Reabilitação psicossocial: entre a segurança e ética da existência / Psychosocial rehabilitation: between security and the ethics of existence / Rehabilitación psicosocial: entre la seguridad y la ética de la existencia

O seguinte artigo tem como objetivo mapear as práticas e pensar nas possíveis resistências à captura da vida pelas políticas públicas de reabilitação psicossocial com usuários de álcool e outras drogas. Utilizando do metodológico da cartografia, acompanhei o cotidiano de um Centro de Atenção Psicossocial álcool e outras drogas do interior de Goiás, registrando a experiência em um diário de campo. Deparei-me com a toda a diversidade teórica e prática da reabilitação psicossocial, atravessadas pelos diagramas do proibicionismo e antiproibicionismo. Analisadas dentro de uma racionalidade neoliberal, como traz Foucault, as práticas de reabilitação psicossocial de usuários de álcool e outras drogas acompanham de perto os movimentos da população modulando condutas e o consumo de drogas. Porém, agenciada à política de redução de danos, também permite linhas de subjetivação, que possibilita a construção de modos singulares de existência, perpassadas pelo cuidado de si, e não inserido simplesmente em um código moral.

The following article aims to map the psychosocial rehabilitation practices with users of alcohol and other drugs and think of the possibles resistances to the capture of life by publics policies. Using the methodology of cartography, I followed the daily routine of a CAPS ad from the interior of Goiás, recording the experience in a field diary. I came across all the theoretical and practical diversity of psychosocial rehabilitation, traversed by the prohibitionist and anti-prohibitionist diagrams. Analyzed within a neoliberal rationality, as Foucault brings, the practices of psychosocial rehabilitation of users of alcohol and other drugs closely follow the movements of the population modulating behaviors and drug consumption. However, it is also linked to the policy of harm reduction. It also allows subjectivation, which enables the construction of singular modes of existence, pervaded by self-care, and not simply inserted in a moral code.

El siguiente artículo tiene como objetivo mapear las prácticas y pensar en posibles resistencias a la captura de la vida por parte de las políticas públicas de rehabilitación psicosocial con usuarios de alcohol y otras drogas. Utilizando el metodológico de la cartografía, acompañé el cotidiano de un CAPS ad del interior de Goiás, registrando la experiencia en un diario de campo. Me encontré con toda la diversidad teórica y práctica de la rehabilitación psicosocial, atravesadas por los diagramas del prohibicionismo y antiprohibicionismo. Analizadas dentro de una racionalidad neoliberal, como trae Foucault, las prácticas de rehabilitación psicosocial de usuarios de alcohol y otras drogas acompañan de cerca los movimientos de la población modulando conductas y el consumo de drogas. Sin embargo, agenciada a la política de reducción de daños, también permite líneas de subjetivación, que posibilitan la construcción de modos singulares de existencia, atravesadas por el cuidado de sí, y no insertado simplemente en un código moral.

The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder.

BACKGROUND: Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations. METHODS AND FINDINGS: We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths. CONCLUSIONS: Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

DSM-5 in patients seeking their first treatment for alcohol use disorder. Sex differences in the multicenter CohRTA study. / DSM-5 en pacientes que solicitan el primer tratamiento del trastorno por uso de alcohol. Diferencias de sexo en el estudio multicéntrico CohRTA.

OBJECTIVE: We aimed to analyze sex differences in the DSM-5 criteria among patients admitted to  their first treatment of alcohol use disorder (AUD). METHODS: Assessment of AUD was carried out using DSM-5 diagnostic criteria in a multicenter study (CohRTA) within the Spanish Network on Addictive Disorders. Further, baseline questionnaires including socio-demographics, family history, lifetime alcohol consumption and other substance use, as well as clinical and laboratory parameters were obtained during admission. RESULTS: 313 patients (74.8%M) were eligible; mean age at first AUD treatment was 48.8 years (standard deviation (SD): 9.9 years). Age at onset of alcohol use was 15.9 years (SD: 3.3 years) and age at starting regular alcohol consumption was 25.6 years (SD: 9.6 years). Almost 69.3% of patients were tobacco smokers and 61% had family history of AUD. Regarding other substance use, 7.7% were current cocaine users and 18.2% were cannabis users. Women started regular alcohol consumption later than men (p<,001) and used benzodiazepines more frequently (p=.013). According to DSM-5, 89.5% of cases had severe AUD (≥6 criteria). In the adjusted analysis (logistic regression), men were more likely to neglect major rules (OR=1.92, 95%CI: 1.06-3.48) and to have hazardous alcohol use (OR=3.00, 95%CI: 1.65-5.46). DISCUSSION: DSM-5 detects sex differences in patients seeking their first AUD treatment. Social impairment and risky alcohol use are significantly more frequent in men.

