ORIGINAL ARTICLE

 

Drug users' perspective on their treatment and the psychosocial care network^*

 

 

Vanessa Ayres Tibiriçá^I; Eduarda Pampolin Miessi Luchini^II; Camila Souza de Almeida^III

^IUniversidade do Estado de Minas Gerais, Divinópolis, MG, Brazil
^IiUniversidade do Estado de Minas Gerais, Divinópolis, MG, Brazil
^IIIUniversidade do Estado de Minas Gerais, Divinópolis, MG, Brazil / Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

Corresponding Author

 

 

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ABSTRACT

OBJECTIVE: to analyze the perception of the user of alcohol and other drugs on their treatment in a Psychosocial Care Center for alcohol and other drugs and their insertion in the psychosocial care network.
METHOD: this is an exploratory qualitative research, in which focal groups were used as a way of collecting data. The study was conducted in the city of Divinópolis, Minas Gerais, from August to November 2017.
RESULTS: in all, five focus groups addressed issues such as treatment, care network and relationship with the city's health system.
CONCLUSION: the psychosocial care network is very fragmented and fragile, which makes it difficult for the users of alcohol and other drugs to be treated and overload the specialized mental health services.

Descriptors: Substance-Related Disorders; Mental Health; Mental Health Services; Nursing; Integrality in Health.

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Introduction

The treatment to the individual with problems related to the use and abuse of psychoactive substances (PAS) has already crossed through several modalities. Currently, it has been advocated the provision of care in the field, without institutionalization and long-term hospitalizations⁽¹⁾.

The individual should be followed up in primary health care (PHC), and this care should not be delegated only to secondary or tertiary care. In addition, mental health, in general, should be conceived as cross-sectional throughout the health network and not just as specific actions⁽¹⁾.

The first devices deployed for mental health care were the Psychosocial Care Centers (CAPS in Portuguese) implemented in 1989, but instituted by Ordinance no. 224 in 1992, replaced with Ordinance no. 336 in 2002. The CAPS was the device that enabled the deinstitutionalization of thousands of people, offering field services and reintegrating the patient into their place of living.

In 2003, the Ministry of Health launched the Policy for Comprehensive Care for users of alcohol and other drugs based on the principles of the Unified Health System (SUS) and of the Psychiatric Reform. The guidelines for this policy are networking, user participation and the creation of alternatives to psychiatric hospitals. The Psychosocial Care Centers for users of alcohol and other drugs (CAPS) are among these alternative services, guided by the strategy of harm reduction, prevention, recovery and social reintegration.

Prior to the publication of Ordinance GM/MoH No. 3,088/2011, the CAPS was considered to be the manager for all the mental health demands of the territory, being responsible for the articulation with other health institutions and networks, such as social assistance. With the Ordinance of 2011, which established the Psychosocial Care Network (RAPS in Portuguese), there was a change in this configuration, and the PHC became the main form of articulation of mental health in the territory⁽²⁾.

The different components of the Psychosocial Care Network must articulate in order to treat and follow the users. The network should not restrain itself, but promote inter-sectorial articulation with education and social assistance, so that, in fact, it is possible to provide a comprehensive care to the individual⁽³⁾.

Comprehensive care to users of alcohol and other drugs in RAPS should be sufficient to prevent hospitalizations and abusive use of drugs. However, in practice, there is a great difficulty in doing this because the network cannot track these individuals at the beginning of illness and cannot even follow the necessary care for them while they are forwarded from the PHC to the secondary or tertiary care⁽⁴⁾.

Regarding the treatment in CAPS, there are still some difficulties related to the need to break the assistance model that is rooted in the health and training of professionals working in this area. There is still the biologicist view, which treats only the signs and symptoms of the disease, not often considering the psychosocial components. This complicates the treatment recommended by the Ministry of Health.

Universities and courses in the health area, such as nursing, with their current curricula, cannot yet cover all the magnitude necessary to understand the phenomenon of use of alcohol and other drugs. Also, prejudice still exists in professionals and society when it comes to users of psychoactive substances⁽⁴⁾.

