CHALLENGES TO HARM REDUCTION PRACTICES IN PRIMARY HEALTH CARE¹

ABSTRACT.

This study aimed to analyze the knowledge and practices of Community Health Agents trained by the Care Pathway Project, aimed at users of alcohol and other drugs from the perspective of the Harm Reduction strategy. Data showed that even those professionals who reported knowing the concept of harm reduction and the possibility of using this approach to provide care for alcohol and other drug users in the context of Primary Health Care (PHC), they are unable to offer care as described in this strategy. This occurs because the interviewees do not respect freedom of choice, they advocate prohibitionism and the ideal of abstinence. This practical difficulty in developing care based on this approach is related to the moralizing perception about drug use, its association with crime and the focus on the possibility of extinguishing the use of drugs by societies.

Keywords:
Harm reduction; community health agent; Professional education

RESUMO.

Este estudo teve por objetivo analisar os saberes e práticas dos Agentes Comunitários de Saúde (ACS), direcionados a usuários de álcool e outras drogas à luz da estratégia de redução de danos. Como característica específica do público deste estudo, foram escolhidos ACS que participaram do curso Caminhos do Cuidado. Utilizando-se o método qualitativo, foram realizadas entrevistas semiestruturadas como fonte de coleta de dados e análise de conteúdo para a sistematização dos achados. Os dados demonstraram que mesmo aqueles profissionais que relatavam conhecer o conceito de redução de danos e a possibilidade de utilizar esta abordagem para o cuidado de usuários de álcool e outras drogas no contexto da Atenção Primária à Saúde (APS), não conseguem ofertar cuidados que se aproximem desta estratégia. Isto ocorre uma vez que os entrevistados não respeitam a liberdade de escolha, pautam-se no proibicionismo e no ideal de abstinência. Esta dificuldade prática em desenvolver o cuidado, baseado nesta abordagem, se relaciona com a percepção moralizante sobre o uso de drogas, sua associação ao crime e o foco na possibilidade de se extinguir o uso de drogas nas sociedades.

Palavras-chave:
Redução de dano; agente comunitário de saúde; formação profissional

RESUMEN.

Este estudio tuvo como objetivo analizar los saberes y prácticas de Agentes Comunitarios de Salud (ACS) frente a usuarios de sustancias psicoactivas y la estrategia de reducción de daños. Fueron elegidos ACS que participaron del curso “Caminhos do Cuidado”. A partir de una perspectiva cualitativa se realizaron entrevistas semiestructuradas, la información obtenida fue análisis de contenido con el fin de sistematizar los resultados. Los datos demostraron que a pesar de que los profesionales relaten conocer el concepto de reducción de daños y la posibilidad de utilizar esta estrategia para el cuidado de usuarios de sustancias psicoactivas en el contexto de Atención Primaria en Salud (APS) no logran ofrecer cuidados que se acerquen de esta estrategia. Esto sucede principalmente cuando los ACS no respetan la libertad de elección de los usuarios, se centran en el prohibicionismo y en el ideal de abstinencia. Esta dificultad para efectuar el cuidado con base en la reducción de daños se relaciona con una percepción moralista acerca del uso de drogas, asociando el consumo con el delito, además de destacar la posibilidad de erradicar el uso de drogas en las sociedades.

Palabras-clave:
Reducción de daño; agente comunitario de salud; formación profesional

Introduction

The consumption of psychoactive substances is part of the history of humankind, being in many contexts linked to rituals, culture and customs. However, the harmful and abusive use of these substances can cause health and social problems to people's lives. Besides these implications, there is a set of beliefs and perceptions of health professionals that can contribute to increase barriers related to access and linkage of alcohol and other drug users to existing health services. Among these barriers that may prevent users and families from seeking help and having access to health services is the stigma that the population, family members, professionals and users have toward this condition (^{Ronzani, Noto & Silveira, 2014}).

The stigmatization of drug users and the repetition of jargons such as "drugs are destroying our society" or "we must declare war on drugs" bring with it a "demonization" of the substance that extends to the users, who is seen as a "bad person" (^{Karam, 2008}). The internalization of this perception on drugs and on the user by the health professionals reduces the perception of individuals and the possibilities of social, educational and health support with them and for them.

