Abstract

Public policymaking is associated directly with the model adopted in the relationship between State and society. According to Höfling ¹1. Höfling EM. Estado e políticas (públicas) sociais. Cad CEDES 2001; 21:30-41., public policymaking reveals conflicts of interest and arrangements produced in the spheres of power involving State and society institutions.

The 21st century was the first to witness global and local contexts that allowed young people to appear as subjects of rights ²2. Novaes RCR. Prefácio. In: Castro JA, Aquino LM, Andrade CC, organizadores. Juventude e políticas sociais no Brasil. Brasília: Instituto de Pesquisa Econômica Aplicada; 2009. p. 13-22.. Such aspects included the effects of disaggregating neoliberal policies, violence from the drug traffic, weapons trade, and police corruption on the one hand and new ways of experiencing the space-time relationship and creative strategies for social belonging. Public policies drafted for youth in Brazil have emerged in this scenario, grounded on social movement protesting the exclusion and stigmatization of young people and were only formalized in the last decade, with the creation of the National Youth Secretariat in 2005.

Despite this change in the conceptualization of public policies, the focus on youth is still heavily tied to the idea of risk and transgression, both in scientific thinking and in public opinion ³3. Takaeti BA, Vicentin MCG. A produção de conhecimento sobre juventude(s), vulnerabilidades e violências: uma análise da pós-graduação brasileira nas áreas de Psicologia e Saúde (1998-2008). Saúde Soc 2015; 24:945-63.. The denial of young people’s civil rights is related to a social perception that this group should be targeted with repressive measures in order to avoid deviations in their socialization process, such as delinquency and drug use, common assumptions in public policies historically focused on youth ⁴4. Sposito MP, Carano PCR. Juventude e políticas públicas no Brasil. Rev Bras Educ 2003; 24:16-39.. Data from the National Youth Secretariat and the Ministry of Health evidence this reality, reporting that more than 20% of young Brazilians 15 to 24 years of age are neither studying or working ⁵5. Ministério da Saúde. Diretrizes nacionais para a atenção integral à saúde de adolescentes e jovens na promoção, proteção e recuperação da saúde. Brasília: Ministério da Saúde; 2010., and that 54.8% of the country’s prison population consists of young people 18 to 29 years of age ⁶6. Secretaria Geral da Presidência da República; Secretaria Nacional de Juventude. Mapa do encarceramento: os jovens do Brasil. Brasília: Presidência da República; 2015..

In the wake of these assumptions, a debate has developed on the so-called “drug phenomenon” among youth. According to Passos & Souza ⁷7. Passos EH, Souza TP. Redução de danos e saúde pública: construções alternativas à política de "Guerra às Drogas". Psicol Soc 2011; 23:154-62., the War on Drugs launched by the United States in the 1970s simultaneously became a means for social control and the expansion of neoliberal policy based on practices of power and violence fomented by the war economy and consumption logic. However, from the perspective of controlling drug supply and demand, this repressive model’s inefficacy is evident ⁸8. Bokan y V. Drogas no Brasil: entre a justiça e a saúde - proximidades e opiniões. São Paulo: Fundação Perseu Abramo; 2015..

Among global public policies on drugs, such as the control of supply and access to social and health services for users, prevention is the policy with the best cost-benefit ratio for the reduction of both abusive consumption and its consequences. According to estimates, each dollar spent on prevention programs in schools avoids an average of 18 dollars in social costs from drug-related problems ⁹9. U.S. Department of Health and Human Services. Substance abuse prevention dollars and cents: a cost-benefit analysis. Washington DC: U.S. Department of Health and Human Services; 2008.. However, as with other policies, the implementation has been based less on scientific evidence than on what politicians deem important ¹⁰10. Strang J, Babor T, Caulkins J, Fischer B, Foxcroft D, Humphreys K. Drug policy and the public good: evidence for effective interventions. Lancet 2012; 379:71-83.. This gap produces discrepancies that hinder the elaboration of an integrated public prevention policy with effective actions. In addition, the limited Brazilian research production on drug abuse prevention leads to the importation of intervention models produced in other jurisdictions ¹¹11. Canoletti B, Soares CB. Programas de prevenção ao consumo de drogas no Brasil: uma análise da produção científica de 1991 a 2001. Interface (Botucatu) 2005; 9:115-29.^,1212. Noto AR, Galduróz JCF. O uso de drogas psicotrópicas e a prevenção no Brasil. Ciênc Saúde Colet 1999; 4:145-51..

This article is intended to discuss the model for public policies in drug abuse prevention targeted to youth in Brazil and the United States, based on the latter country’s hegemony in the determination of drug policies in dependent countries. The methodology adopted here is similar to the policy design assessment model. The Brazilian Federal government’s guidebook for assessing its public policies recommends “conducting design assessment as a way of verifying the hypotheses established for the policy at the time of its formulation, as well as in-depth assessment of the points and definitions which at the time were not supported by clear evidence as to their adoption” ¹³13. Casa Civil, Presidência da República. Avaliação de políticas públicas: guia prático de análise ex post. Brasília: Presidência da República; 2018. (p. 121). According to Jannuzzi ¹⁴14. Jannuzzi PM. Avaliação de programas sociais: conceitos e referenciais de quem a realiza. Est Aval Educ 2014; 25:22-42., design assessment involves analyses based on secondary data or compilation of studies with varying scopes, developed on the theme covered by the policy, the determinants of the problem in question, and the programs and projects elaborated to intervene in the issues. We will address the prevailing legislations, the scopes and contexts for their elaboration, the different prevention programs, and their effectiveness.

