Abstract

Through the stigmatization of drug-using People Living on the Streets (PLS) and the reproduction of violence in health services, this paper reflected on this community and the street space beyond the view of decrepitude with which they are usually seen. In this sense, the research contours were shaped from the objective of knowing practice and knowledge constructed in the care processes among the drug-using PLS. A qualitative study was designed, using the triangulation of participant observation techniques, from the inclusion of one of the researchers in a “Street Clinic” (Consultório na Rua), in an inland city of the state of Pernambuco, Brazil, and two types of in-depth individual interviews: the episodic interview and the narrative interview. Three thematic categories were outlined from the data retrieved, as follows: “subjects, territorialities and contexts”, “drugs, social problem medicalization, and control”, and “harm reduction, singularities and care production in the territory”. Thus, understandings about the norms and dichotomies that cross the view of PLS were constructed to consolidate the care offer guided by the perspective of harm reduction.

Key words:
Homeless persons; Drug users; Harm reduction

Introduction

Displacing the identity constructions established by escaping the relationships that dictate the universe of work and home, People Living on the Streets (PLS) denounce the false autonomy that permeated the ideas of freedom nurtured in the Middle Ages regarding the construction of cities. Thus, they show how social organizations in this space are anti-democratic, subtracting the existence of social groups as a result of economic interests¹.

The expansion of PLS in the country occurred in the mid-twentieth century, resulting from several factors, reaching subjects in migratory processes due to industrialization, unemployed, with problems associated with problematic drug use, and former inmates. Currently, this scenario has intensified by the strengthened neoliberal policy in the country, responsible for higher unemployment rates and weakening of public policies that ensure fundamental social rights, resulting in the growing criminalization of poverty².

This process can be seen in the stigmatization of PLS as “sluts, dirty, crazy, dangerous, and poor things”³3 Mattos RM, Ferreira, RF. Quem vocês pensam que (elas) são? Representações sobre as pessoas em situação de rua. Psicol Soc 2004; 16(2):47-58.. When talking about stigma, Goffman⁴4 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. 4ª ed. Rio de Janeiro: LTC; 1981. approaches it as a socially constructed phenomenon, from which classification types are established, with the category of those considered normal and people or groups clashing with these constructions, enduring stigmatization processes. These constructions produce the social imaginary about PLS, which traverses the identity of these subjects, reproducing oppressive relationships³3 Mattos RM, Ferreira, RF. Quem vocês pensam que (elas) são? Representações sobre as pessoas em situação de rua. Psicol Soc 2004; 16(2):47-58.. The dichotomous and excluding vision that sustains them puts them in a place of decrepitude, reducing the perspective on the complexity and diversity that underpin the street’s space⁵5 Nobre MT, Barreira IAFA. Reinvenção de si no mundo da rua: trajetos e narrativas de quem nela vive. Interação em Psicologia 2018; 22(3):200-210..

Therefore, in this study, we propose to reflect on the street’s space beyond the place of need and deprivation⁵5 Nobre MT, Barreira IAFA. Reinvenção de si no mundo da rua: trajetos e narrativas de quem nela vive. Interação em Psicologia 2018; 22(3):200-210., considering the importance of this approach to the complexification of the perspective on care production. It is necessary to understand the possibility of building other existential territories facilitated by this space, allowing PLS to reinvent how they deal with themselves and the street world⁵5 Nobre MT, Barreira IAFA. Reinvenção de si no mundo da rua: trajetos e narrativas de quem nela vive. Interação em Psicologia 2018; 22(3):200-210..

Within these understandings, a complexified perspective on current drug use is also critical, which is one of the great demands among the PLS. Drug use is one of the most determining factors for these individuals to go to the streets⁶6 Ministério do Desenvolvimento Social e Agrário (MDS). Primeiro censo e pesquisa nacional sobre a população em situação de rua. Brasília: MDS; 2008.. It is also responsible for the place of dual stigmatization to which most of this population is submitted⁷7 Silveira GL, Rodrigues LB. O consumo de substâncias psicoativas e o autocuidado entre pessoas em situação de rua na cidade de Juazeiro-BA. Psicologia, Diversidade e Saúde 2013; 2(1):95-122..

