceive their pain as threatening and who catastrophize will tend to develop fear of pain, avoid regular activities, and monitor excessively bodily sensations [START_REF] Vlaeyen | Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art[END_REF][START_REF] Vlaeyen | The role of fear of movement/(re)injury in pain disability[END_REF][START_REF] Vlaeyen | Fear-avoidance model of chronic musculoskeletal pain: 12 years on[END_REF]. These responses may precipitate physical deconditioning, limit the ability to work and to participate in recreational/ familial activities, and foster depression [START_REF] Vlaeyen | Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art[END_REF][START_REF] Vlaeyen | The role of fear of movement/(re)injury in pain disability[END_REF][START_REF] Vlaeyen | Fear-avoidance model of chronic musculoskeletal pain: 12 years on[END_REF].

Several patient-reported outcome (PRO) questionnaires have been developed to quantify FA related concepts, including the Tampa Scale for Kinesiophobia (TSK) [START_REF] Miller | The Tampa Scale: a measure of kinisophobia[END_REF], the Pain Anxiety Symptoms Scale (PASS) [START_REF] Mccracken | The Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain[END_REF], the Pain Catastrophizing Scale (PCS) [START_REF] Sullivan | The Pain Catastrophizing Scale: Development and validation[END_REF], and the Fear-Avoidance Beliefs Questionnaire (FABQ) [START_REF] Waddell | A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability[END_REF]. However, the FA model has significantly evolved in recent years, and none of these questionnaires comprehensively examine all the cognitive, emotional, and behavioral components of the model [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. Although they have been used in a substantial number of peer-reviewed published research, the psychometric properties of these tools (including construct validity and sensitivity to change) have sometimes been called into question [START_REF] Lundberg | Pain-related fear: a critical review of the related measures[END_REF], and some of their items have received criticism for being either too narrowly defined (only applicable to a single situation) or overly broad (too vague or subject to interpretation) [START_REF] Pincus | The fear avoidance model disentangled: Improving the clinical utility of the fear avoidance model[END_REF]. Furthermore, while pain-related avoidance can occur due to fear of injury or reinjury, fear of increased pain, or an actual increase in pain, none of these questionnaires attempt to distinguish between these different cases [START_REF] Rainville | Fear-avoidance beliefs and pain avoidance in low back pain-translating research into clinical practice[END_REF].

In an attempt to address these shortcomings, Neblett et al. (2015) have developed the Fear Avoidance Component Scale (FACS) [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF], which includes items from other published FA related measures (TSK, PASS, PCS, FABQ). The FACS also includes items based on the Injustice Experience Questionnaire (IEQ) [START_REF] Sullivan | The role of perceived injustice in the experience of chronic pain and disability: scale development and validation[END_REF], designed to assess the degree to which chronic pain sufferers feel injustice in relation to their pain. All FACS items were created to assess specific fear avoidance related beliefs and feelings about a person's painful medical condition, such as cognitive (pain catastrophizing), affective (pain-related fear and anxiety), and behavioral (avoidance) constructs [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. In addition, six items (15 to 20) were developed to assess the specific types of activities and physical intensity of activities (from low to strenuous) that an individual avoids, and three items were developed to evaluate why the individual is avoiding these activities [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF].

The original English version of the FACS has shown acceptable test-retest reliability (r = 0.90-0.94) as well as acceptable internal consistency (Cronbach α = 0.92) [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. The FACS has been translated and validated in several different languages. It has shown good psychometric properties in Serbian (test-retest reliability: ICC = 0.93; internal consistency: Cronbach α = 0.90) [START_REF] Knezevic | Psychometric validation of the Serbian version of the Fear Avoidance Component Scale (FACS)[END_REF], Spanish (convergent validity: r = 0.41; internal consistency: Cronbach α = 0.90-0.88) [START_REF] Cuesta-Vargas | Cross-cultural adaptation and validity of the Spanish fear-avoidance components scale and clinical implications in primary care[END_REF], Gujarati (test-retest reliability: ICC = 0.92; internal consistency: Cronbach α = 0.83) [START_REF] Bid | Cross-cultural adaptation, reliability, and validity of the Gujarati fear-avoidance components scale[END_REF], Dutch (internal consistency: Cronbach α = 0.92; test-retest reliability: ICC = 0.92, CI 0.80-0.96) [START_REF] Baets | The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain[END_REF] and Turkish (internal consistency: Cronbach α = 0.815; test-retest reliability: ICC = 0.53-0.97).

