Night beds in psychosocial attention care centers for alcohol and drugs : analysis and characterization

Objective: To analyze and characterize the use of night beds in a Psychosocial Attention Care Center for Alcohol and Drugs (Centro de Atenção Psicossocial Álcool e Drogas – CAPS ad). Method: It is a quantitative, documental, descriptive and retrospective study. Data were gathered from 565 medical records. An analysis of continuous variables was performed. Results: When admitted to the beds, most users (87.6%) consumed multiple substances daily and were vulnerable, specially in street situation (68.3%). These users were admitted on an average of two times, undergoing a previous evaluation by the nurse (85.8%), usually for detoxication or due to the vulnerable condition. They stayed in the center for an average of seven days and 31.1% did not fi nish what was proposed. For a few cases, hospital support was needed. Overall, discharges were planned, but the return happened without booking. Conclusion: Social issues cut through the use of night beds, however, it is a therapeutic resource that meets signifi cant demands and is present in the daily lives of vulnerable users as a comprehensive care. Descriptors: Mental Health Services; Psychiatric Nursing; Bed Occupancy; Substance-Related Disorders; Social Vulnerability. RESUMO Objetivo: Analisar e caracterizar a utilização dos leitos de acolhimento noturno em um Centro de Atenção Psicossocial Álcool e Drogas (CAPS ad). Método: Estudo de abordagem quantitativa, documental, descritivo e retrospectivo. Dados coletados em 565 prontuários. Realizou-se análise das variáveis contínuas. Resultados: No momento da admissão em leito, a maioria dos usuários consumia diariamente (87,6%) múltiplas substâncias e encontrava-se em vulnerabilidade, principalmente em situação de rua (68,3%). Esses foram admitidos em média duas vezes, com avaliação prévia do enfermeiro (85,8%), geralmente para desintoxicação ou pela própria condição vulnerável. Tiveram uma média de sete dias de permanência e 31,1% não concluíram o proposto. Em poucos casos houve necessidade de suporte hospitalar. No geral as altas foram planejadas, mas o retorno ocorreu sem agendamento. Conclusão: Questões sociais perpassam o uso dos leitos, contudo é um recurso terapêutico que atende demandas signifi cativas e está presente no cotidiano dos usuários em vulnerabilidade como um cuidado integral. Descritores: Serviços de Saúde Mental; Enfermagem Psiquiátrica; Ocupação de Leitos; Transtornos Relacionados ao Uso de Substâncias; Vulnerabilidade Social. RESUMEN Objetivo: Analizar y caracterizar la utilización de las camas de acogida nocturna en un Centro de Atención Psicosocial Alcohol y Drogas (CAPS ad). Método: Estudio de enfoque cuantitativo, documental, descriptivo y retrospectivo. Los datos fueron recogidos en 565 prontuarios y se realizó un análisis de las variables continuas. Resultados: En el momento de la admisión en cama, la mayoría de los usuarios consumía diariamente (87,6%) múltiples sustancias y se encontraba en vulnerabilidad, principalmente en situación de calle (68,3%). Fueron admitidos en promedio dos veces, con evaluación previa del enfermero (85,8%), generalmente para desintoxicación o por la propia condición vulnerable. Tuvieron una media de siete días de permanencia y el 31,1% no Night beds in psychosocial attention care centers for alcohol and drugs: analysis and characterization Leitos em centro de atenção psicossocial álcool e drogas: análise e caracterização Camas en centros de atención psicosocial alcohol y drogas: análisis y caracterización RESEARCH