This context relates to the very constitution of psychiatry as institutionalized knowledge and power. According to Foucault⁸8 Foucault M. História da loucura na idade clássica. São Paulo: Perspectiva; 1978, this way of knowing managed to capture madness as a medical problem by creating the idea of abnormality and an understanding of the “normal” behavior. Thus, normality was institutionalized.

However, changes in these control measures were necessary for contemporaneity due to the organization of capitalist societies. The disciplinary measures of the 19^th century became insufficient for the agency of ways of living, which gave rise to the emergence of the idea of subjects self-managing their lives⁹9 Merhy E. Anormais do desejo: os novos não-humanos? Medicalização e biopolítica- Sinais que vem da vida cotidiana e da rua. In: Collares CAL, Moyses MAA, Ribeiro MCF, organizadores. Novas capturas, antigos diagnósticos na era dos transtornos. 1ª ed. Campinas: Mercado de Letras; 2013. p. 221-232.

However, we cannot perceive the existence of devices that operate in such a way as to allow the production of subjectivity to unfold in specific identity territories, which cannot unfold into any subjectivation. What transcends the established standards is placed as an expression of illness so that the subjects’ desire becomes criminalized from indicating what healthy practices are⁹9 Merhy E. Anormais do desejo: os novos não-humanos? Medicalização e biopolítica- Sinais que vem da vida cotidiana e da rua. In: Collares CAL, Moyses MAA, Ribeiro MCF, organizadores. Novas capturas, antigos diagnósticos na era dos transtornos. 1ª ed. Campinas: Mercado de Letras; 2013. p. 221-232.

Understandings were also permeated by the ideological war waged against drugs in the 20^th century, which sought to deny the existence of the use of substances that alter states of consciousness in an ancient and universal way¹⁰10 Escohotado A. A História Elementar das Drogas. 1ª ed. Lisboa: Antigona; 2004.. In this sense, the search for new existential territories is genuinely criminalized. Thus, we witness some subjection against people who use drugs from the imagery fabrication of the place captured by the addiction⁹9 Merhy E. Anormais do desejo: os novos não-humanos? Medicalização e biopolítica- Sinais que vem da vida cotidiana e da rua. In: Collares CAL, Moyses MAA, Ribeiro MCF, organizadores. Novas capturas, antigos diagnósticos na era dos transtornos. 1ª ed. Campinas: Mercado de Letras; 2013. p. 221-232.

Contrary to these practices, this study defends the Harm Reduction (HR) perspective as a guide for the provision of care to drug users, especially within the Psychosocial Care Network (RAPS), established by Decree 3.088/11¹¹11 Brasil. Portaria n° 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 (SUS). Diário Oficial da União 2011; 23 dez., which establishes the points of care for the care of people in psychological distress, including the harmful effects of drug use, including primary care, specialized psychosocial care, and urgent and emergency care.

In contrast to the HR perspective, which guided the Ministry of Health’s policy for Comprehensive Care to Users of Alcohol and Other Drugs (Ordinance N° 2.197/04)¹²12 Brasil. 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; 14 out., the Bolsonaro government established a “new” drug policy through Decree 9761/19¹³13 Brasil. Decreto nº 9.761 de 11 de abril de 2019. Aprova a Política Nacional sobre Drogas. Diário Oficial da União 2019; 11 abr.. Abstinence is its guiding axis, representing a setback within the Psychiatric Reform, which fights for social rights and care in freedom¹⁴14 Guimarães TA, Rosa LCSA. A remanicomialização do cuidado em saúde mental no Brasil no período de 2010-2019: análise de uma conjuntura antirreformista. O Social em Questão 2019; 22(44):111-138..

One of the guiding HR fundamentals is the possibility of enhancing strategies that minimize drug use-related harm to health. HR “considers the relevance of understanding the complexity that permeates the use of psychoactive substances, from the different modalities of use to the peculiarities of the subjects and the cultures in which they are inserted” (p. 99)⁷7 Silveira GL, Rodrigues LB. O consumo de substâncias psicoativas e o autocuidado entre pessoas em situação de rua na cidade de Juazeiro-BA. Psicologia, Diversidade e Saúde 2013; 2(1):95-122..

