Abstract

Brazilian public policy on drugs has been permeated by two diametrically opposing approaches: one focusing on prohibition and the other on non- prohibition. Similarly, there have been two opposing approaches to mental healthcare, one centered on hospitalization and the other psychosocial care and development. In the context of these different paradigms, this article presents an analysis of twenty-two documents sourced by the legislative rules over the last sixteen years. After the year 2000, a renewed focus by healthcare community on drugs was noticeable as was the immersion of a harm reducing approach. Following international trends, although there are still considerable divergencies between (a) psychosocial care and(b) residential care in the therapeutic communities there seems to be an alignment to anti- prohibition approaches.

Harm reduction; Public policies; Alcohol and other drugs; Inter-sector cooperation and coordination

Introduction

Abusive use of drugs (‘drug abuse’) is a multi-factorial problem in public health involving biological, psychological, social and cultural dimensions, and a challenge for implementation of integrated and wide-ranging policies. It is significant worldwide: it is estimated that 246 million people in the world use psychoactive substances – or a proportion of 5.2% in 2013¹1. United Nations Office on Drugs and Crime (UNODC). World Drug Report [Internet]. Nova York: United Nations; 2015. [cited 2016 Jul 27]. Available from: http://www.unodc.org/documents/wdr2015/World_Drug_Report_2015.pdf
http://www.unodc.org/documents/wdr2015/W... . In the formation of public policies about drugs, there are tensions in various areas. In the area of law, the Courts and public safety, there are two paradigms – in favor of prohibition, and against prohibition – in dispute with each other. In the field of health and social work, there are three approaches in dealing with mental health in relation to alcohol and other drugs²2. Amarante P. Saúde Mental e Atenção Psicossocial. 20ª edição. Rio de Janeiro: Fiocruz; 2007.: the hospital-admission approach, the psychosocial care approach, and ‘harm reduction’. The prohibition approach – the ‘War on Drugs’ – aims chiefly to combat drug trading, and to criminalize users and traffickers, aiming for a world free of drugs. It is associated with the anti-drug discourse, it is the result of various international treaties in which the commitment is to prevention of consumption, repression of production and repression of supply. The ‘anti-prohibition’ approach, on the other hand, places de-criminalization, and legalization of drugs, at the center of the debate; it takes the view that the use of drugs should not be considered to be a crime and that people who make abusive use of drugs should be offered treatment and care, and not confinement to a prison environment³3. Bottini PC. Crime de porte de drogas para uso próprio e o Supremo Tribunal Federal. Rio de Janeiro: Viva Rio; 2015..

In the health sector, the basic characteristic of the ‘hospitalization’ approach is the emphasis on the organic nature of the disorder, with a central belief in medication as a tool for the cure. In his treatment, the individual has a passive position; and is considered to be ill, thus justifying isolation from his/her wider family and social environment. The typical institution of this paradigm is the psychiatric hospital, which has only hospitalization as a model.

In the ‘psychosocial’ model, the way that practices have developed arises from social movements, and various fields of theory. The considerations of this model, at an initial moment, on psychosis in particular and on other forms of suffering, such as those associated with abuse of drugs, strongly feature considerations that go beyond the notion of illness. For this reason the resources used in the care also need to go beyond medication. For context, we take as a starting point a phenomenon based on the phenomenology of Husserl, cited by Basaglia⁴4. Basaglia F. Corpo e instituição - considerações antropológicas e psicopatológicas em Psiquiatria institucional. In: Amarante P, organizador. Escritos selecionados em Saúde Mental e Reforma Psiquiátrica. Rio de Janeiro: Garamond; 2006. p. 73-90., which is the proposal to place the illness ‘in parenthesis’, to examine the process of becoming ill together with as its economic, social and political determining factors. Healthcare is given within the point of view of territorialized Care Networks; and integrality is taken into account as a factor, both in relation to the environment and in relation to the act of therapy with the individual, in which its effects do not aim to suppress the symptoms, nor necessarily achieve abstinence, but rather to reduce risks and harm. This model of care is centered on respect for differences, defense of life and of the right to liberty, and the dignity of the person, and its objective is social inclusion and re-insertion; drug addiction or dependence is seen as a result of the meeting of a person with a drug in a given social-cultural moment, within a triad of factors: the individual, the drug, and the context⁵5. Zinberg NE. Drug, set and setting. New Haven: Yale University; 1984.. Its principles are: de-institutionalization; liberty; autonomy; and citizenship – with interdisciplinary and inter-sectoriality as wider clinical practices⁶6. Bokany V. Drogas no Brasil: entre a saúde e a justiça: proximidades e opiniões. São Paulo: Fundação Perseu Abramo; 2015..

