Harm reduction: trends being disputed in health policies

Objective : to identify the underlying harm reduction trends in Brazilian drug policies. Method: The research, qualitative in nature, used in-depth interviews with experts in the field. The recorded and transcribed material was analyzed via the content analysis method. Results: The analysis exposed the following conceptions: drug use is a disease, and its associated health practices should be treatment, rehabilitation and social reintegration. These conceptions deviate to some extent from the war on drugs approach, and support the adoption of harm-reduction practices, proposed by public health. Less expressively, critical conceptions which clearly distance themselves from the prohibitionist approach and from public health may be seen, in line with the perspective of collective health, for the implementation of emancipatory harm-reduction practices. Final considerations: Harm-reduction conceptions and practices reveal the underlying conservative, liberal, and critical tendencies in Brazilian drug policies.


INTRODUCTION
The underlying harm reduction trends in the Brazilian drug policies is the object of analysis in this study. It is understood that, based on the theoretical framework of the collective health field, health practices, including those performed by nurses, are grounded on the guidelines of health policies. The guidelines of drug policies are, in turn, based on the paradigms that underpin discussions about drugs around the world.
Health policies are understood as state devices to support and enable the process of production in health, which is responsible for the organization of the work of all services of the Brazilian health system, being governed by the logic of a more general process of production of the predominant social formation: the capitalist mode of production.
The State, in turn, is considered the main form of regularization of social relations, controlling and influencing the functioning of other forms of regularization, in an attempt to ensure the reproduction of productive and social relations (1) . Therefore, it is only possible to understand the constitution of policies within the totality of social relations. The State is the agent of the process of imposition of policies, which are the product of the relation of forces between the internal contradictions of the State itself and the external pressure exerted by social conflicts, by groups that represent the interests or needs of civil society, through popular pressure, lobbies and political parties, for example (1) .
The paradigms that anchor the interpretation of the drug phenomenon (production, circulation and consumption of substances), and which have influence over Brazilian society, follow the international trends and are recognized around the world as the war on drugs (WD) and harm reduction (HR) paradigms. Regardless of the origins and propositions of the two chains having been historically very distinct and conflicting, one should pay attention to the current possible convergences derived from the public health neoliberal strategy of adopting HR policies and practices (2) .
The WD paradigm was established based on the social intolerance to the phenomenon of psychoactive drugs in the mid-19th century, which culminated in the consolidation of the prohibitionist conception in the 20th century. Grounded on moral, religious or scientific arguments, depending on the economic and political interests involved and on the need for social control, actions related to the production, marketing and consumption of drugs typified as illicit started being criminalized (3)(4) . In this way, punishment started being promoted, both for those who use drugs through the assignment of guilt and accountability for individual choices, and for those who sell these drugs (5) .
The strengthening of State policies with a prohibitionist, criminalizing and repressive character against consumers of drugs and substances that started being considered illegal in the 20th century occurred concomitantly with the growing international interest for the marketing of psychoactive drugs (6)(7) . In the same period of establishment of international legal and institutional prohibitionism, the consumption of psychoactive substances reached its greatest commercial extension (6) .
The historical preponderance of the WD paradigm in the guidelines of health policies was shaken by the failure of actions, which used to be implemented in health services aiming at the total and lifelong abstinence from drugs. The HR paradigm was historically established as an interface of the social movement that gained relevance, from the antiprohibitionist perspective, due to the undeniable and perverse contradictions arising from the war on drugs. The HR paradigm began spreading more broadly in the 1990s, as possibility set out by the flexibilization of policies aimed at fighting against the phenomenon of drugs (8) and as a strategy to contain the transmission of the HIV virus among injectable drug users, given the alarming dimension of the growth of Aids (a disease that can occur as a result of the HIV's action), which became a public health problem (9) .
In Brazil, the first initiative associated with this perspective was the "needle-exchange program", implemented by the municipal secretariat of Santos, SP, in 1989. Initiatives such as this were suppressed by the police apparatus, on the grounds of violation of the legislation in force, based on the WD (9) . The legalization of needle exchange was sanctioned for the first time in 1997 by a SP state law (10) , and the Ministry of Health effectively regulated the HR policy in mental health care services only in 2005 (11) , following the 2003 edition of the Policy of Integral Care of Users of Alcohol and Other Drugs.
The policies based on the HR paradigm delineate guidelines for health actions that have the purpose of reducing the risks and harmful consequences of drug use. In this paradigm, drug consumption is understood as an individual choice and as consequence of a set of issues pertaining to the subject's psychic constitution, family dynamics and problems faced in everyday life. That is, the health of drug users started being understood as a multicausal phenomenon; drugs ceased being considered a central problem and abstinence was no longer the sole purpose of treatment (12) .
This perspective broadened the understanding of the drug phenomenon and of the strategies for coping with the prohibitionist conception, as it moves away from the assignment of individual guilt and from the conception of deviant, on which the WD paradigm is based. It is guided by the consideration that the individual is always a subject of choices, that is, with freedom to choose among lifestyles and substances used.
Various HR strands were devised based on international trends (12) and, in Brazil, they were more or less incorporated into the mental healthcare policies (11) implemented in the services that make up the psychosocial care network. For the development of HR in primary health care, for example, the Ministry of Health invested in the training of community health agents and nursing technicians and assistants, through the project Caminhos do cuidado (13) .
This study is based on the emancipatory strand of HR, which clearly distances itself from prohibitionism, being grounded on the understanding that the capitalist logic determines the structure and dynamics of the system of production, circulation and consumption of psychoactive substances, whether licit or illicit. In this logic, this system has the same properties for reproduction of capital as any other commodity. Emancipatory HR engages in collective confrontations with the proven social damage surrounding the phenomenon of drugs, challenging individual perspectives, as well as those of biological or behavioral nature, advocating broad social transformations in this sense (14) . This perspective moves away both from the multifatorial pragmatic public health approach to HR, which coincide with the policies of reduction of expenditure on health services, and from the prohibicionist approach, which responds in a controlling manner to social problems surrounding drugs; thus, it distances itself from State policies that implement HR policies and practices in a selective and compensatory way, questioning the intent of these initiatives (2) . It is assumed in this research that health policy in the field of drugs expresses the harm reduction trends identified in the various approaches presented.