INTRODUCTION
After the Psychiatric Reform Law and the evolution of assistance models oriented towards mental health in Brazil, psychosocial care was understood as the basis for the care for persons with mental illness and alcohol and other drugs users (AOD).For that to be effective, a specialized services network was created as a substitute for the hospital model based on psychiatric hospitalization, with the Psychosocial Attention Care Center (CAPS) now acting under a territorial logic, with a view to reduce hospitalizations and to present longitudinal care, focusing on social reintegration and on the subject's autonomy (1) .
Dealing specifically with the problematic use of psychoactive substances, there is the Psychosocial Attention Care Center for Alcohol and Drugs (CAPS ad), in the modality III, as a therapeutic resource that has been potentializing achieving these goals and that acts not only using abstinence, but also damage reduction (DR) as a possible practice.This service has night beds for users who require detoxication, crisis situations, craving and withdrawal syndrome management, besides also intending to shelter other issues such as social vulnerability cases related to substance use.It works 24 hours a day and allows the user to remain there for about 14 days per month, with the possibility of extending the stay after an evaluation by the team (1)(2) .
A community service as CAPS ad III does not aim to have a hospital structure, but to have resources in order to act coordinated to the network whenever needed, always acting on the subject's life context (3) .During nights and weekends, the users admitted to the beds are assisted to exclusively by the nursing team.As a consequence, these are the professionals that deal more closely with this kind of care, however, it is indispensable to have a medical evaluation, both clinical and psychiatric ones, to prevent complications arising from sheltering.
Studies highlight the implementation of this mechanism as a way of reorganizing, institutionally, both the daily lives of users and the work processes of the professionals involved in the care, being understood as a positive differential in the services (4) .
Other satisfactory outcomes have been demonstrated after the inclusion of the CAPS ad III in the Psychosocial Attention Care Network (RAPS), such as the reduction of hospitalizations and of the time the users stay in psychiatric hospitals, as well as in the case of emergencies related to alcohol and drug use in emergency rooms.Consequently, there was a significant reduction in the number of hospitalization beds: in 12 years this number has decreased 50% and resulted on changing the profile of hospitals from big-and medium-sized to small-sized ones (5)(6) .
Internationally, it is also being invested on community models for alcohol and drug use assistance, based on evidences showing that, in relation to traditional models (hospitalization), the user achieves a long-termed change in the usage level, reducing related social issues, being more satisfied with the treatment and also finding, in this kind of service, the attention to the demands not met by others (7) .
Therefore, it is highlighted the necessity for investing on the CAPS as III, which, since they are the most recent health service in the network, have scarce publication related to their functioning, specially regarding the night beds and their role as a substitute for psychiatric hospitalization of alcohol and drug users.

OBJECTIVE
To analyze and characterize the use of night beds in a CAPS ad.

Ethical aspects
The study considered all ethical precepts in the Resolution no.466/2012 and it started after the authorization of the local service administrator and the Regional Health Coordination, being approved by the Committee of Research Ethics in the Nursing School of the Universidade de São Paulo and of the São Paulo Municipal Health Secretary.We were exempted from the Informed Consent Form since it is a study with records.

Design, study place and period
It is a quantitative, descriptive and exploratory, retrospective, and documental study.This kind of research is destined to obtain information on individual characteristics, as well as on the nature of the prevalence and distribution of certain health conditions.The study was performed in a CAPS ad III, in the municipality of São Paulo, from August to December 2016.

Sample, criteria and exclusion
We used the total number of records of users admitted to night beds between July 2010 (01/06/2010, initial period of bed implementation) and June 2015 (30/06/2015), with a total sum of 569 records.Four of them were not found, resulting on a final sample of 565 studied records.There were no inclusion or exclusion criteria for the sample.

Study protocol
In order to find the records of the individuals who were admitted to the beds during this period, we used a control registry made by the nursing team referring to the occupation of beds in the service, in which are the information on admission dates, discharges and the record number corresponding to the user's name.Data collection occurred specifically in two annexes produced by the service that should be mandatorily filled: the service admission form (the user's first registration) and the bed admission form (a form for each bed admission), which had, respectively, as analysis units the individual and the admissions.For the records that had no annexes (between 2010 and 2011), specific information was located through the registries made by the professionals throughout the evolutions and notes taken by them.
As a gathering tool, an on-line form, created through Google Forms ™ and designed by the researchers, was used.It was composed by socio-demographic questions related to the use of psychoactive substances (PAS) and to the period of night sheltering in the CAPS as III, based on the mentioned annexes.The form was tested by a pilot-study performed with eight randomly selected records.
Data from the first up to the seventh admission (for those who had it) were collected, since, according to the service's information, each user had in sporadic cases a number higher than seven bed admissions.

Data analysis and statistics
The data were analyzed with the program Statistical Package for the Social Sciences® (SPSS) version 20.0.Later on, a quantitative and descriptive data analysis was performed, presenting varied statistics for continuous variables.Only variables considered as descriptive for the bed occupation and use profile were used.

