como tornar eficaz a política de álcool e drogas nos diversos níveis prof. dr. ronaldo laranjeira...

Como tornar eficaz a política de álcool e drogas nos diversos níveis

Prof. Dr. Ronaldo Laranjeira

UNIAD-UNIFESP

Resumo

• 1 – Políticas do álcool baseadas em evidências científicas

• 2 – Príncipios do tratamento efetivo

Alcohol, No Ordinary Commodity: Research and

Public PolicySponsored by:

The World Health Organization

and

The Society for the Study of Addiction (UK)

The findings and conclusions represent the consensus views of its 15 authors, none of whom received either direct or indirect support for their participation from the sponsoring organizations or any other organization that might represent a conflict of interest.

Prevention Strategies Reviewed and Evaluated

• Regulating Physical Availability

• Pricing and Taxation

• Altering the Drinking Context

• Education and Persuasion

• Regulating Alcohol Promotion

• Drinking-Driving Countermeasures

• Treatment and Early Intervention

Ratings of 32 Policy-relevant Prevention Strategies and Interventions

1) Evidence of Effectiveness – the quality of scientific information

2) Breadth of Research Support – quantity and consistency of the evidence

3) Tested Across Cultures, e.,g. countries, regions, subgroups

4) Cost to Implement and Sustain – monetary and other costs

aRating Scale: 0, +, ++, +++, (?)b Rating Scale: Low, Moderate, High

Taxation

Strategy or Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Alcohol Taxes

+++

+++

+++

Low

General Population

Regulating Physical Availability

Strategy or Intervention

Effectiveness

Research Support

X-Cultural Testing

Cost

Target Group

Total ban on sales +++ +++ ++ High General Population

Minimum legal purchase age

+++ +++ ++ Low High Risk Group

Rationing ++ ++ ++ High General Population

Government monopoly of retail sales

+++ +++ ++ Low General Population

Hours and days of sale restrictions

++ ++ ++ Low General Population

Restrictions on density of outlets

++ +++ ++ Low General Population

Server liability +++ + + Low High Risk Group

Different availability by alcohol strength

++ ++ + Low General Population

Modifying the Drinking Context Strategy or Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Outlet policy to not serve intoxicated patrons

+ +++ ++ Moderate High Risk Group

Training bar staff and managers to prevent and better manage aggression

+ + + Moderate High Risk Group

Voluntary codes of bar practice

O + + Low High Risk Group

Enforcement of on-premise regulations and legal requirements

++ + ++ High High Risk Group

Community mobilization

++ ++ + High General Population

Modifying the Drinking Context

Many prevention measures seek to limit drinking in the contexts or environments where alcohol is typically sold and consumed (e.g., bars and restaurants).

The most effective options involve:• enforcement of serving regulations • increasing the legal liability of bar staff and

owners for the actions of those they serve.

Responsible Beverage Service (RBS) programs

• Focus on attitudes, knowledge, skills, and practices of persons involved in serving alcoholic beverages on licensed premises

• If supported by actual changes in the serving policies of licensed establishments and reinforced by local police, RBS training can reduce heavy consumption and high risk drinking

Drinking-Driving Countermeasures

Strategy or Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Sobriety check points

++ +++ +++ Moderate General Population

Random breath testing (RBT)

+++ ++ + Moderate General Population

Lowered BAC Limits

+++ +++ ++ Low General Population

Administrative license suspension

++ ++ ++ Moderate Harmful Drinkers

Low BAC for young drivers (“zero tolerance”)

+++ ++ + Low High Risk Group

Graduated licensing for novice drivers

++ ++ ++ Low High Risk Group

Designated drivers and ride services

O + + Moderate High Risk Group

Education and Persuasion

Strategy or Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Alcohol education in schools

O +++ ++ High High Risk Group

College student education

O + + High High Risk Group

Public service messages

O +++ ++ Moderate General Population

Warning labels

O + + Low

General Population

Education and Persuasion Strategies• School-based alcohol education programs have been found to increase

knowledge and change attitudes toward alcohol and other substances, but actual substance use remains unaffected.

• Approaches that address values clarification, self-esteem, general social skills, and “alternatives” approaches that provide activities inconsistent with alcohol use (e.g., sports) are equally ineffective.

• Programs that include both resistance skills training and normative education (which attempts to correct adolescents’ tendency to overestimate the number of their peers who drink) have modest effects that are short-lived unless accompanied by ongoing booster sessions.

• Programs that include both individual-level education and family- or community-level interventions may not be sufficient to delay the initiation of drinking, or to sustain a small reduction in drinking beyond the operation of the program.

Summary: Education and Persuasion Strategies

• The impact of education and persuasion programs tends to be small at best.

• When positive effects are found, they do not persist. • Among the hundreds of studies, only two show significant

lasting effects (after 3 years), and the significance of these is questionable when reanalyzed (Foxcroft et al. 2003).

• The time is past for arguments on behalf of substituting education for other, more effective approaches.

• If educational approaches are to be used, they should be implemented within the framework of broader environmental interventions that address availability of alcohol.

Regulating Alcohol Promotion

Strategy or

Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Advertising bans

++ ++ ++ Low General Population

Advertising content controls

? O O Moderate General Population

Regulating alcohol promotion

• The marketing of alcohol is a global industry. • Alcohol brands are advertised through television, radio,

print, point-of-sale promotions, and the Internet. • Exposure to repeated high-level alcohol promotion

inculcates pro-drinking attitudes and increases the likelihood of heavier drinking.