OBJECTIVE
To identify the underlying harm reduction trends in Brazilian drug policies. The specific objectives are: to understand the conceptions on the consumption of drugs that are representative of this field, as well as the practices based on them; to identify trends expressed by these conceptions.

Ethical aspects
The research was approved by the Research Ethics Committee of the University of São Paulo's School of Nursing, and the participants signed an informed consent form, allowing the recording of the interviews and giving their authorization for disclosure of the data. The term signed ensures the confidentiality of the participants' identity and the right to give up participation at any time.

Type of study
The research, qualitative in nature, consisted of an exploratory and analytical study (15) .

Study setting
The study took place in Brazil, having as setting two public universities and one public institution of the legal sphere, with recognized authority in the field of drugs.

Data source
The research's participants were intentionally chosen for representing different fields of action, central in drug policy-making, with diversity of political positions assumed in the public debate. In this way, three prominent experts, two faculty researchers from public universities and one authority from a public institution of the legal sphere were selected.

Data collection
After the participants had been initially contacted through an email explaining the goals of the research, the interviews were scheduled at the locations chosen by the experts. The interviews were recorded and conducted in 2014. The guiding questions focused on how the human rights of the Federal Constitution are being contemplated in public policies aimed at drug users, and what actions in the field of health have been implemented to enforce them; and also questioned what was the respondent's position in relation to actions based on HR and on WD.

Data analysis
The interviews were transcribed and the material was analyzed both from the reading of the texts transcribed in full and from the listening of the recorded material. The excerpts including the conceptions on drug use and with explanations about health practices were highlighted. The goal was to understand the differences between these conceptions and practices and correlate them with the HR and WD paradigms, considered the categories of analysis in this investigation. This process was conducted using the content analysis technique (16) . To present the results and ensure anonymity, the interviews were identified as I1, I2, I3. Some excerpts from the interviews were edited to make them clearer, the original meaning intended by the respondent having not been altered.

RESULTS
The results were organized into themes, which designate the nuclei of meaning of the respondents' messages: drug use as health issue and challenges to the implementation of rights through state policies; functionalist conception of drug use and conservative position in health; conception of drug use as individual choice and liberal policies; conception of drug use as social phenomenon and critical practices.