There are currently about 321 million French speakers throughout the world [START_REF]Organisation internationale de la Francophonie. La langue franc ¸aise dans le monde[END_REF]. However, a psychometrically validated French version of the FACS has not been made available to date. Clinical settings in French-speaking parts of the world-including France and Canadacould certainly benefit from a French version of this questionnaire. The aim of the current study was to translate the FACS into a common French version, including dialects of France and Canadian French (FACS-Fr/CF), and to assess the psychometric properties of the translated questionnaire-including internal consistency, test-retest reliability, and construct validity.

Materials and methods

The study was approved by the ethics committee of the Research Center on Aging du Centre Inte ´gre ´Universitaire de Sante ´et de Services Sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie CHUS) and registered on the ClinicalTrials website (NCT05217017). This study was conducted according to the principles expressed in the Declaration of Helsinki [START_REF] Wma | The World Medical Association-De ´claration d'Helsinki de L'AMM-Principes e ´thiques applicables à la recherche me ´dicale impliquant des êtres humains[END_REF].

Cross-cultural translation process

The translation was performed using a six-step process according to the guidelines for the cross-cultural adaptation process written by the American Association of Orthopaedic Surgeons and the Institute for Work & Health [START_REF] Beaton | Guidelines for the process of cross-cultural adaptation of self-report measures[END_REF]. Before embarking on the cross-cultural translation process, we obtained permission from the original designers of FACS. Initial translation, synthesis, back translation, expert committee, test of the prefinal version and submission of the final version of the document to the one of the original developers (RN) were performed. For the initial translation, two independent translators (ST and SW), whose mother tongue was French, translated the scale from English to French. A synthesized version of the two translated questionnaires was completed after discussion with the translator and research team. Two independent translators (BVD and AS), blinded to the original scale and whose native language was English, then translated the synthesized version back to English. An expert committee, comprised of the four translators and the research team, consolidated the prefinal version.

The content validity of the French FACS was pre-tested by 10 healthcare professionals (including physiotherapists, nurses, neuropsychiatrists, and orthopedic surgeons) and 20 individuals (pain-free participants and painful patients including 10 in Quebec (Canada), and 10 in France. All of them tested the prefinal version by completing the questionnaire and evaluating their understanding of each item. Each person was invited to report any interpretation difficulties and other observations about each test item [START_REF] Beaton | Guidelines for the process of cross-cultural adaptation of self-report measures[END_REF]. Based on participants' answers, only item 13 « La douleur causée par mon état de santé est un signal d'alerte indiquant que quelque chose ne va pas du tout chez moi » ("The pain from my medical condition is a warning signal that something is dangerously wrong with me") turned into « La douleur causée par mon état de santé est un signal d'alerte indiquant que quelque chose ne va pas du tout » ("The pain from my medical condition is a warning signal that something is dangerously wrong"). This modification was made because of the end of the sentence (« chez moi »), suggesting a psychiatric disorder connotation in French. For the final step, the methods for obtaining the corrected French version (FACS-Fr/CF) were submitted to author (RN), one of the developers of the original FACS questionnaire (Fig 1). The cross-cultural translation process period ran from March 14, 2022 to March 31, 2022.

Psychometric evaluation of the FACS-Fr/CF

After cross-cultural adaptation and translation, the final version of the FACS-Fr/CF questionnaire was administered to a sample of participants suffering from chronic pain to evaluate internal consistency, test-retest reliability, and convergent validity. This validation step was performed according to specialized pain medicine guidelines [START_REF] Tsang | Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine[END_REF].

Study population. The target population for this study included patients with chronic musculoskeletal pain who spoke French as their first language and referred by a physician for a musculoskeletal condition at the hospital CIUSSS de l'Estrie-CHUS (convenience sampling method). The eligibility criteria were: 1) 18 years of age or older; 2) French as first language; and 3) chronic musculoskeletal pain for at least 3 months. Subjects were excluded if they were unable to consent, read or understand the study requirements (see Fig 2). The inclusion period ran from April 26, 2022 to November 1, 2022.