Objetivo: Analizar las diferencias de sexo en los criterios diagnósticos del DSM-5 de los pacientes que solicitan un tratamiento para el trastorno por uso de alcohol (TUA) por primera vez. Métodos: Pacientes incluidos entre enero 2014 y marzo 2016 en el estudio multicéntrico CohRTA de la Red de Trastornos Adictivos. El diagnóstico del TUA se realizó mediante el DSM-5. Además, se recogieron datos sociodemográficos, sobre el consumo de alcohol y otras sustancias, variables clínicas y una analítica general. Resultados: se incluyeron 313 pacientes (74,8% hombres); la edad al inicio del primer tratamiento fue de 48,8 años (desviación estándar (DE): 9,9 años), la edad al inicio del consumo de alcohol de 15,9 años (DE: 3,3 años) y la de inicio del consumo regular de 25,6 años (DE: 9,6 años). Un 69,3% de los pacientes eran fumadores y un 61% tenían antecedentes familiares de TUA. Un 7,7% eran consumidores de cocaína y un 18,2% de cannabis. Las mujeres iniciaron el consumo regular de alcohol más tarde que los hombres (p<,001) y usaban benzodiacepinas con mayor frecuencia (p=,013). Según el DSM-5, el 89,5% de los pacientes presentaban un TUA grave (≥6 criterios). En el análisis ajustado (regresión logística), los hombres tenían mayor probabilidad de presentar el criterio diagnóstico relacionado con el incumplimiento de los deberes fundamentales en el trabajo o en el hogar (OR=1,92, IC95%: 1,06-3,48) y el criterio diagnóstico de consumir alcohol en situaciones de riesgo físico (OR=3,00, IC95%: 1,65-5,46). Discusión: El DSM-5 detecta diferencias de sexo en pacientes que solicitan el primer tratamiento del TUA. El deterioro social y el consumo de alcohol de riesgo son significativamente más frecuentes en hombres.

Atitudes dos profissionais da atenção primária frente à assistência aos usuários de álcool / Attitudes of primary care professionals towards assistance to alcohol users

O álcool é a substância mais usada por diversos grupos da população e o seu consumo abusivo pode levar a diversas consequências para a saúde física, mental e se estende à família e a problemas sociais o que configura um problema de saúde pública. Estratégias de identificação e intervenção para os problemas relacionados ao uso de álcool têm sido lentamente implementadas nos serviços da atenção primária à saúde, tendo em vista a amplitude e complexidade dos problemas e as barreiras que comprometem a oferta e a boa qualidade do cuidado. Entender o fenômeno do uso de álcool em sua multifatorialidade torna-se uma questão relevante para o manejo das barreiras e a oferta de abordagem apropriada. Entende-se como um componente crucial para proporcionar educação e treinamento a esses profissionais que atuam em cuidados aos usuários de álcool na atenção primária à saúde. O estudo teve por objetivo: a) avaliar conhecimentos teórico-práticos, percepções, sentimentos e atitudes de profissionais de saúde da atenção primária, sobre a assistência aos usuários com problemas relacionados ao uso de álcool; b) realizar um treinamento sobre esse tema e c) avaliar os conhecimentos, percepções, sentimentos e atitudes dos profissionais antes e após a aplicação do treinamento aos agentes comunitários da saúde. Método: trata-se de estudo quase-experimental, que envolve avaliação pré e pós-treinamento, e com abordagem quantitativa. O estudo foi realizado nas unidades de atenção primária em Pitangueiras, São Paulo, Brasil. Informações sociodemográficas e relacionadas a conhecimentos teórico-práticos sobre os problemas referentes ao uso de álcool na assistência aos usuários de álcool na atenção primária, a escala de Seaman & Manello: Nurse's Attitudes Toward Alcohol and Alcoholism Scale e o Short Alcohol and Alcohol Problems Perception Questionnaire foram utilizados. Na primeira etapa do estudo, foram entrevistados 89 profissionais de saúde da atenção primária. Posteriormente, participaram 31 agentes comunitários de saúde, que receberam treinamento sobre os problemas relacionados ao uso de álcool e foram avaliados antes e após o treinamento. Resultados: esses profissionais eram adultos jovens (33,8 anos), a maioria do sexo feminino, metade era casado, professava a religião católica e 64,5% possuía o ensino médio. Em relação às percepções sobre a assistência e sua importância, os agentes comunitários de saúde apresentaram melhores percepções sobre "como ajudar os usuários de álcool na atenção primária" - no pós-treinamento, no entanto, assinalaram que, mesmo com o treinamento, ainda apresentavam dificuldades em realizar tais cuidados junto a essa clientela. Obtiveram melhores níveis de conhecimento sobre sinais e sintomas do uso, abuso e dependência de álcool, houve mudança também em relação aos conhecimentos, habilidades específicas e necessárias para realizar assistência adequada aos usuários de álcool. Para um grupo de atitudes, foram relacionadas habilidades para ajudar os pacientes usuários de álcool e não foram observadas mudanças após a realização do treinamento. Conclusão: o treinamento é uma ferramenta que possibilita mudanças das práticas de saúde para a assistência integral ao paciente, que deve ser incorporado nas rotinas das unidades de saúde de forma contínua e permanente