Prohibition in the United States and its importation by Brazil

Prohibition policies in the United States date to the temperance movement in the late 19th and early 20th centuries. Established by the middle class, they adopted an ideology that assumed that alcohol leads inevitably to addiction and thus destroys users’ moral character and physical and mental health. Programs for drug use prevention followed the compulsory abstinence policy to the letter, such as the incorporation of the “Scientific Temperance Instructions” in the school curriculum ¹⁵15. Blocker Jr. JS. Did prohibition really work? Alcohol prohibition as a public health innovation. Am J Public Health 2006; 96:233-43..

In the 1980s, the growth of political conservatism during the Reagan Administration favored the recrudescence of repressive policies. The year 1988 ushered in the Federal Anti-Drug Abuse Act, which created the Office of National Drug Control Policy (ONDCP), aimed at setting drug control priorities. Simultaneously with reinforcement of the “just say no” policy targeted to youth, there was a budget cut on programs for drug use prevention ¹⁶16. Levine HG, Reinarman C. The trouble with drink and drugs: why prohibition and criminalization matter. Addiction 2010; 105:806-7. and later manipulation of statistical data by the ONDCP to forge the efficacy of the War on Drugs ¹⁷17. Robinson MB, Scherlen RG. Lies, damned lies, and drug war statistics: a critical analysis of claims made by the office of National Drug Control Policy. New York: SUNY Press; 2014..

In Brazil, prohibitionist social control policies fit the U.S. model neatly from the beginning. According to Torcato ¹⁸18. Torcato CEM. Breve história da proibição das drogas no Brasil: uma revisão. Inter-Legere 2014; 15:138-62., the Brazilian temperance movement in the 1920s also lobbied legislators for a public policy to condemn alcoholic beverages, but failed to obtain the approval of compulsory abstinence. The increase in consumption for recreational purposes (and no longer exclusively for therapeutic ends) meant that the medical profession sought a ban on such uses and framed drugs as a public health problem. Through political networking, the medical profession obtained the first specific drug law in Brazil in 1921, under the heavy influence of Prohibition in the United States ¹⁹19. Torcato CEM. O uso de drogas e a instauração do proibicionismo no Brasil. Saúde Transform Soc 2013; 4:117-25..

This and subsequent laws ratified within Brazil the international treaties to which the country is a signatory. Brazil’s 1988 Constitution seconded the deliberations of the U.N. Convention Against Illicit Traffic in Narcotic Drugs and Psychoactive Substances that same year ²⁰20. Ventura CAA. Drogas lícitas e ilícitas: do direito internacional à legislação brasileira. Rev Eletrônica Enferm 2011; 13:554-9.. Thus, the analysis of Brazil’s public policy on drugs requires understanding the intertwining of multilateral prohibition by the United Nations, militarized repression by the United States, and the interests of Brazil’s dominant classes ²¹21. Lima RCC. O problema das drogas no Brasil: Revisão legislativa nacional. Libertas 2010; 10:102-23..

Policies for drug abuse prevention in Brazil and the United States

The current legislations ruling public policy on drug control in the United States and Brazil are, respectively, the Federal Anti-Drug Abuse Act of 1988 ²²22. United States. Public Law 100-690, November 18, 1988. Anti-Drug Abuse Act. Government Office 1988; 18 nov. and Law n. 11,343 of August 23, 2006, with the amendments introduced by Law n. 13,840²³23. Brasil. Lei nº 13.840, de 5 de junho de 2019. Altera as Leis nº 11.343, de 23 de agosto de 2006, 7.560, de 19 de dezembro de 1986, 9.250, de 26 de dezembro de 1995, 9.532, de 10 de dezembro de 1997, 8.981, de 20 de janeiro de 1995, 8.315, de 23 de dezembro de 1991, 8.706, de 14 de setembro de 1993, 8.069, de 13 de julho de 1990, 9.394, de 20 de dezembro de 1996, e 9.503, de 23 de setembro de 1997, os Decretos-Lei nº 4.048, de 22 de janeiro de 1942, 8.621, de 10 de janeiro de 1946, e 5.452, de 1º de maio de 1943, para dispor sobre o Sistema Nacional de Políticas Públicas sobre Drogas e as condições de atenção aos usuários ou dependentes de drogas e para tratar do financiamento das políticas sobre drogas. Diário Oficial da União 2019; 6 jun. of June 5, 2019. Importantly, the articles dealing with drug abuse prevention remained unaltered. Both legislations contain provisions for the control of both supply and demand, although the main emphasis is on repression of supply. Both legislations devote a specific section to drug abuse prevention, with specificities on policy financing, execution, and assessment. The U.S. law provides further detail on the policy’s target public: students, homeless, low-income communities, and adolescents in conflict with the law. The current study will focus on students, since Brazil’s prevention policy is based on measures targeted to this population.