In this sense, we highlight the importance of understanding how drug use encompasses the identity processes of most PLS, influencing the invention of other organization modes. Thus, we aim to take ownership of the knowledge built in the reterritorializations forged in the intense PLS journey¹⁵15 Frangella SM. Corpos urbanos errantes: uma etnografia da corporalidade de moradores se rua em São Paulo [tese]. Campinas: Universidade Estadual de Campinas; 2004. and recognize what unfolds as a care possibility.

These constructions occur within a space and time to elaborate on what is experienced in an established material, social and cultural reality, which configures a field of possibilities for the subject. Considering that social structures are not determinants of human actions, but the unique way each subject experiences them unfolds intertwined with the objective meaning of a sociocultural phenomenon¹⁶16 Souza FF, Zambenedetti G. Percursos de cuidado: pistas sobre itinerários terapêuticos em saúde mental. Tempus Actas Saude Colet 2017;11(4):105-122..

Methodological course

The research assumed a qualitative nature to preserve the subjects and groups’ historicity, considering this a methodology sensitive to the concrete situational contexts in which the phenomenon is established¹⁷17 Minayo MCS. Pesquisa social: teoria, método e criatividade. 21ª ed. Petrópolis: Editora Vozes Limitada; 2011.. The research was carried out through the triangulation of participant observation techniques and two types of in-depth individual interviews: the episodic interview¹⁸18 Flick U. Entrevista Episódica. In: Bauer MW, Gaskell G, organizadores. Pesquisa qualitativa com texto, imagem e som. Um manual prático. Petrópolis: Vozes; 2002. p. 114-136. and the narrative interview¹⁹19 Jovchelovitch S, Bauer M. Entrevista Narrativa. In: Bauer MW, Gaskell G, organizadores. Pesquisa qualitativa com texto, imagem e som. Um manual prático. Petrópolis: Vozes; 2002. p 90-114..

The participant observation occurred from the inclusion of one of the researchers in the Street Clinic (CnaR), in an inland city in the state of Pernambuco, in the sub-middle São Francisco hinterland, during the practice internship of the Multidisciplinary Mental Health Residency from the Vale do São Francisco Federal University.

This type of intervention facilitates access to knowledge about the group from experience within it, accessing information that would not be easily available²⁰20 Chiesa CD, Fantinel L. Quando eu vi, eu tinha feito uma etnografia: notas sobre como não fazer uma "etnografia acidental ". In: Anais do Encontro de Estudos Organizacionais da ANPAD, 2014; Gramado/RS. p. 1-16.. It took place over six months, two days a week, during the service’s opening hours. Field diaries were written to record the experience.

In turn, the narrative interview allowed exploring socio-historical contexts from the subjects’ experience, enabling the knowledge of life stories. On the other hand, episodic interviews put in concrete terms the idea of internal triangulation to the method, combining narrative and argumentative approaches, allowing for an understanding of situations and relationships between employees and health devices.

The interviews were conducted with four men and one woman, using three conditions as criteria for choosing the participants: being homeless, considering having problematic drug use, and accepting to participate in the interviews. The interviews lasted an average of 50 minutes, taking place in different contexts, depending on the availability of employees. The statements were recorded using a cell phone and later transcribed for analysis and stored in digital files upon authorization. Fictitious names were adopted in the presentation of data in order to preserve the identity of users.

The six steps that underpin Schütze’s proposal for the analysis of interviews were used¹⁹19 Jovchelovitch S, Bauer M. Entrevista Narrativa. In: Bauer MW, Gaskell G, organizadores. Pesquisa qualitativa com texto, imagem e som. Um manual prático. Petrópolis: Vozes; 2002. p 90-114. to construct the results, which allowed the reconstitution of the trajectories of each subject and the identification of opinions, concepts, and general theories, reflections, and divisions between the common and the unusual. The comparison of information organized from this process allowed the identification of collective trajectories correlated with the theoretical framework, enabling the structuring of three thematic categories.