Theme 1 -Drug use as health issue and challenges to the implementation of rights through state policies
The consumption of psychoactive substances, licit and illicit, is a health issue for two of the interviewees. For them, drug consumers and those who live with chemical dependency need treatment, rehabilitation and social reintegration, as described in the statements below.
[...] people who experience the suffering of chemical dependency, especially those who live with it and also users. When removing the provision of sentences, Brazil establishes that those dependent on illicit psychoactive substances should be offered the health system, the social assistance system and not the prison system. [...] for those who live with the dependency on psychoactive substances, especially illicit but also licit ones, it is necessary to offer services, services that are regulated, services that actually have the concern with human rights. [ The deficit of services is reiterated in the report of I2, who recognizes the implementation of specialized services as a challenge. The WD dimension stands out even more when the drug consumed is crack, which justifies the violation of rights.
[...] if a crack user arrives in an ER service, [...] if he is identified as a crack user he will certainly be condemned, have his rights violated, because the responsibility for his own health condition will be placed upon him. These users are mistreated. (I1) I2 discusses the vulnerability of crack users as a result of them using the drug, which reverses the social explanation assumed at least in part by ministerial policies in the field, which incorporated DR as a form of approach to the drug issue. Despite it being accepted, HR is regarded as a set of strategies that may be useful in special situations only and, in this case, it is not an approach incorporated by all practices in the area. This is what is shown in the report of I2, who considers that in the case of crack, there is no possibility of adopting HR strategies. This is justified by the impossibility of anticipating the controlled used of this drug. The drug itself is what determines evaluation. Compulsory hospitalization, on the other hand, as judicial measure clearly affiliated with the WD, was criticized by all respondents, as can be seen in the following excerpts.
Compulsory hospitalization is the icing on the cake of the violation of rights. Those  Respondents I2 and I3, who advocate social reintegration, consider that chemically-dependent individuals must have access to social rights, as well as to treatment so they may recover and go back to living in society.
[...] schooling is a very important aspect of social reintegration, as are policies that encourage employment opportunities and income generation for those who are undergoing the recovery process or for those who have recovered. That is, for those who have conditions to overcome that critical moment, in more or less serious cases where there is possibility of integration or re-integration in the labor market. The policies of incentive to employment opportunities and income generation, combined with actions that allow their inclusion in the country's education system, are fundamental social reintegration policies; it is not enough to administer the system of entrance in the healthcare system if attention is not given to those who are recovering, or to those who have recovered from serious chemical dependency. These are key measures. (I2) [...] the adoption of the so-called "relapse prevention" measures means the person is no longer hospitalized and living in the outside world [...] a social assistance network will be provided by CRAS [Social Assistance Center of Reference] for the person to seek reinsertion in society. (I3) I1 considers that access to social rights depends on the legalization of drugs. The dichotomy between licit and illicit drugs is seen as a destructive prohibitionist mechanism, which pushes illicit drugs into unprotected social territories, without institutions, where violence prevails.

Theme 3: Conception of drug use as individual choice and liberal policies
This conception was debated among the experts to some extent, being approached from different angles. I2 understands that the consumption of drugs is part of society and that the State's role would be to intervene with harm reduction measures to reduce the risks to health.
We need to move forward, we need to recognize that the country cannot shield the entry of drugs; and imagining that Brazil, or any other country, would be able to ensure a drug-free world, is impossible! The history of the Brazilian and world civilization shows that the use of hallucinogens, psychoactive drugs, is part of society. Our role is to show how unhealthy abusing them is.

And how important, as has been, the damage-reduction policy is for the field of health. I usually say and strongly insist: Europe and the United States have achieved major breakthroughs in the treatment of heroin dependency with the damage-reduction policy through the application of another drug -methadone, in a controlled manner by the health apparatus. Based on the scientific evidence, we see that methadone is effective in treating heroin addiction, and in this way we may achieve great advances. (I2)
For I1, the social discussion of drug legalization represents mostly the interests of the bourgeoisie, who want freedom to make their individual consumption choices, to consume whatever they wish in the market.
[...] this debate is a bourgeois debate on the legalization of marijuana. This group is not in favor of radicalization, it is in favor of the private interest to continue using their pot. Few are those who radicalize the discussion on drugs. They end up reproducing the dichotomy between less harmful and more harmful drugs, without deepening the political debate. (I1)

Harm reduction: trends being disputed in health policies
Moreira CR, Soares CB, Campos CMS, Laranjo THM.