U.S. legislation on drug abuse prevention

The ONDCP prioritizes mental health services for users rather than educational prevention strategies. That is, the U.S. government’s priority is not to control demand, and within demand, prevention is not the priority.

The Anti-Drug Abuse Act states that the prime focus of prevention programs should be the school, which “clearly and consistently teaches that illicit drug use is wrong and harmful” ²²22. United States. Public Law 100-690, November 18, 1988. Anti-Drug Abuse Act. Government Office 1988; 18 nov.. Programs should be offered at all levels of teaching, using proper teaching materials, drafted according to the principle of abstinence as the exclusive goal. The very fact that drugs are considered harmful tends to stigmatize users as dangerous and potentially violent. The association between drugs and violence as a cause-and-effect relationship is one of the prevention programs’ central components.

The Anti-Drug Abuse Act also provides that teachers and mental health and educational professionals receive should prior training on drug abuse before carrying out prevention activities. Aimed at ensuring the reproduction of the legalist discourse, the strategy in the U.S. policy is that the conduction of drug abuse prevention programs is a prerogative of specialists.

The selection of prevention programs with government financing is based on the services’ cost-efficacy ratio. However, there are controversies over the criteria for the programs to be considered recommendable ²⁴24. Gorman DM. Has the National Registry of Evidence-based Program and Practices (NREPP) lost its way? Int J Drug Policy 2017; 45:40-1.^,2525. Gorman DM. The best of practices, the worst of practices: the making of science-based primary prevention programs. Psychiatr Serv 2003; 54:1087-9..

Financing prevention policies

According to data from the U.S. national drug control budget, of the 27 billion dollars earmarked for expenditures in this sector for each year from 2016 to 2018, an average of 56.7% was allocated to reducing the supply, i.e., repression of drug production and the drug traffic, both in the United States and abroad ²⁶26. Office of the Presidente of the United States. National drug control budget. Washington DC: Office of the Presidente of the United States; 2018.. Assessed jointly, only an average of 5% of the expenditures on controlling supply and demand was allocated for programs in drug abuse prevention. A Table 1 shows the distribution of the specific amounts according to the budget areas.

An analysis of spending on drug abuse prevention measures from 2009 to 2018 shows a gradual decrease in the budget for this sector, of around 8.4% ²⁶26. Office of the Presidente of the United States. National drug control budget. Washington DC: Office of the Presidente of the United States; 2018.. The gradual reduction in funds for prevention reveals the lack of priority assigned to programs in drug abuse prevention and the primacy of the perspective favoring a crackdown on drugs.

Prevention programs

In the late 1990s, the U.S. government began to demand scientific evidence for preventive activities in schools. Since then, to receive federal financing, prevention programs must adjust to the efficacy criteria. The first measures of efficacy determined that the primary goal was to “educate and enable America’s youth to reject illegal drugs as well as alcohol and tobacco”, making clear that “the strategy focuses on youth for both moral and practical reasons” ²⁷27. Office of National Drug Control Policy. National drug control strategy. Washington DC: Office of National Drug Control Policy; 1999. (p. 38).

The program’s current criteria center on research methodology issues in the field of prevention, although the goal of abstinence remains. Thus, lists were created of evidence-based prevention programs established by different federal agencies and academic institutions. Schools select their programs according to these criteria ²⁸28. Office of National Drug Control Policy. International standards on drug use prevention. Washington DC: Office of National Drug Control Policy; 2015..

Researchers have criticized both the programs’ assessment and the criteria used to consider them based on scientific evidence ²⁹29. Gorman DM. The decline effect in evaluations of the impact of the Strengthening Families Program for Youth 10-14 (SFP 10-14) on adolescent substance use. Child Youth Serv Rev 2017; 81:29-39.^,3030. Pape H. School-based programmes that seem to work: useful research on substance use prevention or suspicious stories of success? Nordic Alcohol Drugs 2009; 26:521-35.^,3131. McCambridge J. A case study of publication bias in an influential series of reviews of drug education. Drug Alcohol Rev 2007; 26:463-8.. According to Gandhi et al. ³²32. Gandhi AG, Murphy-Graham E, Petrosino A, Chrismer SS, Weiss CH. The devil is in the details: examining the evidence for "proven" school-based drug abuse prevention programs. Eval Rev 2007; 31:43-74., few studies have empirical assessment, with limited evidence of long-term effectiveness, absence of independent evaluators, or use of subsamples, thus producing biased evidence. According to Holder ³³33. Holder H. Prevention programs in the 21st century: what we do not discuss in public. Addiction 2010; 105:578-81., the field of research on prevention programs in the United States suffers from lack of transparency in the analyses of the results, lack of reporting of negative data in the publications, and few replications performed by researchers not affiliated with the respective program’s design. Gorman ³⁴34. Gorman DM. Drug and violence prevention: rediscovering the critical rational dimension of evaluation research. J Exp Criminol 2005; 1:39-62. questions the scientific perspective adopted by U.S. researchers in the field of prevention, aiming solely, as he contends, to prove that the programs work.