Alcohol is the substance most used by various groups of the population, its abuse can lead to several diverse consequences for physical and mental health and extends to family and social problems which configured a public health problem. Identification and intervention strategies for alcohol-related problems have been slowly implemented in primary health care services, given the breadth and complexity of the problems and the barriers that compromise the provision and good quality of care. Understanding the phenomenon of alcohol use in its multifactorialities becomes a relevant issue for the management of barriers and offering an appropriate approach. It is understood as a crucial component to provide education and training to these professionals who work in the care of drug users. alcohol in primary health care. The study aims to: a) evaluate the theoretical and practical knowledge, perceptions, feelings and attitudes of primary care health professionals, about the assistance to users with problems related to alcohol use; b) conduct training on this topic; and c) evaluate the knowledge, perceptions, feelings and attitudes of professionals before and after the application of training to community health agents. Method: this is a quasi-experimental study, involving pre and post training evaluation, with a quantitative approach. The study was conducted in primary care units of a municipality in the interior of São Paulo: Pitangueiras. The data collection instrument contains: sociodemographic information, theoretical and practical information on problems related to alcohol use in assisting alcohol users in primary care, Seaman & Manello Scale: "Nurse's Attitudes Toward Alcohol and Alcoholism Scale" and Short Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). In the first stage of the study, 89 primary care health professionals were interviewed. Participated in the training on problems related to alcohol use, 31 community health agent. Results: the final sample consisted of professionals with an average age of 33.8 years, most were female 83.9%, half were married, 54.8% professed the Catholic religion and 64.5% had high school. Regarding perceptions about care and its importance, community health agents presented better perceptions about "how to help alcohol users in primary care" - however, after training, they pointed out that even with training, they still had difficulties. in performing such care with this clientele, obtained better levels of knowledge about signs and symptoms of alcohol use, abuse and dependence. There was also a change in the knowledge, specific skills needed to provide appropriate assistance to alcohol users. There were no changes in CHA attitudes after training, skills-related attitudes to help alcohol users. Conclusion: it is concluded that the training provided enables changes in health practices for comprehensive patient care, but should be incorporated into the routines of health units on a continuous and permanent basis

Systematic review of untreated remission from alcohol problems: Estimation lies in the eye of the beholder.

BACKGROUND: Remission from alcohol problems in the absence of treatment is common, yet there are wide ranging estimates of the extent to which this occurs, depending on method. A systematic review of the literature on untreated remission from alcohol problems was conducted to analyse the ways different definitions and study designs impact on estimates of untreated remission from alcohol problems, and to explore the implications for treatment planning. METHODS: 2103 texts were identified through systematic searches of databases (Medline, PsycINFO, EMBASE) and other searches. Peer-reviewed journal articles published since 1975 which provided numeric estimates of untreated remission from alcohol problems were included. A narrative synthesis was undertaken. RESULTS: 124 estimates of untreated remission from alcohol problems were extracted from 27 studies. Three different sampling methods were identified: taking an 'alcohol problems sample' (method 1) which estimated the proportion of people with alcohol problems who remit without treatment; taking an 'untreated sample' (method 2) which estimated the proportion of untreated people who enter remission; and taking a 'remitted sample' (method 3) which estimated the proportion of people in remission who have not received treatment. In addition to this sampling diversity, the definitions of an alcohol problem, definitions of remission, and definitions of treatment varied between studies. The combination of the methods and definitional issues impacted on estimates of untreated remission from alcohol problems. CONCLUSIONS: Estimates derived from the 'alcohol problems sample' (method 1) and 'untreated sample' (method 2) are the most appropriate for treatment planners. How a treatment planner defines what treatment is, what remission is, and how an alcohol problem is defined all matter for these estimates.

Participant Evaluation of Twelve-Step Group Linkage for Jailed Women With Alcohol Use Disorder.

Jailed women are an underserved population with elevated rates of alcohol use disorders. Brief jail stays make delivery of case management and traditional alcohol treatment impractical yet women face significant reentry challenges with few help resources. Accounting for these challenges, linking jailed women with a twelve-step program volunteer for a one-on-one meeting has been hypothesized to provide a means of support that can transition with women after jail discharge. In-jail meetings are theoretically consistent with the common twelve-step practice of conducting twelve-step calls. The acceptability and content of a one-on-one, in-jail meeting with a twelve-step volunteer were explored using qualitative data collected through interviews with 72 women directly following their in-jail volunteer meeting. Participants found the meeting to be acceptable and to contain many useful elements, and content was in line with the standard twelve-step calls. Findings are encouraging both for the potential utility of the intervention and for dissemination of similar linkage approaches.

Novel approaches to alcohol rehabilitation: Modification of stress-responsive brain regions through environmental enrichment.

Relapse remains the most prominent hurdle to successful rehabilitation from alcoholism. The neural mechanisms underlying relapse are complex, but our understanding of the brain regions involved, the anatomical circuitry and the modulation of specific nuclei in the context of stress and cue-induced relapse have improved significantly in recent years. In particular, stress is now recognised as a significant trigger for relapse, adding to the well-established impact of chronic stress to escalate alcohol consumption. It is therefore unsurprising that the stress-responsive regions of the brain have also been implicated in alcohol relapse, such as the nucleus accumbens, amygdala and the hypothalamus. Environmental enrichment is a robust experimental paradigm which provides a non-pharmacological tool to alter stress response and, separately, alcohol-seeking behaviour and symptoms of withdrawal. In this review, we examine and consolidate the preclinical evidence that alcohol seeking behaviour and stress-induced relapse are modulated by environmental enrichment, and these are primarily mediated by modification of neural activity within the key nodes of the addiction circuitry. Finally, we discuss the limited clinical evidence that stress-reducing approaches such as mindfulness could potentially serve as adjunctive therapy in the treatment of alcoholism. This article is part of the Special Issue entitled "Neurobiology of Environmental Enrichment".

