Abstract

Introduction

Healthcare services and actions for persons with abusive drug use have been consolidated at the national level in Brazil since the early 2000s, based on the Policy of Comprehensive Care for Users of Alcohol and Other Drugs (PAIUAD 2003) ¹1. Ministério da Saúde. A política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília: Ministério da Saúde; 2003.. Previous government drug policies had been limited historically to the narrow and violent spaces of law enforcement, prisons, and/or mental hospitals. The approach to users, when it existed, was done from the logic of control and punishment ²2. Soares CB. Consumo contemporâneo de drogas e juventude: a construção do objeto na perspectiva da saúde coletiva [Tese de Livre-Docência]. São Paulo: Departamento de Enfermagem em Saúde Coletiva, Escola de Enfermagem, Universidade de São Paulo; 2007.^,33. Machado l, Boarini M. Políticas sobre drogas no Brasil: a estratégia de redução de danos. Psicol Ciênc Prof 2013; 33:580-95.^,44. Souza DR, Oliveira MAF, Soares RH, Domanico A, Pinho PH. Resistências dos profissionais da atenção psicossocial em álcool/drogas à abordagem de redução de danos. J Nurs Health 2017; 7:16-24..

The very distinction between drug use and drug dealing was only consolidated in the 21st century, approximately 15 years ago, with Resolution n. 3/2005 by what was then the Brazilian National Anti-Drugs Council (CONAD), allowing a specific approach to abusive use without strictly legal contradictions. Drug abuse is characterized by producing physical, psychosocial, and/or social harms, including a range of health harms, aggravating users’ vulnerability and social conflicts ⁵5. Medeiros PFP, Garcia LSL, Kinoshita RT, Santos PS, Hayashida G. Rede de Atenção Psicossocial no Sistema Único de Saúde (SUS): Eixo Políticas e Fundamentos. Brasília: Secretaria Nacional de Políticas sobre Drogas; 2017..

The inclusion of a new paradigm on drugs is based at the national level on the above-mentioned PAIUAD ¹1. Ministério da Saúde. A política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília: Ministério da Saúde; 2003.. The policy launched a set of theoretical frameworks and respective practices of care that had been developed in various places, including psychosocial care and harm reduction, aligned with the public system under the field of collective health. This came to be understood as the psychosocial or collective health paradigm in the field of drugs ⁶6. Santos V, Soares CB. O consumo de substâncias psicoativas na perspectiva da saúde coletiva: uma reflexão sobre valores sociais e fetichismo. Saúde Transform Soc 2013; 4:38-54.^,77. Brites C. Política de drogas no Brasil: usos e abusos. In: Bokany V, organizadora. Drogas no Brasil: entre a saúde e a justiça. Proximidades e opiniões. São Paulo: Editora Fundação Perseu Abramo; 2015. p. 119-42.. However, the policy did not prevent the dispute for spaces with notions of control and punishment based on a moralistic and biomedical approach ⁸8. Passos E, Souza T. Redução de danos e saúde pública: construções alternativas à política global de "guerra às drogas". Psicol Soc 2011; 23:154-62.^,99. Teixeira M, Ramôa ML, Engstrom E, Ribeiro JM. Tensões paradigmáticas nas políticas públicas sobre drogas: análise da legislação brasileira no período de 2000 a 2016. Ciênc Saúde Colet 2017; 22:1455-66..

These frameworks that comprise the psychosocial paradigm share an important pillar, namely the counterpoint to the biomedical-psychiatric and moral model (which joins liberal economic policies to constitute the “War on Drugs”) ¹⁰10. Hornstein C. Guerra às drogas: "por que não tentar diferente depois de tanto fracasso?". Carta Maior 2014; 14 mai. https://www.cartamaior.com.br/?/Editoria/Direitos-Humanos/Guerra-as-drogas-por-que-nao-tentar-o-diferente-depois-de-tanto-fracasso-/5/30923.
https://www.cartamaior.com.br/?/Editoria... ^,1111. Gomes-Medeiros D, Faria PH, Campos GWS, Tófoli LF. Política de drogas e Saúde Coletiva: diálogos necessários. Cad Saúde Pública 2019; 35:e00242618.. The biomedical model and its conception of health was heavily criticized in the late 20th century for failing to explain the population’s health-illness process, health systems planning, and the effectiveness of measures of care ¹²12. Paim JS, Almeida Filho N. A crise da saúde pública e a utopia da saúde coletiva. Salvador: Casa da Qualidade Editora; 2000.^,1313. Buss PM. Promoção da saúde e qualidade de vida. Ciênc Saúde Colet 2000; 5:163-77..