Sample size. Sample size was determined on the basis of previous studies-all with a subject to item ratio greater than or equal to 2 [START_REF] Anthoine | Sample size used to validate a scale: a review of publications on newly-developed patient reported outcomes measures[END_REF]-and on the basis of other similar studies involving the French translation of comparable tools [START_REF] Albert | Psychometrics of the Eschelle questionnaire to measure self efficacy in work capacity[END_REF][START_REF] Albert | Internal consistency and construct validity of the Revised Illness Perception Questionnaire adapted for work disability following a musculoskeletal disorder[END_REF]. Thus, we recruited 55 participants to meet the objectives of this study (50+10% loss) for the assessment of internal consistency, reliability and validity. This percentage of loss to follow-up was based on the latest research at the CHUS orthopedic service and on a systematic review focused on orthopedic clinical services [START_REF] Somerson | Loss to follow-up in orthopaedic clinical trials: a systematic review[END_REF].

Patient-reported outcome measures. The FACS is a self-reported questionnaire used to comprehensively measure and identify major FA components in patients with painful medical conditions based on the most recent FA model [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF][START_REF] Pincus | The fear avoidance model disentangled: Improving the clinical utility of the fear avoidance model[END_REF]. This questionnaire consists of 20 items on a Likert scale, ranging from 5 (completely agree) to 0 (completely disagree). The total score, which varies from 0 to 100, is calculated by adding the values of each item. The FACS includes 5 severity levels with increasing severity, based upon quintiles: Subclinical (0 to 20), Mild (21 to 40), Moderate (41 to 60), Severe (61 to 80), and Extreme (81 to 100). Psychometric properties of the FACS show high internal consistency (α = 0.92) and high test-retest reliability (r = 0.90-0.94, P < 0.01) [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. The Serbian version of FACS found 2 different factors; factor 1 dealt with "general fear avoidance" and included items 1-14, while factor 2 was related to "types of activities that are avoided" and included items 15-20) [START_REF] Knezevic | Psychometric validation of the Serbian version of the Fear Avoidance Component Scale (FACS)[END_REF].

The Tampa Scale for Kinesiophobia-Canadian French version (TSK-CF) is a self-reported questionnaire used to assess kinesiophobia. The TSK-CF has demonstrated good psychometric properties (Cronbach's alpha = 0.71 and ICC > 0.7) [START_REF] French | Peur du mouvement chez des accidente ´s du travail: L'E ´chelle de Kine ´siophobie de Tampa (EKT). [Fear of movement in injured workers: The Tampa Scale of Kinesiophobia[END_REF][START_REF] Weermeijer | Clinimetrics: Tampa Scale for Kinesiophobia[END_REF]. This questionnaire consists of 17-items evaluated on a Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). The total score, which varies from 17 to 68, is calculated by adding the values of each item. There is no specific threshold to indicate a clinically disabling level of kinesiophobia [START_REF] Vlaeyen | Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance[END_REF].

The Pain Catastrophizing Scale-Canadian French version (PCS-CF) is a self-reported questionnaire used to measure catastrophic thoughts. The PCS-CF has shown good psychometric properties (Cronbach's alpha = 0.87 and ICC > 0.7) [START_REF] Sullivan | The Pain Catastrophizing Scale: Development and validation[END_REF][START_REF] French | L'E ´chelle de dramatisation face à la douleur PCS-CF: Adaptation canadienne en langue franc ¸aise de l'e ´chelle[END_REF][START_REF] Osman | Factor structure, reliability, and validity of the Pain Catastrophizing Scale[END_REF][START_REF] Tremblay | Pain Catastrophizing Scale for Francophone Adolescents: a preliminary validation[END_REF]. This questionnaire consists of 13 items, rated on a Likert scale from 0 (not at all) to 4 (always), that can be categorized into three subscales: rumination (being unable to stop thinking about how much it hurts), amplification (exaggerating the threat value of pain sensations), and feelings of helplessness (feeling unable to cope with pain) [START_REF] Osman | The Pain Catastrophizing Scale: further psychometric evaluation with adult samples[END_REF]. The sum of the 13 items' values yields the final score, which ranges from 0 to 52. It has been suggested that a threshold score of 30 or higher can be used to identify people who have a clinically significant level of pain catastrophizing [START_REF] Sullivan | The Pain Catastrophizing Scale[END_REF].

