ABSTRACT

We report the experience of the Street Approach Team of the Psychosocial and Alcohol and Other Drugs Care Center. It is a descriptive study, of experience report, from monthly reports and field journals. We highlight the challenging integration and coexistence of this team in a homeless community living on social exclusion because they are drug users, thus, professionals offer a grounded monitoring in welcoming, listening and bonding. The practices allowed individual actions by working in the 'extramural' context with the subjectivity of each user in the social environment and providing the connection between the care aspects of health and social reality.

KEYWORDS:
Mental health; Substance-related disorders; Health promotion; Social environment

Introduction

The Public Health Policies, historically, have allowed the existence of an assistance gap related to the care to users of Psychoactive Substances (PSs), since the issue of drugs was referenced to institutions of justice, public security and religious associations. Therefore, with the individual being considered ill and incapable of responding to one's choices, traditional treatment models converged to the imperative use of drug abstinence as the only treatment option (PASSOS; SOUZA, 2011PASSOS E. E.; SOUZA T. P. Redução de Danos e Saúde Pública: construções alternativas à política global de guerra às drogas. Psicologia & Sociedade, Belo Horizonte, v. 23, n. 1, p. 154-162, 2011.).

During the last decades, there have been significant advances in the National Drug Policy, important changes in the law on drugs, new provisions for promoting reception and care, in addition to actions to reduce harm.

In this sense, Federal Law nº 11.343/2006 establishes the National System of Public Policies on Drugs (Sisnad) which prescribes measures to prevent misuse, attention and social reintegration of users and drug addicts; establishes standards for repression to unauthorized production and illicit drug trafficking, defines crime and pushes forward a little further, as far as it has moved away the use of drugs from the police scope (abolition of the prison sentence for drug users), bringing it closer to health issues (FONSÊCA, 2012FONSÊCA, C. J. B. D. Conhecendo a redução de danos enquanto uma proposta ética. Psicologia & Saberes, Maceió, v. 1, n. 1, 2012.).

It is in this line of understanding that the Policy of Harm Reduction (PHR), the main pillar of attention to the users of PSs in the perspective of the psychosocial model defended as public policy in Brazil, constitutes a set of public health actions aimed at the minimization of adverse consequences caused by the abusive use related to the use of drugs. It is known that, although the clear majority of users of alcohol and other drugs do not have many complications/problems in their lives, due to its use, many people have developed problems, especially health problems, in consequence to drug use, some very serious. It is the responsibility of the public power to take care of these problems, and the PHR extends the possibility of this care (UFSC, 2014UNIVERSIDADE FEDERAL DE SANTA CATARINA (UFSC). Álcool e outras drogas da coerção à coesão. Módulo Recursos e Estratégicos do Cuidado. Florianópolis: UFSC, 2014. Disponível em: <https://unasus.ufsc.br/alcooleoutrasdrogas/files/2015/03/M%C3%B3dulo-6.pdf>. Acesso em: 15 mar. 2017.
https://unasus.ufsc.br/alcooleoutrasdrog... ).

The PHR understands health, in its broadest sense, as the integral health of the human being which, for this purpose, considers that autonomy is indispensable. The user of PSs, from the perspective of the PHR, is seen as an active being, capable and valuable to their peers and to society, being the protagonist of your own life history, without being relegated to a passive role. The person is a citizen bearer of rights, and should not lose rights by making use of illicit PSs (SANTOS; MALHEIROS, 2010SANTOS, A. M. S.; MALHEIRO, L. Redução de danos: uma estratégia construída para além dos muros institucionais. In: NERY FILHO, A; VALÉRIO, A. L. R. (Org.). Módulo para capacitação dos profissionais do projeto consultório de rua. Brasília, DF: SENAD ; Salvador: CETAD, 2010, p. 49-53.).