Thus, the new orientation based on empirical processes and the expanded concept of health developed new definitions in the collective terrain of care. This concept of health reveals the conditions of production and reproduction of life for populations, the bonds established under these conditions, and the uniqueness of individual subjects ¹⁴14. Campos GW, Barros RB, Castro AM. Avaliação de política nacional de promoção da saúde. Ciênc Saúde Colet 2004; 9:745-9.. The process launched a valuing of the subjective dimension and the potentialities of users and healthcare workers, fostering new perspectives for reflection and action ¹⁵15. Czeresnia D. O conceito de saúde e a diferença entre prevenção e promoção. In: Czeresnia D, Freitas CM, organizadores. Promoção da saúde: conceitos, reflexões, tendências. Rio de Janeiro: Editora Fiocruz; 2003. p. 43-58.^,1616. Fleury-Teixeira P, Vaz FA, Campos FC, Alvares J, Oliveira V, Aguiar R. Autonomia como categoria central no conceito de promoção de saúde. Ciênc Saúde Colet 2008; 13 Suppl 2:2115-22.. The understanding was that not only institutional actions impact the health of subjects and groups, but that actions by these subjects can also impact health and the development of practices of care. The concept that unifies the importance of subjectivity and subjects’ protagonist role is building autonomy ¹⁷17. Kinoshita RT. Contratualidade e reabilitação psicossocial. In: Pitta A, organizador. Reabilitação psicossocial no Brasil. 2ª Ed. São Paulo: Hucitec Editora; 2001. p. 55-9.^,1818. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em saúde: um desafio para o público. 2ª Ed. São Paulo: Hucitec Editora; 2002. p. 71-112..

According to Kinoshita ¹⁷17. Kinoshita RT. Contratualidade e reabilitação psicossocial. In: Pitta A, organizador. Reabilitação psicossocial no Brasil. 2ª Ed. São Paulo: Hucitec Editora; 2001. p. 55-9., building autonomy contends that subjects should be acknowledged as bearers of social value, that they are no less responsible due to their suffering and diagnosis, and that it is necessary to respect their wishes in practices of care, besides seeking to allow participation in building a new social place for individuals excluded by stigmatization. Amarante ¹⁹19. Amarante PDC. Avaliação dos novos serviços de saúde mental: em busca de novos parâmetros. Saúde Debate 1996; 52:74-83. emphasizes that the principal way of assessing services resulting from the psychiatric reform (e.g., current services in the field of drugs) should be the degree of autonomy established between users, healthcare workers, and society, and that there should always be a critical assessment of actions and places of care, to prevent the transformation of the logic of care from merely becoming a kind of technocratic and institutional reorganization.

Therefore, the construction (by care) of autonomous subjects is the objective of therapeutic processes in healthcare services for persons with abusive drug use. Furthermore, the frameworks that comprise this new healthcare policy led to numerous actions and conceptions that develop the notion of building autonomy ²⁰20. Basaglia F. As instituições da violência. In: Basaglia F, organizador. A instituição negada. Rio de Janeiro: Edições Graal; 1985. p. 99-134.^,2121. Rotelli F. A instituição inventada. In: Rotelli F, Leonardis O, Mauri D, Risio C, organizadores. Desinstitucionalização. São Paulo: Hucitec Editora; 1990. p. 89-99..

However, as far as we known there is no study that addresses these various practical actions in different realities. Furthermore, the clash with the “War on Drugs” policy has been intense, potentially leading to the loss of the development of the foundations for building autonomy (which was achieved during the years in which the psychosocial paradigm was consolidated). An example of this clash in Brazil is the undermining of harm reduction in the national drug policy by Executive Order n. 9,761/2019, which proclaims total abstinence, in addition to major public investments in therapeutic communities that exceed the funding for the entire Network of Psychosocial Care (RAPS) ²²22. Ribeiro FML, Minayo MCS. As mudanças na política brasileira de drogas: o avanço da lógica da justiça sobre a saúde. Revista Cultura y Droga 2020; 25:17-39.. Changes to the legislation on primary healthcare have also led to budget cuts, a possible decrease in the number of community health agents, and reversal of prioritization for the territorial base of Expanded Center for Family Health (NASF) teams ²³23. Massuda A. Mudanças no financiamento da atenção primária à saúde no sistema de saúde brasileiro: avanço ou retrocesso? Ciênc Saúde Colet 2020; 25:1181-8.^,2424. Silva T, Soares AN, Lacerda GA, Mesquita JF, Silveira DC. Política Nacional de Atenção Básica 2017: implicações no trabalho do agente comunitário de saúde. Saúde Debate 2020; 44:58-69..

The current study thus aims to describe the strategies for building autonomy identified in healthcare services, producing an overview of the RAPS and verifying whether the actions are consistent with the objectives and guidelines of Brazil’s mental health and drug policy. Given this policy’s dismantlement, the study also aims to identify the necessary transformations, including as the basis for assessment of the changes under way.

The current article thus aims to describe the strategies for building autonomy identified in Brazilian public healthcare services for persons with abusive use of crack cocaine, alcohol, and other drugs, based on an integrative review.