References of this sort are the orienting guidelines for disputes in the fields of health, social care, public safety, and justice. They can be reflected in three models/approaches to the users of drugs – according to Marlatt⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999.:

1. In the ‘moral/criminal’ model, the use of certain drugs is defined as unlawful, and for this reason subject to punishment. This remits to prohibitionist policies, and reduction of supply, within the moral concept of pleasure associated with sin, and the individual not being capable of discerning between right and wrong, thus able to be submitted to measures that suspend individual rights. Here an association is made between Justice and Health, through practices such as Therapeutic Justice, and compulsory hospitalizations ordered by Judges, which are provided for in a Health Law, such as Law 10216⁸8. Brasil. Lei no 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 9 abr., which underwent innumerable modifications from Draft Law no. 3657-B, in the lower house of the Brazilian Congress (Chamber of Deputies), of 1989. For this model the sole target is absolute abstinence.

2. The ‘disease’ model⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999. sees dependence on drugs as a biological illness that merits treatment and rehabilitation. The focus is on the individual, and remits to an approach of reduction of demand: its devices would include the experiences of Alcoholics Anonymous, Narcotics Anonymous and the Minnesota Model. Such approaches do not concern themselves with a world free of drugs, because they start from the principle that only some individuals develop dependency. However, this approach can fall into a risk of association with the 1moral’ model, when the idea of incapacity to exercise reason to the detriment of pleasure is related to the subject of the condition. The only acceptable target when starting from this conception is total abstinence – indeed, total abstinence is also a condition for the treatment – because the individual needs to accept that s/he has an incurable disease, which is progressive and fatal, and for this reason cannot be in contact with the substance to which s/he is regarded as being allergic⁹9. Ramôa M. A desinstitucionalização da Clínica na Reforma Psiquiátrica: um estudo sobre o projeto CAPSad [tese]. Rio de Janeiro: PUC; 2005..

3. The ‘harm reduction’ model is understood as a strategy orienting care, in the ethical, clinical and political paradigm¹⁰10. Brasil. Ministério da Saúde (MS). Portaria no 1.028, de 1 de julho de 2005. Determina que as ações que visam à redução de danos sociais e à saúde, decorrentes do uso de produtos, substâncias ou drogas que causem dependência, sejam reguladas por esta Portaria. Diário Oficial da União 2005; 2 jul.^,1111. Brasil. Ministério da Saude (MS). Portaria no 2.197, de 14 de outubro de 2004. Redefine e amplia a atenção integral para usuários de álcool e outras drogas, no âmbito do Sistema Único de Saúde - SUS, e dá outras providências. Diário Oficial da União 2004; 15 nov.. According to Marlatt⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999., harm reduction starts from the philosophical premises of Pragmatism and Human Rights; it breaks with the idea that the use of drugs is abusive, and affirms that it maybe prejudicial, or not. It becomes, also, a strategy for people who do not wish, or do not manage, to reduce or cease use of drugs, and also for the other users that have difficulty accessing health services, or achieving integrated healthcare. One of its principles is respect for the autonomy of the subjects, as part of the point of view of an amplified healthcare which opposes the practices of putting users into hospices or compulsory hospitalization. Marlatt⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999. points to harm reduction as an alternative approach in public health to the moral/criminal model, and the disease model, which are sustained on different principles and assumptions than those of the harm reduction approach.

The first and second of the above models are in tune with the ‘prohibitionist’ paradigm; the third is related to the ‘anti-prohibitionist’ paradigm. A certain approximation is perceived between the public policy models presented by Marlatt ⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999. and the hospitalization and psychosocial paradigms. The multiple aspects of these latter two approaches have been discussed by authors focusing on the Psychiatric Reform. A choice between the two has the potential to keep policies based either (a) on a logic that imprisons, represses and isolates the drug-using subject within a model based on the idea of exclusion as a form of treatment, and supposedly, care, or (b) on another model that is sustained on the relationship between drugs and the context, and proposes an abandonment of stigmas – the model of harm reduction and psychosocial care.

Public policies in Brazil have shown themselves to be little integrated, and with barriers to access, accentuating the inequalities for people who practice drug abuse and who are in a state of extreme social vulnerability. On the other hand, there has been increasing, and promising, acceptance, in the field of drug-user healthcare in Brazil, of a widening and a reorientation of public policies that give priority to access and treatment in the context of a humanized and inter-sectorial healthcare network, with practices oriented by values and principles of participation, inter-sectoriality, and equity, grounded on the Brazilian Health System (SUS) and on the international health promotion movement¹²12. Albuquerque TIP, Sá RMPF, Araújo Júnior JLAC. Perspectivas e desafios da Política Nacional de Promoção da Saúde: para qual arena política aponta a gestão? Cien Saude Colet 2016; 21(6):1695-706.. The aim of this paper is to analyze the models and approaches that have permeated the development of public policies on drugs in Brazil in the sphere of the federal Executive in the 21^st century, in the light of the existing paradigms.

