Epidemiological profile of patients treated at a psychosocial care center ad III

Perfil epidemiológico dos usuários de um centro de atençãopsicossocial ad III

The policies of attention to the user of alcohol and other drugs are based on the reform of psychiatric care in Brazil, which is based on Law 10,216 (Delgado, 2011). Such policies are based on the guarantee of the rights of SUS users and establish as guidelines the universality of access, the right to assistance, integrality, decentralization and territorialization that aim at actions in the psychosocial scope, favoring the autonomy of the subject and the social life (Hirdes, 2009).

The psychosocial practice brought the need to create spaces that would replace the psychiatric hospital. These spaces were guaranteed through strategies such as basic health care, mental health outpatient clinics, Psychosocial Care Centers (CAPS), day hospital, emergency services and psychiatric emergencies, general hospital beds and therapeutic residences (Moraes & Tanaka, 2012). They are based on policies that aim to strengthen humanized care, to build autonomy and the protagonism of the person (Hirdes, 2009).

Psychosocial Care Centers (CAPS) represent a station of the health care network and play a strategic role in articulating, strengthening and ensuring continuity of care. In addition to the regulation of health services, they also fulfill the functions of direct assistance to the user (Moraes, 2008). They direct local policies and Mental Health programs through the development of therapeutic and community projects, the dispensing of medications, referrals and follow-up of users living in therapeutic residences, and also of the articulations carried out in partnership with the Family Health teams by means of the matrix (Hirdes, 2009).

Mental health care is part of the health care network and must be structured in all municipalities to meet the growing demands related to family and social structure. The mental health services of the municipality under study have advanced, through reflections of technicians and service managers on changes of conceptions and paradigms.

These reflections, triggered by public policies in the area of mental health, have allowed to delineate and present a line of mental health care hitherto not established in the public policies of the municipality. These policies encompass actions for prevention, care and resocialization of mental health users (Delgado, 2011). These units represent pilot for services in the state and the Central West region.

Three Psychosocial Care Centers (CAPS) were implemented, two of type III (Ad) with treatment for users of Alcohol and other drugs, in the adult and child mode and a Psychosocial Care Center for children and youth. There was also the migration from CAPS II (Attention to users with mental disorder) to CAPS III that performs care 24 hours. With the encouragement of the Ministry of Health, the Street Clinics project was implemented, which recently integrated the basic care with the name of Street Clinics. This clinic has as objectives to meet demands locally for health and substance abuse disorders and for users with difficult access to traditionally established services (Moraes & Tanaka, 2012). A reception unit (UA) and two child care units (UAI) are in the process of implementation.

The advance in the Psychosocial Care Network (RAPS) of this municipality occurred gradually, as a service was inaugurated and the need for complementary equipment was felt, that is, support services of the mental health care network.

This network was implanted in a paradigm shift movement signaled by public health policies. However, changes do not operate easily and require collective effort, to rethink infrastructure, new ways of caring and to locate the person cared for in this process.

All this movement brought the need to know the profile of the users of this service, especially the users of alcohol and other drugs that have social and vulnerability characteristics that are often unknown. These characteristics should be considered in the context of the planning of health actions and the construction of the singular therapeutic project (PTS).

In this perspective, the question is what is the epidemiological profile of the users treated at a CAPS Ad III? Mapping this profile becomes essential for the construction of care with regard to the construction of public policies in tune with the territorial reality in the management of health services.

Given the above, this study aimed to identify the epidemiological profile of the users served at an Adult Psychosocial Care Center for alcohol and other type III drugs (CAPS Ad III).

This was an epidemiological, descriptive, cross-sectional, retrospective study that covered the period from February 2012 (beginning of the implementation of the reception file) until February 2014. It was conducted at a CAPS Ad III located in the metropolitan region of Goiânia, state of Goiás, Brazil.

The municipality in which the research was developed is conurbated with the state capital. It stands out in the national scenario for violence, social and public health problems and mainly related to the commitment of mental health and the abuse of chemical substances.

It is a municipality that needs advances in the areas of health, safety, leisure and education and considered as a priority among the programs recommended by the Federal Government with needs for social reinclusion, protection and care for the inhabitants. It houses the Penitentiary Center and industrial activities of the state, which determines part of the population, composed of re-learners who serve their sentences in a closed regime, as well as those of the semi-open modality. Situations that lead families to move from a country side way of life, in an unplanned way and with serious social consequences.

The study population consisted of the users of the service, with problems related to the use of alcohol and other drugs. The users served are older than 18 years, as recommended by the Ministry of Health in relation to the population served by a CAPS Ad III (Moraes, 2008).

The study included the users served from February 2012 (beginning of the implementation of the reception file at the service) to February 2014, who had reception files, records and PTS.Users whose files were inactive for not attending the CAPS for more than one year, those who had no records of age or date of birth nor date of the last service were excluded.