Method

This study is a qualitative literature review that followed the methodological stages for the development of integrative literature reviews ²⁵25. Ercole FF, Melo LS, Alcoforado CC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm 2014; 18:9-12..

Integrative review is a method that allows adding knowledge from different studies on the same theme, including studies from different disciplines and with distinct methods ²⁶26. Souza MT, Silva M, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6.^,2727. Soares CB, Hoga LA, Peduzzi M, Sangaleti C, Yonekura T, Silva DR. Revisão integrativa: conceitos e métodos utilizados na enfermagem. Rev Esc Enferm USP 2014; 48:335-45.. Integrative review thus allows the synthesis of results, so long as the data are organized and analyzed rigorously, explaining their basis and methodology ²⁷27. Soares CB, Hoga LA, Peduzzi M, Sangaleti C, Yonekura T, Silva DR. Revisão integrativa: conceitos e métodos utilizados na enfermagem. Rev Esc Enferm USP 2014; 48:335-45.. Integrative review allows approaching different objectives such as the definition of the studies’ concepts and review of theories or methodological analysis ²⁵25. Ercole FF, Melo LS, Alcoforado CC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm 2014; 18:9-12.^,2626. Souza MT, Silva M, Carvalho R. Revisão integrativa: o que é e como fazer. Einstein (São Paulo) 2010; 8:102-6..

Importantly, integrative review fosters an understanding of healthcare, which is characterized as complex work requiring collaboration and integration of different areas of knowledge. Healthcare thus features not only the development of the basis for policies and procedures, but also the critical thinking required for such care ²⁸28. Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization-focused integrative reviews in a nursing service. Appl Nurs Res 1998; 11:195-206.. According to Ercole et al. ²⁵25. Ercole FF, Melo LS, Alcoforado CC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm 2014; 18:9-12., the variety in the sample’s composition and the multiplicity of purposes result in a situation “of complex concepts, theories, or problems pertaining to healthcare” ²⁵25. Ercole FF, Melo LS, Alcoforado CC. Revisão integrativa versus revisão sistemática. REME Rev Min Enferm 2014; 18:9-12. (p. 9).

Selection and organization

From August to September 2019, searches were conducted in the databases PsycInfo, PubMed, VHL (Virtual Health Library), and Web of Science.

The searches were performed according to an appropriate protocol for each database, especially with the descriptors or keywords found in their thesaurus, but also dictionaries. Each database was thus accessed with the following descriptors and combinations, with terms in both the singular and plural.

Terms in the search protocol in Portuguese: (serviço de saúde mental, serviço de higiene mental, centro de atenção psicossocial, centro de tratamento de abuso de substâncias, centro de tratamento de dependentes de drogas ilícitas, centro de tratamento de toxicômanos, centro de tratamento de abusos de drogas, centro de reabilitação de drogados, CAPS, CAPS-AD, consultório na rua, unidade básica de saúde, atenção primária, saúde da família), AND (usuário de drogas, dependente químico, drogadito, farmacodependente, viciado em drogas, drogas ilícitas, drogas de abuso, drogas recreativas, drogas, crack, cocaína, álcool), AND (autonomia, autonomia pessoal, empoderamento, cidadania, direitos do paciente, direitos civis).

Terms in the search protocol in English: (mental health services, mental hygiene services, substance abuse treatment centers, drug rehabilitation centers, drug abuse treatment centers, drug treatment centers, psychosocial care centers, CAPS, CAPS-AD, primary health care, family health, street clinic, street office, street outreach office) AND (drug user, drug abuser, addict, drug-dependent, doper, druggie, stoner, junkie, drugs, crack, cocaine, alcohol, street drugs, drug abuse) AND (personal autonomy, free will, self-determination, empowerment, freedom of choice, civil rights, client rights, interpersonal control, autonomy, patient’s rights).

After searching the databases with the search protocols and the exclusion of duplicate studies in the End-Note Web program (https://endnote.com/), the exclusion and inclusion criteria were applied according to the review’s objective. The exclusion criteria were: (1) studies in which the population or object was not Brazilians; (2) the study’s theme was different from care for persons with abusive drug use; (3) the study site did not correspond to public services or the data on the site or service were insufficient; (4) the studies addressed aspects that did not allow the analysis of building autonomy; (5) the study’s data were not primary. Studies were selected if they: (1) addressed the concept of autonomy and (2) used primary data. After verification of these criteria, 19 articles were left. After reading the articles, three more were added based on the list of references. Figure 1 summarizes the selection and exclusion flow.

The results presented here were produced according to the steps for analysis of qualitative data developed by Minayo ²⁹29. Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. 11ª Ed. São Paulo: Hucitec Editora; 2008., which include ordering of the data, classification, and final analysis. The ordering stage corresponds to mapping the respective data. The classification stage includes a survey of the relevant information concerning the data’s content, based on questions grounded in the theoretical references, where it is possible to elaborate synthesis-categories. The final analysis stage aims to form linkages between the data and the theoretical references, which should be directed to the study’s objectives.