Another development of the process of stigmatization is to attribute to the individuals the causes and individual responsibility for their conditions, which also hinders the possibility of care. Many people do not start treatment or drop out prematurely because they are stigmatized and consequently perceived negatively by the population and by health professionals. Therefore, the quality of health work with users of alcohol and other drugs is related to how professionals perceive drug use and users (^{Ronzani et al., 2014}).

The deficiencies in the training of health professionals to deal with the approach and treatment of users of alcohol and other drugs have an impact on the practice of these professionals, impairing and neglecting possible and necessary care to this target public (^{Peyraube, 2017}). Studies show that the training of primary care professionals to understand the context in which the users are inserted, the use of drugs and stigmatization is one of the prerequisite for achieving comprehensive care for people who make harmful use of drugs (^{Júnior, Silva, Noto, Bonadio, & Locatelli, 2015}).

Several gaps are found in the educational processes currently in force. Generally the offer of educational processes aimed at health professionals is marked by punctual, fragmented, varied actions regarding the methodology (^{Ceccim & Feuerwerker, 2004}) and organized upon political interests. There is no proposal for continuity of the training process or even an interlocution with other areas, which hinders the desired change process. It is also worth mentioning the belief of managers and researchers in a magical effect of the educational process, as if a rapid change in professional attitudes was possible (^{Júnior et al., 2015}).

Other challenges pointed out in the literature to the processes of training health professionals to act in the area of alcohol and other drugs are: the engagement of managers in the proposal; the lack of autonomy of the professionals to carry out the work that they would like to do; the large network of professionals from the SUS, spread through the Family Health Strategy (FHS), Family Health Support Centers (FHSC), Psychosocial Care Centers (PSCC), hospitals; the lack of communication within the health network and between intersectoral devices (^{Júnior et al., 2015}); the work overload of professionals; the high turnover of these actors (^{Mendes, 2012}); the situation of illegality and the prohibitionist perspective (^{Menéndez, 2012}) and the difficulty of dealing with the complexity of problems involving the use of alcohol and other drugs.

However, the process of incorporating knowledge into professional practice is complex, going beyond the mere transmission of information or acquisition of technical knowledge. The very approach of policy on drugs in Brazil is quite ambiguous: while the moment a health policy is focused on the ideal of reduction of damages that seeks the emancipation of the subjects and recognition of their autonomy, sometimes the hygienist moral discourse is imposed through the prohibitionist policy through isolation approaches in hospitals, prisons, treatment clinics and other institutions dedicated to the practice of social exclusion (^{Queiroz, Gomes, Reis, Knupp, & Aquino, 2014}).

In the approach of users of alcohol and other drugs from the perspective of harm reduction, the objective should be to produce more autonomous individuals, responsible for their choices and co-responsible for overcoming their difficulties without, however, failing to acknowledge and intervene on the vulnerabilities that involve this use (^{Conte et al., 2004}; ^{Cavallari & Sodelli, 2002}). As an approach based on a broader concept in the field of collective health, it requires the appreciation of the desire and possibilities of the subjects for whom we are seeking the provision of care.

International experience has shown that where harm reduction policies are in place, health care cost savings - such as reducing viral infections of people with HIV and hepatitis C - and improvement of the quality of life of drug users are perceived as result of intervention practices such as providing drugs in a systematic and monitored way for dependent users. Broader interventions, including legislation and public provision policies, such as some in European countries, have made it possible to reduce drug-related crimes and imprisonments and reduce overdose mortality (^{Wiessing et al., 2017}).

However, according to ^{Menéndez (2012}), the evidence and studies focused on harm reduction and the success obtained through experiences of drug decriminalization - as in the case of Portugal, Latin America and some European countries that have implemented more fully harm reduction actions - from the legalization need to be disseminated, so that we may strengthen human rights-based drug policies (Menéndez, 2012).

However, in most countries, harm reduction actions remain focused on individuals rather than on broader policies that include structural aspects and changes in legislation (^{Menéndez, 2012}). Without addressing this situation, it is also difficult to monitor the effectiveness of harm reduction services, because they produce better results when combined with different intervention strategies (^{Wiessing et al., 2017}).

