PROFILE OF WOMEN DRUG ADDICTS TREATED AT THE PSYCHOSOCIAL CARE CENTER ALCOHOL AND OTHER DRUGS – DOCUMENTAL STUDY

Helder de Pádua Lima1, Jaqueline Queiroz de Macedo2, Violante Augusta Batista Braga³, Aline Mesquita Lemos4, Ivando Amâncio da Silva Júnior5

1,2,3,4,5 Universidade Federal do Ceará, Fortaleza-CE, Brasil

Abstract

The objective was to trace the profile of women drug addicts treated at the Psychosocial Care Center alcohol and other drugs (CAPSad) in the city of Caucaia - Ceará. Documentary and retrospective  study based on information collected from 102 medical records of registered users between 2004 and 2008. The data were organized in Statical Program for Social Science, represented in tables and charts, and analyzed according to descriptive statistics. Results show elements that contributed to the vulnerability of women to use and abuse of psychoactive drugs, predisposing them to addiction. Some of these aspects may have been instrumental in seeking and remaining in service. The study is essential to think about women's health more broadly. Knowledge about the subject it is important for the elaboration of health practices that can improve and modify the accessibility of women drug addicts to mental health services.

Descriptors: Substance-related disorders; Women; Community mental health services; Nursing.

INTRODUCTION

In the field of mental health care, many times doors are not open in an egalitarian way for the entrance of the users at any moment in the tipical substitutive services, as the psychosocial Attention Center (CAPS in Portuguese). This fact alone highlights that great problems to be confronted, including the implementation of a communal attention network, are the ones related to equity, to the accessibility and its barriers, regarding the production of comprehensive care in mental health, in order to contemplate the principles of the psychiatric reform in the country. This experience indicates difficulties in operating the paradigm shift in attention to the person that lives with the psychological distress.

Within the context of drug treatment, we may perceive the need to reflect on the accessibility of drug addicts to health services, in the gender perspective, considering both the woman's perception of what it is offered in the psychosocial Attention Center Alcohol and other Drugs (CAPSad) – her experience and participation in the mental health services in community services – as well as the professional attention given to such users, professionals among which is the nurse as part of the multidisciplinary team.

Cultural factors, such as predominantly male environment, discrimination and prejudice and a space that does not always guarantee the necessary care and the possibility of drug-addicted woman's expression, interfere with the accessibility to health services and equity assistance⁽¹⁾.

The study of the interfaces between gender and drug addiction, shown to be relevant, given that in the context of women's health, the use and abuse of drugs by this population have been shown to be predominant, relating itself to the cultural, social, family and individual context, which are linked to risk factors, like the use of the body for drugs, prostitution and sexually transmitted diseases⁽²⁾.

This study is based on our experience as nurses working in network devices of mental health of the city of Caucaia – Ceará: basic units of family health, CAPS, clinical hospital and other organizations as self-improvement groups. In the daily practice of this activity, we notice the predominance of male population among the individuals seeking treatment for drug addiction at CAPSad; on the other hand women also seek treatment, but do it for a smaller period of time. These circumstances foster a restrained demand of women who often receive care only through home visits. This contributes to the vulnerability to social, occupational, family, physical, legal and violence-related problems.

In the mental health network of the referred municipality, the majority of specific services for treating drug addicts focus clearly on the male population due to women lower demand and the inadequacy of the physical structure (with undefined spaces separated by gender). Under such obstacles in the accessibility of drug addicts to treatment, the following question arose: What is the social-demographic and clinical profile of women seeking treatment at CAPSad?

In search for answers, we have developed this study aiming to discuss the characterization of drug-addicted women treated at the CAPSad of Caucaia, in the perspective of gender.

METODOLOGY

It is a study of a documentary and retrospective kind, developed at the type II CAPSad, located in Caucaia, metropolitan region of Fortaleza – Ceará.

The study population was represented by the number of records contained at SAME (Medical and Statistics Archiving Service) and the sample was selected based on the following inclusion criteria: medical records of women registered delimited in the period from January 2004 to December 2008. 102 records were used.

Data collection was performed during one month, using a standardized form, with the intention of collecting information on social-demographic data and clinical aspects of the women in question. The information was organized in statistical Program for Social Science - SPSS (version 13), represented in tables and charts and analyzed according to descriptive statistics, characterized by exploratory data analysis so that they had an overview of the range of values.