Methodology

This is a documentary survey, in which the source of data is the group of all policies, decrees and other legislative rules published over the period 2000-16. This period was chosen because the present century has highlighted the subject of drugs in various sectors of government and society, with changes in the configuration of policies and public players involved, and increasing conflicts between them, and because there is a vast area of publication in this area in Brazil to be explored. Adoption of a documentary survey makes it possible to add the dimension of time to an understanding of the social dimension over the course of various cycles of variation in policies in this period¹³13. Cellard A. A Análise Documental. In: Poupart J, Deslauriers JP, Groulx LH, Laperrière A, Mayer R, Pires AP, organizadores. A pesquisa qualitativa: enfoques epistemológicos e metodologicos. 2ª ed. Petrópolis: Vozes; 2010. p. 295-316.. Thus, the intention was to become aware of, characterize, analyze and propose summary concepts about the documents written and published by various instances of the federal Executive, relating to the policies on drugs in Brazil. Electronic searches were made by the authors to identify the legislation and rules in question, using the SAUDE LEGIS and SENAD databases¹⁴14. Saúde Legis. Sistema de Legislação da Saúde. [acessado 2016 Jul 27]. Disponível em: http://portal2.saude.gov.br/saudelegis/LEG_NORMA_PESQ_CONSULTA.CFM
http://portal2.saude.gov.br/saudelegis/L... .

Documents were authorized by year of publication (a time dimension), and the government protagonist sectors involved (players), and their relationship with the subject of drugs. Documents that were not converted into ministerial orders, laws or decrees were excluded. Identification of types of model according to Marlatt⁷7. Marllatt GA. Redução de danos: estratégias para lidar com comportamentos de alto risco. Porto Alegre: Artmed; 1999. was used to create analytical categories, with their respective influences on the organization of the health services (Chart 1). Also analyzed was the point of view of inter-sectoriality, an important category when the complexity of the approach to drug abuse is considered, along with a wider understanding of health and its determining factors, dilemmas that require systemic and integrated approaches between the sectors. The items of legislation were also divided by a dimension of inter-sectoriality, classified into three levels: non-existence; incipient; and robust (Chart 2).

Results

Of the total of 22 documents identified as concerning the theme, 18, which met the criteria for eligibility, were selected for this analysis. These were distributed over the period in the study, but there was an increase in their number as from 2009 (Chart 1). The sectors of government involved were the Health Ministry, the Office of the President of the Republic, the Institutional Security Cabinet (National Drugs Secretariat – SENAD); the National Council on Drugs – CONAD; the President of the Republic’s Private Administrative Office (the Casa Civil); and the Justice Ministry (SENAD). Of these documents, the largest number, and the majority (n=10), were issued by the Health Ministry, 7 by the Office of the President of the Republic, and 1 by the Justice Ministry.

On the classification of models/approaches by type, there was a predominance of the Harm Reduction model and/or the psychosocial care/anti-prohibition model, with 8 documents of this type; followed by the illness/hospitalization model, with 6 documents. Only two documents were identified with the moral/criminal/prohibition model (in the years 2002 and 2006), and there were 2 items comprising, in our assessment, more than one type of model – showing even more the dispute between models.

Looking at the beginning of the period, Law 10216⁸8. Brasil. Lei no 10.216, de 6 de abril de 2001. Dispõe sobre a proteção e os direitos das pessoas portadoras de transtornos mentais e redireciona o modelo assistencial em saúde mental. Diário Oficial da União 2001; 9 abr. provided the framework expressing the Psychiatric Reform, legislating a new model for mental health care (psychosocial), with territorially-based services with open doors, replacing the psychiatric asylums. This law, although it did not specifically deal with the subject of drugs, defined three types of admission to a hospital or institution: 1) voluntary, at the patient’s request; 2) involuntary – requested by a third party; or 3) compulsory – “ordered by the Judiciary”. It was only in 2003 that the subject of drugs – the danger of their misuse – made a more tangible appearance on the health agenda, with the publication by the Health Ministry, of the Policy for Integrated Care for Users of Alcohol and Other Drugs (Política para atenção integral aos usuários de álcool e outras drogas). This took the form of a law in the following year (Ministerial Order 2197¹¹11. Brasil. Ministério da Saude (MS). Portaria no 2.197, de 14 de outubro de 2004. Redefine e amplia a atenção integral para usuários de álcool e outras drogas, no âmbito do Sistema Único de Saúde - SUS, e dá outras providências. Diário Oficial da União 2004; 15 nov.), supporting the use of psychosocial care by avoiding hospitalization of users of alcohol and other drugs in psychiatric hospitals, and recognizing drug abuse as a serious public health problem, and presenting harm reduction as a priority intervention strategy, a model which was increasingly strengthened in the following years. In 2005, actions based on Harm Reduction were regulated by Health Ministry Ministerial Order 1028¹⁰10. Brasil. Ministério da Saúde (MS). Portaria no 1.028, de 1 de julho de 2005. Determina que as ações que visam à redução de danos sociais e à saúde, decorrentes do uso de produtos, substâncias ou drogas que causem dependência, sejam reguladas por esta Portaria. Diário Oficial da União 2005; 2 jul., taking a bet on a model of care aiming to minimize the adverse consequences of drug abuse for the individual and society, and reducing the associated risks without, necessarily, interfering in the supply or consumption of drugs.