Data were collected through a documentary analysis of the reception records from July 1st to August 8th, 2014. Data was recorded in a form previously prepared and discussed with experts (experts of the area) and included socio-demographic characteristics (sex, age, schooling, occupation, monthly family income); health history (family history, previous treatments, unit search); history of drug use and motivational status. It was recorded the motivational status identified in the files, which is filled up by the service, according to the URICA classification (Brazilian adaptation) scale (Del Rio & Oliveira, 2008).

Data collection was performed with the help of pre-qualified research assistants and the data collected was checked daily by the principal researcher with review of the doubts and difficulties encountered.

For data analysis, software SPSS version 1.8 was used. Descriptive analysis was performed by means of absolute and relative frequencies (percentage), means and medians.

The present study was approved by the Ethics Committee of the Pontifical Catholic University of Goiás, with the number 626137 and complied with all ethical aspects as recommended by the Brazilian legislation.

This study included 519 users, as presented in Figure 1.

The sociodemographic characteristics and relevant factors in the reception of users in CAPS Ad III, respectively, are listed in Tables 1 and 2.

Predilection drugs and services before the arrival at CAPS are shown in Tables 3 and 4.

The predominance of male users may be related to the greater exposure of men to risk factors for drug use (Faria & Schneider, 2009) or to the underreporting of female users, questioning where they are and why they do not seek health services. Women who use drugs face several barriers in the search for and adherence to the treatment, whether structural, systemic, social, cultural or personal order (Oliveira, Nascimento, & Paiva, 2007).

Structural barriers refer to ineffective approaches, the location of the service, the costs to access it, rigid programming and admission criteria. The systemic ones are related to the lack of abilities to identify gender in the formulations of the policies, and of programs that respond to the specific needs of the women. Social, cultural, and personal obstacles are associated with socially and culturally predetermined behaviors and roles (Oliveira et al., 2007).

However, there is a challenge for health services to overcome these barriers, once it is shown that women use psychoactive substances, and there is no significant difference in relation to smoking and alcohol abuse for both sexes (Malta et al., 2011).

In this context, the elaboration of PTS must consider the specificities of women who use drugs, considering the importance of basic care in guaranteeing access to services and continuity of care, including in special conditions of life of women, such as pregnancy, maternity and others.

In this study, more than half of drug users are single, as in another research in which Horta points to the difficulties of drug users to remain in a marital relationship (Horta, Horta, Rosset, & Horta, 2011). Nevertheless, health services must recognize that, even using drugs, some people remain married and have their family ties preserved.

Assistance should include care and involvement with the family, recognizing the role as a mediator between workers and users of mental health services (Paula, Jorge, Vasconcelos, & Albuquerque, 2014).

CAPS users have an address known as also presented by Malta et al. (2011). This is an important data for his/her location in the territory and favors the network of care. On the other hand, it draws attention to the difficulty of the population on the street in accessing the health services since, for now, there is no way to register those who do not have proof of address. Another point is the situation of those who are in the service through third-party address proofs and who are not recognized as being on the street.

Most users are at the productive age (between 30 and 59 years), but unemployed, as also observed by another Brazilian study (Vargens, Cruz, & Santos, 2011) or enjoy some social benefit, which explains the low or no income identified. In this age group, it is common for the user to begin to observe the social losses that drug use has brought. The identification of retired users demonstrates a concern about the increase of drug users among the elderly (Abou-Saleh, Katona, & Kumar, 2011). Unemployment and low income may be associated with low schooling. A small proportion of users reached the higher education and only half completed this, which corroborates findings from another study that considers schooling as a protective factor for drug use (Bungay, Johnson, Varcoe, & Boyd, 2010).

There is history of suicide among the family antecedents in the obtained data. Suicide reveals a social suffering that limits the human condition to overcome the challenge in the diverse dimensions of life and the social context. Thus, the attempt or the accomplishment of suicide is greater than the individual and even than of the group, since it is characterized as the fruit of social experience. This entire context cannot go unnoticed by professionals dealing with health, and especially with mental health (Alves & Cadete, 2015). This profile of users should be observed in the elaboration of PTS in the sense of proposing actions to prevent suicide among the components of this group.

The data indicate that the majority of users have already been admitted to a psychiatric hospital, followed by the therapeutic communities. It draws attention to the specificity of a drug user who experienced 47 hospitalizations. This context shows the need for reassessment of drug treatment modalities and an in-depth discussion on the practice of psychosocial care. The model of biopsychosocial care is able to lead the professional to improve the quality of the care in the follow-ups and attendance to the demands based on the singularity of the person (Kessler et al., 2010).

The data presented herein strengthen the discussion that we still live in the culture of healing or salvation. The substitutive services are not accessed by the population that still has the hospital network as reference of care, apparently, with low resolution and historical remnants of classical psychiatry.

The criteria established by the Psychiatric Reform and Mental Health Policy in Brazil pointed to the need to revise models of hospitalization, time and the guarantee of institutional oversight and supervision (Hirdes, 2009). Mental health services must act to develop user autonomy to deal with hihs/her weaknesses. The challenge is the availability of out-of-the-way services, such as outpatient clinics, CAPS and community centers to efficiently perform care based on individual and social context (Ferreira et al., 2015).