Feasibility, acceptability, and preliminary effects of a brief alcohol intervention for suicidal adolescents in inpatient psychiatric treatment.

Alcohol use, both short-term intoxication and longer-term use, is a notable risk factor for suicide. Despite the strong relationship between alcohol use and suicidal thoughts and behaviors, providers typically treat these two problems independently. In particular, acute psychiatric care hospitalizations for adolescents are typically brief, and many only cursorily address alcohol use. Integrating a brief motivational enhancement intervention for alcohol use into an inpatient psychiatric hospitalization treatment protocol has the potential to enhance motivation to stop or reduce drinking if adolescents can more fully understand how it increases risk for suicidal behavior. This study tested the feasibility, acceptability, and preliminary effects of the Alcohol and Suicide Intervention for Suicidal Teens (ASIST), a brief motivational enhancement intervention targeting alcohol use and suicidal thoughts and behaviors for suicidal adolescents receiving inpatient psychiatric treatment. Results from a randomized pilot trial of ASIST (N = 50) revealed that the intervention was both feasible and acceptable, with 92% of those in the ASIST condition reporting that the intervention helped them to understand how their alcohol use is related to their suicidal thoughts and behaviors. Study findings suggest a larger randomized controlled trial may be warranted to test the effectiveness of ASIST with psychiatrically hospitalized adolescents.

Effectiveness of a national 'Minnesota Model' based residential treatment programme for alcohol dependence in Ireland: outcomes and predictors of outcome.

OBJECTIVES: The aims of this study were (a) to examine the effectiveness of an inpatient treatment programme for alcohol dependence based on the 'Minnesota Model' and (b) to examine potential predictors of outcomes from such treatment. METHODS: Demographics and data relating to psychosocial functioning of a group of individuals who commenced treatment for alcohol dependence were gathered at the point of treatment entry. These individuals were then followed up 6 months after they were to complete their inpatient treatment to establish their alcohol-related outcomes. Outcomes from treatment were identified as an index of treatment effectiveness and the outcome data were analysed to determine whether any of the baseline variables could be used to predict outcomes from treatment. RESULTS: Of those who were contacted at 6-month follow-up, 81.5% had a 'good outcome'. This represented 66.7% of the total group who participated in the study. The only variable that was found to predict outcomes at 6-month follow-up was severity of alcohol dependence at treatment entry, with more severe alcohol problems associated with poorer outcomes. CONCLUSIONS: This study provides evidence of the potential for a Minnesota-based treatment programme to be effective in helping people with alcohol dependence to reduce the amount of alcohol they consume and sustain this reduction beyond the treatment period.

On being "in recovery": A national study of prevalence and correlates of adopting or not adopting a recovery identity among individuals resolving drug and alcohol problems.

The concept of recovery has become an organizing paradigm in the addiction field globally. Although a convenient label to describe the broad phenomena of change when individuals resolve significant alcohol or other drug (AOD) problems, little is known regarding the prevalence and correlates of adopting such an identity. Greater knowledge would inform clinical, public health, and policy communication efforts. We conducted a cross-sectional nationally representative survey (N = 39,809) of individuals resolving a significant AOD problem (n = 1,995). Weighted analyses estimated prevalence and tested correlates of label adoption. Qualitative analyses summarized reasons for prior recovery identity adoption/nonadoption. The proportion of individuals currently identifying as being in recovery was 45.1%, never in recovery 39.5%, and no longer in recovery 15.4%. Predictors of identifying as being in recovery included formal treatment and mutual-help participation, and history of being diagnosed with AOD or other psychiatric disorders. Qualitative analyses regarding reasons for no/prior recovery identity found themes related to low AOD problem severity, viewing the problem as resolved, or having little difficulty of stopping. Despite increasing use of the recovery label and concept, many resolving AOD problems do not identify in this manner. These appear to be individuals who have not engaged with the formal or informal treatment systems. To attract, engage, and accommodate this large number of individuals who add considerably to the AOD-related global burden of disease, AOD public health communication efforts may need to consider additional concepts and terminology beyond recovery (e.g., "problem resolution") to meet a broader range of preferences, perspectives and experiences. (PsycINFO Database Record

The association between impulsivity, emotion regulation, and symptoms of alcohol use disorder.

Emotion dysregulation and impulsivity are important factors influencing the development and course of alcohol dependence. However, few empirical studies investigate the association between different aspects of impulsivity (cognitive, attentional, behavioral), emotion regulation, and alcohol use disorder symptoms in the same model. The goal of this study was to assess the association between emotion regulation and different facets of impulsivity among patients with an alcohol use disorder and healthy controls. The sample was comprised of 273 individuals: 180 participants with an alcohol use disorder undergoing inpatient alcohol treatment and 93 healthy controls. Emotion regulation was assessed using the Schutte Self-Report Emotional Intelligence Test subscale. Impulsivity was assessed with Barratt's Impulsiveness Scale (BIS-11). Statistical models tested both the BIS-11 total score, as well as three secondary factors (non-planning, attentional, and motor impulsivity). Findings indicate that individuals with alcohol use disorder symptoms were characterized by poor emotion regulation and high levels of impulsivity in all analyzed domains. Moreover, path analytic models indicated that after accounting for demographic factors (i.e., biological sex, age, education) there was evidence for a significant indirect effect of alcohol use disorder symptomatology on non-planning and attentional impulsivity via emotion regulation. There was no association between emotion regulation and motor impulsivity. These findings indicate the importance of targeting emotion regulation skills as well as behavioral control when treating patients with alcohol use disorder.