In Brazil, one of the education actions aimed at the teams working in primary care with a focus on harm reduction was the creation of the Care Pathway Project in 2013. Aiming at expanding mental health care in primary care with emphasis in the approach of users of alcohol and other drugs, the project led more than 280 thousand professionals to reflections based on the harm reduction strategy. The proposal included community health agents and nursing assistants and technicians of the FHS throughout all Brazil (^{Brasil, 2016}).

The purpose of the course was to train the professionals through face-to-face activities and field activities (dispersion activities) distributed over a five-week period. Each class was supported by tutors, health professionals graduated with at least one year of professional experience in mental health or primary care, in order to reflect on the care they use on their territory towards the population involved with drugs.

The activities proposed by the Care Pathway project were characterized as dynamic, carried out from the construction of care in each territory and sought to integrate the cases experienced in the day-to-day of the FHS to lead the professionals enrolled in the course to reflections. The application methodology proposed to problematize the attitudes of professionals, to identify drug use and user in the context of a capitalist society and to build care possibilities in intersectoral networks. The course sought to reflect with the students the possibilities of care from two axes of formation: a) Knowledge of the territory, care networks, concepts, care policies and practices in Mental Health according to the National Policy of Integral Attention to users of alcohol and other drugs; b) construction of the "toolbox" with PHC members for the possible care for users of alcohol and other drugs in each territory based on the harm reduction perspective (^{Brasil, 2016}).

In this context, we propose, in this article, to reflect on the perceptions and practices of community health agents trained by the Care Pathway project aimed at users of alcohol and other drugs, grounded on the reflection of harm reduction.

Method

This study had a qualitative approach and sought the understanding of specific subjects and their health practices based on their particular experiences. The context of the study was a municipality located in the Atlantic forest region of the State of Minas Gerais. The context was chosen for being considered the most populous municipality in the health region where it is located, easily accessible by the responsible researcher, and due to the large number of community health agents who attended the training of the Care Pathway project in this territory.

The municipality has an approximate population of 110 thousand inhabitants, has a low coverage of the Family Health Strategy (63%), with the support of two FHSC nuclei in the primary care component. Up to December 2016, the municipality in question had the following psychosocial care network: in specialized care, a PSCC modality II regional and a PSCC alcohol and drugs (PSCC ad) III Regional. It should be noted that the PSCC ad III was implemented in early 2016 and until the data collection (April and May 2016) had no ministerial funding and incomplete staff, which probably compromised the quality of the support given to the cases identified by the FHS. In the hospital component, there were 6 mental health beds implemented and; finally, in the urgency and emergency component, there were 2 general hospitals and the Regional Urgency Mobile Care Service (SAMU) coverage (^{Ministry of Health, 2016}).

The first criterion used to select the sample plan was the selection of Community Health Agents (CHAs) that had completed the Care Pathway course. Participants were chosen by intentional sampling and were intentionally indicated by nurses based on the quality of the information that could be obtained from them (^{Turato, 2011}). The researcher's contact with the nurses happened through a telephone call, and these professionals were asked to suggest a CHA representative of the possible care to be directed to users of alcohol and other drugs in each territory and who had completed the Care Pathway course. Subsequent telephone contact was made with the person indicated to obtain the agreement or not of the professional to the invitation to contribute to this study by giving an interview to the responsible researcher. There were no denials.

The option to include CHAs who had attended this training was based on the belief that there were professionals who would sustain less stigmatizing perceptions and that could contribute with innovative findings regarding the possibilities of care of users of alcohol and other drugs in the context of PHC.

Six semi-structured interviews were carried out, interrupting them at this point, because the participants began to repeat the contents already found and considering that we already had a wide range of material to be explored.

Each interview was conducted supported on a guidebook that sought to conduct the dialogue in a way that motivated the CHAs to report on how they perceived the use of drugs and drug users, how they understood harm reduction, what practices they use on a day-to-day basis of their work to relatives and users of alcohol and other drugs and what factors made it difficult and which facilitated the care for this public. All six participants (5 women, 1 man) had an permanent employment bond, had been working for about 10 years in the primary care network of the municipality, and had a mean age of 36.5 years.