The data was grounded on the basis of selected literature, which addressed the studied theme, found in the following databases: BIREME, SciELO and BVS (Biblioteca Virtual em Saúde or Virtual Health Library). For the pursuit of theoretical material, the descriptors used were 'women', 'mental health' and 'disorders related to drug use'.

We emphasize that the precepts of Resolution 196/96 of the National Health were followed. The research was initiated only after the approval of the Research Ethics Committee of the Federal University of Ceará, under protocol 198/08 to guarantee the basic principles of bioethics, that is, autonomy, non-maleficence, benevolence and justice⁽³⁾.

Results

The presentation of the results begins with the social-demographic characterization of the female customers assisted in the service and proceeds with the clinical aspects prevalent in this table.

Table 1 – Distribution of sample according to social-demographic characteristics. Caucaia – Ceará, 2011. N=102
variables		No	%	variables		No	%
Age (in years)	Up to 17	07	6,8	Origin	Caucaia	97	95,0
	18 – 30	37	36,2		Other municipalities	05	5,0
	31 – 40	12	11,7
	41 – 50	22	21,5	Marital Status	Single	35	34,3
	51 – 59	20	19,6		Married	18	17,6
	Equal or above 60	04	3,9		Divorced	10	9,8
					Widow	06	5,8
Education	illiteracy	22	21,5		Friendly union	33	32,3
	incomplete elementary	48	47,0
	complete elementar	04	3,9	He/she lives with	nuclear family	78	76,4
	Incomplete high school	12	11,7		extended Family	12	11,7
	High school	04	3,9		Friends	02	1,9
	higher education	02	1,9		Lives alone	04	3,9
	not applicable	10	9,8		not applicable	06	5,8
Profession / occupation	Housewife	25	24,7	Income	not applicable	101	99,0
	Unemployed	37	36,2		1 minimum wage	1	1,0
	Student	08	7,8
	Beneficiary of the INSS *	04	3,9
	saleswoman	06	5,8
	Others	22	21,5

       * National Institute of Social Security

According to Table 1, it is evident the majority of women (36.2%) aged between 18 and 40 years of age. In the sample, 42 persons (21.5%) were in the age group between 41 and 59 years of age, Interval of time that typically occurs the climacteric (menopause). In addition, we identified 04 elderly and 07 adolescents. The women had low level of education. This reflects less-skilled professionals and therefore less job opportunities and higher unemployment (36.2%). Most of them (47.0%) had not completed elementary school, 21.5% were illiterate and 34.3% were single. The largest contingent of the sample (90.2%) lived with family or friends.

Of the individuals assisted at the service, 95% proceeded from the city of Caucaia and the remaining seven other municipalities in the 2nd Regional Health Cell (CRES) of the State. Only one record contained information on the amount of monthly income which makes questionable the investigation or the recording of this information. It is often necessary to move through urban transportation to access the CAPSad, buy drugs that are not provided by public health service, and to take on other expenses for treatment and rehabilitation. Ways of acquiring drugs by the users must be investigated, in order to preserve health and psychosocial integrity, given that a considerable portion of these women get involved in robberies, thefts, burglaries, homelessness, prostitution and others.

Picture 1 - Distribution of the sample according to psychoactive drug(s) used and problem(s) due to use or abuse of psychoactive substance. Caucaia – Ceará, 2011. N=102
Variables		No	Variables		No
psychoactive Drug(s) used	Alcoholic beverages	73	Problem(s) due to use or abuse of psychoactive substance	Clinical**	58
	Marijuana	46		Mental disorders ***	56
	psychotropic Drugs *	38		Attempted suicide	30
	Tobacco	72		aggressiveness	36
	Crack	34		Lies	20
	Cocaine	21		Family, relatives and/or friends	50
	Solvent	07		Justice/police	07
	Glue	04		Burglary / theft	01
	analgesics	03		Work	11
				financial	15
				Not applicable	09

* mostly benzodiazepines; ** Burns, convulsions, vomiting, pneumonia, gastritis and ulcers mainly; *** Anxiety and mood disorders mostly.

