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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.