Strengthening mental health services and alcohol and other drugs in the primary care centers in Florianopolis, Brazil: Building a thrives partnership

Transcription

1 Strengthening mental health services and alcohol and other drugs in the primary care centers in Florianopolis, Brazil: Building a thrives partnership A proposal to the Pan American Health Organization (PAHO) and the Alliance for Health Policy and Systems Research (AHPSR) - World Health Organization (WHO) for health programs implementation Submitted by: SARAIVA, Sonia Leitao, M.D Mental Health Manager Florianopolis City Department of Health Florianopolis City Mental Health Services Ministry of Health Federative Republic of Brazil soniasaraiva@hotmail.com saudementalpmf@gmail.com Co-participants: DE CERQUEIRA CAMPOS, Renata, M.S DE CONTO, Fernanda, RN, M.S Florianopolis City Department of Health Florianopolis City Mental Health Services Mailing Address: Professor Henrique da Silva Fontes Avenue, # 6100, Trindade, Zip code: Phone: +55 (48) ; +55 (48) address: smsgabinete@pmf.sc.gov.br; saudementalpmf@gmail.com Website:

2 Abstract The abuse of alcohol, alone or in combination with other substances is a common issue found among outpatients centers, primary care services and hospitals and, substance use history and problems may be under identified or misidentified. According to some authors the substance abuse patients when seek treatment, can find challenges such as not adequate substance use histories by professionals who don t have skills to treat substance abuse problems and inadequacy of using discharge diagnoses to document the presence of alcoholism or other substance among the patients (1, 2, 3, 4). Other reports showed that even though the substance abuse is identified and discussed with the patient, action is often not taken to refer them for appropriate outpatient or inpatient treatment (1, 3, 5). Training health providers in service and work with multidisciplinary team can help managers and professionals to overcome this reality. In response of this challenges faced by health professionals, we propose to establish a lasting relationship among mental health managers, primary care centers and psychosocial care centers, through systematic meetings and specific trainings in order to improve the health providers' knowledge, skills and daily practice regarding to mental health and substance abuse issues. This research proposal and practice will allow us to asses the current health providers' knowledge and skills in these topics, and evaluate the efficacy of trainings toward broaden the applicability of our results to elucidate problems. The comparative assessment of the two parts, pre and post, will also allow us to contribute to the literature about appropriate or best approaches in mental health and substance abuse issues and health providers. The results will be shared and presented in the state and federal levels events, debates and conferences, in order to spread and motivate more initiatives across Brazil. Background In Brazil, recent national surveys regarding to substance abuse develop by National Secretary in Drug Policies (SENAD) and Brazilian Information Center on Psychotropic Drugs (CEBRID) showed that substance abuse is a huge problem among the population. They found that the lifetime consumption of illegal drugs in Brazil was 19,4% in 2001 and increased for 22,8% in Between the years 2001 to 2005, the lifetime consumption increased

3 among alcohol, tobacco, marijuana, stimulants, solvents, cocaine, crack, benzodiazepines and hallucinogens users. Regarding to gender, the consumption of benzodiazepines, stimulants and opioids was prevalent in women than the other drugs. Previous studies in Brazil among the years 1987, 1989, 1993 and 1997 showed that the licit drugs were the most consumed by the population, and the alcohol was in the top of the list, followed by tobacco. Regarding to the hospitalizations for drugs, the alcohol keeps being the most significant issue in the general population, responsible for 95% of the cases, since the year 1990 the hospitalizations for cocaine are increasing, and most recent years, have been registered hospitalization for crack/cocaine. The use of psychoactive substances, considered a major public health problem in Brazil, causes undesirable complications such as family crises, marginalization, violence and rehospitalizations, increasing the occupancy rate of hospital beds (6,7). This has contributed to the overloading of the Unified Health System (SUS), the Brazilian public health system, which requires attention systematized, adequate services and professionals with skills in substance abuse care (8). The consumption of alcohol in adult population in Brazil is prevalent among men, 24% of the people who drink assume to do it with potentially risks and 45% of the adults who drank, had problems in consequence of the alcohol. While in Brazil the sale of alcoholic beverages is prohibited for under age 18, nearly 35% of teenagers drink alcohol at least once a year. The data referred to deaths whose underlying cause was poisoning (intoxication) or substance use disorders, notified by Brazilian Mortality Information System (SIM) system in the period 2001 to 2007, showed that the alcohol use disorders are responsible for the largest number of deaths associated with drug use, corresponding to approximately 90% of cases, followed by tobacco use disorders with about 6% and cocaine use disorders with 0.4%. The data considering the number of individuals not working or retired due accidents and problems related to psychoactive substances reported to Brazilian National Social Security Institute of the Ministry of Social Welfare (INSS) from 2001 to 2007, showed that the main reason for sickness leave or retirements was the alcohol consumption. According to Federal University of Sao Paulo through a national survey in 2012, around 11.7 million people in Brazil are alcohol dependent, and drink heavily. The survey also showed that the consumption among women is increasing if compared with previous years, increasing between 29 to 39%. For the researchers, the reasons for this increase can be the better economical situation in Brazil and also a lack in public policies to punish the sale and