Brazilian legislation on drug abuse prevention

The National Secretariat on Drug Policies (SENAD) is an agency of the Ministry of Justice and Public Security that coordinates activities in drug abuse prevention, care, and social reinsertion of users, besides repression of the drug traffic. It was created in 1998 under President Fernando Henrique Cardoso as the National Anti-Drug Secretariat, aimed at ratifying (for the international community) the adoption of the model based on drug repression ³⁵35. Garcia MLT, Leal FX, Abreu CC. A política antidrogas brasileira: velhos dilemas. Psicol Soc 2008; 20:267-76..

Brazil’s Law n. 11,343/2006, which governs public policy on drugs, establishes as one of the principles of prevention the “strengthening of individual autonomy and responsibility” and also recommends “non-use” or “delaying use” and risk reduction as the goals of preventive activities. However, with the recent amendments under Law n. 13,840/2019²³23. Brasil. Lei nº 13.840, de 5 de junho de 2019. Altera as Leis nº 11.343, de 23 de agosto de 2006, 7.560, de 19 de dezembro de 1986, 9.250, de 26 de dezembro de 1995, 9.532, de 10 de dezembro de 1997, 8.981, de 20 de janeiro de 1995, 8.315, de 23 de dezembro de 1991, 8.706, de 14 de setembro de 1993, 8.069, de 13 de julho de 1990, 9.394, de 20 de dezembro de 1996, e 9.503, de 23 de setembro de 1997, os Decretos-Lei nº 4.048, de 22 de janeiro de 1942, 8.621, de 10 de janeiro de 1946, e 5.452, de 1º de maio de 1943, para dispor sobre o Sistema Nacional de Políticas Públicas sobre Drogas e as condições de atenção aos usuários ou dependentes de drogas e para tratar do financiamento das políticas sobre drogas. Diário Oficial da União 2019; 6 jun., the system no longer assumes the harm reduction perspective, adopting abstinence as the only approach to drug use.

Brazil’s national policy stipulates the implementation of prevention programs in public and private teaching institutions, where teaching professionals at the three levels should receive training through policies for continuing education. However, studies have revealed Brazilian teachers’ unpreparedness to perform this function, due to either fear and/or lack of information and skills to broach the subject ³⁶36. Ferreira TCD, Sanchez ZM, Ribeiro LA, Oliveira LG, Nappo SA. Percepções e atitudes de professores e escolas públicas e privadas perante o tema drogas. Interface (Botucatu) 2010; 14:551-62.^,3737. Moreira FG, Silveira DX, Andreoli SB. Situações relacionadas ao uso indevido de drogas nas escolas públicas da cidade de São Paulo. Rev Saúde Pública 2006; 40:810-7..

The law also recommends that the preventive activities be based on scientific evidence to avoid prejudice and stigmatization towards users and services. Studies on the effectiveness of preventive interventions in Brazil are few, scarcely valued, and discontinuous ¹¹11. Canoletti B, Soares CB. Programas de prevenção ao consumo de drogas no Brasil: uma análise da produção científica de 1991 a 2001. Interface (Botucatu) 2005; 9:115-29.^,1212. Noto AR, Galduróz JCF. O uso de drogas psicotrópicas e a prevenção no Brasil. Ciênc Saúde Colet 1999; 4:145-51.^,3838. Campos GM, Figlie NB. Prevenção ao uso nocivo de substâncias focada no indivíduo e no ambiente. In: Diehl A, Cordeiro DC, Laranjeira R, organizadores. Dependência química: prevenção, tratamento e políticas públicas. Porto Alegre: Artmed; 2011. p. 481-94. or circumscribed to local programs without a national reach. However, since 2013, at the initiative of the U.N. Office on Drugs and Crime (UNODC) and in partnership with the Brazilian Ministries of Health and Social Development and the Fight Against Hunger and SENAD, three programs originally developed in the United States are being validated for Brazil as part of the export package of the U.S. “War on Drugs”: the Elos game, #Tamojunto, and Famílias Fortes.

The law recommends an inter-sector approach and shared responsibility among services that provide activities in prevention and those working with users and their families. To establish mutual collaboration, partnerships are suggested with private sector institutions and with various social segments. On the other hand, social movements do not appear as important partners in this process. Currently, however, social movements in mental health and universities have played a leading role in social control of public policies on drugs.

Financing prevention policies

The Administrative Reports by SENAD provide a budget and financial statement on the Program “Crack: It is Possible to Win”, which foments the item on “Prevention of Drug Use and Abuse in Brazil” with the following objectives: promote and link continuing activities in drug use prevention in order to inform, discourage initial use, encourage less consumption, and decrease the risks associated with improper use ³⁹39. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça. Relatório de gestão do exercício de 2015. Brasília: Conselho Nacional de Políticas sobre Drogas/Fundo Nacional Antidrogas; 2016.^,4040. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça. Relatório de gestão do exercício de 2016. Brasília: Conselho Nacional de Políticas sobre Drogas/Fundo Nacional Antidrogas; 2017.^,4141. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça. Relatório de gestão do exercício de 2017. Brasília: Conselho Nacional de Políticas sobre Drogas/Fundo Nacional Antidrogas; 2018.. Table 2 presents the date from the last three reports published by SENAD (2015-2017), based on the budget of the National Anti-Drug Fund (FUNAD).