Analytical path

The following stages were performed to systematize and describe the actions and barriers in the strategy for building autonomy by the services discussed in the selected studies.

The first stage was the development of an instrument for systematization, referring to Box 1, which presents a set of 16 actions pertaining to the process of building autonomy and five principal difficulties.

These 16 actions and five difficulties were selected and organized according to three references: the RAPS guidelines ³⁰30. Ministério da Saúde. 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 (SUS). Diário Oficial da União 2013; 21 mai.; the orientation in the technical material by the Brazilian National Secretariat for Drug Policy (SENAD) ⁴4. Souza DR, Oliveira MAF, Soares RH, Domanico A, Pinho PH. Resistências dos profissionais da atenção psicossocial em álcool/drogas à abordagem de redução de danos. J Nurs Health 2017; 7:16-24.; and the principles of psychosocial care as state in Yasui ³¹31. Yasui S. Rupturas e encontros: desafios da reforma psiquiátrica brasileira [Tese de Doutorado]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2006., resulting in Box 1.

The actions described in Box 1 were divided into three dimensions, corresponding to the first three columns in the chart. The latter come from the conceptual synthesis on building autonomy, based mainly on Kinoshita ¹⁷17. Kinoshita RT. Contratualidade e reabilitação psicossocial. In: Pitta A, organizador. Reabilitação psicossocial no Brasil. 2ª Ed. São Paulo: Hucitec Editora; 2001. p. 55-9., Merhy ¹⁸18. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em saúde: um desafio para o público. 2ª Ed. São Paulo: Hucitec Editora; 2002. p. 71-112., and Onocko-Campos & Campos ³²32. Onocko-Campos R, Campos GWS. Co-construção de autonomia: o sujeito em questão. In: Campos GWS , Minayo MCS, Akerman M, Drumond JM, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec Editora/Rio de Janeiro: Editora Fiocruz; 2006. p. 669-88., namely: (1) uniqueness, reclaiming autonomy in the therapeutic process, (2) bonds, in shared construction of autonomy, and (3) the social and political dimension, building autonomy with a collective scope.

The second stage involves the verification of which actions in Box 1 are developed in the selected services and which barriers in the strategy for building autonomy were found in the selected studies. This verification was based on an exhaustive reading of the 22 studies.

Results and discussion

We begin with the data on identification and publication of the 22 selected studies in Box 2. These include the first author’s undergraduate training, year of publication, journal in which the study was published, title, categorization/location of the health service, and study’s objective.

These 22 studies addressed primary healthcare services (health units and street clinics) and specialized care (Centers for Psychosocial Care for Alcohol and Drug Abuse - CAPS AD). Box 3 presents the actions developed in each site.

The first column in Box 3 lists the study number. The second to fourth columns list the actions developed, organized in the three dimensions presented in Box 1. The fifth column describes the limitations encountered in each service. In the last column, the service was categorized according to the predominant dimension of building autonomy.

We used the results of the review to describe the set of actions in building autonomy that have occurred in the respective services, as well as their limitations, which was the proposed objective. This allows highlighting characteristics of the RAPS that have produced progress or setbacks in this process.

The key activities include those related to the first dimension, or uniqueness, reclaiming autonomy in the therapeutic process. These actions, namely receiving deinstitutionalized care (i.e., with the user in liberty), with solidarity and a reference healthcare provider, development of a unique treatment plan (UTP), care in a territory-based facility, and the organization of groups and workshops were found in most of the services. No requirement of abstinence was most infrequently cited action (11 studies). Many services also report actions in the second dimension, such as the promotion of shared responsibility in the therapeutic process (13 studies), collaborative care with other facilities in the network (9 studies), and harm reduction strategies/workshops (8 studies).

In the social and political dimension of building autonomy, almost no actions were reported, only five in different services (initiatives in work/income generation and participation in users’ associations, three and two times, respectively). However, all the services showed difficulties or limits for building autonomy, especially difficulties in “relations with facilities in the inter-sector network or lack of network” and “lack of healthcare professionals or professional training”, cited in 18 and 12 studies, respectively.

The studies thus show that there are important consolidated services in Brazil with various actions in care for drug users, aimed at building their autonomy through healthcare. There is a cohesive set of practices in keeping with the theoretical foundations of the psychosocial paradigm. However, many of these services still emphasize abstinence, and the healthcare providers display a limited understanding of these theoretical foundations. These actions are constituted by the territory-based facilities, functioning with open doors and promoting deinstitutionalized care (in liberty) through interdisciplinary teams.