Convergent with the trend seen in Health, in the same period other sectors underwent changes in the approach to drugs, moving in the direction of anti-prohibition. This was expressed in the realignment of the title of government policies and sectors in the area: there was a change from the National ‘Anti-drugs’ Policy (Política Nacional ‘Anti drogas’ – 2002) to the National Policy on Drugs (Política Nacional sobre Drogas – 2005¹⁵15. Brasil. Resolução no 3/GSIPR/CH/CONAD, de 27 de outubro de 2005. Aprova a Política Nacional sobre Drogas. Diário Oficial da União 2005; 28 out.); and with the National ‘Antidrug’ Department (Secretaria Nacional ‘Antidrogas’ – SENAD) and the National ‘Antidrugs’ Policy (Política Nacional ‘Antidrogas’ – PNAD), giving way, with the ‘anti’ changed to ‘on’, to the construction of a new identity in the approach to drugs, and a movement which was consolidated in the National Council for Policies on Drugs (Conselho Nacional de PolíticassobreDrogas – CONAD). A first result of this change can be seen in 2006, with Law 11343¹⁶16. Brasil. Presidência da República. Lei no 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas – SISNAD, prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. Diário Oficial da União 2006; 24 ago., which abolished the penalty of imprisonment for possession of unlawful substances for personal use, emphasizing actions of prevention, treatment and social re-inclusion – although it maintained the prohibition on use, with sanctions distinguishing a user from a dealer. However, this law left a gap in the form of non-specification of precise parameters of differentiation, including between user and dealer, opening loopholes for interpretations as to the type of user, which in practice increased the volume of imprisonments for possession of drugs³3. Bottini PC. Crime de porte de drogas para uso próprio e o Supremo Tribunal Federal. Rio de Janeiro: Viva Rio; 2015..

The National Policy on Alcohol (Política Nacional sobre o Álcool – 2007)¹⁷17. Brasil. Decreto no 6.117, de 22 de maio de 2007. Aprova a Política Nacional sobre o Álcool, dispõe sobre as medidas para redução do uso indevido de álcool e sua associação com a violência e criminalidade, e dá outras providências. Diário Oficial da União 2007; 23 maio., although focused, presented an innovative formulation in the integrality of actions to reduce social damage, damage to health and damage to life, associated with the consumption of this substance, and also the situations of violence and criminality associated with the abuse of alcohol, in an inter-sector approach. Amplifying the scope of healthcare to people practicing drug abuse, in 2010, the Health Ministry recognized the gap in care and launched the Emergency Plan for Widening of Access to Treatment and Prevention in Alcohol and Other Drugs (Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e Outras Drogas – PEAD) in the SUS¹⁸18. Brasil. Ministério da Saude (MS). Portaria no 1.190, de 4 de junho de 2009. Institui o Plano Emergencial de Ampliação do Acesso ao Tratamento e Prevenção em Álcool e outras Drogas no Sistema Único de Saúde - SUS (PEAD 2009-2010) e define suas diretrizes gerais, ações e metas. Diário Oficial da União 2009; 5 jun., in a cross-sector perspective with various lines of intervention.

It should be noted that expansion of the Harm Reduction model in healthcare was incorporated in the National Basic Healthcare Policy (Política Nacional de Atenção Básica)¹⁹19. Brasil. Ministério da Saúde (MS). Portaria no 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da atenção básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Diário Oficial da União 2011; 24 out. (reviewed in 2011), by recommending this strategy in primary care, and instituting a new modality of family health team, which we can call the ‘Clinics in the Street’ (Consultórios na Rua), to provide care, literally, to people living in the street, and drug users. As a capillary aspect of this model in other sectors, in 2016 the Social Development and Hunger Combat Ministry (Ministério do Desenvolvimento Social e Combate à Fome), in collaboration with the Justice Ministry/SENAD, launched the Technical Orientations Manual of the SUAS²⁰20. Brasil. Ministério do Desenvolvimento Social e Combate à Fome. Secretaria Nacional de Assistência Social. Caderno de Orientações Técnicas: Atendimento no SUAS às famílias e aos indivíduos em situação de vulnerabilidade e risco pessoal e social por violação de direitos associada ao consumo de álcool e outras drogas. Brasília: Ministério do Desenvolvimento Social e Combate à Fome; 2016. in the field of Harm Reduction, in which it recognized the multi-causal nature of consumption of drugs, the serious consequences in the lives of people and their families, the vulnerabilities associated with the use of crack, and the need for territorialized integration in Networks (Healthcare and Social Work).