The criteria established by the Psychiatric Reform and Mental Health Policy in Brazil pointed to the need to revise the models of hospitalization, time and the guarantee of institutional oversight and supervision (Hirdes, 2009). Mental health services must act to develop user autonomy so that they can deal with their weaknesses. The challenge is the availability of extra-mural services such as outpatient clinics, CAPS and cohabitation centers to efficiently perform care based on the individual's social context (Ferreira, et al., 2015).

It is necessary to reflect on the low demand for basic health units as verified herein, since it should be the gateway and the first service to the user of alcohol and other drugs. This data refers to the difficulties of articulating the network between primary care and specialized attention, the competence of network professionals to care for these people, the lack of knowledge of professionals about the lines of care established in the network and the user’s own culture, in which the resolution is centered on the doctor and the hospital. All these aspects contribute to perpetuating the fragmentation of disease-centered care.

These difficulties lead us to think about the role of nurses in the health care network. Few nurses provide guidance to users of alcohol and other drugs during the nursing consultation, due to difficulties in addressing this issue (Kessler et al., 2010). The primary care nurse has the possibility to know the context in which the individual is inserted, but the nurse also has difficulties to elaborate prevention and promotion strategies related to the use and abuse of alcohol and other drugs (Moraes & Tanaka, 2012).

The difficulties presented by nurses for the management of drug use and abuse are aggravated by observing the results of this study, in which the drug of predilection is alcohol or tobacco with an average of 18 to 19 years of use. Data that confirm the CEBRID study (Carlini et al., 2010), in which the highest dependence is still on alcohol, although crack is a drug of great social and political repercussion.

Moreover, alcohol is the substance that produces the most complications and morbidities and is known to cause most preventable deaths in the world (Carlini et al., 2010). The fact is that we cannot minimize or condemn this or that drug. All of them can bring potential harm and danger that must always be considered, regardless of whether it is a licit or illicit drug.

Among the illicit drugs, crack is mentioned in this study as the drug used by half the users of the service, with a relative time of five years of use. Data from a National Survey reinforce the discussion that Brazil is the country that most consumes crack in the world and in the Central West region, 51 thousand people consume crack (Secretaria Nacional de Políticas sobre Drogas. Pesquisa, 2013)

Although crack is an emerging drug touted by the media and an important factor pointed out in this study, it should not be forgotten that alcohol is admittedly the gateway to the use of other drugs (Paula et al., 2014). To this end, the nurse inserted in this context must pay attention to this reality, directing his/her care to actions to prevent the use and abuse of alcohol and to welcome actions for drug users.

This reception should consider that the search for the service has different reasons. It is observed, in this study, that the majority of users report having arrived at the service voluntarily and a small portion, by lawsuit. Nonetheless, attention is drawn to the fact that the service is a reference care to the re-learners of the prison agency. This voluntariness needs to be re-evaluated, since some of the demands found as spontaneous may actually be the result of judicial guidance rather than court order.

It makes necessary to understand that the motivational status of the user inserted in the service influences significantly in the therapeutic conduct. The user transits between the stages of relapse, precontemplation, contemplation, preparation for change, action and maintenance (Prochaska & Diclemente, 1982).

In this sense, most of the users in this study reach the CAPS in the contemplation period, when they begin to make connections between their addictive behavior and the problems related to it, andit is often at this stage that the search for treatment occurs. However, at this stage there is still an ambivalence (Prochaska & Diclemente, 1982), hence the importance of having a perceptive and welcoming staff to assist in this transition that can evolve into the preparation phase for action or retroaction. From this perspective, a networkstructured service with the development of PTS, real and feasible, can contribute to a multiple therapy, articulated with social equipments.

In the elaboration of a singular therapeutic project, nursing plays a key role, which begins with an attentive and welcoming listening that directs to the individualized care plan. However, it is recognized that advances beyond medication treatment are necessary, establishing care centered on the person, on the reception, the therapeutic communication and the various individual and group activities (Guimarães, Borba, Maftum, Larocca, & Nimtz, 2015).

Identifying the profile of the users of a specialized service regarding the abuse of alcohol and other drugs was of primary importance for the team to recognize the variables involved and their implications in the elaboration of PTS, which should necessarily take into account also the socio-cultural conditions of these users.

The high index of hospitalizations in the psychiatric hospital and the low demand for the Basic Health Unit demonstrate the urgent need to strengthen the Basic Attention Network as a component of the Psychosocial Care Network (RAPS). But there is the challenge of articulating the services of the network to meet the complexity of drug user care and the appropriation, by nursing staff, of the potential devices of basic care for the joint planning of care actions.

Although national policies are focused on the prevention and treatment of crack users, the fact that alcohol is the drug of choice for this population shows the importance of turning care to the user of this licit drug, once it represents the gateway for other drugs.

The limitations of the study are related to the size of the sample due to the characteristics of the studied population and the lack of records in the documents analyzed. However, the results contribute to a reflection on the needs of attention to alcohol users and the strengthening of the Basic Attention Network to overcome difficulties in receiving this user.