The Hospital Anxiety and Depression Scale-French Canadian version (HADS-FC) is a self-reported questionnaire used to measure the symptoms of anxiety and depression [START_REF] Roberge | A psychometric evaluation of the French Canadian version of the Hospital Anxiety and Depression Scale in a large primary care population[END_REF]. This questionnaire consists of 14 items intended to evaluate the severity of anxiety and depressive symptoms on two different subscales using a 4-point Likert-type scale (ranging between 0 and 3). Higher scores on the total scale indicate greater psychological distress. The internal consistency of the French version is good [START_REF] Boce ´re ´an | A validation study of the Hospital Anxiety and Depression Scale (HADS) in a large sample of French employees[END_REF], with the depression subscale having Cronbach's alpha of 0.78 and the anxiety subscale having a Cronbach's alpha of 0.81.

Study process and procedures. Participants were recruited during an initial medical consultation visit at the orthopedic clinic of the CIUSSS de l'Estrie-CHUS. After the orthopedist completed the examination and written informed consent to participate was obtained, patients were asked to complete a short sociodemographic questionnaire (including sex, age, physician's diagnosis, pain duration and academic level) using an online REDCap platform (RED-Cap 12.4.2 -© 2023 Vanderbilt University) [START_REF] Garcia | Research Development Using REDCap Software[END_REF]. Patients were then asked to fill out the four questionnaires (FACS-Fr/CF, TSK-CF, PCS-CF, HADS-CF). The questionnaires were completed online (REDCap) or on paper, depending on the participants' convenience or preference.

Then, seven days later, the patients were asked to complete the FACS-Fr/CF a second time, in the same way as the first time (online or paper). This timeframe was short enough to avoid significant clinical fluctuations from first completion and allow an appropriate test-retest evaluation [START_REF] Streiner | Health measurement scales: A practical guide to their development and use[END_REF].

Statistical analysis. Cronbach's alpha was used to assess the global internal consistency of the FACS-Fr/CF. We performed a global and confirmatory factors analysis (1 and 2) of the Serbian version. According to [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF], α � 0.80, α � 0.70 and α < 0.70 are considered as high, moderate and low, respectively [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF].

The reliability was calculated with test-retest intraclass correlation coefficients (ICC) and Pearson correlation coefficients. According to [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF], ICC � 0.90, ICC � 0.75 and ICC < 0.75 are considered as high, moderate and low, respectively [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF].

Convergent validity was assessed using Pearson's correlation coefficients, comparing the FACS-Fr/CF with the TSK-CF, the PCS-CF, and the HADS-FC. According to [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF], r � 0.60, r � 0.30 and r < 0.30 are considered as high, moderate and low, respectively [START_REF] Wind | Assessment of functional capacity of the musculoskeletal system in the context of work, daily living, and sport: a systematic review[END_REF]. Considering the constructs of these different questionnaires, we expected to find stronger correlations with TSK-CF, followed by the PCF-CF and the HADS-FC.

All statistical analyses were performed using SPSS 1 (version 21); the significance level set at p = 0.05.

Results

Clinical characteristics of patients

Clinical characteristics of patients are provided in Table 1. Fifty-five (55) participants took part in the study, including 30 men (54.5%) and 25 women (45.5%). The average age for the total sample was 51.15±16.47 years old. The average pain duration was 65.67±86.80 months. The clinical diagnoses of the patients are given in Table 1. One subject each, for the remaining 10 patients, were diagnosed with the following: stenosing flexor tenosynovitis, femur elongation, cervical surgery, elbow fracture, ankle pain, complex regional pain syndrome (CRPS), neuropathy of upper limbs, patellofemoral syndrome, Baker's cyst, crowned dens syndrome. The study ended on November 11, 2022 with the receipt of the last questionnaire.

Internal consistency

The global internal consistency of FACS-Fr/CF calculated by Cronbach's alpha was high (α = 0.94, 95% CI: 0.91-0.96). For factors 1 and 2, the Cronbach's alpha was high for both (α = 0.90, 95% CI: 0.86-0.94 and α = 0.90, 95% CI: 0.85-0.94 respectively). The descriptive statistics and internal consistency for the FACS-Fr/CF items are shown in Table 2.

Reliability test retest

Test-retest reliability of the FACS-Fr/CF was moderate, close to high (ICC = 0.89; 95% CI: 0.82-0.94 and r = 0.89; p<0.005).

Convergent validity

The convergent validity was assessed with Pearson's correlation coefficients (unilateral). The FACS-Fr/CF scores were highly correlated with scores on the TSK-CF (r = 0.82; p < 0.005), PCS-CF (r = 0.72; p < 0.005) and HADS-FC (r = 0.66; p < 0.005). All correlation coefficients are shown in Table 3.