Within the specificities of each service (CAPS AD and primary care), most of the services analyzed here develop such actions, which prove to be essential for users to view them as places of care in which they can place their trust, addressing their immediate health needs and with continuous follow-up.

However, according to the psychosocial paradigm, the strategy of building autonomy should not apply only inside the facilities’ walls. The services are immersed geographically in their territory precisely to articulate it, to discover and explore the established bonds, as well as to create new possibilities for support networks, to create facilities to guarantee rights, leisure, art, and culture ³¹31. Yasui S. Rupturas e encontros: desafios da reforma psiquiátrica brasileira [Tese de Doutorado]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2006.^,3333. Amarante P, Lancetti A. Saúde mental e saúde coletiva. In: Campos GWS, Minayo MCS, Akerman M, Drumond JM, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec Editora/Rio de Janeiro: Editora Fiocruz; 2006. p. 615-34.. They should also link actions to generate employment and income to the facilities in the RAPS and integrate the users’ families with the institutions involved in the therapeutic process. This allows users, who often need to deal with stigmatization, to be part of the social milieu, to develop the autonomy provided by reclaiming value and self-care within the services ²¹21. Rotelli F. A instituição inventada. In: Rotelli F, Leonardis O, Mauri D, Risio C, organizadores. Desinstitucionalização. São Paulo: Hucitec Editora; 1990. p. 89-99..

Thus, viewing the systematization of actions and considering the previous reflections, we find that actions in relational autonomy fall short of actions in the dimension of valuing uniqueness. The strategy of building autonomy in the social and political dimension, namely the development of citizenship within society, is practically nonexistent.

Thus, the actions by services that users say develop their autonomy, such as sheltering, the unique treatment plan, and nonmandatory groups, stand out as a huge stride in comparison to approaches based on reclusion and objectification. This is consistent with other authors who report that users feel welcomed and in a process of territory-based care with adequate treatment plans ³⁴34. Sena J. Produção do cuidado no Centro de Atenção Psicossocial de Fortaleza - CE: limites e desafios na construção da autonomia do usuário [Dissertação de Mestrado]. Fortaleza: Universidade Estadual do Ceará; 2010.^,3535. Borges CD, Schneider DR. Trajetória do cuidado e o percurso ao CAPSad: com a palavra os usuários. Cadernos Brasileiros de Saúde Mental 2018; 10:224-49.. The notion of respect for choices and the characteristics of the second dimension of autonomy, i.e., network-based care, allow shared responsibility for treatment, as recommended in the literature ¹⁷17. Kinoshita RT. Contratualidade e reabilitação psicossocial. In: Pitta A, organizador. Reabilitação psicossocial no Brasil. 2ª Ed. São Paulo: Hucitec Editora; 2001. p. 55-9.^,1818. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em saúde: um desafio para o público. 2ª Ed. São Paulo: Hucitec Editora; 2002. p. 71-112..

Non-obligation is also an important factor for the therapeutic process to develop, since it allows the continuity of bonds, which happens frequently in the care for users by street clinics ³⁶36. Londero M, Ceccim R, Bilibio L. Consultório de/na Rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18:251-60.^,3737. Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer RCB, Moreira R. Consultório na Rua: as práticas de cuidado com usuários de álcool e outras drogas em Macapá. Esc Anna Nery Rev Enferm 2019; 23:e20180261.. Furthermore, the notion of conquering their space and bonds, even in conditions that entail vulnerabilities, show that users fear returning to a life that also included many difficulties, such as violent family relations, unhealthy work relations, poverty, etc. ³⁶36. Londero M, Ceccim R, Bilibio L. Consultório de/na Rua: desafio para um cuidado em verso na saúde. Interface (Botucatu) 2014; 18:251-60.^,3838. Paula M, Jorge MB, Vasconcelos M, Albuquerque R. Assistência ao usuário de drogas na atenção primária à saúde. Psicol Estud 2014; 19:223-33..

Thus, when the approach to users builds bonds of trust, they acknowledge the service’s importance, since in these studies healthcare providers and users report that the stigmatization towards abusive drug use is real and brings real losses, such as loss of employment, family ties, and material goods, beyond the health difficulties, so that users want to adhere to the therapeutic process. That is, respect and shared responsibility are essential principles, as affirmed by Onocko-Campos & Campos ³²32. Onocko-Campos R, Campos GWS. Co-construção de autonomia: o sujeito em questão. In: Campos GWS , Minayo MCS, Akerman M, Drumond JM, Carvalho YM, organizadores. Tratado de saúde coletiva. São Paulo: Hucitec Editora/Rio de Janeiro: Editora Fiocruz; 2006. p. 669-88..