Paradoxically – in relation to the strengthening of the Harm Reduction model and of psychosocial care – at the end of the 2000 decade rules were passed which reinforced the model centered on illness, especially through the Therapeutic Communities (CTs) – evidence the continuing existence of controversy and disputes. In 2009, Law no. 12101²¹21. Brasil. Lei nº 12.101, de 27 de novembro de 2009. Dispõe sobre a certificação das entidades beneficentes de assistência social; regula os procedimentos de isenção de contribuições para a seguridade social; altera a Lei no 8.742, de 7 de dezembro de 1993; revoga dispositivos das Leis nos 8.212, de 24 de julho de 1991, 9.429, de 26 de dezembro de 1996, 9.732, de 11 de dezembro de 1998, 10.684, de 30 de maio de 2003, e da Medida Provisória no 2.187-13, de 24 de agosto de 2001; e dá outras providências. Diário Oficial da União 2009; 30 nov. certified Charitable Social Care Entities, including the CTs. In 2011, Anvisa [the health oversight authority] presented its Board Resolution (RDC) 29²²22. Anvisa. RDC 29, de 30 de junho de 2011. Dispõe sobre os requisitos de segurança sanitária para o funcionamento de instituições que prestem serviços de atenção a pessoas com transtornos decorrentes do uso, abuso ou dependência de substâncias psicoativa. Diário Oficial da União 2011; 1 jul., which defined the health safety requirements for functioning of institutions that provide care services to people with disorders arising from use or abuse of, or dependence on, psychoactive substances – under a residential regime, but did not denominate them as CTs. Also in 2011, the Health Ministry instituted the Psychosocial Care Network for people undergoing suffering, mental disorders or needs associated with the use of crack, alcohol and other drugs (RAPS) (Ministerial Order 3088)²³23. Brasil. Ministério da Saude (MS). Portaria no 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde. Diário Oficial da União 2011; 24 dez., including the CT as one of the items of this network. In 2012, the Health Ministry itself instituted an effort to regulate the CTs in the mold of the Receiving Units, issuing Ministerial Order 131²⁴24. Brasil. Ministério da Saude (MS). Portaria 131, de 26 de janeiro de 2012. Institui incentivo financeiro de custeio destinado aos Estados, Municípios e ao Distrito Federal para apoio ao custeio de Serviços de Atenção em Regime Residencial, incluídas as Comunidades Terapêuticas, voltados para pessoas com necessidades decorrentes do uso de álcool, crack e outras drogas, no âmbito da Rede de Atenção Psicossocial. Diário Oficial da União 2012; 27 jan. which stated criteria for registry of the CTs in the ambit of the RAPS. One of these was compliance with the religious orientation of the resident. In 2013, a Health Ministry Technical Note²⁵25. Agência Nacional de Vigilância Sanitária (Anvisa). Nota técnica no 055/2013 - GRECS/GGTES/ANVISA. Esclarecimentos sobre artigos da RDC Anvisa no 29/2011 e sua aplicabilidade nas instituições conhecidas como Comunidades Terapêuticas e entidades afins. Brasília: Anvisa; 2013. provided clarification on RDC 29 and its applicability in the CTs, presenting them as non-governmental institutions, of civil society, for care gaps in the SUS. In this political tension, the CTs began to be financed by SENAD, through the Justice Ministry, in 2014²⁶26. Brasil. Portaria nº 10, de 28 de fevereiro de 2014. Acrescenta modelo de relatório de fiscalização de comunidades terapêuticas como anexo à Portaria nº 70, de 18 de outubro de 2013. Diário Oficial da União 2014; 7 mar.. In 2015, CONAD Resolution No. 1 of 2015²⁷27. Brasil. Resolução no 1/CONAD, de 19 de agosto de 2015. Regulamenta, no âmbito do Sistema Nacional de Políticas Públicas sobre Drogas - Sisnad, as entidades que realizam o acolhimento de pessoas, em caráter voluntário, com problemas associados ao uso nocivo ou dependência de substância psicoativa, caracterizadas como comunidades terapêuticas. Diário Oficial da União 2015; 20 ago. regulated, in the ambit of the Sisnad, the entities that carried out (voluntary) collection of people with problems associated with drug abuse, and these were, now, characterized as CTs. These were not to be health establishments as such, but entities of interest and support for public policies in care, treatment, protection, promotion and social re-inclusion – thus being connected to the Justice Ministry, and supervised and inspected by SENAD. However, in 2016, in a statement that negated that link, responsibility for the CTs was returned to Health, with Health Ministry procedures creating rules for certification of charitable social work entitles in the area of health – CEBAS (Ministerial Order 834)²⁸28. Brasil. Ministério da Saúde (MS). Portaria 834, de 26 de abril de 2016. Redefine os procedimentos relativos à certificação das entidades beneficentes de assistência social na área de saúde. Diário Oficial da União 2016; 27 abr.. This Order laid down that the institutions recognized in the legislation, with care services in a residential and transitory regime (including the CTs) that provide services for the SUS, may be certified, provided they are qualified as health entities and with provision of services proven by a statement by the manager of the SUS. However, a duality was established in terms of financing of the CTs, which was able to be done by either the SENAD of the Justice Ministry or the Health Ministry.