In addition to this, there are the difficulties imposed by lack of funds from the government, especially with the proposal of Constitutional Statement No. 241, which brings changes that will compromise the financing of PHC in Brazil and the quality of services provided.

The CAPS are still new services in the country, that have gained strength after 2011. However, the possible cuts foreseen not only by the Constitutional Statement, but by Resolution no. 32 of December 14, 2017 that increases the financing of the therapeutic communities and that was the subject of protests by society and scholars of the health area, can bring significant changes in the way mental health is addressed in the coming years.

But despite the difficulties presented in the provision of care, the path for a dignified treatment to individuals in abusive use of alcohol and other drugs still must encompass the strengthening of CAPS ad and RAPS, since the Ministry of Health recommends them as a treatment device for Harm Reduction (HR), and this HR can only be effective when carried out in partnership with the user in his/her territory. Thus, these individuals can be empowered to make changes in their lives, from being mere spectators of their treatments to becoming protagonists.

Based on the above, the only way to perceive the strengths and weaknesses of the network, in order to strengthen it, is to know the configurations of the CAPS and RAPS and the path the individual makes through the network. To understand this process, we should give the user a voice, since he/she is the one that needs the treatment and, in fact, goes through the RAPS in search of medical treatment and of social insertion.

Thus, the objective of this study is to analyze the user's view regarding the Psychosocial Care Center for alcohol and other drugs he/she attends and his/her path through the RAPS.

 

Method

This is a qualitative study, in which the focal group technique was used with type III CAPS patients in the city of Divinópolis, Minas Gerais, Brazil, from August to November 2017, in all five focal groups.

The social determination of the health-disease process was used as a theoretical basis, because it is believed that drug use is not only a biological or only a social factor, but a dialectical phenomenon in which the general, particular and singular dimensions influence and are mutually influenced⁽⁵⁾.

Because it is an open substitutive service, patient turnover is great and changes of participants during groups were expected. On average, the site had 35 patients per day, but the mean participation per focal group was eight to twelve. Invitations for group participation occurred in the CAPS itself with users present at that moment, except for patients who were restricted to bed and under 18 years of age. Due to the great turnover, it was not possible to check the interviews after transcription by the users participating in the groups.

The meetings took place on the spot and lasted between one hour and one and a half hour, and were held weekly, on Wednesdays. The interviewers were psychology and nursing undergraduate students of the fourth semester who had been previously trained by the teacher responsible for the project to carry out the groups. All students had previous knowledge about the subject and participated in projects related to the use of drugs with the said teacher, who is a nurse and has the use of alcohol and other drugs as a work theme. During the meetings, other employees or students were not allowed to participate so as not to curb the users.

Focus groups were chosen as a form of collective data collection, a non-directive technique that is based on the human tendency to form opinions and attitudes when interacting with others⁽⁶⁾. Because it was a focus group, semi-structured scripts were used to guide the discussion. Each of the five focus groups had a goal, such as discussion about the place of treatment, triggers for relapse and its management, social network and drug user attention network in the city.

Prior to the start of the focus groups, the students and the main researcher visited the place and conducted field observation. All previous observations and those made during focus groups were written in the field diary that aided in data analysis. After the analysis of the data, a report was made with the results and sent to the managers of the place.

All participants were informed about the type of study and signed the Informed Consent Form (ICF). All the group meetings were recorded and then fully transcribed by the researchers. Each participant received an alphanumeric code to maintain the secrecy of the information.

The present study was approved by the Research Ethics Committee of the State University of Minas Gerais, under certificate no. 69361717.1.0000.5115. It meets the determinations of Resolution 466/12 of the National Health Council and was funded through a scientific initiation grant of the Institutional Program for Research Support Grants of the State University of Minas Gerais (UEMG).

The theoretical reference to be used required a methodological reference that could cover the objectivities and subjectivities of the object. Thus, the dialectical hermeneutic analysis technique was considered pertinent because it sought to understand the use of drugs at the same time it sought to understand the macro-social processes of the use^(7-8).