According to table 1, alcohol, tobacco and psychotropic were the most used licit drugs. Among the illicit drugs, Marijuana, crack and cocaine were the most frequently recorded respectively. The problems mostly reported, from the use or abuse of psychoactive substances, were: clinical diseases, mental disorders, social problems – in family and friendship circles – and psychiatric comorbidities, particularly anxiety and mood disorders.

Table 2 - Distribution of the sample according to the reason for the search for the service, diagnosis hypothesis, period of abstinence from drugs of abuse, performance of previous treatment and treatment plan. Caucaia – Ceará, 2011. N=102
Variables		No	%
Reason for seeking the CAPSad	Personal decision	61	59,8
	symptoms correlated	18	17,6
	Family Influence	07	6,8
	judicial proceedings or social support network	07	6,8
	drug therapy	04	3,9
Diagnostic hypothesis	Tobacco dependence	10	9,8
	Alcohol dependence	24	23,5
	Dependence on benzodiazepine	11	10,7
	Dependence on multiple drugs	45	44,1
	Dependence on crack	01	0,9
	other psychopathology	03	2,9
	Information not included	08	7,8
Time of abstinence from drugs of abuse	No day	06	5,8
	1 to 15 days	26	25,4
	16 to 30 days	06	5,8
	31 to 90 days	19	18,6
	90 days and 363	17	16,6
	Above 1 year	07	6,8
	Information not included	21	20,5
Realization of prior treatment	No	65	63.7
	Yes	24	23.5
	Information not included	13	12.7
Therapeutic plan *	Intensive	27	26,4
	Semi-intensive	34	33,3
	Non-intensive	21	20,5
	Information not included	15	14,7

* intensive regimen (user who attends the service every day), semi-intensive (three times a week) and non-intensive (once a month).

According to Table 2, 61 women (59,8%) voluntarily sought treatment, 18 (17,6%) for symptoms related to drug addiction and 07 (6,8%) for direct influence of the family. In other 07 (6,8%) cases there were judicial proceedings or social support network and 04 (3.9%) had the belief that there is a drug therapy for drug addiction.

There was a significantly higher number of poly-users than mono-users. It is noteworthy that 26 (25.4%) people remained abstinent for a period of 1 to 15 days and 19 (18,6%) for a period between 1 and 3 months. Most of the sample (63.7%) had never done any kind of treatment for chemical dependency prior to the one performed at CAPSad.

Finally, the records showed 90.2% of cases with individualized treatment plan. Among the types of treatment plans drawn, semi-intensive has stood out in 33.3% of the sample.

Discussion

Considering the existence of feminine demand, its growth and also the constitutional right of access to health services, contemplated by SUS, intriguing is the low demand and stay of this clientele at CAPSad. Over five years "only" 102 women, out of eight municipalities, accessed the CAPSad of Caucaia.

The increased rates of use of psychoactive drugs among women, besides the problems arising from the consumption, have been more and more evident in the Brazilian scientific literature, which implies immediate concern from the perspective of the public health.

In contemporary society, drug use is highlighted by its complexity and expansion in all regions of the world, leading managers, health professionals and public policy makers to discussions, with a view to resolve and/or minimize the many problems resulting from their growth. In 2005, was recorded an overall increase of 15 million people, aged between 15 to 64 years of age, involved with drug use and in this quota has been identified the increasing number of women compared to men for some types of drugs, especially those considered illegal⁽³⁾.

A significant portion of the drug addicts seems to postpone search for treatment or simply do not think about the possibility of treating it. The denial of severity is one of the most cited barriers by drug addicts and occult users to health services. To evaluate the treatment as irrelevant to promote lifestyle changes is another frequent claim when users choose to deal with the problem alone. Other barriers may arise after the decision to treat: waiting lists; recurrences while waiting for vacancy; policy of services that do not "detoxify"; bureaucracy; women who do not want to be attended by men or male patients, who do not have with whom to leave their children during treatment and are afraid of the stigma⁽⁴⁾.

The data reveals the involvement of women in various stages of life by chemical dependency, including menopause. This is a phase which represents a milestone in the determination of changes in women's lives, both in its social role and in their health conditions. Many factors favor the genesis of mental pictures in the climacteric. Smoking, illicit drug use and unprotected sex are directly or indirectly associated with mental disorders in women and establish a risk for other conditions harmful to their health⁽⁵⁾.

