Emancipatory drug practices : building projects with Primary Healthcare workers

2 Universidade Federal de Pelotas, Departamento de Terapia Ocupacional Social, Rio Grande do Sul, RS, Brasil. ABSTRACT Objective: To build projects for implementing emancipatory drug practices with Primary Healthcare workers. Method: An emancipatory action research based on historicaldialectical materialism developed at the Vila Prudente/Sapopemba Health Technical Supervision of the city of São Paulo with the participation of Primary Healthcare workers (care providers and management). Results: Seventeen (17) health workers participated in sharing 13 workshops. The workshops discussed the following topics: the health needs of residents of the territories in which they operate; social dimension of drug use; limitations and contradictions of public healthcare policies and practices in the area of drugs; purpose of working in Primary Healthcare; and implementing drug evidence. Four intersectoral implementation projects were designed based on critical policy discussions. Conclusion: The emancipatory workshops enabled workers to position themselves in the health production process and capture the contradictions of this process, thereby strengthening their ability to develop and implement tools in response to health needs based on the social processes that involve the production, circulation and consumption of drugs.


INTRODUCTION
The object of this work comprises the practices of Primary Healthcare (PHC) in the area of drugs.
In recent years, Brazil has been adopting ministerial guidelines on drugs influenced by the Harm Reduction (HR) movement, having made several advances over time.However, such achievements have not been stable and compete with setbacks from the influence of the War on Drugs (WD) policy, which engages society in a smokescreen with repressive and uncritical actions, ignoring humanizing approaches to valuing social relationships of protection and social criticism (1) .
Although democratic governments have favored HR, especially since 2003, there is a persistence in practice of one-off actions which fail to strengthen workers who have to cope with PHC demands and who at times tend to approach risky behavior, other times to criticize social factors, presenting multiple views on the object-subject relationship of HR (1) .
The collective health field has adopted a critical framework in order to instrumentalize workers who deal with this phenomenon on a daily basis; it explains the process of drug commodification based on changes in the accumulation regimes and social values which foster the demand for the drug commodity, which may cause problematic consumption forms (1) .
For better understanding, it is known that psychoactive substances are part of humanity's history, being used in many cultures as part of sociability and as a form of strengthening (1) .However, it is from the capitalist production mode that one observes the process of drug fetishization, resulting from the most contradictory forms of the social production process.It is capitalist social relations that dictate drug use today, and therefore drug use cannot be understood without understanding the contradictions inherent in the class structure and current social dynamics (1) .
We currently live under a regime of integral accumulation characterized by productive restructuring, as well as by the neoliberal configuration of the state legitimized by political and ideological conditions.Many changes in social life are observed as a consequence of this accumulation regime, especially those related to work organization with a view to increase profit generation through overexploitation of the workers (2) .
In theory, it is the insertion of the individual in the social division of labor which determines their class belonging, and this belonging determines the lifestyle of individuals (2) .It is in this regime of integral capitalist accumulation that the exploiter-exploited dichotomy worsens, with the exploited (worker) being the weakest part of this relationship subject to fragmented working and living conditions: weakened labor rights (temporary contracts; retirement procrastination, etc.) and the disruption of acquired or ongoing social policies (social security and the Unified Health System (SUS)).With the worsening social reproduction conditions of the working class, there is an increase of marginalized sectors (1)(2) , the neoliberal agenda favors a loss of rights, causing insecurity and fear and thus exposing the worker to a loss of human dignity (1) .
The social contradictions arising from this production mode aggravate the tensions between the different social classes, and the state must be equipped with tools and strategies to reduce the class struggle.However, being essentially bourgeois, the capitalist state prioritizes the interests of the ruling classes by using such strategies to maintain the status quo in order to strengthen the reproduction of capitalist relations (3) .
Thus, state policies aimed at drug use adopt a path of user pathologization by promoting actions focused on promoting the internment of users, sometimes compulsory, and reinforcing the prohibitionist structure to drug use based on the combat against illicit drugs (4) .These policies are divergent and often contradictory to other knowledge areas such as public health and human rights (4) .
The lack of commitment to SUS (Sistema Único de Saúde) principles, the existence of municipal power disputes, a predominance of the technical and operative dimension in work, and the increased competition of the private sector for public resources, especially with the implementation of therapeutic communities, lead to healthcare mechanisms which are contrary to the HR movement and are funded by the Brazilian State (5) .
The recently passed Law 13.840 of June 5, 2019, provides a further setback, making clear the State's interests in securing profitability for the private sector by encouraging hospitalizations in private therapeutic communities, as well as reinforcing the conservative prohibitionist outlook, which allows involuntary hospitalization.
A literature review shows that institutionalizing HR is fundamental to overcome the political barriers that hinder implementing strategies.These strategies produce transformations which, although limited, contribute to improving living and health conditions and survival, keeping users in the health and social care network, and avoiding marginalization (6) .
Such strategies and policies remain under the aegis of the capitalist production mode, causing no change in the social structure.Thus, users continue to occupy the same social position as before and continue to depend on the benefits offered by the government, presenting a welfare policy which does not promote changes in the social reproduction chain.
Contrary to prohibitionist practices and with the purpose of overcoming pragmatic HR objectives, the creation and implementation of emancipatory HR practices is encouraged.Emancipatory Harm Reduction (EHR) is one that promotes critical processes of reality which surrounds those who use drugs in a problematic way, in their interdependence with the social totality in order to guide solidarity and critical practices (7) .Education is shown as a fundamental resource for implementing EHR actions, proposing approaches based on less instrumental and more critical conscientious practices aiming at the structural understanding of the psychoactive substance production, distribution and consumption system (8) .
In view of the above, collective health uses a powerful instrument -emancipatory education.Based on Paulo Freire's concept of popular education which is based on promoting the student's participation in the educational process in union and co-participation with the educator so that tools are developed to help them to re-read the world in which they are inserted.It is considered essential to take into account the social, political and historical structure so that the process of reflecting on the reality in which they are involved enables them to become a questioning subject of this world and an agent of change (9) .
It is argued that the practices are built considering the social determination chain, shaped by societal structure and the historical and political moment (1) .Therefore, in order to assert the comprehensive character of healthcare of consumers who are using harmful drugs, it is recommended that PHC should adopt approaches which broaden the understanding of the health-disease process as socially determined, using the EHR and intersectoriality perspective for constructing critical and productive work, which expands human potentialities and guides worker practices (7) .
Thus, this investigation aimed to collectively build projects for implementing emancipatory practices regarding drugs with PHC workers.