 

Results

The CAPS III under study was inaugurated in 2015 with 24/7 care and a total capacity for 45 patients. Eight users participated in each focus group, with a total of 32 participants in the five groups. The majority of the participants were male (81%) and the mean age of the male participants was 30 years old or older and the mean age of the females was 50 years old.

The mean level of schooling among men was complete elementary education. Women had a higher level of education, since 33.3% had complete elementary education and 33.3% complete secondary education. Regarding marital status, 61.5% of men were single. In women, this percentage reached 83.3%.

As for the analysis of focus groups, five thematic categories emerged: "Paths of use"; "Social network"; "Psychosocial Care Network: users' path" and "Real CAPS x Advocated CAPS". This article will address the last two thematic categories.

Real CAPS X Advocated CAPS

In the first focus group, the researchers addressed the CAPS and asked questions understand the level of knowledge of users about what it is and the role of CAPS.

Users have demonstrated they do not specifically understand the role of the place as harm reducer, but rather as a place to achieve abstinence: (It is meant for us) to stop using. (U4); I think it is an institution to help us stop addiction, right? Stop with addiction. (U3)

This view is rooted in Brazilian society, even with the advances of the Psychiatric Reform and Public Policies. The populations still attaches to the notion of "cure", that an effective treatment would be what causes the person to cease the use completely. Of course, this could be a goal, but not the only one. The CAPS should address this theme more properly, for the deconstruction of the paradigm of total abstinence, focused on the biologicist vision of healing.

During the field observations and reports of professionals, it was noticed that, due to the short time of operation and the high demand, the communication between team and users is shown to be flawed. This may occur because the place serves to all the population that uses alcohol and other drugs in the city, not having a street clinic or other devices helping in the HR logic, which may prejudice the users' understanding of the role of the institution: They (team) should also make a meeting, with questions, in which they should talk to us, but they do not do it. (U17); None of this is talked here (about Harm Reduction), none of this. (U16)

These reports and the field notes show the dialectics present at the study site, where health professionals report working with harm reduction, but in practice, either because of the enormous workload or even because of the professional training, they do not address the user empowerment.

One of the pillars of RAPS and consequently of CAPS is the participation of the user in the treatment. This individual should be considered a citizen of rights and duties and, together with the health team, should build his/her treatment.

There is also the hierarchy in which health professionals position themselves as holders of knowledge, believing that "patients" should only follow the recommendations. However, within the logic of harm reduction and treatment in the territory, the patient should be the one to guide his/her treatment.

When asked about the relationship with the team, the reports showed an apparently conflict-free coexistence: For me it is cool, just as we respect them [employees], they respect us, too. (U1); Nothing to complain; each one respects the limit of the other, here. (U2). The speeches show that employees understand the limits for the treatment of users of alcohol and other drugs, and there are no impositions regarding treatment modalities. The observations showed a great rapprochement between the nursing technicians and the patients, as these are the professionals that remain for a longer time with the users.

But there is a contradiction when the users report not being informed about the treatment and the lack of meetings and the speeches presented above, in which they report a harmonious coexistence, since each one would respect the limit of the other. Would it be a respect for the other's limit or a lack of dialogue and chores in which patients would feel too free on the institution?

Field observations have shown a little rapport between the higher-education health staff and service users, in which the nurse was the higher-level professional that was closest to patients. On the other hand, the nursing technicians were the professionals who actually dealt with the users, being often the professionals with whom the patients had more disagreements and, at the same time, with whom they talked the most. The health professionals had a greater approximation during the individual visits and during the workshops, which were not performed on a regular basis.

As already reported, one of the failures of CAPS is communication and this could be facilitated through groups and/or workshops, which are techniques advocated by the Ministry of Health to be held in CAPS. But one of the complaints is the small number of activities and the lack of continuity or periodicity: There is little activities to be performed here. (U16); We just keep thinking about lying in bed. There is nothing to do here. (U2) I think there should be courses for us too, you know? Doing something, I do not know, some kind of craft. (U2)

The lack of workshops and groups makes the patients idle and sleepy. Many carried cards to pass the time, playing with each other and with the nursing technicians, or they were seen sleeping on the floor or in cardboards in the yard because one of the rules of the institution was to close the multimedia room and the dormitories at certain times for patients to stay awake and active. However, with the lack of the workshop schedule, they ended up sleeping or sitting on the yard floor, reproducing the reality they lived in the streets.