Discussion

This study aimed to establish and validate a cross cultural adaptation of the FACS questionnaire in French and Canadian French, using the guidelines for questionnaires in pain medicine proposed by Tsang, Royse and Terkawi [START_REF] Tsang | Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine[END_REF]. Following a forward and backward translation process, and feedback from 10 healthcare professionals and 20 patients, a final version of the FACS-Fr/CF was established. The psychometric properties were then assessed in a sample of 55 chronic pain patients who completed the final FACS-Fr/CF on 2 occasions at a 2-week interval, as well as 3 other questionnaires, which assessed related constructs.

Global internal consistency of FACS-Fr/CF was high (α = 0.94,) and comparable to the original FACS (α = 0.92) [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. The internal consistency of the 2 factors identified previously in the Serbian version was also high, despite the relatively small number of items for factor 2. Test-retest reliability of the FACS-Fr/CF was moderate, very close to high. These values are consistent with those obtained for the original version (r = 0.90-0.94, P < 0.01) [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF].

For convergent validity, we assessed the relationship between the scores of the FACS-Fr/ CF, the TSK-CF, the PCS-CF and the HADS-FC. A previous study with the Spanish and Turkish versions of the FACS found a moderate and strong correlation with the Spanish and Turkish version of the TSK, with a coefficient r = 0.39 and r = 0.56 respectively [START_REF] Gutie ´rrez-Sa ´nchez | Validity and reliability of Spanish fear-avoidance components scale in breast cancer survivors[END_REF][START_REF] Turan | Psychometric properties of the Turkish version of the fear avoidance components scale in patients with chronic pain related to musculoskeletal disorders[END_REF]. In the present study, we observed a high correlation between the FACS-Fr/CF and the TSK-CF (r = 0.82). As expected, the correlation was higher with the TSK-CF, compared to the PCS-CF (r = 0.72) and the HADS-FC (r = 0.66), suggesting that the constructs underlying the FACS and TSK are particularly close [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF]. This finding is perhaps not so surprising when we bear in mind that some of the items from the FACS were borrowed directly from the TSK [START_REF] Neblett | The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance[END_REF].

We also examined the convergent validity of FACS, by assessing its relationship with the PCS. In previous studies, the Spanish version showed a moderate correlation with the PCS (r = 0.49 to 0.53) [START_REF] Gutie ´rrez-Sa ´nchez | Validity and reliability of Spanish fear-avoidance components scale in breast cancer survivors[END_REF][START_REF] Pe ´rez-Cruzado | Validation of pain catastrophizing scale on breast cancer survivor[END_REF], and the Serbian and Turkish versions showed a high correlation (r = 0.77 and r = 0.68 respectively) [START_REF] Knezevic | Psychometric validation of the Serbian version of the Fear Avoidance Component Scale (FACS)[END_REF][START_REF] Turan | Psychometric properties of the Turkish version of the fear avoidance components scale in patients with chronic pain related to musculoskeletal disorders[END_REF]. The high correlation between the FACS-Fr/CF and PCS-CF (r = 0.72; p < 0.005) was very close to the Serbian and Turkish versions.

FA is frequently associated with anxiety [START_REF] Pincus | Fear avoidance and prognosis in back pain: a systematic review and synthesis of current evidence[END_REF] and depression [START_REF] Brindisino | Depression, fear of re-injury and kinesiophobia resulted in worse pain, quality of life, function, and level of return to sport in patients with shoulder instability. A systematic review[END_REF]. Though anxiety and depression are related to FA, these constructs are somewhat different [START_REF] Sloan | Emotion regulation as a transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline personality disorders: A systematic review[END_REF]. The association between FACS-Fr/CF and HADS-FC scores was therefore expected to be weaker than those observed between the FACS-Fr/CF and TSK-CF, and between the FACS-Fr-CF and PCS-CF.

All in all, the pattern of convergent validity results in the present study is consistent with the a priori assumptions that postulated a higher correlation coefficient between FACS-Fr/CF and TSK-CF scores [START_REF] Abma | Appraising convergent validity of patient-reported outcome measures in systematic reviews: constructing hypotheses and interpreting outcomes[END_REF][START_REF] French | Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK)[END_REF], followed by the PCS-CF (with symptoms of helplessness, rumination and magnification being an important component of the FA model [START_REF] Sullivan | The Pain Catastrophizing Scale: Development and validation[END_REF]) and by the HADS-FC [START_REF] Djukanovic | Is the Hospital Anxiety and Depression Scale (HADS) a valid measure in a general population 65-80 years old? A psychometric evaluation study[END_REF].