Although the amounts actually spent on preventive measures doubled from 2015 to 2017, there is a discrepancy between what is earmarked in the budget and the amounts actually spent in this sector. Oliveira ⁴²42. Oliveira AB. Fundo nacional antidrogas e o financiamento de programas e ações sobre drogas no Brasil no período de 2012 a 2015 [Monografia]. Brasília: Universidade de Brasília; 2017. points to weakness in the transparency of SENAD’s data, since no information is provided on these funding cuts or on the transfer of some prevention activities to other Ministries.

Until 2013, the Brazilian Federal government lacked specific budget funding for a drug abuse prevention policy. When financing for this policy began, it was for importation of a technology from the United States rather than for fomenting a line of Brazil’s own research on the issue.

The National Division of Mental Health, Alcohol, and Drugs of the Ministry of Health conducted studies for the cultural adaptation of three programs in drug use prevention. These are universal prevention programs originally adapted in the United States: Good Behavior Game ⁴³43. Barrish HH, Saunders M, Wolf MM. Good behavior game: effects of individual contingencies for group consequences on disruptive behavior in a classroom. J Appl Behav Anal 1969; 2:119-24., Unplugged ⁴⁴44. Van der Keeft P, Wiborg G, Galanti M, Siliquini R, Bohrn K, Scatigna M, et al. 'Unplugged': a new European school programme against substance abuse. Drugs (AbingdonEngl) 2009; 16:167-81., and Strengthening Family Program (SFP) ⁴⁵45. Kumpfer KL, Alvarado R, Whiteside H. Family-based interventions for substance abuse and prevention. Subst Use Misuse 2003; 38:1759-87.. According to data requisitioned from the Citizens’ Information Service of the Brazilian Federal government, in 2013 and 2014 the Ministry of Health spent BRL 2,230,020.19 on payments to three international institutions holding the programs’ copyrights - Oxford Brooks University (United Kingodm), University College Ghent (Belgium), and American Institute of Research (United States) - for the programs’ purchase and follow-up of pilot interventions in ten municipalities (counties) in two states of Brazil; hiring translation services for the original teaching materials, illustration, design, dubbing, and printing and distribution to the states and municipalities; and payment of a technical team to supervise the programs’ rollout with the Ministry of Health.

The three programs’ implementation is coordinated by researchers from the Federal University of São Paulo (UNIFESP) and the Federal University of Santa Catarina (UFSC). From 2013 to 2014, these universities received, respectively, BRL 682,866.40 and BRL 299,979.20. Since 2015, the National Division of Mental Health, Alcohol, and Drugs reports that the expenditures have been lower since the programs were acquired with a single payment.

Brazilian prevention programs

The history of drug prevention programs in Brazil is marked by the importation of models developed in other jurisdictions. Canoletti & Soares ¹¹11. Canoletti B, Soares CB. Programas de prevenção ao consumo de drogas no Brasil: uma análise da produção científica de 1991 a 2001. Interface (Botucatu) 2005; 9:115-29. identify two phases in prevention activities in Brazil. The first phase, lasting until the early 1990s, involved the lack of scientific research in the area, scarce and discontinuous prevention activities, and inadequate programs that had been developed in other countries. The second phase occurred under the influence of the AIDS epidemic through programs to prevent HIV transmission from shared injecting drug-use paraphernalia. In this phase, due to investments by the U.N. Educational, Scientific and Cultural Organization (UNESCO), drug use prevention programs began to focus more on education.

The official prevention activities with a national scope that remain to this day are very limited. They are limited to distance training courses, like the System for Detection of Abusive Use and Addiction to Psychoactive Substances: Referral, Brief Intervention, Social Reinsertion, and Follow-up (SUPERA) ⁴⁶46. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça. Sistema para detecção do uso abusivo e dependência de substâncias psicoativas: encaminhamento, intervenção breve, reinserção social e acompanhamento. Módulo 5: atenção integral na rede de saúde. Brasília: Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça; 2016., and a prevention program, the Educational Program for Resistance to Drugs (PROERD), developed in schools by the Military Police since 1992. PROERD is a spinoff of the Drug Abuse Resistance Education (DARE) program, created by the Los Angeles Police Department in 1983 for elementary students. Although PROERD is still offered in schools, studies in the 1990s already showed the inefficacy of DARE ¹⁰10. Strang J, Babor T, Caulkins J, Fischer B, Foxcroft D, Humphreys K. Drug policy and the public good: evidence for effective interventions. Lancet 2012; 379:71-83.^,4747. West SL, O'Neal KK. Project D.A.R.E. Outcome Effectiveness Revisited. Am J Public Health 2004; 94:1027-9.^,4848. Ennett ST, Tobler NS, Ringwalt CL, Flewelling RL. How effective is drug abuse resistense education? A meta-analysis of project DARE outcome evaluations. Am J Public Health 1994; 84:1394-401.. Current studies have also assessed PROERD negatively, reporting the use of scare tactics ⁴⁹49. Domingues VG. Educação e guerra às drogas: uma reflexão sobre o PROERD na escola. Alabastro 2016; 1:56-72. and lack of evidence of efficacy ⁵⁰50. Caputi TL, McLellan AT. Truth and D.A.R.E.: Is D.A.R.E.'s new Keepin' it REAL curriculum suitable for American nationwide implementation? Drugs 2016; 24:49-57..