RESULTS
The age average for the users admitted to night sheltering beds in the CAPS ad III was 40 years-old, with a maximum age of 76 and minimum of 18 years-old.In this service's records, no data referring to the users' education and income level was found, we have also observed cases of under-notification in relation to the other data presented in Table 1.
Regarding the substance use, the average age when the use began was 16 years-old, with a maximum age of 54 and minimum of 6 years-old, having a prevalence of alcohol use, according to Table 2.
CAPS' beds were occupied 1,167 times during five years by 569 users, resulting on an average of 2.0 admissions per user.
The average length of stay ranged from 7 to 11 days, having a minimum of 1 and maximum of 256 days.In 58.7% of admissions, the length proposed by the team was of 14 days.From the 565 users evaluated, only 22 have occupied the beds for 7 times.Other information on these devices' use is described in Table 3.It is important to clarify that the different discharge kinds concern the ones who have participated in the user care after the night sheltering.Discharges can have been planned solely by the users (by looking for a pension by themselves, a rented house, among others) the CAPS as may mediate the contact to a shelter or the family can take part in this process along with the user and the service.
Regarding the nursing care, 85.8% of users were evaluated by the nurse in order to be admitted to the night bed.

DISCUSSION
As it is confirmed by most studies in this area, the profile of users who present a problematic substance use and access mental health services in search for treatment is comprised by men (77.5%), with an average age of 40 years-old, single and/or without a partner (80%) and declared as brown-skinned (5)(6)8) . In his study, the information on race was not found in 56.5% records, which could affect the result that most users declared themselves as white (21.9%), a datum that does not corresponds to the literature.
The lack of epidemiologic information about this item is wellknown in the health area and its collection is still disputed and stigmatized by professionals.However, data point out significant differences among races regarding the prevalence and incidence of substance use (9) , which makes this evaluation necessary.
The users' great vulnerability includes being exposed to risks caused by the problematic substance use, specially in indicators as: housing, access, resource availability, family structure, health conditions, socio-economic conditions, and social support (10)(11) .This confirms the results of a research in which 68.3% users who were in street situation and 22.1% who were sheltered referred to almost inexistent social and support networks, once 85.8% cases considered the family bonds as interrupted or bad/conflictive and 82.8% had no employment bonds.Another data that can be related to the vulnerability situation is the fact that 30% users are natural from other Brazilian states, specially Bahia (5.8%), Pernambuco (4.1%) and Minas Gerais (3.9%).
The last census about population in street situation in the municipality of São Paulo confirmed that this number has been growing exponentially, reaching, in 2015, 15,905 cases: 8,570 people sheltered and 7,335 living on the streets.In that number, there was a predominance of migrants who did not have good relationships with the family (80.0%) and only a few declared receiving a salary through a employment bond (22.7%).About 83.8% affirmed they used PAS, specially alcohol (9) , which validates the description of the users in this study.
It is known that issues related to the dependent use of AOD are mostly related to people living in vulnerable contexts.Studies have shown that street populations have a higher prevalence of alcohol dependence than the general population, having worldwide estimations of 56%.Consequently, these simultaneous problems may also be connected to the lack of health and quality of life (12) .In this sense, the care for this user profile may not be only oriented towards the use itself, but should also  act on the subjects' basic needs, as envisaged in the CAPS as work in territorial coordination.International programs known as "housing first" have been efficient in treating addictive disorders for those cases, and what is most interesting is that good results happen regardless of abstinence (13) .
When admitted to the beds, 87.6% subjects used multiple substances daily, specially alcohol (77%), crack (60%), and cocaine (48.1%).A result that is very close to the average in specialized services in the Brazilian capital cities, in which 78% users consumed alcohol and 51% used cocaine/crack at the moment they looked for treatment (5,8,14) ; consequently, these were the substances that most encouraged the search for treatment (60.2%, 38.7%, and 26.2%, respectively) (14) .
A Canadian study found out that alcohol dependents had higher chances of looking for the services due to the severity of withdrawal symptoms, as well as to the clinical comorbidities they may present (15) .Another study carried out in Brazil showed that the CAPS ad were the most looked for services by crack users for treatment, specially due to craving and basic needs as feeding, hygiene, among others (16) .
It was also observed in this population a high percentage of clinical comorbidities diagnoses (14.7%), as well as psychiatric ones (33.2%), related to AOD use, but it was not possible to identify if they already existed before the use or if there was a causal relation.The main notifications were of: schizophrenia/psychoses (14.5%), systemic arterial hypertension (5.5%), depressive disorders (5.3%), liver diseases (3.0%) and tuberculosis (3.0%), diagnoses that can be related to the prevalent use of alcohol and crack.
There is a proven correlation between the groups of AOD abuse/ dependence and of mental disorders and, therefore, users require a widen attention for these symptoms during their bed stay.Double diagnoses appear in 50.8% to 71% of users being treated in mental health services, with a higher frequency of depressive disorders (14)(15)(16)(17) .
A recent research has shown that people with alcohol problems have a 36.6%chance of developing a mental disorder and 53.1% chance of presenting problems with other substances (17) .Another follow-up performed in an Australian treatment service for AOD use has showed that social disadvantage is directly related to the problematic use of alcohol, concluding that the attention for vulnerable populations has higher chances of success when developed in community services (18) , as the CAPS ad, for example.