What's in a Trial? On the Importance of Distinguishing Between Experimental Lab Studies and Randomized Controlled Trials: The Case of Cognitive Bias Modification and Alcohol Use Disorders.

OBJECTIVE: Recently, the National Institutes of Health (NIH) redefined clinical trials to include any study involving behavioral or biomedical interventions. In line with a general framework from experimental medicine, we argue that it is crucial to distinguish between experimental laboratory studies aimed at revealing psychological mechanisms underlying behavior and randomized controlled trials (RCTs) in clinical samples aimed at testing the efficacy of an intervention. METHOD: As an illustration, we reviewed the current state of the evidence on the efficacy of cognitive bias modification (CBM) interventions in alcohol use disorders. RESULTS: A recent meta-analysis "cast serious doubts on the clinical utility of CBM interventions for addiction." That analysis combined experimental laboratory studies and RCTs. We demonstrated that, when studies are differentiated regarding study type (experimental laboratory study or RCT), mode of delivery (controlled experiment or Internet), and population (healthy volunteers or patients), the following effects are found: (a) short-lived effects of CBM on drinking behavior in experimental laboratory studies in students, but only when the bias is successfully manipulated; (b) small but robust effects of CBM on treatment outcome when administered as an adjunct to established treatments in clinical settings in RCTs with alcohol-dependent patients; and (c) nonspecific effects (reduced drinking irrespective of condition) in RCTs of CBM administered online to problem drinkers. CONCLUSIONS: We discuss how CBM might be improved when it is better integrated into regular treatment, especially cognitive behavioral therapy, and we conclude that disregarding the difference between experimental laboratory studies and RCTs can lead to invalid conclusions.

Enfoque de género y maternidad en programas de alcohol y drogas: análisis crítico a partir de un caso clínico / Gender and maternity focus on alcohol and drug programs: critical analysis from a clinical case

El presente trabajo analiza la relación entre enfoque de género, maternidad y los procesos de rehabilitación, en casos de consumo problemático de drogas y/o alcohol. Se indaga en los aspectos nombrados desde una revisión teórica para, posteriormente, hacerlos dialogar con el caso clínico de una usuaria del Programa de Alcohol y Drogas del Consultorio Pudahuel La Estrella, con el objetivo de describir los elementos que configuran al proceso de gestación y futura maternidad como posible estado facilitador de la abstinencia y deseo de cambio. Se habla de enfoque de género en salud, basando los análisis en comparaciones referidas a la diferencia sexual-biológica, sin relevar los constructos sociales erigidos históricamente respecto al sistema sexo-género. Se expone el caso clínico de una usuaria de 19 años, quien presenta historial de consumo de pasta base de cocaína, marihuana y tabaco. La búsqueda de ayuda en programa mencionado se produce de forma espontánea, luego de enterarse de sus 6 semanas de gestación. La maternidad, eje central en el abordaje de la situación planteada, nos da el punto de partida en la realización de un análisis socio-cultural desde un enfoque de género crítico, desglosando los elementos que se conjugan en la construcción del proceso de rehabilitación de ésta mujer, para posteriormente reflexionar respecto a los elementos que favorecen o no la adherencia al tratamiento.

This paper analyzes the relationship between gender, maternity and rehabilitation processes in cases of problematic drug and / or alcohol use. We investigated in the named aspects from a theoretical review to make them dialogue subsequently with the clinical case of a user of the Alcohol and Drugs Program of Pudahuel La Estrella, with the aim of describing the elements that shape the gestation and future maternity process as a possible facilitator state of abstinence and desire for change. It is often referred to as a gender approach in health when basing the analyzes on comparisons referring to the sexual-biological difference, without underlining the social constructs erected historically with respect to the sex-gender system. The clinical case of a 19-year-old female user is presented, who presents a history of cocaine base, marijuana and tobacco consumption. The search for help in the mentioned program occurs spontaneously, after knowing of her 6 weeks of gestation. Maternity, central axis in the approach of the situation presented, gives us the starting point in the realization of a sociocultural analysis from a critical gender approach, disaggregating the elements that are combined in the construction of the rehabilitation process of this one woman, to later reflect on the elements that favor or not the adherence to treatment.

Effectiveness of inpatient withdrawal and residential rehabilitation interventions for alcohol use disorder: A national observational, cohort study in England.