The drug abuse prevention programs currently implemented in Brazil were renamed on the basis of those that served as their models. Box 1 lists the Brazilian programs and the respective programs originally developed in the United States.

Both the Unplugged program, adapted by a group of European researchers ⁵¹51. Faggiano F, Galanti MR, Bohrn K, Burkhart G, Vigna-Taglianti F, Cuomo L, et al. The effectiveness of a school-based substance abuse prevention program: EU-Dap cluster randomised controlled trial. Prev Med 2008; 47:537-43. from a traditional prevention program from the United States ⁵²52. Botvin G, Griffin K. Life skills training: empirical findings and future directions. J Prim Prev 2004; 25:211-32., and the SFP are based on the global social influence model ⁵³53. Sussman S, Earlywine M, Wills T, Cody C, Biglan T, Dent C, Newcomb MD. The motivation, skills, and decision-making model of "drug abuse" prevention. Subst Use Misuse 2004; 39:1971-2016., which involves teaching life skills to students to avoid pro-drug social influences (especially peers), and to refuse to use drugs, still along the lines of “just say no” from the height of the War on Drugs. The Good Behavior Game was born with different objectives from those of the 1960s. The purpose is to improve the quality of sociability among students themselves and between students and teachers, especially in classrooms where there are children with behavior problems related to social interaction. The central focus is thus not drug use prevention. However, studies have shown that by intervening positively in children’s developmental paths, they tend to become adolescents and adults who are less vulnerable to risk behaviors, including drug abuse ⁵⁴54. Kellam SG, Brown CH, Poduska JM, Ialongo NS, Wang W, Toyinbo P, et al. Effects of a universal clasroom behavior management program in first and second grades on young adult behavioral, psychiatric and social outcomes. Drug Alcohol Depend 2008; 95 Suppl 1:S5-28.^,5555. Kellam SG, Wang W, Mackenzie ACL, Brown H, Ompad DC, Or F, et al. The impact of the Good Behavior Game, a universal classroom-based preventive intervention in first and second grades, on high-risk sexual behaviors and drug abuse and dependence disorders into young adulthood. Prev Sci 2010; 15:6-18..

The Brazilian Ministry of Health recently partnered with the UNIFESP to launch a report with data on the cultural adaptation and assessment of efficacy in the three programs suggested by UNODC ⁵⁶56. Ministério da Saúde; Universidade Federal de São Paulo. Prevenção ao uso de drogas: implantação e avaliação de programas no Brasil. Brasília: Ministério da Saúde; 2018.. Both Elos and #Tamojunto were considered useless, since the positive effects were not maintained in the long term, and also iatrogenic, since they produced negative effects.

The adverse effects included increased aggressiveness and disruptiveness of students assessed as cooperative at the start of the Elos program, who constituted the majority of the sample in the group that received the intervention ⁵⁶56. Ministério da Saúde; Universidade Federal de São Paulo. Prevenção ao uso de drogas: implantação e avaliação de programas no Brasil. Brasília: Ministério da Saúde; 2018.. The #Tamojunto program showed no significant effect on consumption of the target drugs (tobacco, marijuana, cocaine, crack, and binge drinking), besides a 30% increase in the odds of alcohol initiation during the nine-month follow-up after the program’s application ⁵⁷57. Sanchez ZM, Valente Y, Sanudo A, Pereira APD, Cruz JI, Schneider DR, et al. The #Tamojunto drug prevention program in Brazilian schools: a randomized controlled trial. Prev Sci 2017; 18:772-82..

Based on these results, SENAD and the General Division of Mental Health of the Ministry of Health suspended the large-scale implementation of the programs #Tamojunto, Elos, and Famílias Fortes. According to what SENAD considered a “risky” strategy, that is, the rollout of prevention programs in various Brazilian municipalities without pilot projects, it determined a new condition for financing prevention activities. Section IV, Article 1 of CONAD Resolution 1/2018 provides that “promotion and incentives for prevention programs developed by Brazil or adapted to the Brazilian reality in linkage with international agencies should exclusively involve initiatives where the results of the impact are satisfactorily measurable in meeting the objectives of protection” ⁴¹41. Secretaria Nacional de Políticas sobre Drogas, Ministério da Justiça. Relatório de gestão do exercício de 2017. Brasília: Conselho Nacional de Políticas sobre Drogas/Fundo Nacional Antidrogas; 2018. (p. 128).

The Brazilian Ministry of Education did not approve these prevention programs, nor does it participate in their implementation, since they originated in foreign countries and exhibit a methodological proposal that differs from Brazil’s National Educational Policy.

Comparative analysis of the prevention policies

Latin America is witnessing alarming rates of violence related to the internationalization of crime, maintained by the weapons and arms traffic and illegal financial transfers ⁵⁸58. Barreira C, Batista E. (In)Segurança e sociedade: treze lições. Fortaleza: Fundação Demócrito Rocha; 2011., largely created by the War on Drugs. This scenario sparked growing resistance by some Latin American nations to the global prohibitionist model for drug regulation, based almost exclusively on the control of supply. These States have established alternative drug policies and demanded a shift from the paradigm of repressive approaches to preventive interventions with a focus on harm reduction and citizens’ safety ⁵⁹59. Carvalho IS. O despertar da América Latina: uma revisão do novo debate sobre políticas de drogas. Rio de Janeiro: Instituto Igarapé; 2014..