Results and discussion

Subjects, territorialities, and contexts

In order to understand the phenomenon of using the streets as a space for living and surviving, it is essential to understand the diversity of circuits covered that precede this extreme situation¹⁵15 Frangella SM. Corpos urbanos errantes: uma etnografia da corporalidade de moradores se rua em São Paulo [tese]. Campinas: Universidade Estadual de Campinas; 2004.. Understanding the processes that lead PLS to the context of vulnerability in which they find themselves and the recognition of their specificities and potentials allows the complexified perspective on the analysis of the functioning of society²¹21 Silva DG, Lemos FCS, Galdino D. Corpos em situação de rua: entre práticas de normalização e resistência. Contemporâneo 2016; 6(2):467-484. and the existing heterogeneity among this audience²²22 Brasil. Decreto de lei nº 7.053 de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento e dá outras providências. Diário Oficial da União 2009; 23 dez..

Paths are usually bordered by comings and goings to the street, loss of family connections, and skipping through several jobs¹⁵15 Frangella SM. Corpos urbanos errantes: uma etnografia da corporalidade de moradores se rua em São Paulo [tese]. Campinas: Universidade Estadual de Campinas; 2004.. Castel²³23 Castel R. A dinâmica dos processos de marginalização: da vulnerabilidade a "desfiliação". Caderno CRH 1994; 10(26):19-40. points out that understanding the existing diversity among marginalized people is essential so that they are not placed on the same level of exclusion.

In this sense, it is essential to understand the different life stories for the development of this study, focusing on the subjects’ practices through the understanding that they relate to the relationship established between the subject and society²2 Nobre MT, Moreno NS, Amorim AKMA, Souza EC. Narrativas de modos de vida na rua: histórias e percursos. Psicol Soc 2018; 30(175636):1-10.. Thus, in this category, the life stories of males - Raul, Guimarães, Galeano, and Bob - and female collaborators - Ana - will be briefly presented, but they will also be found in the entire discussion.

Raul

Raul is a 41-year-old man, born in an inland city of Pernambuco state, where the research took place. As a teenager, he moved to other cities with relatives. He later lived only in São Paulo, in the Cubica favela, where he claimed to have suffered a lot of police violence. He returned to his hometown at the age of 19. At 13, he used alcohol and marijuana, later starting to use crack. He said that he “snapped” during a period of discontinued substance use and was diagnosed with schizophrenia. Raul spent five years and six months in a forensic asylum, claiming that this is a thing of the past and that he currently “survives” one day at a time. He has two children from his former marriage and a daughter from another relationship, to whom he claims to be very attached. Also, according to his report, art was always very present in his life, first in the rock songs he likes so much, and then when writing poetry, which he brought in to deal with monotony and depression, which he says were related to recurrent suicide attempts.

Guimarães

Guimarães is 35 years old and currently works as a car watcher. He came from Minas Gerais, where his last job was in a shoe store. He is a crack, alcohol, and marijuana user and started using substances at eight. He mentioned having already been in charge of a multinational in Recife, Pernambuco, questioning me about: “It doesn’t even seem like it, right? I was the example”. He said he was fired after being diagnosed with HIV. He spoke about the desire to have a family, the death of his mother, to whom he was very attached, and later on his father, who was a police officer and with whom he had a conflicting relationship. During the same period, he separated from his ex-partner, with whom he has two daughters, and moved to his aunts’ house in Recife, where he spent five years in a therapeutic community. After leaving the therapeutic community, he married and had a son he was forbidden to see because of his HIV diagnosis, claiming that this was “the biggest pain” of his life. Then he moved to an inland city of Pernambuco state at the invitation of a friend and was admitted to a therapeutic community after a suicide attempt. He has been living on the streets since leaving the institution four years ago. Currently, he spends most of his day at the “spot” where he works as a car watcher, a space where he has established relationships with local merchants, who always call him for side jobs. He said he began “practicing harm reduction”, reducing the number of crack stones smoked during the day, replacing them with alcohol and marijuana. Within this context, he rented a “little house” with another individual living on the streets a few days before the start of the interviews, pointing out the importance of what happened to his care since substance use was widespread at night.