• Alcohol advertising predisposes minors to drinking well before legal age of purchase.

• Advertising has been found to promote and reinforce perceptions of drinking as positive, glamorous, and relatively risk-free.

Regulating alcohol promotion

Legislation restricting alcohol advertising

• A well-established precaution used by governments throughout the world, despite opposition from the alcoholic beverage industry.

• Findings suggest that while the restrictions have not achieved a major reduction in drinking and related harms in the short-term, countries with greater restrictions on advertising have less drinking and fewer alcohol-related problems (Saffer, 1991).

Regulating alcohol promotion

Industry Self-regulation Codes

• Self-regulation tends to be fragile and largely ineffective.

• These codes may work best where the media, advertising, and alcohol industries are all involved, and an independent body has powers to approve or veto advertisements, rule on complaints, and impose sanctions.

• Few countries currently have all these components.

Treatment and Early Intervention

Strategy or Intervention

Effective-

ness

Research Support

X-Cultural Testing

Cost

Target Group

Brief intervention with at-risk drinkers

++ +++ +++ Moderate High Risk Group

Alcohol problems treatment

+ +++ +++ High Harmful Drinkers

Mutual help/self-help attendance

+ + ++ Low Harmful Drinkers

Mandatory treatment of repeat drinking-drivers

+ ++ + Moderate Harmful Drinkers

Melhores Práticas

• Idade mínima para a compra de álcool

• Monopólio governamental para a venda de álcool

• Restrições de horário para a venda de álcool

• Restrições a densidade de bares

• Taxação álcool

• Sobriety check points• Diminuir BAC limits• Suspenção

administrativa de cartas de motorista

• Intervenção Breve

Piores Práticas

• Código voluntário de prática em bares

• Promover atividades sem álcool

• Educação sobre álcool nas escolas

• Educação nas universidades

• Propaganda contra o álcool

• Warning labels• Motorista alternativo

ou taxi para alcoolizados

Evolving Views of Alcohol Policy: Optimism

• Opportunities for effective, evidence-based alcohol policies are more available than ever to better serve the public good.

• Alcohol policies that limit access to alcoholic beverages, increase the price of alcohol, and enforce laws and regulations through deterrence, are likely to reduce the harm linked to specific drinking patterns and per capita consumption.

• Alcohol problems can be minimized or prevented using a coordinated, systematic policy response.

CONCLUSIONS• The difference between good and bad alcohol policy is not

an abstraction, but very often a matter of life and death. • Research has the capacity to indicate which strategies are

likely to succeed in their public health intentions, and which are likely to be less effective or even useless, diversionary, and a waste of resources.

• Opportunities for evidence-based alcohol policies that better serve the public good are more available than ever.

• There are still too many instances of policy vacuums filled by unevaluated or ineffective strategies and interventions.

• Because alcohol is no ordinary commodity, the public has a right to expect a more enlightened, evidence-based approach to alcohol policy.

13 Princípios do Tratamento Efetivo

NIDA

Princípios Tratamento Efetivo

1Nenhum tratamento é efetivo para todos os

pacientes

Princípios Tratamento Efetivo

2

O Tratamento necessita ser facilmente disponível

Princípios Tratamento Efetivo

3Tratamento deve atender às várias necessidades e

não somente ao uso drogas

Princípios Tratamento Efetivo

4O tratamento necessita

ser continuamente avaliado e modificado de

acordo com as necessidades.

Princípios Tratamento Efetivo

5Permanecer em

tratamento por período adequado é fundamental

para a efetividade

Princípios Tratamento Efetivo

6Aconselhamento e outras

técnicas comportamentais são fundamentais para o

tratamento

Princípios Tratamento Efetivo

7Medicamentos são

importantes, principalmente quando

combinados com terapia

Princípios Tratamento Efetivo

8A comorbidade deveria

ser tratada de uma forma integrada

Princípios Tratamento Efetivo

9Desintoxicação é só o começo do tratamento

Princípios Tratamento Efetivo

10O tratamento não

necessita ser voluntário para ser efetivo

Princípios Tratamento Efetivo

11A possibilidade de uso

de drogas deve ser monitorada

Princípios Tratamento Efetivo

12Avaliação sobre HIV,

hepatites B e C e aconselhamento para

evitar esses riscos

Princípios Tratamento Efetivo

13Recuperação é um

processo longo e muitas vezes necessita vários

episódios de tratamento

CRECHES

ORIENTAÇÃOVOCACIONAL

SERVIÇOSDE SAÚDE MENTAL

OUTROS SERVIÇOSMÉDICOS

ABORDAGENSEDUCACIONAIS

ORIENTAÇÃO E DIAGNÓSTICO

PARA DST-AIDS

APÓIO JURÍDICO

ORIENTAÇÃO FINANCEIRA

ALBERGAGEM &TRANSPORTE

ABORDAGENS VOLTADAS À FAMÍLIA

PROCESSO DE ENTRADAE AVALIAÇÃO

ASSESSORIA &PSICOTERAPIA

PLANO DETRATAMENTO

MONITORAMENTO(USO DE DROGAS)

EQUIPE MULTIDISCIPLINAR FARMACOTERAPIA

CUIDADOS CONTÍNUOS

Os melhores programas de tratamento provêm uma combinação de terapias e outros serviços para satisfazer as necessidades do paciente. FONTE: NIDA.