This work provides an important basis for the future use of the FACS-Fr/CF in assessing fear-avoidance beliefs in various French-speaking cultural contexts.

This study has a number of strengths and limitations. One strength was that the American Association of Orthopedic Surgeons and the Consensus-based Standards for the Selection of Health Measurement Instruments recommendations were followed in the cross-cultural adaptation and validation process. Furthermore, the FACS-Fr/CF was developed as a standardized version, accommodating two distinct French language dialects (France and Canada). As a result, it has potential for broad applicability across diverse French-speaking regions, worldwide. However, it is important to exercise caution when using the instrument in specific contexts, as further validation studies may be necessary to ensure its appropriateness for local linguistic variations and cultural nuances.

An important limitation of this study concerns recruitment, as the 55 patients included in the sample were recruited from a single hospital-a situation that may raise questions about the generalizability of the results. However, it is important to note that this limitation may be partially mitigated by the important variability observed among the pain conditions encompassed within the sample. Nonetheless, extrapolating the results to broader chronic pain populations, outside the specific context of the study, should be done with caution.

Conclusions

This is the first translation, intercultural adaptation and validation study of the FACS in French version, including dialects of France and Canadian French. The FACS-Fr/CF showed a high global internal consistency and moderate (very close to high) test-retest reliability. The convergent validity of the FACS-Fr/CF was demonstrated by positive correlations with TSK, PCS and HADS.

Fig 1 .

 1 Fig 1. Flowchart of the development of the FACS-Fr/CF. https://doi.org/10.1371/journal.pone.0288899.g001

Fig 2 .

 2 Fig 2. Patient recruitment flowchart. https://doi.org/10.1371/journal.pone.0288899.g002

Table 1 . Clinical characteristics of patients. Characteristics Total sample or mean (% or SD)

 1

	Age (years)	51.15 (16.47)
	Sex	30 men (54.5%)
		25 women (45.5%)
	Diagnosis	Arthrosis (12)
		Tendinopathy (9)
		Coxalgia (8)
		Ligamentoplasty (6)
		Labrum tear (5)
		Tendon rupture (3)
		Low back pain (2)
		Other (10)
	Pain duration (months)	65.67 (86.80)
	FACS-Fr/CF (at first time)	47.35 (22.85)
	PCF-CF	19.40 (13.81)
	TSK-CF	40.94 (9.71)
	HADS-FC	13.49 (8.06)
	FACS-Fr/CF (retest 7 days later)	45.43 (21.84)

https://doi.org/10.1371/journal.pone.0288899.t001

Table 2 . Internal consistency for the FACS-Fr/CF items. FACS-Fr/CF items Corrected total-item correlation Cronbach's alpha if item deleted

 2

	1

Table 3 . Pearson's correlations (2-tailed) among PROs.

 3 Hospital Anxiety and Depression Scale-French Canadian version https://doi.org/10.1371/journal.pone.0288899.t003

		FACS-Fr/CF a	PCS-CF b	TSK-CF c
	PCS-CF b	0.72***	-
	TSK-CF c	0.82***	0.61***	-
	HADS-FC d	0.66***	0.69***	0.66***
	*** means p<0.005
	a Fear Avoidance Components Scale-French/Canadian French version
	b Pain Catastrophizing Scale-Canadian French version
	c Tampa Scale for Kinesiophobia-Canadian French version

d

PLOS ONE | https://doi.org/10.1371/journal.pone.0288899October 12, 2023

Acknowledgments

We would especially like to thank Doctor Ste ´phane Ricard and the orthopedic service of CIUSSS de l'Estrie-CHUS for recruiting participants, as well as Professor Cynthia Gagnon for her help with the translation process.

This study was funded by the Fond de recherche et enseignement en orthope ´die de Sherbrooke (FREOS). GL received salary support by the Fonds de recherche du Que ´bec -Sante (FRQS, Senior clinical research scholar). Funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data cannot be shared publicly due to restrictions imposed by the ethics committee, as data sharing was not mentioned in the consent form. Data are available from the Research Center on Aging

Supporting information

S1 File. Fear-Avoidance Components Scale, French/Canadian French version (FACS-Fr/ CF). (PDF)

Author Contributions