Another important action related to valuing users and shared responsibility is the service’s collective organization ²⁰20. Basaglia F. As instituições da violência. In: Basaglia F, organizador. A instituição negada. Rio de Janeiro: Edições Graal; 1985. p. 99-134.^,3939. Saraceno B. Libertando identidades: da reabilitação psicossocial à cidadania possível. Rio de Janeiro: Instituto Basaglia/Te Cora; 2001.^,4040. Junqueira A, Carniel IC, Mantovani A. As assembleias como possibilidades de cuidado em saúde mental em um CAPs. Vínculo 2015; 12:31-40.. Examples include discussions in assemblies, joint development of workshops, in which users themselves can reclaim and share their values and knowledge (on music, poetry, and other arts, computer work, carpentry, photography, etc.), organization of events such as seminars (on health and drugs, the city and the territory, etc.), and commemorative events (Deinstitutionalization Day, June Festivals, Carnival, etc.). However, these actions are infrequent in practice, as evidenced in the chart on systematization, corroborating other studies ⁴¹41. Godoy MC, Viana A, Vasconcelos K, Bonvini O. O compartilhamento do cuidado em saúde mental: uma experiência de cogestão de um centro de atenção psicossocial em Fortaleza, CE, apoiada em abordagens psicossociais. Saúde Soc 2012; 21 Suppl 1:152-63.^,4242. Martins J. CAPS AD III entre a cor cinza da técnico-burocracia e as cores vibrantes que articulam clínica e política [Dissertação de Mestrado]. São Cristóvão: Universidade Federal de Sergipe; 2015.^,4343. Tibiriçá V, Luchini E, Almeida C. Perspectiva do usuário de drogas sobre seu tratamento e a rede de atenção psicossocial. SMAD, Rev Eletrônica Saúde Mental Álcool Drog 2019; 15:1-9..

The groups approaching harm reduction are also important, with collective education on drugs and the relationship to healthcare and reduction of social risks, including sharing the users’ own knowledge. Users share not only their experiences with drug use, but also difficulties in the territory, violence, and access to healthcare ⁴⁴44. Gomes T, Vecchia MD. Estratégias de redução de danos no uso prejudicial de álcool e outras drogas: revisão de literatura. Ciênc Saúde Colet 2018; 23:2327-38.. Groups are especially important in the health units, where follow-up daily or several times a week would be difficult. Groups thus allow overcoming certain health iniquities while also increasing self-esteem and autonomy in daily life processes ⁴⁵45. Vasconcelos SC, Frazão I, Vasconcelos E, Cavalcanti A, Monteiro E, Ramos V. Demandas de autocuidado em grupo terapêutico: educação em saúde com usuários de substâncias psicoativas. Rev Enferm UERJ 2013; 21:79-83..

The notion of relational autonomy is also highlighted in the studies through users’ immersion in an external support network, among other reasons because even while attending the services they do not fail to have a territorial network of relations ⁴⁶46. Lacerda A. Redes de apoio social no Sistema da Dádiva: um novo olhar sobre a integralidade do cuidado no cotidiano de trabalho do agente comunitário de saúde [Tese de Doutorado]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2010.^,4747. Peiter P, Belmonte P, Teixeira M, Cobra G, Lacerda A. Homeless crack cocaine users: territories and territorialities in the constitution of social support networks for health. Soc Sci Med 2019; 227:111-8.. However, it is a dimension that faces many difficulties due to the lack of relations between the network’s facilities and the healthcare providers’ difficulty in being in the territory to strengthen the established bonds. This emphasizes the need for the family’s involvement through associations and social centers, as well as the connection to educational institutions (especially for adolescents). Still, these actions do not take place in the services studied here either. The closest thing is the work by healthcare providers in the NASF and the community health agents ⁴⁸48. Oliveira EM, Santos NTV. A rede de assistência aos usuários de álcool e outras drogas: em busca da integralidade. In: Santos LMB, organizador. Outras palavras sobre o cuidado de pessoas que usam drogas. Porto Alegre: Conselho Regional de Psicologia do Rio Grande do Sul; 2010. p. 71-86.^,4949. Cardoso MP, Agnoll R, Taccolini C, Tansini K, Vieira A, Hirdes A. A percepção dos usuários sobre a abordagem de álcool e outras drogas na atenção primária à saúde. Aletheia 2014; (45):72-86..

Therefore, the lack of policies for work and income, housing, associations of users and families, and territory-based cultural initiatives in which users are protagonists, as well as violent incursions in the territory by the public powers constitute the main barrier, an obvious limit on building autonomy by the networks to which the facilities belong. And if we consider building autonomy as a process, we identify a gap in it. As proposed by Jervis ⁵⁰50. Jervis G. Manuale critico di psichiatria. Milano: Feltrinelli; 1975. and Sena ³⁴34. Sena J. Produção do cuidado no Centro de Atenção Psicossocial de Fortaleza - CE: limites e desafios na construção da autonomia do usuário [Dissertação de Mestrado]. Fortaleza: Universidade Estadual do Ceará; 2010., the development of full citizenship takes place in the community and society in which people live and in which they are marginalized.