At the end of the sixth interview and with the material all transcribed, we carried out the reading process of the material, leading to the identification of the following subjects: a) the perception that the informant brought about the use of drugs; b) the perception about the user, c) what appeared on the concept, practices and perception about the harm reduction strategy; d) factors that made it difficult to care for users of alcohol and other drugs; e) the potentialities of this care; and f) what actions the FHS has directed this public. Each of these themes was identified in the text with a specific color. Following ^{Bardin's (1977}) guidelines, after this step we identified elements in the contents that were close, that stood out or were repeated more frequently.

At each interview and repetition of this process, it was necessary to carry out regroupings or new identifications in previous interviews. After this stage of vertical categorization, horizontal categorization was performed by comparing the frequency of each category, as well as all categories, subcategories and sub-themes identified in the documentary corpus.

All the procedures that guarantee the confidentiality and privacy of the participants were fulfilled, and this study obtained the favorable Opinion of the Research Ethics Committee of the Federal University of Juiz de Fora.

Results

Reflections on drug use and users

While dealing with users of alcohol and other drugs, the CHAs usually reveal fear, unpreparedness and feel poorly supported to act with the drug issue, situations already found in the study by ^{Cordeiro, Soares, Oliveira, Oliveira and Coelho (2014}). Although the drug issue is often considered a public health problem and the harm reduction approach is inscribed as a guideline for care in mental health and basic health care legislation, this does not reflect in the organization of the necessary approach of health professionals and services; approaches of blaming users and the desire for abstinence prevail, according to CHA 4 and CHA 2, respectively:

It depends a lot on their wants. Without the patient's good will, to want to improve, to want to get involved in the treatment, to engage in the cause, there is no way. I think there is no solution.

Sometimes drug users, they do not tell us. It's the family that tells us. That's why you know they use it, do you understand? They do not come to you and they talk to you. It's the family that speaks up. These people want to quit, but at the same time that desire passes fast, do you understand? Because of their attitudes of searching for drugs, stealing, and so on.

Other times, the coexistence between the moral perception directed to the use of drugs and the perception as a health problem occurred. Despite the apparent contradiction between understanding drug use as a moral problem or understanding it as a health problem, both models go towards abstinence as the only desired outcome. While causing disquiet and feeling of frustration to the CHAs participating in this study, this led to immobility. Regarding health actions, they reported that "we do not know what to do. We want to do something, but we do not know what to do" (CHA 5).

None of the interviews presents a perception about drugs that is not marked by the stigma of prohibition, of malignant and undesirable substance.

Regarding the factors perceived by CHAs that can lead to abusive use of alcohol and other drugs, the interviewees pointed out a large range. Among these points perceived as conditioning factors for drug use are: the need for refuge from problems (all informants), peer pressure (3), inequality of opportunities (3), drug use in the family (2), and easy availability of drugs (1). However, informants did not report actions developed or sought by FHTs to minimize these risk factors. In this sense, there are no actions to prevent the use of drugs developed by the FHT, which leads us to believe that, in relation to drug abuse, the teams remain against the proposal of action of the family health teams, acting in a curative way.

It is worth mentioning that this range of factors identified by the CHAs is typical in all the complexity of individual, cultural, political and social issues that involve the use of drugs. The harm reduction approach that takes collective health as a guide proposes a broader view of this problem, seeking to understand the complexity of factors related to drug use in contemporary society. This approach criticizes the prohibitionist policy that feeds trafficking and instrumentalizes a practice that understands and interferes with social inequalities, directing actions in a more politicized way and with more global impacts (^{Santos, Soares & Campos, 2010}).

Aspects that hinder or help in the possible care of users of alcohol and other drugs in the context of PHC:

In addition to the limitations caused by the stigmatization of users of alcohol and other drugs already mentioned, the lack of preparation and lack of support from other professionals and other points of attention to deal with the problems encountered may contribute to aggravate the situation of vulnerability, as we can observe in the report of the CHA 1 when mentioning an approach adopted with a drug user within his coverage area:

But look what you're doing with your life! You are excluding yourself from society. It is not the society that excludes you. It is you, first, you are excluding yourself from society. It's not in every place you feel good to enter. You [think] the others are afraid of you. You think that the others are disgusted with you and sometimes the person is not even (...). Then I said: you see! Is it worth using drugs? When it's just you two, okay, it's another person, you two. You stop with that, understand? So ... I show to them: pay attention to what you are doing to your life!