Theme 4 -Conception of drug use as social phenomenon and critical practices
This conception was found in the report of I1, who examined the process of social marginalization to which drug users are exposed, especially crack users, making considerations about the economic interests involving the issue of drug consumption, as in the case of cracolândia. [ The proposal of harm reduction, as political and social movement that encompasses humanitarian and antiprohibitionist ethical-political practices, did not advance for receiving little investment and encouragement.
Out first contact with damage reduction happens via the social movement stemming from the HIV epidemic. We thought that this experience would encourage health professionals to adopt damage-reduction practices. But in reality, the prohibitionist policy returned, which is something that secretes, which begets more violence, which generates more illness. [ There would be advances in this direction if drugs were legalized, without distinction, with nationalization of production, marketing and consumption, to avoid commoditization. And advances in policies for discouragement of compulsive consumption should be achieved in parallel.
Firstly, the legalization of all drugs. Regulating what are the drugs to be legalized, their active ingredients, and not commodifying consumption, as in the case of tobacco [e.g., Souza Cruz will take over the production of marijuana], because another logic is delineated. The idea is to work in cooperative schemes; I stand before the State and say: "look, I'm going to set up a cooperative to produce drugs for consumption". Then the State will recognize and authorize it, check whether all health surveillance standards for any drugs, including crack, have been met. Marketing, but in the sense of the State having control over it as well as over production and consumption. And at the same time, creating a policy for discouragement of consumption. A serious health policy for discouraging consumption through prevention, with broad dissemination. What we're talking about here is drug consumption at the price of barbarism. What we need is a public social policy to ensure rights, like those of alcohol and tobacco, a legislation that regulates consumption. It would stop crime. When the State assumes this, it legalizes it; you legalize it, you place it in the sphere of citizenship. (I1) Even today, the concepts that support policies and practices focused on the phenomenon of drugs in Brazil denote influences of both the WD and HR paradigm. The HR seems to have accomplished much more as a set of strategies, which are evaluated for special cases, than as a paradigm shift in the area.