The CAPS should also promote activities aimed at the treatment of use of alcohol and other drugs, as well as at the social insertion of these users, for example, through their reintegration into the labor market. Thus, training workshops or even the creation of cooperatives and solidarity economy should be explored and proposed. But there are no workshops for this purpose.

Some users reported this lack of professional activities: There should be a course, an education. Something like that. (U1); A workshop that can assure us something later. (U15)

Lack of activity can lead the user to have recurring thoughts about drug use and even lead them to abandon treatment: As I usually say, the empty mind it the Devil's workshop. If I'm here all day idle, there's a time I'm here all day thinking about when it is 5p.m., I will go out, find a way and use my drug, do you understand? So, there is no occupation." (U15)

There is a schedule, in the institution, with activities that should be carried out, but they often do not occur due to the overload of professionals with other demands, such as reception, meetings and bureaucratic demands, in addition to the high number of individual demands carried out in consultations, which could be transformed into assemblies or groups.

With regard to the infrastructure of CAPS, it is improvised. Many activities that would be held together with the focus groups were compromised due to improvised facilities, such as lack of space for simultaneous activities and lack of ventilation. The lack of bathrooms was also one of the complaints: Another thing that I think they should have here ... poor women ... Women have to use men's restroom; this does not work. So, there should be a bathroom for women. (U3)

But despite the reported problems, the CAPS III was seen by the users as a place of support and assistance, as reported in the speeches: For me it's a salvation right? It's a life call that I'm having, I've had several, right? I took them for granted. Here, for me, it is being one of the best, for now. (U1) The CAPS is a support, it is a support indeed, because we used to be in the streets. (U2)

In the said city, the CAPS is the only place for the reception and treatment of users of PAS, and the activities of reception and follow-up of these users by the PHC are still incipient.

Thus, the CAPS is extremely important in the treatment of users of alcohol and drugs because in addition to being identified as a place of support by users, it is an institution that advocates the individuals and their rights and tries in the best possible way to support and help to overcome drug use. Furthermore, it is accessible to all people.

Psychosocial Care Network: users' path

The CAPS, as discussed in the previous session, is the only place in the city that fulfills the demand of users of alcohol and other drugs, a reality that makes it difficult for the patient the social reintegration and treatment in the territory.

The Psychosocial Care Network aims to broaden the access of the population in general, promoting care to people with mental suffering and needs arising from the use of drugs. In the Primary Health Care (PHC), attention points were established as basic health units; family health support centers; street clinics and social centers.

In spite of the great importance of RAPS and the appreciation thereof by the user, many participants did not know what RAPS was and what its purpose and function are. However, two participants reported that they had used other services that are within the network, such as the Emergency Care Unit (UPA): The UPA, if we are not feeling well, they take us there, and we are not well attended there. (U16)

With the exception of UPA, the other RAPS services were not mentioned. The devices of the network that are sought are those related to physical signs and symptoms, and the psychosocial components of the phenomenon are little explored and receive little importance.

A conversation with the employees revealed a difficulty in communicating with the other points of the network. It is believed, in the city, that the patient who is a user of alcohol and other drugs "belongs" to CAPS.

The idea of a network is established on paper but, in practice, the professionals and managers have not been able to make this connection. The other domains of the phenomenon of use, such as macro-social, family and even psychological issues are not fully addressed, which does not favor the user's treatment.

The RAPS also has flaws as to "having a place to stay". Some CAPS users use it as a social support environment, as a place to stay and not just to seek harm reduction due to drugs.