Galeano

Galeano is from the inland city of Pernambuco state, where this research took place and is currently 60 years old. He went to São Paulo at the age of 17, attributing the fact to his involvement in a “fight”, and since then, he has traveled to several cities, moving from one to another, asking for a ride or a ticket. He lived for a while in Mato Grosso, from where he moved after his mother’s death, going to Cuiabá, where he met his former partner, who also died shortly after. He related these losses to the onset of the use of the “base, the product that makes crack and cocaine”. However, he only referred to alcohol and tobacco when talking about the current drug use. He mentioned the importance of the Psychosocial Care Center for Alcohol and Other Drugs (CAPS ad) in the city for his care process, citing Harm Reduction and the feasibility of some rights, such as the Free Pass. He is currently removed from service because he was involved in a “fight” with another individual in follow-up. His relationship with churches was also brought up, referring to these experiences, abstinence, and return to drug use. He has a young daughter, who is currently under the care of his mother-in-law because the child’s mother is in a therapeutic community, and he talks about the difficulty of being able to see his daughter. During the interview, he also brought up the recently rented house he is sharing with Guimarães.

Bob

Bob is 35 years old, from Lagoa Grande, an inland city of Pernambuco state, and works as a car watcher. He was “raised” by his grandmother, who died when he was nine, and then by his aunts. At age 15, he asked one of his aunts to meet his mother as a gift, discovering that she lived in poor conditions with nine other children. Thus, he remained with his aunts, going at the age of 16 to live in Maranhão with his father, where he stayed for 12 years. He related the onset of the practice of robberies to his father’s “lack of guidance and support”. He was imprisoned several times before being institutionalized and completed a socio-educational measure for nine months. A year after having fulfilled the measure, he was sentenced to nine years in the Pedrinhas penitentiary, which, according to him, is one of the most violent prisons in Latin America, where he learned to make a drug that, at the time, was called merla (cocaine chemical mix). He states that the relationship with his father worsened after being released and that other family members did not want to see him, highlighting the recurrence of reports of similar situations during the internship period at the CnaR. He returned to Pernambuco, living in the city where this research was conducted for seven years, escalating the use of drugs, and has been “steady” in his workplace for four years. Other homeless people stay in this space, known among them as “little favela”, where they sleep, work, and use drugs.

Ana

Ana is a 37-year-old woman, usually at an open market, where other homeless people meet. Among them is Victor (fictitious name), the person with whom Ana has been in a relationship for 19 years. She was the only woman I was able to interview, a difficulty that possibly has to do with the lower percentage of women in this situation compared to the number of men, as already pointed out by the “First Census and National Survey on the Homeless Population”⁶6 Ministério do Desenvolvimento Social e Agrário (MDS). Primeiro censo e pesquisa nacional sobre a população em situação de rua. Brasília: MDS; 2008.. However, there was greater difficulty in talking about themselves among them in the service routine, which hampered the selection of subjects for the research. At the time of the interview, Ana was in a vulnerable situation resulting from Victor’s arrest. He was serving time in the socio-educational measure due to the physical abuse against her, so she felt guilty for the situation at the time. Given the fragility, the interview with Ana had to be interrupted, and it was not possible to access it at other times for this purpose. Although reports of constant physical and verbal abuse against Ana are always brought up in visits to the CnaR, she also places Victor as her “protector”. She has been in a relationship with him for 19 years, having two daughters and a son with him, whom she lost custody of. Currently, the oldest daughter lives with Ana’s grandmother in another inland city in Pernambuco state, and the other two children live with Victor’s father and mother, a context that Ana always brings up as something that causes her suffering due to the difficulty in seeing the children. During the interview, the loss of custody of the daughters and son, the loss of family members, and breaking bonds with them were constantly brought up, and she reported a feeling of loneliness related to the problematic use of alcohol. Ana still maintains the only family bond with her grandfather, so her routine alternates between periods when she stays at the market or his house. However, she has difficulty staying at home with him due to a lack of food and loneliness.