BACKGROUND: This was a national English observational cohort study to estimate the effectiveness of inpatient withdrawal (IW) and residential rehabilitation (RR) interventions for alcohol use disorder (AUD) using administrative data. METHODS: All adults commencing IW and/or RR intervention for AUD between April 1, 2014 and March 31, 2015 reported to the National Drug Treatment Monitoring System (n=3812). The primary outcome was successful completion of treatment within 12months of commencement, with no re-presentation (SCNR) in the subsequent six months, analysed by multi-level, mixed effects, multivariable logistic regression. RESULTS: The majority (70%, n=2682) received IW in their index treatment journey; one-quarter (24%, n=915) received RR; 6% (n=215) received both. Of treatment leavers, 59% achieved the SCNR outcome (IW: 57%; RR: 64%; IW/RR: 57%). Positive outcome for IW was associated with older age, being employed, and receiving community-based treatment prior to and subsequent to IW. Patients with housing problems were less likely to achieving the outcome. Positive outcome for RR was associated with paid employment, self/family/peer referral, longer duration of RR treatment, and community-based treatment following discharge. Community-based treatment prior to entering RR, and receiving IW during the same treatment journey as RR, were associated with lower likelihood of SCNR. CONCLUSIONS: In this first national effectiveness study of AUD in the English public treatment system for alcohol-use disorders, 59% of patients successfully completed treatment within 12months and did not represent for more treatment within six months. Longer duration of treatment and provision of structured continuing care is associated with better treatment outcomes.

Beyond Abstinence: Changes in Indices of Quality of Life with Time in Recovery in a Nationally Representative Sample of U.S. Adults.

BACKGROUND: Alcohol and other drug (AOD) treatment and recovery research typically have focused narrowly on changes in alcohol/drug use (e.g., "percent days abstinent") with little attention on changes in functioning or well-being. Furthermore, little is known about whether and when such changes may occur, and for whom, as people progress in recovery. Greater knowledge would improve understanding of recovery milestones and points of vulnerability and growth. METHODS: National, probability-based, cross-sectional sample of U.S. adults who screened positive to the question, "Did you used to have a problem with alcohol or drugs but no longer do?" (Response = 63.4% from 39,809; final weighted sample n = 2,002). Linear, spline, and quadratic regressions tested relationships between time in recovery and 5 measures of well-being: quality of life, happiness, self-esteem, recovery capital, and psychological distress, over 2 temporal horizons: the first 40 years and the first 5 years, after resolving an AOD problem and tested moderators (sex, race, primary substance) of effects. Locally Weighted Scatterplot Smoothing regression was used to explore turning points. RESULTS: In general, in the 40-year horizon there were initially steep increases in indices of well-being (and steep drops in distress), during the first 6 years, followed by shallower increases. In the 5-year horizon, significant drops in self-esteem and happiness were observed initially during the first year followed by increases. Moderator analyses examining primary substance found that compared to alcohol and cannabis, those with opioid or other drugs (e.g., stimulants) had substantially lower recovery capital in the early years; mixed race/native Americans tended to exhibit poorer well-being compared to White people; and women consistently reported lower indices of well-being over time than men. CONCLUSIONS: Recovery from AOD problems is associated with dynamic monotonic improvements in indices of well-being with the exception of the first year where self-esteem and happiness initially decrease, before improving. In early recovery, women, certain racial/ethnic groups, and those suffering from opioid and stimulant-related problems appear to face ongoing challenges that suggest a need for greater assistance.

[Health Care Organization - The New German S3-Guideline on Alcohol-Related Disorders and its Relevance for Health Care]. / Versorgungsorganisation ­ Die neue S3-Leitlinie Alkohol und ihre Bedeutung für die Versorgungspraxis.

BACKGROUND: Alcohol dependence is one of the most serious diseases of addiction in Germany. The new S3-guideline "Screening, Diagnostics and Treatment of Alcohol-Related Disorders" has been presented in 2015 and summarizes the present state of knowledge pertaining to the diagnosis and treatment of alcohol abuse and alcohol dependence. METHODS: This guideline was developed over four years within the framework of the Association of the Scientific Medical Societies in Germany (AWMF). The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) and the German Society for Research and Therapy in Addiction (DG-Sucht) took the lead in the organization. More than 50 professional societies and associations and health organizations as well as more than 60 acknowledged experts were involved, including networks of self-help groups and relatives. The working group on "health care organization", whose results are presented here, was one out of thirteen working groups, focusing on the task how to implement the guideline under the basic conditions of the German health care system with its sectors and interfaces. RESULTS: For the chapter on "health care organization" 27 recommendations have been consented. Many of these have been prepared by the respective working groups. These recommendations cover areas such as screening, diagnostics and short interventions, detoxification and withdrawal as well as pharmacotherapy, physical complications and psychic comorbidity, medical rehabilitation and other forms of post-acute treatment, primary care by general practitioners, as well as specific target groups such as children and adolescents, (pregnant) women and the elderly, and, in addition, self-help approaches. CONCLUSION: For needs-based diagnostics and treatment of alcohol-related disorders, guideline-based recommendations for health care organization offer a framework for the cooperation and coordination of all health sectors and occupational groups, especially with respect to their interfaces. This includes the cooperation between the medical and the psychosocial system and stretches from harm reduction to social inclusion of people concerned. Particularly the field of rehabilitation with its explicit aims for participation relies heavily on such a cooperation.

Web-based alcohol intervention for veterans: PTSD, combat exposure, and alcohol outcomes.