In relation to the specific policies for crack, these became more evident as from 2010, coinciding with the profusion of media reports on the supposed epidemic of crack. Within the outlook of integrated interventions between sectors, in 2010 the Integrated Plan for Dealing with Crack and Other Drugs (Plano Integrado de Enfrentamento ao Crack e outras Drogas)²⁹29. Brasil. Decreto no 7.637, de 8 de dezembro de 2011. Plano Integrado de Enfrentamento ao Crack e outras Drogas. Diário Oficial da União 2011; 9 dez. was launched. This created the It’s Possible to Beat Crack Program (Programa Crack é Possível Vencer) in 2011, which had substantial financial investment and actions that directly involved the policies on health, social work, public safety and education, bringing with it, as a directive, integration of the actions of the various sectors – care, authority and education.

This paper explores the inter-sector characteristics of the documents with the division of categories used in Chart 2. This showed that the majority of the documents (a total of 8) dealt with inter-sectoriality in a way that was still incipient; a further 6 involved the concept in a robust manner; and in only 3 there was no approach at all to the concept (the category ‘non-existent’) – and, thus, that this is an important dimension for analysis of public policies.

This categorization is important not only for the possibility of expanding inter-sector alliances in the development of projects and draft legislation, but also for an understanding of the competencies that are necessary for implementing actions, dealing with political and personal disputes for spaces of power, new competencies and skills for working with new bodies of information and practices, and a cross-sectional reading on the problems underlying a policy¹²12. Albuquerque TIP, Sá RMPF, Araújo Júnior JLAC. Perspectivas e desafios da Política Nacional de Promoção da Saúde: para qual arena política aponta a gestão? Cien Saude Colet 2016; 21(6):1695-706.. According to Buss and Carvalho³⁰30. Buss PM, Carvalho AI. Desenvolvimento da promoção da saúde no Brasil nos últimos vinte anos (1988-2008). Cien Saude Colet 2009; 14(6):2305-2316., inter-sectoriality cannot be restricted to mere rhetorical intentions, nor to fragile accords, and should be systematized in “concrete projects directed to concrete populations (...) submitted to procedures of evaluation that make it possible to scale their impacts on health and on the quality of life”.

It should be highlighted that in 2002, the National Antidrugs Policy³¹31. Brasil. Decreto no 4.345, de 26 de agosto de 2002. Institui a Política Nacional Antidrogas (PNAD). Diário Oficial da União 2002; 27 ago. presented, although only in an incipient fashion, a widened perspective involving both health and social work. In 2005, with the realignment of the policy, inter-sector integration became more robust. With the National Policy on Alcohol¹⁷17. Brasil. Decreto no 6.117, de 22 de maio de 2007. Aprova a Política Nacional sobre o Álcool, dispõe sobre as medidas para redução do uso indevido de álcool e sua associação com a violência e criminalidade, e dá outras providências. Diário Oficial da União 2007; 23 maio., in 2007, the inter-sectoriality and integrated nature of actions being taken became more visible; and in 2011, the It’s Possible to Beat Crack program actually required an intersectorial treatment, by proposing integrated work through inter-sector Committees.

Discussion

Formulation of public policies in Brazil on the subject of drugs in the period studied did not experience a linear progressive tendency in the direction of the Harm Reduction / psychosocial model, although that had predominated in the provisions of law that were passed. There is an alternation between (a) the approach that emphasizes public safety and justice, reaffirming the ‘War on Drugs’ paradigm, and (b) the approach to drugs as a public health problem³²32. Medina MG, Nery Filho A, Von Flach PM. Políticas de Prevenção e Cuidado ao Uusário de Substâncias Psicoativas (SPA). In: Paim JS, Almeida-Filho N, organizadores. Saúde Coletiva: Teoria e Prática. Rio de Janeiro: MedBook; 2014. p. 479-500.. However, in all these sectors the Harm Reduction model has been gaining the principal protagonist role, as from 2005, with the realignment of the National Policy on Drugs³³33. Brasil. Ministério da Justiça (MJ). Secretaria Nacional sobre Drogas (SENAD). Legislação e Políticas Públicas sobre Drogas. Brasilia: MJ; 2010..

The use of Harm Reduction practices as an important strategy for health, and the psychosocial care model, has, in contrast to the disease model, benefited people who use drugs, their families and the community because these are interventions that are based on a strong commitment to public health and human rights³⁴34. Internacional de Redução de Danos (IHRA). “Briefing: O que é Redução de Danos? Uma posição oficial da Associação Internacional de Redução de Danos (IHRA)” [Internet]. Londres; 2010. [cited 2016 Jul 27]. Available from: www.ihra.net
www.ihra.net... , the main focus of which is its actions, and the supply of integral care, reducing the harm that attaches to the use of drugs, and preventing those that have not yet taken route, without necessarily interfering in the use of drugs. Harm Reduction, thus, becomes a strategy orienting care; and an ethical, clinical and political paradigm showing itself to be more problem-solving for the users of crack and other drugs. This therapy is considered to be ‘low-demand’ because it does not demand abstinence as an obligatory requirement. Abstinence is not denied, it merely does not enter the picture as the sole alternative for treatment for harmful use of drugs⁹9. Ramôa M. A desinstitucionalização da Clínica na Reforma Psiquiátrica: um estudo sobre o projeto CAPSad [tese]. Rio de Janeiro: PUC; 2005..