The users are individuals in conditions of social vulnerability, and the other RAPS components, such as shelters and Social Assistance services, either do not exist in the city or do not articulate with the health area: While she (mother) does not take the house, I have to walk from recovery house to house until she gets (mother) the house. So I do not have the guts, I'm a man, but I admit it, I do not dare go under the bridge and sleep on a cardboard. (U9); It is like I said, "If you are doing treatment with medication," I will not take medicines to sleep on the street, because I know the consequences of sleeping on the street, so I have to stay here, you know? There is a much wickedness. So it's no use in they (CAPS professionals) giving me a cardboard this size and I go to the street there. Then, someone comes and sets fire in me." (U15)

The patients are in great social vulnerability due to the use of drugs and lose their social place. And when the RAPS reproduces this same picture, the user has few chances of an effective social reinsertion, needing to resort to alternative networks of care and support.

As said by one of the users about the Alcoholics Anonymous group and the church: I'm going to the AA, Alcoholics Anonymous. I have also attended the evangelical church, doing various activities with them there ... and ... it is, that's it, I'm doing everything I can to stop. (U3); I leave (the CAPS) praying, asking God, I do like this "my God, help me, do not let me drink. Help me from there, give me strength, I have to stop." I talk to God until I get home. It helps me until I get home. (U4); It has been 3 years she (the patient's mother) attends the church. God entered and she does not drink anymore. (U6)

The alternative networks are of great value and should be more articulated with the formal network of treatment, since in order to achieve a comprehensive treatment for the user, one must consider all the dimensions of care. However, in the daily practice of the CAPS, there is no articulation with religion and with religious entities.

 

Discussion

The CAPS is the specific place for the treatment of abusers of alcohol and other drugs, being guided by the strategy of harm reduction (HR), prevention, recovery and social reintegration of the individual. The HR aims to solve problems associated with the use of PAS, in which abstinence is not mandatory and would come in time⁽⁹⁾.

Due to the difficulties of the network and the professionals' own difficulties in understanding and doing HR actions, the CAPS can become a place to stay and "spend time". A study carried out in Campinas, SP, Brazil, corroborates with the present study when reporting that the CAPS a would be used more as a social support than specifically to address the reduction of damages caused by the use of PAS⁽¹⁰⁾.

The lack of communication and time for groups is a reality not only in the CAPS, but throughout the Unified Health System (SUS) due to the large bureaucracy of the service, and the demand to achieve purely quantitative goals of pre-established procedures, causing the health team to become hostage to tables and graphs of goals, failing to respond to the population demands⁽¹¹⁾.

The relationship between health professionals and CAPS users should occur not only in individual appointments, but in groups and workshops. The observations showed that it would be necessary to train the nursing technicians to approach the users, so that the professional/user relationship is not of friendship, solely⁽¹²⁾.

Nursing plays a prominent role because it is in the "front line" of care, and nurses' leadership is linked to their academic training, which encompasses disciplines such as administration, management and others addressing the psychosocial and biological spheres. This enables these professionals to work as important linkers and this capacity is observed when the higher level professionals are the ones that are closest to the users⁽¹²⁾.

The on-site workshops do not occur regularly, as demonstrated, which is a gap in the treatment because the activities promoted in the CAPS are essential, and should be alternatives for leisure and free PAS activities. Workshops, for example, besides containing manual activities, should cover income-generating activities, targeting the patient's potential professional future, a fact that worries patients, as demonstrated⁽¹³⁾.

As for the CAPS articulation, it should be linked to other network devices such as street clinics, public hospital beds and foster homes, and Family Health Strategies⁽¹⁴⁾. But CAPS often acts alone in the treatment of users of alcohol and other drugs, and is guided by referrals to the RAPS⁽⁴⁾. This fact was perceived in the present study in which, in addition to the network gaps, communication does not occur in the network, but in single-track paths, and the patient is alone trying to make a path between existing devices.

The integration of services, besides facilitating access to the user, is also capable of promoting the early recognition of diseases, creating strategies so that the individual has the least possible loss of social, family and physical functions^(3,15).

If the PHC initially recognized and welcomed these users, as well as promoted actions aimed at preventing and promoting mental health, this would reduce health costs, referrals, or even the free demand for CAPS⁽¹⁵⁾.