The development of actions of integral attention to the use of alcohol and other drugs must be articulated and planned in order to consider all the complexity and amplitude involved in the historical, political and social scenario of the ritual use of PSs, understanding that the suffering process that entails the abusive use of these substances is not restricted to the biological or organic sphere, but to an experience of discomfort in the society and the subjective relationship of the user with the PSs bringing with them their personal experiences in the way they relate to themselves and to life in community, as well as the way they react when shaped by this social expression that builds and gives new meaning to their living.

The reduction of harms places the use of drugs as a public health issue, aiming at the elaboration of strategies of care closer to reality, along with people who use or abuse of psychoactive drugs. By adopting a pragmatic and expanded approach, the reduction of harms brings contextualized and communal notions of care and self-care, valuing the autonomy of the person who uses drugs (DANTAS; CABRAL; MORAES, 2014DANTAS, S.; CABRAL, B.; MORAES, M. Sentidos produzidos a partir de experiências de bad trip: drogas, prevenção e redução de danos. Saúde em Debate. Rio de Janeiro, v. 38, n. 102, p. 539-550, jul./set. 2014.).

By following this logic, was created the Street Approach Team (SAT), in October 2013, to perform activities with harm reduction in places where users of PSs are concentrated. This team was initially formed by a psychologist, a damage reducer, a nurse and a nursing technician, later a social worker was added to this team.

In the face of the implementation of the actions of this SAT and in compliance with the Mental Health Policy and Policy on Drugs, this study aims to report an experience lived by an SAT of the Center for Psychosocial Care Alcohol and other Drugs 24h (Capsad type III), in the approach in the street under the logic of the PHR, evidencing the integral attention to the person who makes use of PSs.

Methods

This is a descriptive study, type experience report, based on the experience of a team of the Capsad III that works with the street approach of users of psychoactive substances.

The experience report is a type of information source dedicated to the collection of statements and record of relevant situations and cases that occurred during the implementation of a program, project or in a given problem situation (BIREME, 2011CENTRO LATINO-AMERICANO E DO CARIBE DE INFORMAÇÃO EM CIÊNCIAS DA SAÚDE (BIREME). Organização Pan-americana de Saúde (OPAS). Organização Mundial de Saúde (OMS). Guia BVS 2011. São Paulo: Bireme, 2011. Disponível em: <http://bvsmodelo.bvsalud.org/download/bvs/Guia_da_BVS_2011_pt.pdf>. Acesso em: 10 jan. 2016.
http://bvsmodelo.bvsalud.org/download/bv... ).

The chosen scenario was the neighborhood Bosque, located in the city of Floriano, state of Piauí. This community space is low income considered and with a concentration of people living in social vulnerability, located near the banks of the Parnaíba river, where there is a great concentration of users of psychoactive substances, based on empirical data and frequent trading of PSs. There are also other problems, among them: poverty situation, with no or little access to the formal health and education system, people living at personal and social risk. Unemployment, prostitution, selling of stolen objects, breaking of emotional, family and social bonds, violence of all forms are some of the most cited reasons that conduct these people to the street situation, a precarious public space used by them as housing or sustenance provider.

The report is based on monthly reports and the field diary used by the multidisciplinary team, which were filled by the professionals (nurse, nursing technician, damage reducer, social assistant and psychologist), after the completion of the routine of the approach, which were developed in the first six months of intervention (October 2013 to March 2014).

The activities of the team were initiated, and the fridays were established as the days to perform the actions. The proposal is to work to reduce risks and damages in the place where the user makes frequent use, developing thus a relationship of care and respecting their particularities, as well as the context in which this subject is inserted.

Pre-field and post-field meetings were held, with the purpose of discussing strategies and planning the actions to be developed. It is worth highlighting the main barriers found at the beginning of the work, among them, the difficulty in forming a bond with the users of PSs, in which it was possible to perceive the question of the initial fear on the part of these subjects, with the purpose of the professionals being questioned. However, this difficulty was soon resolved, allowing the construction of bonds with some users, who promptly passed on to others the real intentions of the team.