However, the development of social policies in Latin America remains dependent on the policies practiced in the central countries ⁶⁰60. Paiva BA, Ouriques ND. Uma perspectiva latino-americana para as políticas sociais: quão distante está o horizonte? Katálysis 2006; 9:166-75.. The relationship of dependence between First and Third World countries marks the production of knowledge to back public policies in the latter. This dependence divides the nations that create models, the so-called central countries (such as the United States), from those that reproduce models, ideas, technology, and culture (the so-called peripheral countries like Brazil). Knowledge production remains under the command of the central nations, while the peripheral nations are left with the role of consumers of the content conceived in the Northern Hemisphere ⁶¹61. Vecchio R. Ensino superior e a produção de conhecimento no Brasil e na América Latina. REBELA 2012; 2:24-36.. This relationship has shaped drug abuse prevention policy in Brazil. Box 2 compares the characteristics of drug use prevention policies in the United States and Brazil.

Despite significant differences between the drug control policies adopted by the United States and Brazil, the repressive paradigm is imposed via technology transfer as a function of the United States’ political and economic domination. The prohibitionist model is thus maintained, merely shifting the programs’ focus from fear to persuasion.

The harm reduction approach, no longer adopted by Brazil’s drug policy, is based on the assumption that if a drug-free society does not exist, it is plausible to draw on strategies on drug use with the maximum possible safety, acknowledging the different possibilities of use - from recreational, occasional, and frequent to heavy - and thus the different effects: beneficial, neutral, or harmful ⁶²62. Feffermann M, Figueiredo R. Redução de danos como estratégia de prevenção de drogas entre jovens. Bol Inst Saúde 2006; 12:37-40.. This approach requires the replacement of the prevention perspective with education for children and adolescents. Based on the principle that drug consumption results from a relationship between the subject, the drug, and the environment, education is essential for autonomy and self-protection and community protection ⁶³63. Acselrad G. Avessos do prazer: drogas, aids e direitos humanos. 2ª Ed. Rio de Janeiro: Editora Fiocruz; 2005.. Studies that assess practices of care for drug users in Brazil’s health services, both in primary care and in mental health services, are still based on the prohibitionist model and stigmatizing and moralizing approaches, besides displaying insufficient knowledge on the drug issue’s complexity ⁶⁴64. Malvezzi CD, Nascimento JL. Cuidado aos usuários de álcool na atenção primária: moralismo, criminalização e teorias da abstinência. Trab Educ Saúde 2018; 16:1095-112.^,6565. Carvalho B, Dimenstein M. Análise do discurso sobre redução de danos num CAPSad III e em uma Comunidade Terapêutica. Temas Psicol (Online) 2017; 25:647-60..

The economic and political interests that determine drugs’ legality or illegality become evident in both the United States and Brazil, since the arguments for protecting subjects’ health fail to stand up due to the significant individual and social harms caused by legal drugs. The public policies reflect these interests. Government policy-making for drug prevention in Brazil has been based on programs that are questioned on epistemological, theoretical, and methodological grounds ⁶⁶66. Gorman DM. Hypothesis testing and the EU-Dap evaluation of the Unplugged curriculum. Prev Med 2009; 48:604-5.^,6767. Foxcroft DR, Callen H, Davies EL, Okulicz-Kozaryn K. Effectiveness of the strengthening families programme 10-14 in Poland: cluster randomized controlled trial. Eur J Public Health 2017; 27:494-500.^,6868. Riesch SK, Brown RL, Wang K, Canty-Mitchell J, Johnson DL. Strengthening Families Program (10-14): effects on the family environment. West J Nur Res 2012; 34:340-76.^,6969. Gorman DM, Conde E, Huber JC. The creation of evidence in 'evidence-based' drug prevention: a critique of the Strengthening Families Program plus life skills training evaluation. Drug Alcohol Rev 2007; 26:585-93..

In the United States, a country whose health system is not universal, the Third Sector emerges as the “ideological justification for the State’s disengagement in terms of public action” ⁷⁰70. França Filho GC. Terceiro setor, economia social, economia solidária e economia popular: traçando fronteiras conceituais. Bahia: Análise & Dados 2002; 12:9-19. (p. 11). Private nonprofit nongovernmental organizations (NGOs) predominantly execute the prevention programs.

In Brazil, although the Unified National Health System (SUS) is written into the Constitution and other laws, guaranteeing its full execution is still one of the country’s greatest challenges. Teixeira & Paim ⁷¹71. Teixeira CFS, Paim JS. A crise mundial de 2008 e o golpe do capital na política de saúde no Brasil. Saúde Debate 2018; 42:11-21. identify three strategies in the dismantling of the SUS: approval by the Executive and Legislative branches for participation by foreign capital in health, outsourcing, and health plans; defense by the media, politicians, and part of the middle class of the creation of a precarious SUS for the poor; and underfinancing via one of the most drastic onslaughts on the SUS: Constitutional Amendment 95/2016 (the ceiling on budget spending). Underfinancing of mental health is part of the chronic underfinancing of the SUS ⁷²72. Trapé TL, Onocko-Campos R. Modelo de atenção à saúde mental do Brasil: análise do financiamento, governança e mecanismos de avaliação. Rev Saúde Pública 2017; 51:19.. From 2001 to 2016, the Ministry of Health spent an average of 2.4% of the annual budget of the SUS on mental health ⁷³73. Oliveira EFA. Gastos da política de saúde mental e os rumos da Reforma Psiquiátrica [Tese de Doutorado]. Vitória: Universidade Federal do Espírito Santo; 2017., when the World Health Organization recommends that funds allocated to mental health should represent 5% of the health budget.