The World Health Organization advocates that middle-income and low-income countries invest in integrating mental health into primary health care as a form of reducing costs. Countries such as South Africa, Nigeria, and other African countries already plan or have begun to articulate for this integration⁽¹⁶⁾. And developed countries like England and the Netherlands have already implemented this incorporation. The Netherlands has made a major reform in the field of mental health in the year 2012 with the interventions in this area incorporated in Primary Health Care⁽¹⁷⁾.

One of the measures that the Brazilian Ministry of Health took to help the integration of the network, mainly with the PHC was the creation of the Matrix Support; the teams are called Family Health Support Centers (NASF). It constitutes a therapeutic device for case discussions between the teams, more specific care for family and users, in addition to promoting spaces for the community to express themselves and participate in the construction of the health of the territory⁽¹⁷⁾.

In the city, the NASFs are still insufficient, which impairs the exchange between Primary and Secondary Care, as well as the lack of street clinic teams, which are key elements for health promotion and prevention of the street population that, consequently, can make use of alcohol and other drugs⁽⁴⁾. Thus, most of the alcohol and other drug users are cared for by CAPS.

With the difficulties of articulating the RAPS, patients end up looking for alternative networks such as self-help groups, that are places that through group work and the example of other individuals who experience the same situations manage to modify a whole picture. All forms of help are positive when working with PAS users. Having contact with individuals recovered or in the process of recovery is seen as beneficial to the drug users⁽¹⁸⁾.

As for religion, studies corroborate this item by citing it as a coping strategy⁽¹⁸⁾. Religion approaches an offer/response by associating the use of PAS with distancing from God, so when the individual turns to a religion, he/she becomes a member of a new community and reunites with God.

The recovery of a drug user occurs through several components. A religious person may feel an increase in self-esteem through an expansion of their valuation in a religious community, which facilitates their recovery⁽¹⁹⁾. The CAPS, together with the RAPS, must know how to articulate with each other and with the alternative care networks.

Because there is only one CAPS in the city and it has started its activities recently, users and the general population still find it difficult to understand their goals and usefulness in the treatment of alcohol and other drug use. A greater approximation of PHC and strengthening of the other mechanisms of the health network may provide a better understanding of the work done in the place and consequently an improvement of the service.

This study has the limitation of having been carried out in one place, and it did not look for other users of alcohol and drugs who attend other points of the RAPS to know their visions about their treatment paths, which would be of extreme importance when drawing other mistakes and successes of the network. But within that proposed, the present study was able to portray users' view regarding their treatment and understanding of RAPS.

 

Conclusion

This research had the objective to know the PAS user's view and path in the CAPS and in the RAPS. As a qualitative research, it sought to deepen and know the view of the other on the subject in a given reality, so one cannot close the subject or make generalized affirmations. However, based on the presented discussion, this is a reality that approaches other national realities.

The strengthening of RAPS is crucial so that the PAS user can have their rights as a citizen guaranteed. For this purpose, it is necessary to empower the user and this will only be possible from the moment that they play the major role in their treatment. The CAPS is one of the main devices to strengthen the user's participation through social reintegration.

PHC should be the gateway for any citizen, including PAS users. To improve this input and communication between PHC and CAPS, it is necessary that both teams are trained and can understand what their role to the drug user. Universities should have disciplines on mental health within their curricula. These disciplines should be comprehensive and not limited to psychopathologies so that future professionals are able to understand all the dimensions of the phenomenon.

And, finally, neither the CAPS alone nor the PHC can meet these individuals' needs. It is urgent that the street clinics, foster homes and beds in general hospitals are operative and so, in fact, a comprehensive care network is established.

 

Acknowledgments

To the Center for Research, Management, Society and Epidemiology in Nursing and the Health Care Network (GSEERAS) of the Universidade Estadual de Minas Gerais.

 

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Corresponding Author:
Camila Souza de Almeida
E-mail: csalmeida_1@hotmail.com

Received: Oct 22th 2018
Accepted: Jan 30th 2019

 

 

* Supported by Programa Institucional de Apoio à Pesquisa (PAPQ), Universidade Estadual de Minas Gerais, Brazil, grant # 16711655-17.