The report by Ana and other collaborators points to what the literature brings about when discussing how the situation of being on the streets or surviving from it is preceded by an overdetermination of factors that are difficult to grasp. These are cross-sectional to each subject’s life story, occurring as a “marginal drift”¹⁵15 Frangella SM. Corpos urbanos errantes: uma etnografia da corporalidade de moradores se rua em São Paulo [tese]. Campinas: Universidade Estadual de Campinas; 2004.. Understanding these social inequalities from Robert Castel²³23 Castel R. A dinâmica dos processos de marginalização: da vulnerabilidade a "desfiliação". Caderno CRH 1994; 10(26):19-40. onwards, one can speak of social “disidentity” or disaffiliation, a perception that reiterates the dynamics of exclusion preceding the completely desocializing effects of the marginalization of subjects.

In this sense, it is crucial to understand the determinants that encompass marginalization. When talking about his trajectory, Raul brings in his statement one of the leading social issues to PLS in Brazil, pointing out racism and the social organization that stems from it as the cause of impoverishment for a large portion of the population: “It is the social pyramid: all the money is up there, and nothing down here, and most of them are blacks” (Raul).

Thus, we see how Brazil “went from a slave labor market to a formally free one, but kept all slavery potentialities in the new situation”. This class agreement reverberates in the structural racism that historically crossed the establishment of Brazilian society, decisively reverberating in the number of PLS²⁴24 Souza J. A elite do atraso: da escravidão à lava jato. 1ª ed. Rio de Janeiro: Leya; 2017.. The National Survey on the Homeless Population⁶6 Ministério do Desenvolvimento Social e Agrário (MDS). Primeiro censo e pesquisa nacional sobre a população em situação de rua. Brasília: MDS; 2008. expresses this reality by pointing out the sharp discrepancy between the number of black people (black and brown) (67%) and the number of white people (44.6%) within this excerpt, which is also observed in the city where this research was carried out.

Given the above, it can be seen that multiple reasons lead people to live off/on the streets, all of which are expressive of the relationship with a process of loss or rupture. These are updated in daily life so that new breaks are imposed, and the need to weave other paths is materialized in the invented place⁵5 Nobre MT, Barreira IAFA. Reinvenção de si no mundo da rua: trajetos e narrativas de quem nela vive. Interação em Psicologia 2018; 22(3):200-210..

Drugs, the medicalization of social problems, and control

This axis proposes to talk about drug use among the PLS, bringing the different meanings attributed and the relationships established within the socio-historical context in which this event is established. It starts from the perception brought by Antônio Nery²⁵25 Nery Filho A. Introdução: Por que os humanos usam drogas? In: Nery Filho A, Macrae E, Tavares LA, Nuñez ME, Rêgo M, organizadores. As drogas na contemporaneidade: perspectivas clínicas e culturais. Salvador: EDUFBA: CETAD; 2012. p. 11-20. when addressing substance use as a human issue, referring to their personal and social needs. In this sense, he points out the importance of understanding the relationships established with drug use from the “gaps/faults” (p. 20) that underpin each subject’s story.

By discussing this issue, Maria Rita Kehl²⁶26 Café Filosófico [programa de televisão]. São Paulo: TV Cultura; 2014. brings out the need for all subjects to escape to endure reality, considering the problematic use of drugs as a symptom highlighting the problematization of all relationships in contemporary life. This practice is also part of one of the underlying fabrics of being on the streets, implying means of sociability and addressing hunger and facing psychosocial difficulties²⁷27 Costa APM. População em situação de rua: contextualização e caracterização. Texto Contexto 2006; 4(1):1-15..

Understandings in the statements of collaborators and the research collaborator, in which the fact of being on the streets for many years, hunger, the humiliation often suffered, loss of family and custody of children, disrupted bonds, and loneliness were brought as a motivation for use, as Guimarães states in the excerpt: “[...] I miss them all, I feel sad, it makes me want to kill myself. I hear voices and see things. So, I prefer to use and drink because I forget the voices and don’t see anything. Drugs and cachaça cut all this off and kill my pain a little”.