This gap increases significantly with the absence of continuous training in health under the principles and actions of the psychosocial paradigm, especially harm reduction, preventing for example the development of harm reduction workshops ⁵¹51. Coelho HV, Soares CB. Práticas na atenção básica voltadas para o consumo prejudicial de drogas. Rev Esc Enferm USP 2014; 48:111-9.^,5252. Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Ciênc Saúde Colet 2016; 21:1839-48.. This also results in the lack of a critical view by healthcare workers vis-à-vis the centrality of diagnoses and the “War on Drugs” notion, resulting in turn in users’ objectification and the focus on detox treatment and abstinence ⁵³53. Rosenstock KIV, Neves MJ. Papel do enfermeiro da atenção básica de saúde na abordagem ao dependente de drogas em João Pessoa, PB, Brasil. Rev Bras Enferm 2010; 63:581-6.^,5454. Lima A, Dimenstein M, Macedo JP. Consumo de álcool e drogas e o trabalho do psicólogo no núcleo de apoio à saúde da família. Psicol Pesq 2015; 9:188-97.. This obviously also results from the difficulty in working in teams with limited numbers of healthcare professionals and in precarious services, as identified by Bittencourt et al. ³⁷37. Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer RCB, Moreira R. Consultório na Rua: as práticas de cuidado com usuários de álcool e outras drogas em Macapá. Esc Anna Nery Rev Enferm 2019; 23:e20180261. and Conejo ⁵⁵55. Conejo SP, Lisboa VC, Oliveira A, Garcia MR. Contribuindo para a construção da autonomia com profissionais que atuam com usuários de drogas: uma análise de dois projetos de intervenção no maior polo manicomial do Brasil. In: Garcia MV, Conejo SP, Melo TM, organizadores. Drogas e direitos humanos: caminhos e cuidados. Holambra: Editora Setembro; 2017. p. 17-44..

Finally, the development of bonds with shared responsibility, namely effective participation by users, cited in 13 studies, strengthens the notion of therapeutic process, as proposed by Ongaro-Basaglia ⁵⁶56. Ongaro-Basaglia F. Rovesciamento istituzionale e finalità comune. In: Basaglia F, organizador. L'istituzione negata. Milano: Baldini Castoldi; 2018. p. 321-35. and Basaglia ⁵⁷57. Basaglia F. A utopia da realidade. In: Amarante P, organizador. Escritos selecionados em saúde mental e reforma psiquiátrica. Rio de Janeiro: Garamond; 2010. p. 225-36.. As it decreases the difference in power between users and healthcare workers, it also promotes the building of contractual power, that it, reclaiming values to build greater self-confidence to develop relations, even outside the “treatment spaces”. However, the development of external relations, the dimension of citizenship and social rehabilitation, with participation in processes of collective exchanges - economic, political, and affective - is limited by the difficulties discussed above.

Thus, these limitations often prevent a practical transformation of users’ lives, making them dependent on the CAPS and health units, exacerbating the so-called “revolving-door” process or career of institutionalization ²¹21. Rotelli F. A instituição inventada. In: Rotelli F, Leonardis O, Mauri D, Risio C, organizadores. Desinstitucionalização. São Paulo: Hucitec Editora; 1990. p. 89-99., that is, the lack of a network of services and professionals prepared to continue therapeutic processes and the lack of transformation of conditions for reproduction of the users’ daily lives, such that they often return to the same treatment site with the same demands ⁵⁸58. Wandekoken K, Quintanilha B, Dalbello-Araujo M. Biopolítica na assistência aos usuários de álcool e outras drogas. Rev Subj 2015; 15:389-97.^,5959. Lacerda C, Fuentes-Rojas M. Significados e sentidos atribuídos ao Centro de Atenção Psicossocial Álcool e outras Drogas (CAPS AD) por seus usuários: um estudo de caso. Interface (Botucatu) 2017; 21:363-72.^,6060. Silva L, Almeida A, Amato T. A perspectiva dos profissionais sobre o processo de alta de pacientes do Caps-AD: critérios e dificuldades. Saúde Debate 2019; 43:819-35.^,6161. Sanches L, Vecchia M. Reabilitação psicossocial e inclusão social de pessoas com problemas decorrentes do uso de álcool e outras drogas: impasses e desafios. Interface (Botucatu) 2020; 24:e200239..