The support of professionals and services of the inter-, intra-sectoral network and the use of spaces cited by some informants and identified as enhancers for care - such as PSCC ad, FHSC, Social Assistance Referral Centers (SARC) and discussions of cases among matrix teams - are strengthened as necessary to the realization of effective practices and healthy relational technologies between CHAs and the affiliated population. In addition to these matrix teams, in this study the CHAs emphasize the importance of FHS nurses and FHSC professionals as essential to the care of drug users.

Among the informants, four mentioned that they have the support of the FHSC professionals of the municipality to think about the possibilities of care directed to users of alcohol and other drugs. While legitimating the importance of this mechanism for the resolution of the more complex cases accompanied by FHS professionals, this also make us question the training of the health professionals who make up the FHSC, who should contribute to a more critical and comprehensive perception of the drug issue.

However, it should be pointed out that the implantation of the FHSC in the municipality is recent, started about a over a year, and that the low coverage of FHS, as well as the large number of people under the responsibility of each team, impair the possibility of more continuous support. We believe that the work possibilities of the FHSC professionals in order to problematize the experiences, to carry out case discussions and to help in a more continuous and qualified way in the training process of FHS professionals may have been hindered by the factors described above.

It is also worth mentioning the speeches of the CHAs that the support of FHS nurses is essential to direct care to this target public. All informants cite nurses as references in this care. Sometimes they criticize or denounce the lack of support of these professionals and others emphasize their importance. It is usually to nurses that the cases are forwarded. In daily practice, these professionals are the ones that give immediate response to the anxieties of CHAs and direct referrals with users of alcohol and other drugs and their families.

On the other hand, strengthening the care and support of nursing professionals to the other members of primary care teams also involves redesigning the role of these professionals in FHS. Several studies propose to analyze the real capacity of nursing professionals who are members of the family health strategy teams to develop the ideal proposed for this PHC device. ^{Silva, Motta and Zeitoune (2010}), in a study carried out in Vitória/ES, found that the time spent with health promotion and disease prevention actions by FHS nurses is significantly lower than that spent on management activities in health care units and curative care. Other aspects pointed out by the authors are: the number of duties of FHS nurses as a hindering factor to carry out the actions assigned for FHS; the productive tendency of professionals and health managers that has made the moments of reflection about the work processes and health situations of the population unfeasible; the lag regarding the permanent education actions of these professionals.

It is important to note that some limitations pointed to the care of users of alcohol and other drugs relate to a range of limitations of implementation of any context of health policy in general (^{Mendes, 2012}). In this sense, the following limitations were recurrent: excessive number of families under the responsibility of each CHA, difficult communication between points of attention, lack of other community and social resources, bureaucratization of access to some specialized devices, lack of material resources for work, difficulties with transportation for team actions, difficulty with patient transportation, fragmented teamwork, poor physical structure of BHUs (Basic Health Units) and territories without FHSC coverage. However, this cannot lead to the immobility of primary care and mental health management teams, but still helps to understand the complexity of the problems involved in strengthening PHC teams.

Harm Reduction and practices directed at users of alcohol and other drugs

Although a quasi-unanimous discourse by the CHAs of "what I could do with such a user [who does not want to or cannot stop using drugs] is harm reduction" (CHA 6), the direction of practices shows that the care offered by the CHAs to this public is not close to harm reduction approach insofar as it does not respect freedom of choice; it is based on prohibitionism and the thought of abstinence, while these are the basic principles of the harm reduction approach according to ^{Sodelli (2012}) and ethical principles to be observed and respected by health professionals according to ^{Peyraube (2017}).