It is essential to consider the uniqueness of the relationship between any substance and the person who uses it²⁸28 Corrêa G. Drogas para além do bem e do mal. In: Santos LMB, organizadora. Outras palavras sobre o cuidado de pessoas que usam drogas. Porto Alegre: Ideograf; 2010. p. 167-176.. It is crucial to understand the subjectivities and sociocultural contexts in which consumption occurs²⁹29 Nery Filho A, Soares GG, Nunez ME, Macrae, E. Diá logo com Dr. Antonio Nery Filho, George Gusmão Soares, Maria Eugênia Nuñes e Edward Macrae sobre o crack. In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 27-58.. This sociocultural context concerns the physical, social, and cultural environment, enunciated as the “setting” where drug use takes place³⁰30 Zinberg N. Drug, set, and setting: thebasis for controlledintoxicant use. Yale: Yale University Press; 1984..

The social variables and control measures that make up the “setting” influence the drug use-related effects and the social consequences of this practice.³⁰30 Zinberg N. Drug, set, and setting: thebasis for controlledintoxicant use. Yale: Yale University Press; 1984. As a result, knowing the context in which the subjects experience substance use enables us to understand their experiences, which reflect or are related to social settings³¹31 Nuñez ME. A chegada do crack em Salvador: quem disse que o crack traz algo de novo? In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 135-170.

Besides the doses and pharmacological nature of drugs, the ideas and beliefs built around them also influence their subjective effects. In this sense, interpreting its effects and addressing the consequences of the experience unfold on the use modes³¹31 Nuñez ME. A chegada do crack em Salvador: quem disse que o crack traz algo de novo? In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 135-170.

Given the above, it is essential to reflect on how the negative discourses related to crack cross the relationship between PLS and this drug, considering that many users of this substance identify with these premises³²32 Macrae E. Prefácio. In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 11-26.. All of the four male informants reported using multiple substances, having already used or currently using crack.

In all the different contexts referred to the inclusion of crack in their consumption practices, they brought a very negative perspective on the drug, which was not necessarily compared to other substances, as can be seen in the following excerpts: “This crack is violent. It came to destroy many people. Whoever enters this crack really takes a while to get out. It takes a long time because it is very addictive.” (Raul); “[...] then I came here to reduce my years because I didn’t use crack. Then I started using crack here.” (Galeano); “There are simple things that the drug [crack] makes you forget. Then, there is a time that you give up the drug life, and you start to see what you have truly become.” (Bob).

Antônio Nery²⁹29 Nery Filho A, Soares GG, Nunez ME, Macrae, E. Diá logo com Dr. Antonio Nery Filho, George Gusmão Soares, Maria Eugênia Nuñes e Edward Macrae sobre o crack. In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 27-58. points out structural determinants as the great producer of crack’s disastrous effects, bringing the work of the media to publicize issues related to poverty and violence, without bringing, however, the social nature of the problem. Thus, he focuses on events such as crack use among layers of the population excluded by the current socioeconomic model from the place of individual pathologies.

Thus, the reality of the most affected subjects is disregarded³²32 Macrae E. Prefácio. In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 11-26.. Nor is it said about how the sensations caused by use are “highly subjective experiences, driven by the social imagination that claims immediacy, extreme pleasure, risk, dizziness, speed for our lives”³¹31 Nuñez ME. A chegada do crack em Salvador: quem disse que o crack traz algo de novo? In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 135-170. Processes that contribute to forms of subjecting this public, from the imagery construction of the place of people captured by the drug. These subjects are socially killed so that they “resort even more to drugs, affronting society in broad daylight”. (p. 16)³²32 Macrae E. Prefácio. In: Macrae E, Tavares LA, Nuñez ME, organizadores. Crack: contextos, padrões e propósitos de uso. Salvador: EDUFBA; 2013. p. 11-26.. It is a reality pointed out by the interlocutors in the statements such as Bob’s, who stated that “society wants you to be ready to reintegrate, but it is never ready to accept you”, and Raul, who points out the racist bias of these practices to which impoverished people are submitted:

Why is it that only the poor who live in the favela, who live in the ghettos, are the ones who are discriminated against? [...]. Do you know what is missing? Opportunity, which they don’t even give, right? It’s the social pyramid. All the money is up there, and nothing at the bottom, where most are black [...] So, is it like this forever? (Raul)

In contrast to the several measures of control over the individual and collective body, HR proposes to look at the uniqueness of drug users. In this sense, it values the leading role of social actors, opposing care medicalization by promoting the autonomy and emancipation of subjects and groups³³33 Gomes TB, Vecchia MD. Estratégias de redução de danos no uso prejudicial de álcool e outras drogas: revisão de literatura. Cien Saude Colet 2018; 23(7):2327-2338..