Results and discussion

The progress of the experience

The first steps, given by the SAT, were due to the need to work in the 'beyond-walls' perspective to promote care directed to people who use PSs.

The model of this approach was developed from the perspective of the PHR and was mirrored, also, in the performance of the Street Clinic. Due to the fact that the municipality in question does not have enough population to adhere to this device, it was based on these assumptions.

The appearance of the Street Clinics, based on an idealized experience proposed by Dr. Antônio Nery Filho, in the city of Salvador, Bahia state, Brazil, offering services in the form of beyond-walls attendance, aiming to promote accessibility to health services, integral assistance to street users and promotion of social bonds with an intersectoral approach. The evaluation of this experience, carried out between 1999 and 2006, was considered successful, allowing the inclusion of the Street Clinic in the Emergency Plan of Access Expansion to Treatment and Prevention in Alcohol and other Drugs (Pead), and in 2010, the Integrated Plan of Crack Confrontation (BRAZIL, 2010B______. Ministério da Saúde. Secretaria de Atenção à Saúde. Consultório de Rua do SUS. Brasília, DF. 2010b. Disponível em: <http://www.defensoria.sp.gov.br/dpesp/Repositorio/31/Documentos/consultorio_rua_SUS.pdf>. Acesso em: 15 mar. 2017.
http://www.defensoria.sp.gov.br/dpesp/Re... ).

The work of the SAT consisted in providing care, through the promotion of strategies of the PHR related to the care of people who use PSs, proposing orientations and interventions in relation to health and social problems.

This approach in the street is justified by the fact that the consumption of alcohol and other drugs and the sanitary and social consequences for both the community and the users cause a stir in many segments of society, as it is often related to the dependence of these substances and with social vulnerability (BRAZIL, 2010B______. Ministério da Saúde. Secretaria de Atenção à Saúde. Consultório de Rua do SUS. Brasília, DF. 2010b. Disponível em: <http://www.defensoria.sp.gov.br/dpesp/Repositorio/31/Documentos/consultorio_rua_SUS.pdf>. Acesso em: 15 mar. 2017.
http://www.defensoria.sp.gov.br/dpesp/Re... , 2011). Some researches argue that the (increase of the) consumption of these substances reflects a society that stimulates the immediate consumption of objects (including psychoactive drugs) as an alternative to alleviate the sufferings (TONDIN; BARROS NETA; PASSOS, 2013TONDIN, M. C.; BARROS NETA, M. A. P.; PASSOS, L. A. Consultório de rua: Intervenção ao uso de drogas com pessoas em situação de rua. Revista de Educação Pública, Cuiabá, v. 22, n. 49/2, p. 485-501, 2013.).

About the PHR, Nery Filho (2009)NERY FILHO, A. et al. Toxicomanias Incidências clínicas e socioantropológicas. Entrevista realizada com o Prof. Antônio Nery Filho Salvador: EDUFBA; CETAD, 2009. state that it is a work strategy that does not develop according to the substance, but to the human circumstances of use; harm reduction has to be a permanent tool for protecting life.

Among the care promotions, there were the hospitality in the territory, therapeutic listening, orientations on health and also issues related to citizenship, such as guidance on documents issuing, besides some redirection to the health network and social assistance network. In the field, were also carried out orientations on the strategies of the PHR (general and specific for each substance), blood pressure measurement, juice distribution (for hydration), preservatives (male and female) and informational materials.

Initially, resistance was faced by the public in question, because the vast majority thought that the team had some connection with the police and/or did not understand the real meaning of the work. As an example, in the field interventions, fruit juice was offered, however, some of these subjects believed that the team put some drug in the juice, and they did not drink; subsequently, this obstacle was overcome as a result of the construction of bonds.