Financing for mental health was cut by 0.8% from 2010 and 2016, and this decrease is related directly to implementation of the plan “Crack, It is Possible to Win”, due to the reallocation of expenses between old and new items. The plan regulates the costing of therapeutic communities, one of the largest expenses in the program, which runs counter to the Psychiatric Reform Law, since it represents a return to the asylum model and a form of privatization of mental health ⁷²72. Trapé TL, Onocko-Campos R. Modelo de atenção à saúde mental do Brasil: análise do financiamento, governança e mecanismos de avaliação. Rev Saúde Pública 2017; 51:19.^,7474. Garcia ML, Oliveira EF. An analysis of the federal funding for mental health care in Brazil. Soc Work Health Care 2017; 56:169-88., besides lacking evidence of the efficacy of compulsory hospitalization ⁷⁵75. Werb D, Kamarulzaman A, Meacham MC, Rafful D, Fischer B, Strathdee SA, et al. The effectiveness of compulsory drug treatment: a systematic review. Int J Drug Policy 2016; 28:1-9..

Mapping of preventive actions conducted in Brazil is limited. Abreu et al. ⁷⁶76. Abreu S, Miranda APV, Murta SG. Programas preventivos brasileiros: quem faz e como é feita a prevenção em saúde mental? Psico USF 2016; 21:163-77. performed a systematic review aimed at identifying Brazilian centers that systematically develop preventive interventions and describing assessment studies of the programs. The review’s results showed that the programs are executed by public universities in the Southeast of Brazil, with a small share supported by research agencies. The authors also found that 62.79% of the programs are targeted to schools and that only 6.82% focus on drug use. They conclude that the methodological limitations in the studies’ design require a cautious assessment of the data on the programs’ efficacy. Laport et al. ⁷⁷77. Lapot TJ, Costa PHA, Mota DCB, Ronzani TM. Percepções e práticas dos profissionais da atenção primária à saúde na abordagem sobre drogas. Psicol Teor Pesq 2016; 32:143-50. showed that primary care professionals, in principle, are those responsible for prevention and health promotion in Brazil, and still adopt a practice centered on the curative perspective in relation to drugs, both as a function of limitations in training and the organizational culture established in Brazil’s health units.

For a public policy to be considered effective, it must be sensitive to the context in which it will be adopted. In a country like Brazil with profound socioeconomic inequalities, young people do not have access to leisure, sports, or spaces for social interaction, and drugs emerge in this context as one of the few options for pleasure. Thus, persuading young people to refuse to use drugs appears not to be a feasible pathway in this scenario, even if such persuasion involves interactive strategies and realistic information on drugs. These are merely new means to maintain old practices.

Tensions persist between the prohibitionist model and the harm reduction model, between the provisions of the policies for drug abuse prevention by SENAD and the Ministry of Health and what is actually executed. Thus, prevention activities remain in the middle of the clash between the psychosocial paradigm and the curative and asylum-based mental health perspective. Law n. 13,840/2019, by deepening the repressive side of Law n. 11,343/2006, tends to aggravate the obstacles to the elaboration of educational programs focused on the promotion of young people’s reflection and responsibility towards drugs.

Final remarks

The War on Drugs failed. More than acknowledging the scientific evidence proving this fact, it is necessary, first and foremost, to overcome Brazil’s dependence on U.S. domination. Although Brazil is signatory to the United Nations’ prohibitionist conventions, the inefficacy of preventive programs, with insignificant results on the prevalence of drug use by youth, highlights the need to deconstruct the logic of persuasion in order to elaborate that of education.

According to Soares & Jacobi ⁷⁸78. Soares CB, Jacobi PR. Adolescentes, drogas e Aids: avaliação de um programa de prevenção escolar. Cad Pesqui 2000; 109:213-37., a prevention program is defined not only by its theoretical and methodological frame of reference, but also by its ideological premises. It is thus important to seek autonomy from the prevention models imported from the United States, through a wider debate among researchers, health professionals, users, and social movements to lead to more adequate policies for Brazil, aimed at building educational programs that allow Brazilian children and adolescents to make more authentic choices and that minimize their conditions of vulnerability. Despite all the obstacles cited in this study on Brazil’s programs for drug abuse prevention, one should emphasize the attempt to draft a policy based on scientific evidence as an inestimable gain for the country.

This study aims to contribute to the debate on prevention, currently on the rise in Brazil, analyzing pertinent and sovereign strategies for a national drug policy that serves the Brazilian reality. The study has some limitations, since the selected prevention programs were limited to those offered to children and adolescents in the school setting. Future studies can investigate the analyses of efficacy of different Brazilian prevention programs that have already been elaborated.

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