4 consumption of alcohol. The estimate number of crack and cocaine users in Brazil in 2012 was 2.6 million people, in this population 1.5 million people are addict to drugs, and these numbers represent that, probably, Brazil is the largest consumer of crack in the world and second largest consumer of cocaine. Besides this, 1.5 million people smoke marijuana everyday. The consequences of alcohol and other drug abuse are negatives, such as diseases, drug overdose, motor vehicle accidents resulting from intoxication, domestic violence, violence associated with drug traffic and trade, and sometimes deaths. All these aspects increase the costs in the criminal justice and health care system, where the drug abuse is associated with HIV/AIDS; liver disease; cirrhosis; pancreatitis; cardiovascular diseases and others (9). Substance abuse treatment in Brazil is a public policy issue. Untreated drug use disorders may prolong length of stay and add to total health care costs. Epidemiological evidence suggests that slight reductions in alcohol consumption are associated with large decreases in alcohol-related illness and injury. The effects of treating substance abuse extend beyond the individual; where there are significant reductions in total family medical insurance claims ensue after the chemical dependency treatment of just one family member (10, 11, 12). According to the Brazilian Laws, specially the Ordinance #3088 from December 23, 2011, it was established the Network for Psychosocial Care for people with mental distress or disorder and needs arising from the use of crack cocaine, alcohol and other drugs within the Unified Health System. With this Network for Psychosocial Care the people with drug issues can access treatment and the health professionals in different levels of attention such as: I- Primary Health Care: primary care centers; doctors and nurses visitors; street's office and welfare and work centers; II - Psychosocial Care Specialized: Psychosocial care centers for mental disorders and substance abuse for youth and adults; III - Urgent and Emergency Care: Hospital day; Mobile Urgent Services operating by phone call for the numbers 192 and 190; IV - Transitional Care Residential Character: hosting units for youth and adults; and therapeutic communities; V - Hospital Care: beds in general hospital, psychiatric unit in general hospital and beds in

5 psychiatric hospitals; VI - Social reintegration and psychosocial rehabilitation: social programs; incentive for jobs; culture and art initiatives; work in cooperatives and more. Florianopolis City, located in the Santa Catarina State in Southern area of Brazil, a medium sized city, has been over the years investing and expanding the services to address this population. Nowadays the city has 04 Psychosocial Care Centers, where 01 is exclusive for Mental Health, 01 is for youth and 02 are reference for drug abuse treatment. Besides this, the city is organized in primary care centers which are the main entrance of the population in the health system. There are 49 primary care centers providing all sorts of health care and attention working supported by urgency units (2), the polyclinics (4), the central pharmacy and the owned labs. All this services compose the complex network of health in the city, where the main idea is to work integrated, in a human way and attending the population needs. The primary care centers have been working with mental health and a substance abuse issue, however, not every professional feels capable and has skills for that, situation that has local implications and for patients, where they need to move long distances to seek the specialized treatment, and facing many barriers, related to stigma, professional disqualification, reduced number of services, professionals, etc. The treatment in general, for any kind of disease, even nowadays, has the tendency to be centered in the doctors, in the exams and/ or in medication. We intend to involve the whole team in the process. Health providers have to have skills and knowledge in mental health and substance abuse problems, but the reality has shown that not all professionals know how to deal with these issues, then, this research proposal and practice intend to reduce or eliminate this gap. Nurses in Brazil represent the majority of the health providers either in inpatient and outpatient centers, responsible for many actions regarding to education, prevention and treatment of the population. This proposal aims to train nurses working in primary care centers in substance abuse approaches such as screening, brief intervention and referral to treatment (SBIRT), detoxification, motivational interviewing, harm reduction and drug treatment, and also to train nurses technician and community agents of health, who integrate the nursing team. Others professionals, part of the health team, will be welcome to be part of the training group. Training the nursing group is a strategic plan in order to address the target population considering that those professionals are spending most of their time educating and