The PHR method faced, in principle, great resistance from many sectors of society, which treated the distribution of syringes among drug users as a way to encourage the consumption of psychoactive substances. This concept was, therefore, demystified, since the distribution of syringes reduced the spread of Human Immunodeficiency Virus (HIV) among users besides not increasing drug consumption, offering advantages in relation to cost-benefit (ANDRADE, 2011ANDRADE, T. M. Reflexões sobre políticas de drogas no Brasil. Ciência & Saúde Coletiva, Rio de Janeiro, v. 16, n. 12, p. 4665-4674, 2011.). In addition, the understanding that harm reduction is a health policy that aims to reduce the biological, social and economic damage of drug use, based on respect for the individual right to use drugs was amplified (NIEL; SILVEIRA, 2008NIEL, M.; SILVEIRA, D. X. Drogas e Redução de Danos: uma cartilha para os profissionais da saúde. São Paulo: PROAD; UNIFESP; Brasília, DF: MS, 2008. Disponível em: <http://www.prefeitura.sp.gov.br/cidade/secretarias/upload/direitos_humanos/Cartilha%20para%20profissionais%20da%20saude.pdf>. Acesso em: 15 mar. 2017.
http://www.prefeitura.sp.gov.br/cidade/s... ).

It shall be noticed that it is very important for professionals who deal directly with these subjects to overcome the barriers of the stigma of the user of psychoactive drugs in street situations, since, beyond this stereotype, there is a subject of rights that must be respected (MÜLLER, 2013MÜLLER, G. S. Atenção e cuidado aos habitantes da rua: perspectivas enunciadas pelo consultório na rua. 2013. 50 f. Trabalho de Conclusão de Curso (Graduação em Saúde Coletiva) - Escola de Enfermagem, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2013.). Broadening the look and listening makes it possible to understand the complexity of the users' lives and the way workers understand the sufferings of life, imply, also, placing the user somewhere else, in another position: that of an active agent in the production of their health and the in the meeting with health workers (MERHY; FEUERWERKER, 2009MERHY, E. E.; FEUERWERKER, L. C. M. Novo olhar sobre as tecnologias de saúde: uma necessidade contemporânea. In: MANDARINO, A. C. S.; GOMBERG, E. (Org.). Leituras de Novas Tecnologias e Saúde. São Cristóvão: Editora UFS, 2009. p. 29-56.).

Along the way, the number of people who participated in the activities increased. Over the months, a process of clarification was carried out about the work that was happening; the treated people, initially, were disseminating and, gradually, the reliability was acquired. It is a fact that no one could go to places where it was not allowed to go. Only after a few trips to the field the bond between the team and these people was established, making possible, this way, the performance's improvement.

From the reports and field diary, it is noticed that the professionals reflect about their practices and emphasize that the fundamental purpose of the action conducted in the territory by them is to accept and provide opportunities to protect the lives of users, making it possible to build social and affective bonds, intervening in the situations experienced by them, under the logic of respect for their subjectivity.

According to Bueno and Merhy (2002), acceptance in health must build a new ethics, that of diversity and tolerance to the diverse, social inclusion with clinical solidarity listening, committing to the construction of citizenship.

Furthermore, acceptance means the commitment to recognize the other in their individuality, as an individual that has one's differences, joys, frustrations, a way of living, feeling in life. Moreover, it even promotes quality listening. Also in this perspective, the bond, when established, allows a partnership based on sincerity and responsibility and enables a service that covers the needs of users and their families, assuming a team character, which is more sensitive to the identification of risks or vulnerabilities, contributing to the construction of therapeutic interventions appropriate to perceived needs (BRAZIL, 2010ABRASIL. Ministério da Saúde. Acolhimento nas práticas de produção de saúde. 2 ed. Brasília, DF: Ministério da Saúde; 2010a.).

By fomenting the discussion, it is noticed that the initial difficulty of the team in inserting itself in the collective space of these people in a street situation was immersed in feelings of fear and anguish on the part of the users of PSs, because in their imaginary emerged: the fear that they had before the team because they thought they would be forcibly taken to the hospital or to the police.