OBJECTIVE: The purpose of the current study was to evaluate the relationship between baseline levels of posttraumatic stress disorder (PTSD), combat exposure, and alcohol outcomes in a sample of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans using a web-based self-management intervention (VetChange) for problem drinking. METHOD: The current study focuses on 523 veterans who participated in a larger randomized clinical trial. Analyses in the current study include (a) multivariable linear regression models to assess the relationship between PTSD, combat exposure, and alcohol variables at baseline, and (b) general linear models accounting for correlated data within subjects to analyze change over time for alcohol outcomes as a function of baseline PTSD symptoms, combat exposure, and covariates. RESULTS: There was a positive association between PTSD symptom severity and alcohol use and alcohol problem severity at baseline. However, participants with higher baseline PTSD symptoms demonstrated a significantly greater reduction in alcohol use during the intervention and a greater reduction in alcohol problems from baseline to 3-month follow-up. Combat exposure severity was positively associated with alcohol problems at baseline. However, veterans with higher exposure demonstrated a greater reduction in average weekly drinking between end of intervention and follow-up, and otherwise showed changes similar to participants with lower exposure. CONCLUSIONS: Higher levels of baseline PTSD symptoms and combat exposure severity did not prevent OEF/OIF veterans from achieving positive alcohol outcomes through participation in a self-management web intervention for problem drinking. (PsycINFO Database Record

Trends in mortality rates where alcohol was a necessary cause of death in Brazil, 2000-2013 / Tendencias en las tasas de mortalidad donde el alcohol fue una causa necesaria de muerte en Brasil, 2000-2013 / Tendências nas taxas de mortalidade onde o álcool foi uma causa necessária de morte no Brasil, 2000-2013

ABSTRACT Objective To analyze trends in mortality due to diseases and conditions fully attributable to alcohol in Brazil. Methods This was an ecological time-series study. Proportional, specific, and age-standardized mortality rates between 2000 and 2013 that were due to underlying or contributing causes fully attributable to alcohol use were analyzed by sex, ethnicity/skin color, age group, and region of residence in the country. Data on deaths were obtained from the Brazilian Mortality Information System (SIM). Prais-Winsten regression was used to analyze trends. Results Deaths with underlying causes and/or conditions contributing to death fully attributable to alcohol accounted for 2.5% of total deaths in the period. There were more deaths among men (3.8%) than among women (0.7%). In both sexes, there was a higher proportion of deaths in those 40-49 years old (27.9%) and those of black or pardo (mixed race) skin color (48.8%). Between 2000 and 2013, there was an upward trend in specific mortality rates attributable to alcohol in the country as a whole (average annual growth rate (AAGR) = 5.59%; 95% confidence interval (CI) = 3.55%-7.68%), especially in people aged less than 20 years old, in pardos (AAGR = 13.42%; 95% CI = 9.70%-17.25%), and in residents of the North region (AAGR = 17.01%; 95% CI = 14.94%-19.13%), the Northeast region (AAGR = 15.49%; 95% CI = 10.61%-20.58%), and the Midwest region (AAGR = 8.40%; 95% CI = 5.57%-11.32%). Conclusion Alcohol is an important and growing cause of premature death in Brazil, especially among men, black/pardo people, and the population living in the most disadvantaged regions. This overall increase in the harmful use of alcohol reflects ethnic and socioeconomic inequalities in Brazil, and it also points to the need for population-based policies to reduce the impact of morbidity and to prevent early mortality.

RESUMEN Objetivo Analizar las tendencias en la mortalidad debido a enfermedades y condiciones totalmente atribuibles al alcohol en Brasil. Métodos Se realizó un estudio ecológico de series temporales. Las tasas de mortalidad proporcionales, específicas y estandarizadas por edad entre 2000 y 2013 que se debieron a causas subyacentes o contribuyentes totalmente atribuibles al consumo de alcohol se analizaron por sexo, raza/ color de piel, grupo de edad y región de residencia en el país. Los datos sobre muertes se obtuvieron del Sistema Brasileño de Información de Mortalidad (SIM). Se utilizó la regresión de Prais-Winsten para analizar las tendencias. Resultados Las muertes por causas subyacentes y / o condiciones que contribuyeron a causar la muerte totalmente atribuibles al alcohol representaron el 2,5% del total de muertes en el período en estudio. Hubo más muertes entre los hombres (3.8%) que entre las mujeres (0.7%). En ambos sexos hubo una mayor proporción de muertes entre los 40-49 años (27.9%) y en las personas de piel negra o parda (mestizos) (48.8%). Entre 2000 y 2013, hubo una tendencia ascendente en las tasas de mortalidad específicas atribuibles al alcohol en el país en general (Tasa de Crecimiento Anual Promedio (TCAP) = 5,59%, Intervalo de Confianza(IC) 95% = 3,55% −7,68%), especialmente en personas menores de 20 años, de tez pardos (TCAP = 13.42%, IC 95% = 9.70% −17.25%), y en residentes de la región Norte (TCAP= 17.01%, IC 95% = 14.94% −19.13%), Región Nordeste (AAGR = 15.49%, IC 95% = 10.61% −20.58%) y la región Medio Oeste (AAGR = 8.40%, IC 95% = 5.57% −11.32%). Conclusión El alcohol es una causa importante y creciente de muerte prematura en Brasil, especialmente entre hombres, personas de raza negra y parda y la población que viven en las regiones más desfavorecidas. Este aumento general en el uso nocivo de alcohol refleja las desigualdades étnicas y socioeconómicas en Brasil, y también señala la necesidad de políticas basadas en la población para reducir el impacto de la morbilidad y prevenir la mortalidad temprana.