6 teaching the population on several topics. This proposal comes as a tool to implement and improve nursing care process which is one goal of the city managers and nurses managers. Work with nurses has many reasons, but especially because they interview and follow all the patients while they are in the primary care centers, and nurses have very good and strong relationship with patients, families and communities. Besides this, nursing team manifested the desire of having more skills to work with mental health and drug abuse, which are common issues in their jobs. The Mental Health Managers understand the importance of the team engaged in the process of treatment, and considering the perspectives for the future, we intend to extend these actions and train more health providers, as maintenance of the goals of this project. The goals of the proposal: 1- Increasing the number of nursing teams addressing mental health and substance abuse issues, by training, assessing current and post knowledge and skills; 2- Improve knowledge and skills in substance abuse approach for nursing teams and 3- Establish a lasting partnership among primary care services, mental health services and psychosocial care centers. Methodology Florianopolis city has 5 health districts which are: East, Central, South, North and Continental each one coordinated by a director, responsible for health demands related to the district, including the primary care centers, the mental health services, the polyclinics, urgency and emergency units, and so on. In each district there are around 10 primary care centers, with multidisciplinary team, including doctors, psychologists, social workers, pharmacists, nurses, nurses technician and community health agents, which means that the number of health providers in each one is big. The first step of the process will be to establish a channel of communication between us, mental health managers, and the primary care centers, through the 5 directors, making some agreements in order to implement the proposal. The second step will be establish meetings with primary care centers' coordinators and nurses supervisors, sharing the proposal and gaining information about the local reality, in

7 order to have a better understanding and to plan the trainings. The inclusion in the trainings groups will be free choice and we intend to have around 50 % of adherence in to the program. The first region will be defined by local solicitation from health teams and directors, and the calendar of meetings will be decided together with them. A pre and post anonymous questionnaire will be applied in order to gain information about knowledge and skills in mental health and substance abuse. This proposal aims to train nursing team in mental health and substance abuse issues through local and non local experts. The next step includes training abilities and competencies and changes in the practice. The last step will include evaluation of the process and improvements. Timeframe Year Actions Outcomes 2014 (September to December) 2015 (January to June) 2015 (July to December) 2016 (January to December) Meetings and field trips Discussions about local reality and the proposal Questionnaires Application and data analysis Elaboration of training modules Local trainings combining theory and practice Formal trainings with non local experts Systematic meetings with district sand primary care centers Evaluation of the process Improvements in the process Current mental health and substance abuse' demands in each health district Definition of training models and content Increased number of nursing teams addressing mental health and substance abuse issues Increased knowledge, skills and abilities in these topics Consolidate the process Expand the methodology to others services Budget Investment Description Cost Total Epidemiologist and/or Data analysis and design $ 4 thousand statistician interventions projects Data base system Applied to upgrade the $ 2 thousand

8 Trainings Computer and/or notebook and printer Printing material Buying materials such as books, cd s and guidelines Elaboration of education materials current data base system Formal trainings with national and international experts Utilization during meetings, surveys, data base and data analysis Questionnaires, educational material for the meetings and trainings Specific materials related to mental health and drug abuse, national and international Educational and illustrative material according to each local health district, elaborated in partnership with health providers and managers $ 20 thousand $ 4 thousand $ 600 hundreds $ 2 thousand $ 2 thousand Total costs: $ 34, References 1. Hopkins TB, Zarro VJ, McCarter TG: The adequacy of screening, documenting, and treating the diseases of substance abuse. J Addict Dis 1994;13 : Moore RD, Bone LR, Geller G, et al: Prevalence, detection, and treatment of alcoholism in hospi- talized patients. JAMA 1989; 261: Sherin KM, Piotrowski ZH, Panek SM, et al: Screening for alcoholism in a community hospital. J Fam Pract 1982, Dec; 15(6) : Umbrict-Schneiter A, Santora P, Moore R Alcohol abuse: comparison of two methods for assessing its prevalence and associated morbidity in hospitalized patients. Am J Med 1991; 91:llO Mitchel WD, Thompson TL, Craig SR: Underconsultation and lack of follow-up for alcohol abusers in a university hospital. Psychosomatics 1986; 27: Brazilian Center for Information on Drugs (CEBRID) National Secretary on Drugs (SENAD) Carlini-Cotrim B, Carvalho CG, Gouveira N. Health Behaviors among youth students in

9 public and private schools in the area of the State of Sao Paulo, Brazil. Public Health Magazine December; 6 (34): National Survey in Alcohol and drugs. Federal University of Sao Paulo (UNIFESP) Powers PS, Stevens B, Arias F, et al: Alcohol disorders among patients with bums: crisis and oppor- tunity. J Bum Care Rehabil l994; 15: Smart RG, Mann RE: Large decreases in alcohol- related problems following a slight reduction in alcohol consumption in Ontario, Br J Addict 1987; 82: Spear SF: Impact of chemical dependency on family health status. Int JAddict 1991; 26:

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