In this offer modality of health care and attention, it is common to face fears (understood as an affective state raised by the awareness of the real or supposed danger) and expectations (understood as beliefs in changes of the immediate reality) of people in street situation, considering the marginalized and exclusionary conditions to which they are exposed (SANTOS, 2003SANTOS, L. O. O medo contemporâneo: abordando suas diferentes dimensões. Psicol. cienc. prof, Brasília, DF, v. 23, n. 2, p. 48-55, 2003.; NEIVA-SILVA, 2003NEIVA-SILVA, L. Expectativas futuras de adolescentes em situação de rua: um estudo autofotográfico. 2003. 176 f. Dissertação (Mestrado em Psicologia do Desenvolvimento) - Instituto de Psicologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2003.).

It is evident that the condition of vulnerability and social risk potentially exposes people in street situation to dangers that arouse fears related to the street space such, for example, fear of being raped, forcibly captured by the police, which leads to a constant state of alertness and tension.

However, it is important to understand how such fears and expectations are signified and experienced by this specific population, respecting, this way, the particularities of this condition and grouping. Thus, according to Santos (2003)SANTOS, L. O. O medo contemporâneo: abordando suas diferentes dimensões. Psicol. cienc. prof, Brasília, DF, v. 23, n. 2, p. 48-55, 2003., fear can be understood as a reaction (retraction, negation, precaution or inhibition), configuring a set of emotions full of different meanings considering the context of vulnerability of individuals.

Historically, the issue of the abuse use and/or dependence on alcohol and other drugs has been addressed by a predominantly policing, psychiatric or medical perspective (CARDOSO ., 2014CARDOSO, M. P. et al. A percepção dos usuários sobre a abordagem de álcool e outras drogas na atenção primária à saúde. Aletheia, Canoas, n. 45, p. 72-86, dez. 2014.); in which repression, control and the 'war on drugs and its users' was the pillar of the actions and was materialized, in their majority, in the labeling of PSs users as outcasts and, this way, in prison or subjected to an exaggerated medication dosage as restraint and involuntary and compulsive hospitalization as a form of treatment and health care.

The indiscriminate use of psychoactive substances is continuously associated with criminality and antisocial practices related to the irresponsible behavior of the user, who ends up committing acts of delinquency and getting involved with problems of court order. This entails individual and social losses, which leads the dependent to social exclusion (SILVA ., 2010SILVA, L. H. P. et al. Perfil dos dependentes químicos atendidos em uma unidade de reabilitação de um hospital psiquiátrico. Esc. Anna Nery, Rio de Janeiro, v. 14, n. 3, p. 585-590, 2010.).

Gradually, it was possible to know the territory and the people that circulated through it. Initially, the access to the SAT was only in the beginning of the street, over time, the team became invited to enter the territory, and was granted permission to attend the riverside (where abusive use of the PSs was more frequent).

The initial rejection has been gradually replaced by acceptance; fear and distrust, by credibility. Thus, the understanding was extended to the care and attention dedicated to these users, who began to express that they have spent the whole week waiting for the team to talk and make questions and that the work developed was very beautiful, because they helped those who were rejected by the family and society.

In this sense, it is worth to reinforce the fear of loneliness before the fear of total rupture of family and social bonds, a suffering that denotes abandonment and rejection. This way, in times of violence and generalized competition that present a constantly changing social situation, a world of insecurity and constant fear is generated, with drug consumption being a probable response to the abandonment of the subjects (SANTOS, 2003SANTOS, L. O. O medo contemporâneo: abordando suas diferentes dimensões. Psicol. cienc. prof, Brasília, DF, v. 23, n. 2, p. 48-55, 2003.; TONDIN; BARROS NETA; PASSOS, 2013TONDIN, M. C.; BARROS NETA, M. A. P.; PASSOS, L. A. Consultório de rua: Intervenção ao uso de drogas com pessoas em situação de rua. Revista de Educação Pública, Cuiabá, v. 22, n. 49/2, p. 485-501, 2013.).