Regarding the use of night beds in these services, the average number of admissions was two per user.In 58.7% cases, the team indicated the maximum stay period of 14 days, as prescribed in the decree (2) , however, the average period ranged from 7 to 11 days.A study that described the bed occupation in a CAPS ad III during a year has also shown an average of two admissions per user, and, in this case, the stay period varied from 5 to 10 days.The users who stayed the entire 14 days in the beds were in street situation (81.2%) (8) .
This connection can also be reaffirmed when observing the referrals for bed admissions (Table 3), of which 63.3% to 79.2% were for detoxication/use interruption, 38.8% to 51.1% due to other vulnerability situations, and 30.5% to 40.2% due to street situation.Once again, it can be observed the influence of social issues on the use of mental health beds, being them many times used as substitutes for the insufficient assistance services in the covered territory.It can be understood, thus, that when the CAPS ad user profile is similar to the one shown here, the probability of the beds being occupied integrally is higher.
It is important to highlight that the distinction in the bed referral between street situation and other vulnerability situations regards the data found in the tool designed by the service and used for that end.
During night sheltering there was the need for removing users for hospital support, specially due to clinical complications in 3.7% to 22.7% cases (Table 3).No deaths were notified.These data can be related to the great demand of alcohol users admitted for detoxication, whose clinical states may have evolved to a severe alcohol withdrawal syndrome, even though they were evaluated by the nursing team (85.8%) before being admitted.It is important to highlight that the night beds do not have a structure that can accommodate clinical emergencies, as well as they do not require the permanence of a medical professional during nights and weekends.In this case, general hospital beds should be used (2) , and, for that, the nursing team needs to be capacitated and structured for evaluating and handling possible complications.
However, this poses a challenge for this kind of service, since the social representation of CAPS ad nurses on PAS abusive and/or dependent user is not different from the representation of psychiatric hospital nurses.They believe the subjects are ill and directly responsible for their condition, which triggers moral perceptions about the problematic use, labeling the individuals as manipulative and having no limits (19) , which makes it harder to understand certain situations.
Overall, night beds are still considered as a hospitalization by the nurses, which causes disagreement among the multidisciplinary team on handling, admission and discharge criteria for those users, which, in its turn, can instigate conflicts and interruptions in the work process (20) .It is then seen that at the same time this device widens the attention for this population, it can also reflect on the juxtaposition of care models in biomedical and psychosocial mental health.
In this study, referrals for post-bed hospitalizations, both for therapeutic communities and psychiatric hospitals, have ranged from 8.8% to 17.5%, a result also observed by another study in 5.4% cases (8,21) .It can be understood that, due to the low use rate of this resource, good results can be achieved by the sole use of beds in extra-hospital services in a secondary level.
Regarding the end of the proposed bed treatment, 31.3%users did not finish it, due to requested discharges (20.4%) or evasion (10.7%).This data is also observed in another study for 15.2% cases (2) , an aspect that needs to be highlighted since the use of this service is completely voluntary.It can be suggested that alcohol and crack dependence (most of the admissions in the CAPS ad), since it presents more severe signs and symptoms regarding withdrawal and craving, as well as the team's handling when facing these situations, can be related to abandoning the treatment.
Concerning the discharge types, the most common was the one planned with the user's own resources (34.7% to 50.9%), in which the users themselves look for household rental, pensions, shelters, family, or even to go back to the streets, if that is their will.Another kind of discharge was the one planned along with a shelter (20.7% to 29.8%), in which the service's Night beds in psychosocial attention care centers for alcohol and drugs: analysis and characterization Boska GA, Oliveira MAF, Claro HG, Araujo TSG, Pinho PH.
team coordinates the transference from the bed directly to this place, reaffirming the lack of family support to this population.
After being discharged, most users came back to the service in dates that were not previously booked for (30.0% to 52.8%), a result that can evince the difficulty these people have in post-discharge organization, specially for those who go back to vulnerability contexts and, consequently, to the problematic use of substances.We have also found users that were sheltered in the night beds and have never returned to the service, according to the records registered up to the moment the research was performed (abandoning treatment), those users were usually the ones that had only one admission (14.7%).
The return to the CAPS in crisis situations ranged from 22.6% to 36.3%, which have, in the addition scope, a highlighted dimension, not only because the use of some substances affects the senses or the level of consciousness, but also because the subject's social relation is tested or even broken by the stigma, exclusion, segregation and vulnerability situations to which the subject is exposed, making these conflicts' handling and treatment more frequent and complex (18,22) .
The attention to crisis situations was considered as the number one indicator for the evaluation of positive results of CAPS type III, valuing the service's capacity in meeting its own territory's demands, thus avoiding referrals for a third care level (23) and reaffirming its importance in the RAPS and in the care policies for PAS users oriented towards psychosocial rehabilitation.
It cannot said that there was an evolution or tendency in the use of beds, but we observed that situations as the need for detoxicating and vulnerability contexts were present in a significant share of the treatment, highlighting this relationship.The results presented here cannot be generalized since they reflect the reality of a single service, however, they bring contributions to a better understanding of the role of beds in extra-hospital services.