Harm reduction, singularities, and care production in the territory

PLS statements about the difficulty of accessing health services were constant during the Street Clinic (CnaR) practice, which was also experienced in the articulation of CnaR with other services to ensure comprehensive care. Problems regarding care seem to deteriorate among PLS who use drugs through the dual process of stigmatization they endure, so that health services recurrently reproduce marginalization, placing this population on the sidelines, neglecting their care process⁷7 Silveira GL, Rodrigues LB. O consumo de substâncias psicoativas e o autocuidado entre pessoas em situação de rua na cidade de Juazeiro-BA. Psicologia, Diversidade e Saúde 2013; 2(1):95-122..

Given this, to expand PLS access to health services, the CnaR was established by the National Primary Care Policy (PNAB)³⁴34 Brasil. 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; 21 out. in 2011, a service that makes up an intersectoral network, in which it is inserted to produce a unique therapy for PLS³⁵35 Londero MFP, Ceccim RB, Bilibio LFS. Consultório de/na rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18(49):251-260.. Care production modes were brought in the interviews through statements such as:

In CnaR practices, the need to address the unpredictability that invades the routines of health services at all times, related to the “encounter with life stories in distressing contexts in its course”, is intensified. (p.5)³⁵35 Londero MFP, Ceccim RB, Bilibio LFS. Consultório de/na rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18(49):251-260.. Care processes that dialogue with the physical, social, and cultural environment in which use occurs, the “setting” brought by Norman Zinberg³⁰30 Zinberg N. Drug, set, and setting: thebasis for controlledintoxicant use. Yale: Yale University Press; 1984., enable the understanding of the uniqueness of the relationship between the subject and their use practices.

These actions take place in the territory, in contact with the relational space of the subjects, dealing with the production of meanings forged in the fabrics between natural settings and social history³⁶36 Lima EMFDA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saude Debate 2014; 38(102):593-606. The approximations of these territories transcend the physical context, enabling the understanding of social, economic, political, and cultural values that cross different existential territories³⁶36 Lima EMFDA, Yasui S. Territórios e sentidos: espaço, cultura, subjetividade e cuidado na atenção psicossocial. Saude Debate 2014; 38(102):593-606.

When assisting people who make problematic drug use, we should consider the culture and knowledge of the local worlds of meaning to provide care. Thus, we can outline concrete issues and objectives, which dialogue with different realities and subjects³⁷37 Lancetti A. Contrafissura e plasticidade psíquica. 1ª ed. São Paulo: Hucitec; 2015.. This type of care production speaks of a participatory approach, bringing the importance of the different actors involved in the process having a voice, identifying problems and approach criteria³⁸38 Romaní O. Políticas de drogas: prevención, participación y reducción del daño. Salud Colect 2008; 4(3):301-318..

This perspective helps us build practices in which possible ways of singularization are possible from the meeting, which allow the construction of new territories and new meanings within the care processes. Thus, possible interventions are established based on different consumption forms and consumer groups, producing autonomy and a certain “level of self-control”³⁵35 Londero MFP, Ceccim RB, Bilibio LFS. Consultório de/na rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18(49):251-260.. Constructions are brought up in the statements of Guimarães and Bob when talking about the singularities in the care strategies built in everyday life:

Final considerations

Given the above, the importance of reflecting on the drug-using PLS is highlighted beyond the lenses of dichotomous normativity that organize existential space and territories. For the construction of care processes, it is necessary to look at “the process of recreation at the extremities”⁵5 Nobre MT, Barreira IAFA. Reinvenção de si no mundo da rua: trajetos e narrativas de quem nela vive. Interação em Psicologia 2018; 22(3):200-210., moving understandings about ways of life that escape the logic of the hegemonic world. These possibilities can only be realized in the territory, where one can understand the PLS’ and meetings’ specificities that allow for singularization processes. It is necessary to be open to the encounter with the deterritorialization of meanings and practices to reinvent care that produces life in the street arena.

References

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