Following the monitoring, in a given meeting, the team carried out a group dynamic with some of these users using a questioning (what are the expectations, dreams and wishes in your life?) as a guiding principle of the speeches. Given this question, about expectations, the most recurrent was that one day they could leave that life, that is, they would stop being psychoactive drug users in street situations, with great hope deposited in family, more precisely in regaining their loving partner and regaining the trust of their parents and their children, as well as resuming activities (work, leisure, social, etc.) that they practiced before drug use and the street situation. There has also been a story about the hope of alerting the general population that street life consuming psychoactive drugs is neither dignified nor easy, as well as calling for more respect and better treatment for street psychoactive drug users.

Therefore, the appropriation of the street as an expression of the subjective aspects of each individual is something understandable, since it is in this space that many will build their reference points of identity, survival and relationship with the other (NERY FILHO; VALÉRIO, 2010NERY FILHO, A.; VALÉRIO, A. L. R. Módulo para capacitação dos profissionais do projeto consultório de rua. Salvador: CETAD, 2010.).

Having dreams, wishes and desires is something extremely present in the lives of the users accompanied. Plans are elaborated, and perspectives are drawn on the most diverse subjects, especially those related to the very existence. For Neiva-Silva (2003)NEIVA-SILVA, L. Expectativas futuras de adolescentes em situação de rua: um estudo autofotográfico. 2003. 176 f. Dissertação (Mestrado em Psicologia do Desenvolvimento) - Instituto de Psicologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2003., in the case of people in street situation, often, because they do not find in their daily lives opportunities to structure and develop a new life project, the role played by expectations and beliefs in immediate reality changes is fundamental.

Among the most frequent complaints, heard by the team, stand out: difficulty in having access to health services and social assistance, police violence and social stigma. Therefore, listening was the main working tool, since the act of listening produces itself a significant proposal to promote care. In this perspective, listening was fundamental to understand the trajectories and repertoires that composed the lives of these subjects, without neglecting the social contexts, the socioeconomic situations that position these subjects and the most diverse social problems.

There was the possibility of hearing complaints, dreams, aspirations and desires, enabling the exchange of enriching experiences from a professional and also a human point of view. Therefore, the PHR allows a mobility, serving as a reference and bridge between the subject and the social bond of which it seems detached. Favorable work conditions were created to the reception of these subjects, building with them protection and self-care schemes, fundamental for the exercise of citizenship of the drug users (CONTE ., 2004CONTE, M. et al. Redução de danos e saúde mental na perspectiva da atenção básica. Boletim da Saúde, Porto Alegre, v. 18, n. 1, p. 59-76, 2004.).

Conclusions

The reality found in the field was immersed in social and health problems that surrounded the life of these subjects, in addition to issues related to the prejudices and stigmata, rooted in society, which, sometimes, position these subjects in a situation considered 'marginalized'. The challenges presented here condition the need for a 'new look', that involves people who use psychoactive substances, in a logic of guaranteeing rights and freedom of choice.

The diverse situations that appeared in the field were very peculiar and often inherent to the subjects, causing unpredictable demands, reinforcing, thus, the need for professionals to understand the importance of subjectivity, work articulated with care networks, widening the look on the specificities that the subject brings within oneself.

However, it was observed, with this experience, that being willing to promote care to this public, within the community, is extremely necessary, since many users of PSs do not seek or accept (in a way) to be monitored by mental health devices. This way, it brings to light the possibility of reviewing the conditionalities for implementation of some devices in the municipalities, considering the valuable experience with the approach on the street performed by professionals of the Capsad III of Floriano-PI.

It is worth emphasizes that the street approach is still incipient and has its work dynamics planned and guided according to legislation and public policies, including drug policy.

Finally, it can be stated that the practices produced by the approach team in the street allowed dynamic actions that provided an understanding of the challenge of working in the beyond-walls context, in addition to the understanding of the private universe (in which subjects are inserted), with the purpose of providing health care that is integral, ethical and humanized.

References

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History