Study deSign
This is a qualitative study.Historical-Dialectical Materialism was adopted as a reference.It comprises social relations as dynamic, i.e. it is a dialectical movement which exposes the dominant production relations in the capitalist system, revealing the constant social inequalities (1) .
As a methodological instrument, this study followed the principles of emancipatory action research (EAR), a participatory methodology which has been extensively used in implementation research (10) .
EAR incorporates the four guiding principles of Action Research (AR): 1) participation -considers the existence of different participation levels; 2) spiral-reflective cycle process -a constant learning process that seeks implication of the participants in the action; 3) knowledge production; and 4) transformation of practices.These last two are in dialectical relation, providing changes in the two spheres of knowledge and practice (10) .

PoPulation
The study counted on the participation of 17 PHC workers from different health units who volunteered to participate in the research based on their affinity with the theme and without mandatory participation, and included nurses (10), psychologists (03), occupational therapists (02), a dentist (01) and a social worker (01).These professionals work beyond care actions, developing educational activities with co-workers and/or with the population in their area of coverage.It should be noted that five of them also perform management tasks of the Basic Health Unit (BHU).

Scenario
The emancipatory workshops were developed at the Vila Prudente/Sapopemba Health Technical Supervision of the city of São Paulo in a meeting room that was intended for the activity.The process involved 13 pre-scheduled workshops which were agreed to by the managers of each unit to which the workers were employed, with an average duration of 3 hours and a break of 30 minutes for a snack, being conducted twice a month throughout 2017.
The strategy chosen for the workshop progress was a conversation wheel, placing the participants side by side in a circle for better interactivity during the process.The themes were selected based on previous experiences in the area with adaptation to each workshop, and based on the needs introduced by the participants: origin of social problems existing in the operation area ; social issues involving drug use; limitations and contradictions of drug guidelines, public policies and health practices on drugs; the working purpose of the Family Health Strategy (FHS) and traditional health units; educating workers' for implementing evidence based on the criticism of collective health, thus constituting themes which were considered pertinent to constructing the educational proposal.These meetings were conducted by five researchers and faculty at the Universidade de São Paulo Nursing School (USP).