Tensions that appear in this analysis focus on the disease model used by the CTs for drug-dependent subjects. This model tries to break with the conception of failure of character which was until then attributed to people dependent on alcohol, based on the concept of disease, since in the society of the 18^th century behaviors classified as addictions or vice were considered signs of weakness and moral failure⁹9. Ramôa M. A desinstitucionalização da Clínica na Reforma Psiquiátrica: um estudo sobre o projeto CAPSad [tese]. Rio de Janeiro: PUC; 2005.. The report of the Federal Psychology Council’s 4^th National Inspection of Human Rights (Relatório da 4ª Inspeção Nacional de Direitos Humanos do Conselho Federal de Psicologia – CFP)³⁵35. Conselho Federal de Psicologia. Relatório da 4a Inspeção Nacional de Direitos Humanos: locais de internação para usuários de drogas. [Internet]. Brasilia: CFP; 2011. [cited 2016 Jul 27]. Available from: Disponível em http://site.cfp.org.br/wp-content/uploads/2012/03/2a_Edixo_relatorio_inspecao_VERSxO_FINAL.pdf
http://site.cfp.org.br/wp-content/upload... presented a positioning contrary to the practices implemented by these entities, due to identification of various violations of human rights. Based on the Health Ministry document “Mental Health in Data, 12” (Saúde Mental em Dados 12)³⁶36. Brasil. Ministério da Saude (MS). Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Coordenação Geral de Saúde Mental, Álcool e Outras Drogas. Saúde Mental em Dados. Brasília: MS; 2015., and the Census of Therapeutic Communities (Censo de Comunidades Terapêuticas)³⁷37. Universidade Federal do Rio Grande do Sul (UFRGS). Centro de Ecologia. Censo das Comunidades Terapêuticas, 2011. - Pesquisa Google [Internet]. 2011. [cited 2016 Jul 27]. Available from: https://www.google.com.br/search?q=SENAD%2C+CPDA%2FHCPA%2FLABGEO%2FUFRGS+%E2%80%93+Censo+das+Comunidades+Terap%C3%AAuticas%2C+2011.&ie=utf-8&oe=utf-8&client=firefox-b-ab&gfe_rd=cr&ei=awqZV7zWOO2p8wemyK64Bw#q=Censo+das+Comunidades+Terap%C3%AAuticas%2C+2011.
https://www.google.com.br/search?q=SENAD... , it was seen that the community base structures such as the Psychosocial Care Centers for Drug Abuse (CAPS-AD) received less investment than the CTs. In 2011 there were 277 CAPS-ADs compared to 1,179 CTs.

In the legal field, even after Law 11343¹⁶16. Brasil. Presidência da República. Lei no 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas – SISNAD, prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. Diário Oficial da União 2006; 24 ago., which supposedly made a distinction between drug users and dealers, there was no de-criminalization nor de-penalization of any drug: possession for use continued to be a crime, though this law no longer specified imprisonment, but rather alternative penalties (warning about the effects of drugs; community service; and education measures such as attending an educational course)³⁸38. Brasil. Ministério da Justiça. Atuação policial na proteção dos direitos humanos de pessoas em situação de vulnerabilidade: cartilha [Internet]. 2013 [cited 2016 Jul 25]. Available from: https://www.justica.gov.br/central-de-conteudo/seguranca-publica/cartilhas/a_cartilha_policial_2013.pdf
https://www.justica.gov.br/central-de-co... . In spite of this law, there was an increase in the rate of imprisonment for possession of drugs in the country. Data from InfoPen (2013) reported 574,027 people in prison, of which 146,276 due to dealing in drugs, related to Article 33 of Law no. 11343¹⁶16. Brasil. Presidência da República. Lei no 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas – SISNAD, prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. Diário Oficial da União 2006; 24 ago., with an increase of approximately 317.9%, from 74 to 300.96%³⁹39. Conectas. Mapa das Prisões. [Internet]. Conectas; 2014. [cited 2016 Jun 28]. Available from: Disponível em http://www.conectas.org/pt/noticia/25378-mapa-das-prisoes#.
http://www.conectas.org/pt/noticia/25378... .

In this paper we discuss the process of creation of laws as imposed by the policies on drugs in Brazil, in the context of the SUS. The gradual growth, in the policy, in the direction of community-based psychosocial care, protection of the individual rights of users, and a multi-disciplinary and intersectorial approach, stands out clearly. In this paper it is not the decision process that is analyzed, but the outlines of the tendencies that were in progress in the debate, and the conflict of ideas.