These difficulties obviously limit the development of the entire psychiatric reform project, since the reform with its practical and conceptual foundations, such as the psychiatry of deinstitutionalization ²⁰20. Basaglia F. As instituições da violência. In: Basaglia F, organizador. A instituição negada. Rio de Janeiro: Edições Graal; 1985. p. 99-134.^,5050. Jervis G. Manuale critico di psichiatria. Milano: Feltrinelli; 1975., seeks to create and foster the development of a territorial network with various facilities spread across the city, such as shelters, work cooperatives, and associations for sociocultural production and political expression. Such elements, according to Rotelli ²¹21. Rotelli F. A instituição inventada. In: Rotelli F, Leonardis O, Mauri D, Risio C, organizadores. Desinstitucionalização. São Paulo: Hucitec Editora; 1990. p. 89-99., are the invented institution’s objective and practice, seeking “reentry into the social body, consumption, and production, exchanges, new roles, other material ways of being for the other, in the eyes of the other” ²¹21. Rotelli F. A instituição inventada. In: Rotelli F, Leonardis O, Mauri D, Risio C, organizadores. Desinstitucionalização. São Paulo: Hucitec Editora; 1990. p. 89-99. (p. 95).

The difficulties also place constraints on harm reduction, which is based on the development of peer help groups and self-care interventions performed in the territories by users themselves, as harm reduction is developed in other countries. These and other actions are highlighted in a global study on harm reduction by the Dutch institution Mainline ⁶²62. Rigoni R, Breeksema J, Woods S. Speed limits - harm reduction for people who use stimulants. https://idpc.net/publications/2018/09/speed-limits-harm-reduction-for-people-who-use-stimulants (acessado em 20/Nov/2018).
https://idpc.net/publications/2018/09/sp... . These actions feature the need to fight poverty, violence against users, and precarious access to housing and the supply of counseling services and safe use ⁴⁴44. Gomes T, Vecchia MD. Estratégias de redução de danos no uso prejudicial de álcool e outras drogas: revisão de literatura. Ciênc Saúde Colet 2018; 23:2327-38.^,6262. Rigoni R, Breeksema J, Woods S. Speed limits - harm reduction for people who use stimulants. https://idpc.net/publications/2018/09/speed-limits-harm-reduction-for-people-who-use-stimulants (acessado em 20/Nov/2018).
https://idpc.net/publications/2018/09/sp... .

Final remarks

The results of this review reveal a set of contradictory and diffuse strategies for building autonomy. Some actions build autonomy, while others reaffirm control over users. Although this review is current and addresses various services in a new paradigm of care for drug users, the results indicate that biomedical rationale still controls what is considered deviation, lack of self-control, and madness.

The review identified users’ lack of participation in the organization of services, which impose rules, even when there is a certain autonomy for participation in groups and workshops, besides unique treatment plans. In addition, the activities for building autonomy are all carried out inside these facilities. That is, there are virtually no inter-sector activities or participation in community and political spaces such as users’ associations or health and social assistance councils. The literature consulted here shows that there is still a veiled and organized predominance of the individual dimension, even with the idea of therapeutic treatment to the detriment of shared responsibility and especially of social and political participation.

Even though the Brazilian network includes some services with temporary sheltering and social rehabilitation beyond the CAPS, such as Social Centers and Shelter Units, they are not being developed and used as recommended by the policy of care. Such services are crucial for building autonomy and combatting drug users’ stigmatization and marginalization, but this review has not identified their inclusion, pointing to the lack of effective inter-sector action by the RAPS itself. Therefore, the central role of the CAPS AD, namely of performing inter-consultation with other services, has not happened as recommended by the country’s mental health and drug policy.

Even so, the specific activities developed by CAPS AD and primary care services prove to be essential for beginning to reclaim users’ autonomy and self-worth in the face of their stigmatization and marginalization. The work by the NASF teams, community-based health agents, and street clinics allow a kind of care that is much closer to the reality of users and their families, guaranteeing certain rights, mediating family conflicts, and sometimes sheltering based on harm reduction. This set of actions allows follow-up in health which can otherwise be hindered by users’ fear of accessing services simply because they use drugs (which shows the intensity of the prejudice and stigma they still face in their daily lives).

Care is performed in the internal institutional space, in addition to the lack of inter-sector collaboration, reinforcing the dependence created by the policy itself for users of specific services. The space of reclusion that was reserved for individuals that were considered addicts was expanded, but it remained separate from social contact, and the psychiatric institution still dictates the words and acts with which individuals are allowed to speak and live. The needs of persons in treatment are addressed in a fragmented way rather than comprehensively as recommended by the health system, leading the RAPS to promote capillarization in the forms of control, partly perpetuating the chronicity-based logic of total institutions.

This review clearly shows that the guideline of a strategy for building autonomy requires greater investment in the RAPS to truly combat the marginalization of individuals with abusive drug use. In addition to the CAPS AD and health units, investment is necessary in services that allow health promotion, with quality housing, employment, and possibilities for embracing what the individual human being has already produced, beyond lives marked by the impacts of a society that produces illness.

It is necessary to support the construction of this logic of care at the social level, with a society that receives and builds the material conditions together with excluded individuals for them to rebuild their lives. The services and actions of care should not only extend outside the white-tiled and insurmountable walls of total institutions, but must be part of social transformation, constantly in search of autonomy.

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