data analySiS and ProceSSing
The AR process takes place in a spiraled cycle of planning, action, observation and reflection, and these steps are fluid and often overlap.Action research considers that all participants involved in the process are researchers -internal (who experience) and external (academic, with scientific knowledge).Both hold diverse and equally important knowledge (10)(11) .
The 13 workshops had pre-established themes, objectives and strategies; however, it is reiterated that they underwent changes since the participatory process of action research demands a collective construction of knowledge according to the needs presented by the participants.Thus, the workshops were evaluated and redesigned as the meetings progressed.
All recorded material from the meetings was transcribed, and in each meeting it was verified if the set objectives were achieved so that the next meeting could be followed: 1) Propose the research, know the participants and their expectations for the meetings and Present the evidence implementation concept; 2) Discuss the social problems of the territories and particularly those related to drug use; 3) Analyze public policies aimed at drug users, understanding their limitations and contradictions; 4) Raise and analyze the contradictions and purpose of work in the FHS; 5) Discuss the potentialities and limitations of FHS worker practices; 6) Reflect on the foundations of emancipatory education; 7) Reflect on the foundations of emancipatory education: development of evidence-based practices; 8) Discuss the development of evidence implementation projects; 9) Instruct workers to use evidence to formulate practices in PHC; 10 and 11) Evaluate the implementation project roadmap and responses; 12) Discuss the health needs related to the drug phenomenon; and 13) Validate educational material built throughout the process.Each meeting was transcribed and analyzed separately, and the statements were analyzed according to the adopted theoretical framework.

ethical aSPectS
The study was evaluated and approved by the Research Ethics Committee of the Nursing School of USP, and by the Research Ethics Committee of the Municipality of São Paulo, under Opinion No. 001/16-CEP/SMS.The norms and guidelines for conducting research involving humans were respected, being in compliance with the provisions of Resolution 466/12 of the National Health Council.In its execution, the participants signed the Free and Informed Consent Form, which stipulates the right to confidentiality and freedom to participate or not in the research, as well as to withdraw at any time.We used the letter "P", qualified as a participant, followed by the order number of their occurrence as a way of identifying FHS workers participating in the study to expose their statements and maintain the anonymity of the research participants.

RESULTS
The first workshop focused on presenting the evidence implementation concept in order to deepen the critique on the importance of developing practices in PHC based on the population characteristics in the covered area and based on scientific evidence in order to offer basis for the intended practices.To stimulate debate, the participants sought to highlight the contradiction between this ideal and the space and time offered in work to seek evidence in databases or to read scientific documents.
Participants soon exposed the difficulties experienced in the services, such as: motivation of professionals beyond achieving quantitative goals, as required by municipal director plans; high worker turnover in primary services; and preference for hospital/physician care.