DISCUSSION
At the beginning of the 21st century, HR principles and practices in mental health were formally adopted in the scenario of Brazilian public policies. These policies advocate going beyond strategies to minimize risks and damages and are based on the involvement of users, on the respect for the individual and on the right to the use of drugs. At the end of the 2000s, investments were made in the Psychosocial Care Center for Alcohol and Other Drugs (CAPad), in addition to other government initiatives such as the Emergency Plan of Expansion of Access to Treatment and Prevention for Alcohol and Other Drugs and the "Crack, é possível vencer" Plan (17) .
Analyses of performance in the area of drugs of primary health care, CAPads and street offices show problems associated with implementation, structure and training of workers (8) . The evaluation of the training intended by the "Caminhos do Cuidado" project, an initiative of the Ministry of Health, the Oswaldo Cruz Foundation, Grupo Hospitalar Conceição and the Federal University of Rio Grande do Sul, to educate community health agents and nursing technicians and assistants on the theme of crack, alcohol and other drugs, shows a decrease of prejudice in relation to users of these substances, but notes the long road ahead in the pursuit of effective changes in practices in the area (18) .
It is understood that in addition to the historical origin of the problems shown, which has particularities in relation to the Brazilian social treatment of drug users, public healthcare is subject to a neoliberal State, which moved away from the implementation of social rights, making room for State policies that favor the health market, the freedom of purchase for those who can pay and the compensatory character of measures intended for those who cannot access this market (19) . The policies are generated, on the one hand, to ensure the reproduction of the labor force of capitalist enterprises and, on the other hand, to respond to pressures exerted by demands of the working class and other groups; and also by the necessity of mitigating social conflicts, which can generate a governability crisis or unwanted social transformations. However, in this clash of forces, policies are fundamentally determined in favor of the general interests of the capital and of the needs of capitalist accumulation (1) . This correlation of forces and the pole generated by the clash between these forces explain the trends of the policies implemented by the State and, consequently, the guidelines of actions against the contemporary phenomenon of drugs, within the spheres of production, marketing and consumption. The positions presented in this study reflect the clash between the WD and HR paradigms in dispute in the area of drugs, represented here by the policies' underlying conservative, liberal and critical trends.
The functionalist conception explains drug use as a deviation from the normality standards and focuses the analysis on the bio-psychic functioning of the individuals (20) . Practices associated with this conception combine medicinal and psychosocial interventions, aimed at changes in the individuals' habits so they may be reinserted in society through their efforts of adaptation and adherence (21) . This conception seems to limit HR practices to cases in which there is no serious dependency or when the dependency is not determined by the drug, moving just a little away from the paradigm of the WD, thus being labeled as conservative in this study. Social (re)insertion is its functional goal, and it assigns to drug consumers the status of subject of social rights, referring them to social services (social assistance, health, education, professional training, employment) so they may obtain assistance and reclaim their citizenship (22) .
The conception considered as liberal in this study explain the use of psychoactive drugs as inherent to human sociability and has been gaining territory both in the field of health as in the legal sphere. It advocates the protection of individual freedoms and human rights, consistently with liberal idealism, promoting actions aimed at the reduction of damages derived from the consumption of psychoactive drugs. It steers away from prohibitionism and from the WD, and is positioned within the HR paradigm. The intervention should combine social policies to meet the needs of drug users, without the commitment of spreading the ideology of a drug-free society (12,23) , intervening to reduce the vulnerabilities of certain groups of consumers of illicit psychoactive substances (24) .
The critical conception, which explains the use of drugs as socially determined, shows that psychoactive substances follow the same dynamics of other goods for the accumulation of capital and questions the existence of freedom of individual choice in capitalist society, as it is divided into classes which determine the power of individuals to enjoy freedoms. These freedoms are relative to the freedom of purchase in the market. In this perspective, the adoption of HR practices is not determined by the type of drug, but by the severity of dependency, or by the condition of vulnerability and risk; neither does it refer to the right of individual choice. The adoption of HR practices relates to the political strengthening of groups, to expose social contradictions and vocalize radical transformations related to elements of the social dynamics and structure that underlie the compulsive and problematic consumption of drugs in contemporary times (12,14,20) .
The paradigmatic tension in the area of drugs was evidenced in a documentary research about Brazilian policies, which revealed the protagonism of the HR paradigm, especially since 2005, with the realignment of the National Drug Policy Secretariat (SENAD). The study exposes concerns with the resumption, since 2016, of the paradigm of the war on drugs, especially expressed by the political incentive to therapeutic communities (25) . Thus, it may be concluded that, with the rise of conservatism in Brazil in recent years, HR, despite being formally adopted by the State policy, has suffered setbacks in practice, being overrun by abstinence-focused models, and, in relation to treatment, by therapeutic communities therapies that operate under strong religious influence (26) .
In this work, it is considered that the HR paradigm, in Brazilian healthcare policies, may be found since its inception, permeated by trends which reflect the ideas and practices in the area. These trends reflect the incorporation of HR in very different ways.
Although the conservative trend somewhat moves away from the prohibitionist paradigm, with the adoption of a few HR strategies, its proposals are uncapable of overcoming the misfortune arising from the production, circulation and consumption of drugs as a whole. In the legal sphere, this trend is expressed in the changes in the penalization of possession of drugs for personal use, this conduct, however, still being regarded as a crime. In the case of Brazil, the current legislation imposes on drugs users the vulnerability stemming from the vagueness of the law. In addition to the criticism of how shyly it moves away from the prohibitionist model in relation to the limitation of its reach, the conservative trend is also criticized for the maintenance of repressive practices that promote the stigmatization of drug consumers. In this perspective, Brazil follows HR policies, i.e., those aiming to strengthen public health measures through pragmatic actions (27) .
The liberal trend corresponds in the legal sphere to the one known as decriminalization, a proposition that is more in line with human rights, which reduces the effects of repression in the context of consumption, as well as the effects of drug trafficking and the criminality associated with it. This trend is followed by many European countries, such as Portugal, which decriminalized all sorts of drugs. Allied to the liberal perspective, public health adopts HR and prevention measures, in addition to providing access to voluntary treatment (27) . Brazil recently applied billion of reais in the fight against the consumption of crack, adopting the Crack, é possível vencer program, its educational branches being impregnated with old slogans and strategies of the war on drugs (28) .
In the current Brazilian political scenario, the State's monitoring of the action of therapeutic communities that provide care to those who engage in the problematic consumption of psychoactive substances is strongly compromised, which undermines the protection of the human rights of drug users (25) . HR is accepted as a way to reduce the State's burden and expenses with the problems arising from the use of drugs (2) .
The critical trend expressed radicality in its understanding that the decriminalization of drug use does not have the necessary conditions to solve drug-related problems, as it leaves aside the issue of trafficking and, according to Boiteux (26) , exposes an important contradiction: it is liberal for users and punitive for trafficking. The critical and radical perspective and the urgency of society discussing the legalization of drugs, with regulation by the State, have been shown in this study.