RESUMO Objetivo Analisar tendências de mortalidade por doenças e condições totalmente atribuíveis ao álcool no Brasil. Métodos Este foi um estudo ecológico de séries temporais. As taxas de mortalidade proporcionais, específicas e padronizadas por idade entre 2000 e 2013, decorrentes de causas subjacentes ou contribuintes, totalmente atribuíveis ao consumo de álcool foram analisadas por sexo, etnia / cor da pele, faixa etária e região de residência no país. Os dados sobre óbitos foram obtidos do Sistema Brasileiro de Informações sobre Mortalidade (SIM). A regressão Prais-Winsten foi usada para analisar as tendências. Resultados Mortes com causas subjacentes e / ou condições que contribuíram para a morte, totalmente atribuíveis ao álcool, representaram 2,5% do total de mortes no período. Houve mais mortes entre homens (3,8%) do que entre mulheres (0,7%). Em ambos os sexos houve uma maior proporção de óbitos entre 40-49 anos (27,9%) e na cor da pele negra ou pardo (mestiço) (48,8%). Entre 2000 e 2013, houve uma tendência ascendente nas taxas de mortalidade específicas atribuíveis ao álcool no país como um todo (Taxa de Crescimento Anual Média (TCAM) = 5,59%; Intervalo de Confiança (IC) 95% = 3,55% −7,68%), especialmente em pessoas com idade com menos de 20 anos, em pardos (TCAM = 13,42%; IC 95% = 9,70% −17,25%) e em residentes da região Norte (TCAM = 17,01%; IC 95% = 14,94% −19,13%), Região Nordeste (TCAM= 15,49%; IC 95% = 10,61% −20,58%) e região Centro-Oeste (TCAM= 8,40%; IC 95% = 5,57% −11,32%). Conclusão O álcool é uma causa importante e crescente de morte prematura no Brasil, especialmente entre homens, negros / pardos e a população que vive nas regiões mais desfavorecidas. Esse aumento geral do uso prejudicial do álcool reflete desigualdades étnicas e socioeconômicas no Brasil e também aponta a necessidade de políticas baseadas na população para reduzir o impacto da morbidade e prevenir a mortalidade precoce.

Funcionamento de um centro de atenção psicossocial para oatendimento a usuários de crack / Funcionamiento de un centro de atención psicosocial para tratamiento de los usuarios de crack / Operation of a psychosocial care center for the treatment of crack users

Objetivo: analisar o funcionamento de um Centro de Atenção Psicossocial para Álcool e outras Drogas (CAPS AD) para o atendimento a usuários de crack. Métodos: Trata-se de um recorte da pesquisa “ViaREDE”. Possui natureza avaliativa, do tipo estudo de caso, baseando-se na utilização da avaliação de quarta geração como referencial teórico-metodológico. Resultados: o CAPS AD é apontado enquanto um serviço potente na rede de atendimento ao usuário de crack. Destaca-se a importância da porta aberta do serviço para garantia do acesso universal e comprometido com o usuário. Outras questões discutidas são a necessidade de fortalecimento da rede intersetorial e a ampliação de horários de funcionamento do serviço. Conclusão: A análise do funcionamento do serviço contribuiu para pensarmos a constituição cotidiana da rede, bem como a capacidade reformadora dos dispositivos de cuidado.

Objective: to analyze the functioning of a Psychosocial Care Center for Alcohol and Other Drugs (CAPS ad) for the treatment of crack users. Methods: This is a part of the research “ViaREDE”. Has an evaluative nature, the type case study, based on the use of the assessment of Fourth Generation as theoretical-methodological framework. Results: CAPS AD is pointing as a service powerful in the service network to the user of crack cocaine. It highlights the importance of open door of service to guarantee universal access and committed to the user. Other issues discussed are the need to strengthen the network intersectorial and extension of hours of operation of the service. Conclusion: The analysis of the operation of the service helped to think through the constitution of daily network, as well as the ability to undertake reform of care.

Objetivo: analizar el funcionamiento de un Centro de Atención Psicosocial para el consumo de alcohol y otras drogas (CAPS ad) para el tratamiento de los usuarios de crack. Métodos: Se trata de una parte de la investigación “ViaREDE”. Tiene un carácter evaluativo, el tipo estudio de caso, basado en el uso de la evaluación de cuarta generación como marco teórico-metodológico. Resultados: El CAPS AD mientras un potente servicio en la red de servicio a los usuarios de cocaína crack. Subrayamos la importancia de la puerta de servicio para garantizar el acceso universal y comprometido con el usuario. Otros temas discutidos son: la necesidad de reforzar la red intersectorial y ampliación del horário de funcionamiento del servicio. Conclusión: El análisis de la operación del servicio ayudó a pensar a través de la constitución de la red de diarios, así como la capacidad de emprender la reforma de la atención.