Among the possibilities of actions developed by the FHS and cited by the CHAs, we found some interventions that initially could consider actions directed to the harm reduction strategy, such as: "offer of condoms, home visit for these users and offer of care for other health conditions" (CHA 5). However, sharing with ^{Sodelli's (2012}) understanding that the harm reduction strategy should be based on the perception that drug use is embedded in the context of vulnerabilities and that care goes beyond the technical tasks of professionals, actions based on the care proposed by the harm reduction approach were not effectively identified.

When guided by the principle of harm reduction that we advocate in this study, PHC professionals, supported by other intra and intersectoral devices, should be able to identify social networks by finding and helping to strengthen protective factors such as school, family and friendships. Moreover, these professionals are expected to take a critical stance in politics, including the macro-contexts that make it possible to misuse drugs: misery, which attracts young people and children to trafficking; affective abandonment; the incentive to create capitalist society's own consumption needs; individualism and the stimulus to an ever more frantic, competitive and modern life (^{Sudbrack & Borges, 2002}).

It is noteworthy that during the dialogues, the CHAs cited examples of drug users who had made or are currently on treatments and follow-ups of chronic health situations such as tuberculosis, leprosy and others, although they did not report this fact as an effective care that contributed to the quality of life of people, since only interventions that can promote the interruption of the use of drugs are perceived as successful.

The one that caused more trouble, he moved, which is one that we gave assistance... He lived by the side of the health center. That he was a patient who gave us a lot of work because he was a hypertensive patient, who did not use medication and made lots of use of alcohol. Then his family moved and he was living alone on the street there. He stayed in a little room in the church and did not eat... we had to be taking care of him. Guiding him always... when I started to work, there was still an internment in the colony. He was hospitalized there two or three times. To detoxify. He would come back. He stayed a while without drinking. He was an epileptic, too. He has not yet died. He was hospitalized again. But we did not succeed with him. He still makes use of alcohol (CHA 6).

When asked if there would be any action developed by the FHS team that the CHA believed would meet the harm reduction strategy, we observed that they basically associated it with actions of syringe and condom distribution. This perspective is related to the first experiences of harm reduction in Brazil, which initially aimed at reducing the risk of transmission of hepatitis and Aids among injecting drug users. ^{Santos, Soares and Campos (2010}) report that damage reduction has been diffused with excess of pragmatism, often reproducing technical practices without defined theoretical foundation. In this sense it is necessary to present harm reduction as a guideline of work and not as an action with an end in itself, focused on the distribution of material.

This practical difficulty in developing care based on the harm reduction strategy, this perception that "little can be done in reality" (CHA 5), is due to the prohibitionist perspective adopted by the CHAs, since they consider drugs as essentially immoral. Thus, the reported difficulty has to do with the established goal of total abstinence, with the moralizing perception about drug use, its association with crime and the focus on the possibility of extinguishing the use of drugs from societies, issues that are greatly reinforced in the media and common sense.

Discussion and data analysis

The dialogue with CHAs demonstrated the prevalence of negative views of drugs and the extension of this understanding to users. This moral perception about the use of psychoactive substances as crime and error follows the "War on Drugs" model and also reflects the conduct of Brazilian drug policy (^{Rodrigues, 2008}).

Another implication of the perception of drugs as a priori malignant substances is that this affects the identification of the relationships that individuals establish with substances and use patterns (^{Rodrigues, 2008}). This may be a factor to explain the resistance that PHC practitioners have to implement in the day-to-day work of the various available and effective resources to approach and treat people with drug problems. These resources include simple screening tools, effective medications and appropriate techniques that can decisively modify substance use patterns. With these resources, primary care services could contribute with high resolution to minimize drug problems in the direction of health and social reintegration (^{Costa, Mota, Paiva & Ronzani, 2015}). However, it is necessary, beforehand, to problematize the conception that the professionals have about the use of drugs in the different contexts.

In spite of the moralizing conception observed in the context of this study, several training processes, such as the Care Pathway project and the courses offered by the National Secretariat for Drug Policy (SENAD), have in their structure the direction to provoke reflection on attitudes, beliefs and feelings towards the use of drugs and the users. However, according to ^{Costa et al. (2015}), the formulation of a concept or thought by the subject occurs not only through training, but also from their physical, moral, spiritual and psychological experience. The authors argue that the health professionals' view on drug use is not detached from the rest of society, but instead is embedded in it as part of a socio-historical process and is crossed by current societal values.