With respect to adolescents identified in the sample, we may say that even with a current population of 324,738 inhabitants⁽⁶⁾, the municipality of Caucaia does not have a juvenile CAPS, which indicates a gap in attention addressed to the health of these clients in the prevention and treatment of chemical dependency. Despite the alternative of referring to users for follow up in Fortaleza-CE, factors as low income, poor access and lack of family support hamper the participation in the health service and treatment adherence.

Such event is particularly worrying, since the first experiences with drugs occur, in most cases in adolescence. In this stage, the individual is vulnerable through a psychological and social perspective. Therefore, it is particularly important to study this population in detail, especially with regard to the frequent and intense use of psychoactive drugs and identify the influence of psychological and sociocultural factors⁽⁷⁾.

Protective factors to drug use can be incorporated into the mental health services still in the primary care network, as means of preservation. Among such factors are cited: the family (the establishment of affective bonds among its members, monitoring of activities and friendship of the adolescent and the construction of appropriate social conduct); involvement in school and/or religious activities; access to information about drug use, etc⁽⁸⁾.

Drug use, particularly alcohol, has spread in various social groups and drug addiction has affected people with different education levels, wages and professions/occupations.

The second household survey on the use of psychotropic drugs in Brazil, held in 2005, in the 107 largest cities of the country, indicated that 12.3% of people aged between 12 and 65, were dependent on these drugs, rate higher than the 11.2% found in the first survey, done in 2000^(9,10).

Disorders related to alcohol use affect five times more men than women. Men are affected at an earlier age, but, as with the disorder, women have a faster progression of the disease. Over the past few years, people have started drinking alcohol at an earlier age, the risk of dependence has increased and the pattern of alcohol use and dependence among women has become similar to men⁽¹¹⁾.

As from the decade of the 60s in the last century the incorporation of women into the labor market led to the change in their social habits (increasing the consumption of alcohol and tobacco). It is estimated that of the 800 million smokers worldwide, 250 million are female. In Brazil there are about 36.5 million smokers; of these 40.4% are women⁽¹²⁾.

Women have become the target of special interest of the tobacco industry and a significant share of society to consume tobacco. Such practice has been associated with drinking, encouraged by the big industries of alcoholic beverages which, in turn, increase each year, its production. These facts contribute to the universalization of risk factors and changes in the epidemiological profile of diseases such as neoplasms, bringing decrease in the proportion of cancer among men and women⁽¹²⁾.

Several factors contribute for higher susceptibility to smoking, highlighting the changes in the structure of the population, greater urbanization, the influx of women in the economically active population, increased access to education and propaganda.

As for psychotropic drugs, female adolescents present a higher consumption of anxiolytics and amphetamines. On the other hand benzodiazepines are most consumed by adult women. It has been highlighted also a high consumption of anorectics and consumption of psychotropic drugs two times higher in women than in men⁽¹³⁾.

We must consider that women and men have culturally different life experiences and present different responses to stressful situations. The presence of more frequent symptoms/depressive episodes among women would be responsible, at least in part, by greater use of antidepressants. Allied to this fact, the drug advertisements tend to stereotype psychological illnesses like depression and anxiety as women's diseases⁽¹⁴⁾.

In addition, drug-addicted women present needs that sometimes are not perceived at specialized services and that are related to the reproductive condition, attention to children, the impact of experienced physical and sexual violence and social taboos⁽²⁾.

The dependence of the benzodiazepinics has intensified in the elderly, who may be stimulated by its continued use and it is common among women and people with low education and low income. However, this disorder is not always noticed, which means that there is no notification of this type of dependence in the records. It is observed that, besides the use focusing on females, benzodiazepines are the fourth most widely used drug in life and have levels of dependence compared to marijuana⁽¹⁰⁾.

The contextualization of the phenomenon indicates that benzodiazepine use is not restricted to a biological relationship of its effects, but an interaction with cultural and social issues. Conditions such as gender and aging are relevant in understanding the consumption of these psychotropic drugs. In cases of dependence, the manner of consumption differs from the prescribed and is adapted to reality and concepts involving the health/disease process of that who consumes it.

As regards to the procedure for seeking treatment, it is suggested that therapeutics favors, initially, the drug addict's awareness about addiction and its losses. Thereafter, the treatment would aim at promoting a process of self-knowledge and the search for other sources of pleasure, rather than a sense of guilt⁽¹⁵⁾.