Study's limitations
The biggest limitations of this study were the under-notification of information or its lack of clarity in the service's records, specially in relation to the tools used for admitting the users to the beds, which were the main sources for data collection.Another significant factor was the lack of publications on the theme in literature, which restricted the discussion of some findings.

Contributions to the nursing, health or public policies areas
This study has shown that the use of night beds in CAPS ad is very frequent among PAS users in vulnerability situations.Given that, a possible contribution would be to design a standard tool for the service's team, specially the nursing one, based on the Ministry of Health's guidelines and other available evidence, so to stablish biopsychosocial criteria for admitting an user to the bed, as well as enabling referring demands that cannot be met by this device, as severe clinical issues, for example.

FINAL CONSIDERATIONS
The use of night beds in the analyzed CAPS as III cuts through complex social matters, directly related to the profile of populational vulnerability with a problematic use of AOD.However, the results show a bond among team, service, vulnerable user and the incorporation of beds in their care routine, embracing many demands and caring for biopsychosocial needs.
It is understood that specific compounds of this device may benefit people distinctly, depending on the variables related to their current condition.However, it is clear that the few cases demanding hospital support during the stay at CAPS and the number of users who did not return to the service indicate a good practice conduction.
Even with the numerous and common referrals for detoxication in the treatment, it is noteworthy the efforts in embracing, beyond the abusive or dependent substance use, other risk conditions, as the street situation, for example, a fact clearly observed in this study.This is one of the main challenges when proposing an open clinic that advocates subject autonomy in living with the substance, investing on finding their own resources within their context.
We suggest, thus, after this investigation, performing studies with a broader coverage, as well as inferential analyses in order to recognize and improve the investments on such an important therapeutic resource represented by the night beds at CAPS ad III.

Table 1 -
Socio-demographic profile of users admitted to night beds in a Psychosocial Attention Care Center for Alcohol and Drugs III, São Paulo, Brazil, 2016

Table 2 -
Characteristics of psychoactive substance use by users admitted to a Psychosocial Attention Care Center for Alcohol and Drugs III, São Paulo, Brazil, 2016Night beds in psychosocial attention care centers for alcohol and drugs: analysis and characterization Boska GA, Oliveira MAF, Claro HG, Araujo TSG, Pinho PH.

Table 3 -
Characteristics of admissions and discharges in night beds of a Psychosocial Attention Care Center for Alcohol and Drugs, São Paulo, Brazil, 2016 Note: (*) Defined by the team of the Psychosocial Attention Care Center for Alcohol and Drugs as deficient support and family networks, risk/threats situations, affected socio-economic conditions, lack of support and other services

Table 2 (
concluded)Night beds in psychosocial attention care centers for alcohol and drugs: analysis and characterization Boska GA, Oliveira MAF, Claro HG, Araujo TSG, Pinho PH.