However, it can be emphasized that various theoretical traditions seek to analyze decision-making process in public policies. Several areas of action are important, in particular the actions of government specialists, teaching and research institutions, and groups that defend vulnerable sectors of society, as in the case of advocacy coalition frameworks (in Portuguese, coalizões de defesa). Further, against this, veto groups play an important role in the outcomes and the political paths. Studies of a multidisciplinary type have been used to investigate mechanisms through which information is transmitted to governments and which affect their decision-making processes⁴⁰40. Ribeiro JM, Inglez-Dias A. Ribeiro JM, Inglez-Dias A. Policy analysis and governance innovations in the federal government. In: Policy Analysis in Brazil. Bristol: Policy Press; 2013. p. 13-26., and policies oriented towards drugs are very sensitive to flows of information from specialists and interest groups in this format.

In government institutions where political specialists and sectors share the arenas of decision with leaders and groups of active interests, Kingdom⁴¹41. Kingdom J. Agendas, alternatives and public policies. 2nd ed. Boston: Longman; 2011. identifies flows of decision where players take initiative, and when there are certain windows of opportunity and favorable conditions of public opinion can establish a virtuous coordination able to produce innovation and political change. A recent study made an updating of these theoretical traditions for the Brazilian case in terms of concepts and methods⁴²42. Vaitsman J, Lobato L, Andrade G. Professionalization of policy analysis in Brazil. In: Lobato L, Ribeiro JM, Vaitsman J, editors. Policy Analysis in Brazil. Bristol: Policy Press; 2013. p. 13-26. that was important, and could potentially orient a vigorous agenda of research on policies on drugs in Brazil.

In terms of the current situation at any time, certain events in the legal sphere can affect the path of policy as analyzed here. At present, there is a case before Brazil’s Federal Supreme Court dealing with decriminalization of drugs: Extraordinary Appeal 635659/2015, which in August 2016 had not yet been decided. However, due to the changes in the people leading the ministries of Justice, Health and Social Development, the policy of the Health Ministry for integral care for users of alcohol and other drugs, guided by the principle of Harm Reduction, is currently halted. There are signs of a conservative approach in the area of drugs policy, from 2016 – a resumption of the ‘War on Drugs’ paradigm centered on repression of supply and a policy for care and treatment of people misusing drugs based on the disease model present in the CTs, to the detriment of the psychosocial model of the RAPSs⁴³43. PBDB. Nota do PBPD - Nota da Plataforma Brasileira de Política de Drogas sobre a política de drogas no governo interino. [Internet]. 2016. [cited 2016 Jun 20]. Available from: http://pbpd.org.br/wordpress/?p=3959
http://pbpd.org.br/wordpress/?p=3959... . It should be remembered that the Brazilian State is non-religious, and democratic, and for this reason cannot, on the pretext of treatment, impose any religious belief on any of its citizens. It is the role of the State to respect and promote the citizenship of users, refusing all proposals that violate their rights, such as compulsory hospitalization and restriction of liberty as a method of treatment. The CTs, although they are part of the RAPS, do not share the same ethical and technical criteria, because they do not work with the notion of territory, nor with the concept of expanded health, nor with criteria for acceptance based on the logic of Harm Reduction.

Final considerations

The 2016 report of the Global Commission on Drug Policy⁴⁴44. Eastwood N, Fox E, Rosmarin A. A Quiet Revolution: drug decriminalisation across the globe. Geneva: World Health Organization; 2016., of 2016, points to the damages caused by criminalization: increase in the prison population, increase in infectious contagious diseases, and contribution to the increase in the number of deaths related to drugs – which, in 2013, was close to 200,000 worldwide. Due to these damages, the paradigm of prohibition has been strongly debated at a global level. Harm reduction, as a measure taken in public health, has been considered as the most appropriate approach to the problem of drugs in relation to human rights. In the last 15 years, a new wave of countries has moved in the direction of the drugs decriminalization model, suggesting recognition at global level of the failures of the criminalizing approach, and reinforcing a line of policy in the direction of an historic change in direction of paradigm⁴⁴44. Eastwood N, Fox E, Rosmarin A. A Quiet Revolution: drug decriminalisation across the globe. Geneva: World Health Organization; 2016.. This opening has happened in various countries with milder penalties for users of drugs, aiming for savings in costs⁴⁴44. Eastwood N, Fox E, Rosmarin A. A Quiet Revolution: drug decriminalisation across the globe. Geneva: World Health Organization; 2016.. Decriminalization is in tune with the model of psychosocial care, because it helps in the process of leading drug users to treatment, very much diminishing their stigmatization, and protects users from the devastating effect of criminal conviction.

It is concluded that policies on drugs should not have as their focus only the use of drugs, or the attempt to eliminate their production – the direction taken by the prohibition-based policy – but rather should invest in education with clear information on their effects so that (i) people can use drugs without causing much greater damage to their own lives, and (ii) for those who do use drugs in a damaging way, there should be a guarantee of access to healthcare in the psychosocial care model, with Harm Reduction as premise and point of departure.

References

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