The drug addict sometimes refuses to receive treatment, although he recognizes, minimally, that his condition requires attention. This fact hampers the entry into the health service which happens mostly by the very process of psychosocial and financial wear, besides blaming the family and/or transference of their condition to others.

The current policy of the Ministry of Health to provide comprehensive care to users of alcohol and other drugs, is in accordance with the national mental health policy in force, and tends to be built in the program interface with the other ministries, as well as sectors of civil society, and actions that attempt to contemplate large portions of the population. The strategy of the Ministry does not have abstinence as the only feasible and possible target to users, but the reduction of health damage caused by drug use.

It is considered that drug addiction is a disorder in which predominates the heterogeneity that affects people in different ways, for different reasons, in different contexts and circumstances. Many drug users do not share the expectation and desire of abstinence of health professionals, and abandon the services. Others do not even seek such services because they do not feel welcomed in their differences. Hence the level of adherence to treatment or preventive practices and promotion is low, not contributing to social and family reintegration of the user⁽¹⁶⁾.

Concerning the treatments provided by health professionals, most drug users will not submit themselves to treatment in the health services for drug addiction, in which case their first choice is usually the religion, because it is something free, easily accessible and immediate. The few who seek professional help emphasize the difficulty of finding public services in the area and the delay in arranging consultations and possible therapies⁽¹⁷⁾.

Among the specialized services CAPSad should represent a support for providing individualized care planning, in order to reduce the stigma on treatment. In this service, the nurse, as part of a multi-professional team, must act with the purpose of providing care focused on the needs of each individual in the context in which he belongs, from the principles defended by the movement of the Psychiatric Reform, which include hosting, connection, listening, interdisciplinary approach, comprehensive care, social inclusion and psychosocial rehabilitation⁽¹⁸⁾.

However, faced with the reality imposed by the gender perspective, it is necessary a discussion involving also the professional training so that they may overcome barriers regarding the care focused on the needs of this clientele that is increasingly present.

There are several models that support the planning of nursing care to drug-addict women. This practice should consider the need for answers to the specific demands of gender and health of this particular woman, her accessibility to health care and equity of care. Unfortunately it is perceived that today, not always, the specifics of the users of psychoactive substances have been met.

The basic principles for assistance to users of alcohol and other drugs do not differ from other areas of nursing. There is need to promote a therapeutic alliance through a warm ambience and empathy (essential for motivation), leading to interpersonal relationships, ensuring the individual continuous and comprehensive care and contributing to the collective competence of the team work. It is important the therapeutic communication and cooperative work. The drug-addict woman should be understood and addressed from the perspective of the whole in a holistic perspective that focuses primarily on the human comprehension and treatment of problem or discomfort. In this view, the use of the chemical substance is seen as the agent generator of harmful effects that must be treated in some way, but, undeniably, the individual should receive the inputs necessary to achieve the balance. In this sense, the nurse can assist in this instrumentalization, encouraging and supporting the users to take responsibility for improving their quality of life at all levels⁽¹⁹⁾.

Thus, the nurse, since trained, can contribute effectively to their practice in this area of great social relevance. The knowledge about the category gender can provide a means to subsidize its operations, according to the needs of users and health guidelines.

CONCLUSION

Results show social elements that contributed to the vulnerability of women in the use and abuse of psychoactive drugs, predisposing them to addiction. Some of these aspects may also have been decisive for the search of the service, and reflected in the clinical characteristics of the demand studied.

The drug-addict woman needs a different look for their specific needs, giving priority to health promotion, self-esteem and social reintegration. For professionals, including nurses, it is of great importance a theoretical training to deal with gender aspects and social representations related to the woman seeking treatment as well as the information as a tool to acquire her rights as a citizen, to be reinserted into society.

It is worth noting the important role of the multiprofessional team of the CAPSad, which includes the nurse for the understanding and incorporation of gender perspective in their actions. To study the reality of women users of psychoactive drugs and their demands is essential to think about women's health more broadly. Knowledge about the subject allows the development of health practices that can improve and modify the accessibility of drug-addict women to the mental health network, impacting positively on equity of care.

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Authors' contributions: Conception and design:1; Analysis and interpretation: 1,2,3,4; Article Writing: 1,2,4,5; Critical revision of the article: 1,2,3,4,5. Final approval: 1,2,3,4,5.