Study limitations
The study would benefit from the positioning of other sectors of society, which also have influence over the creation and implementation of policies, such as harm-reducing associations, managers and other healthcare workers involved with municipal and state administrations.

Contributions to the fields of nursing, health, and public policies
The study contributes to the construction of criticism against the effects to the field of health of state policies that conciliate prohibitionism and neoliberalism, as well as to the identification of the need for emancipatory practices. Such practices aim to overcome both those used by the State to exercise its control over the most unprotected populations -as is the case of those corresponding to the conservative trend -as well as those that overburden individuals with the responsibility for the choice of healthy habits, such as those identified as liberal or neoliberal.

FINAL CONSIDERATIONS
Three trends that influence drug policies and practices in the field of health may be noted: the conservative trend, which is based on the understanding of drug consumers as diseased individuals who should be treated by mental healthcare actions focused on their psychosocial recovery and rehabilitation; the liberal trend, which considers the subject that consumes drugs as a bearer of civil, political and social rights, who may thus choose what to do with their own body, including using psychoactive substances, and which admits HR strategies adopted by mental healthcare to ensure the humanized care and citizenship of this individual; and the critical trend, which analyzes the phenomenon of compulsive or problematic drug consumption as arising from the dynamics of the capitalist mode of production and proposes emancipatory HR as paradigmatic approach, with the intention of strengthening social groups through emancipatory education.
The trends identified correlate to HR to a greater or lesser degree. At one extreme is the adoption of a few particular strategies that allegedly could assist in the treatment of addiction. In this case, the core value lies on what is imposed on society and which must be seized by individuals. At the other extreme is the humanitarian movement, of radical opposition to prohibitionism, which criticizes the functionalist explanation for the consumption of drugs and highlights social understanding, questioning the pragmatic adoption of HR strategies. In this case, the core value lies on the exposure of inequalities that are deepened with prohibitionism and the strengthening of collective groups of those affected. This positioning advocates changes in what has been established. Between these two positions, the liberal one is expressed, based on the understanding that individuals who use drugs have the right to health and even to the use of drugs without constraints created by the State. In this case, individual liberties constitute the core value.
It is undeniable that the policies based on the HR paradigm induced humanizing practices towards drug users. However, the policies do not regularize the expansion of actions from the perspective of critical and radical HR, those focused on the roots of the individuals' problems and on the understanding of the dynamics of the drug phenomenon as reflex and product of the capitalist production dynamics, which turns everything that is possible into merchandise, for accumulation of capital.
It is advocated that health policies include guidelines associated with actions that allow health workers to reflect about work processes, to promote their understanding of the limits and contradictions of the forms of regularization of the process of production in health. Their acknowledgment of the conceptions about drug use that underlie health policies will allow them to understand the limits of these policies to induce practices that respond more broadly to the harmful consumption of drugs, and also free them from the frustrations produced by idealization, as well as strengthen them so they may develop emancipatory practices -practices that bring benefits both to health workers and to the subjects of the actions -and the reflection on the origin of health problems, allowing the subjects of social groups to demand answers to their health needs, in contrast to groups mobilized by interests.
HR policies and practices in Brazil are becoming increasingly more structured in accordance with neoliberal precepts, and in this sense they are composed of a set of actions to remedy the needs of groups of drug users who are marginalized or considered vulnerable, which persist and increase as consequence of the enormous social inequalities. Without the social analysis of the issues involved in the production, circulation and consumption of drugs, there will not be a real paradigm change, but a rhetoric one only.