Considering that the basic health units (BHUs) are the closest or in some cases the only institutions that people can use when they experience problems with drug use, unpreparedness or the moralizing and stigmatizing approaches found in this study, or even the reproduction of common sense, can reinforce exclusion and social unfitness and are often more harmful than the use of substances themselves, as pointed out by ^{Ronzani et al. (2014}) and ^{Peyraube (2017}).

Considering the relevance of PHC to nursing professionals in the FHS, we believe that investing in training of these professionals and supporting them for a more confident, less stigmatizing and evidence-based practice is paramount for the effective care of users of alcohol and other drugs in the context of PHC, and should be a constant in the investments and directions of mental health policies at federal, state and municipal level.

We share the understanding of ^{Costa et al. (2015}) that the care of users of alcohol and other drugs requires time for listening, bonding, co-responsibility and it requires a high level of integration among professionals of the care teams. It also requires good will, skills training for innovative care alternatives, technical and managerial capacity, as well as political commitment to the quality of public policies.

These considerations are made not to search of another place of care for users of alcohol and other drugs, but rather to strengthen the need for greater investments in primary care, to reaffirm the need to re-discuss the training focused on integrality with a focus on collective health and reaffirm the need for training for these professionals. It is also urgent to recognize the imperative need to expand the teams that must support this care, emphasizing healthy working relationships that are so important in the care process.

As for the harm reduction approach, people can establish diverse relationships with drugs ranging from recreational use to harmful and compulsive use. Actions directed to the practice of harm reduction consider the individual as the center of treatment and in this sense it is the construction of the bond and listening that will make it possible to evaluate the place that each substance occupies in people's lives, what motivations they see for the use, for the reduction or interruption of this use, if necessary (^{Sodelli, 2012}). Only based on this, we can understand that it is possible to construct singular therapeutic projects necessary for the care of those who make harmful use of alcohol and other drugs.

This study demonstrates that the focus of CHAs is abstinence. Since this is the goal, we cannot speak of actions based on liberating harm reduction proposals (^{Sodelli, 2012}) in order to produce more autonomous subjects and bet on the possibilities that the link between professionals and users can provoke and on actions that address the harmful use of drugs without focusing on the need to discontinue this use.

Final considerations

The data from this study reinforce that, in order to be able to provide care for users of alcohol and other drugs in the space of PHC, an articulated health and intersectorial network is necessary, considering the social determinants and the complexity of individuals and social issues that surround the use of drugs. An isolated or disjointed level of attention will not even be able to achieve its function in this network. Hence, using the matrix tool, to cover other strategic sectors such as security, education and other community devices is of importance.

However, care directed at users of alcohol and other drugs also depends on the State's ability to lead and coordinate an evidence-based drug policy that overcomes the decision-making power of private and external actors with interests to perpetuate the situation of exclusion or to take financial advantage of the vulnerabilities of certain groups (^{Bello, 2015}).

The Care Pathway project, due to its methodology of thinking about actions based on the daily needs of the PHC actors, and being one of the most ambitious numerical training processes, deserves to be highlighted and new studies must be made on its impacts. Moreover, it is necessary to investigate its developments in other contexts and at the national level. At the moment, we believe that it provided space for reflection on the subject of drug use in a reflexive way in the health services, since this is a subject that continues to deliberate the sector. However, in relation to the findings of this study, they direct us to think about the continuous training processes, involving the large range of health professionals and without ends in themselves.

Finally, we believe that continuing education programs are needed for health professionals who focus on the theoretical basis of harm reduction in order to increase their capacity to direct the care of users of alcohol and other drugs.

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• 1
  Support and funding: Coordination of Improvement of Higher Education Personnel (CAPES); National Council forScientific, Technological Development (CNPq); and Research Support Foundation of the state of Minas Gerais (FAPEMIG)

Publication Dates

• Publication in this collection
  13 Mar 2020
• Date of issue
  2018

History

• Received
  31 May 2017
• Accepted
  12 Feb 2018