A group that has taken ownership of how it works and what I can do to change, but the problem is staff turnover. So, the professional understood, appropriated, but then you have professional turnover which ends up making implementation difficult to really modify this reality (P12).
The second and third workshops addressed elements which are in the social reproduction of populations living in the areas covered by the basic health units, considering that their understanding is fundamental to understand the drug phenomenon, the concrete realities of social territories and their health needs.Participants were asked to split into groups and survey the characteristics of the territories, taking into consideration the possible physical structure, work and leisure in the communities in which they work.The region has very formal commerce, but even more informal commerce, there is the late evening fair, which is very informal commerce and demands a lot of working people, people who at-tend the fair and who live on the fringes of the informal economy, for example, there are many sewing businesses (P6).
There is the issue of drug trafficking, in the alleys, we have an area that has no running water, no water, no sewage, and just now the power grid has arrived (P9).
This moment was important for workers to relate work insertion in the capitalist system with the possibilities of social reproduction when analyzing the housing and work conditions.It was possible to identify the strong presence of unemployment and exploited informal work; a situation which prevents improvement in social reproduction, forcing this population to live in peripheral regions, in hostels or tenements, unhealthy places marked by social precariousness.
The fourth and fifth workshops had work contradictions in PHC as their theme, and aimed to raise and analyze the contradictions and the purpose of work in the FHS, revealing productivist and inflexible work from the workers' reports.
The workshop began with a dialogued exposition on the health production process and departed from the understanding that our work processes respond to the needs of the capital as we are in a capitalist accumulation system, which in turn is concerned with profit generation.Therefore, an organization level and labor division subordinated to a care model is essential.
Our daily life has no freedom and no creativity, it is molded (...), the protocols end up preventing us from having this freedom and creativity of production (P12).
Working in this (re)productive logic implies an exploitation of professionals through concepts such as resilience and polyvalence, which impose guilt and force the worker into doing exhaustive work, assuming tasks which go beyond professional attributions.The person is responsible for the subject of their territory, but as far as the responsibility is ours alone or we understand that the production process is the same process that we are also a part of.Our patients are also subjects of the social mechanism we are in.I keep thinking that maybe in recognizing it we can lighten the load a bit, I don't know if in practice it relieves us as a worker (P5).
The sixth and seventh workshops first aimed to reflect on the foundations of emancipatory education and secondly on health education as a tool for transforming practices and problematizing reality.
We began our conversation by highlighting elements that constitute the educational process posed by educators from the theoretical framework of critical historical education: Demerval Saviani and Vitor Paro, with the contribution of Paulo Freire, understood as intrinsic to the health work process.The elements worked on were: subject; object; method; objective, including intentionality, an essential element of the work process (12) .
The discussions on this topic led to forming various criticisms of PHC work, such as the pragmatic practices and implemented programs, which often do not cover specific needs of the BHU's operation territory, eventually only serving a predetermined population, such as pregnant women, hypertensive patients, diabetics, and children, among others.The issue of smoking, I think is much broader.The culture of resolving with complaint/conduct, this I think is one of the main challenges that we face, we realize that it's difficult to work, I don't even know if we can answer these questions, especially also because the problems are not limited to Primary Healthcare, there are social, economic, safety, and education issues.That's why you subspecialize so much, because it's easier to take care of a fragment than completely (P6).The eighth, ninth and tenth workshops provided space for workers to discuss innovative evidence-based FHS practices on the drug issue, aiming for building implementation projects.
The discussion began by summarizing the policies and practices in the area of drugs in the world, and notably those pertaining to Brazil.We subsequently sought to analyze whether the practices found were plausible and relevant to the BHU reality and how they could be adapted to the reality of each area.
As a result, four implementation project proposals were obtained: 1) training elementary school teachers from a Unified Educational Center (Centro de Educação Unificado -CEU; 2) training BHU workers to care for homeless people; 3) instrumentalizing young students in identifying and responding to their needs; 4) educating young people in social and educational measures about their social rights.
The four project proposals were the subject of the three subsequent workshops, considering that in the twelfth workshop it was seen that it was necessary to broaden the discussion on health needs.This moment was not foreseen in the initial schedule; however, as the workers were discussing problems of the territories, it was difficult to define health needs, more precisely to answer the question about which needs would be at the root of the problems raised.Thus, the intended practices could go beyond the lack of health services.
The last workshop was intended to clarify questions and support workers in completing the projects.
The projects were constructed following four stages: 1) health needs assessment of the social groups in the BHU territory (diagnosis); 2) planning the approach and how to implement it (strategic-situational planning); 3) implementation itself (process itself ); 4) development of a comprehensive framework for evaluation and reflection (process review).
The first stage sought to bring up social problems and interpret -applying the theory of social determination of health -which are the health-related needs of social groups central to these problems.Participants were asked to articulate with colleagues in the units in which they work to survey these needs, so that the problems of the groups living in the unit's operating territories were selected.The projects made it possible to identify the following health needs which underlie problematic drug use: improvements in sociability of social groups, expanding leisure and cultural spaces in the territories; expanding and improving guidelines, public policies and health practices; expanding state participation and strengthening social support networks in the territory.
With regard to the second stage (strategic planning), the social groups of the territories which are directly involved in the detected needs were identified: school-age youth, homeless men and teachers from the public education system.Each group chose the population they actually have contact with in their daily work, which made the projects plausible to be implemented.This step was important in determining the objectives and purposes of the practices.The practices generally proposed promoting emancipation and awareness of the subjects involved in the action.
Regarding action implementation strategies in terms of program implementation strategies in the third phase of the process, participants used several references presented during the 13 workshops, such as: emancipatory workshops and educational games about drugs based on public health, but also other strategies such as: soiree; theater of the oppressed; expression workshops, among others.The focus was on using strategies which encouraged the full participation of all those involved in the action, so that they could more easily expose their ideas and afflictions without moral judgment or restriction of expression.
The last stage of the project included a review and evaluation of the process.The intention was to emphasize the need for an evaluation process that counts on the effective participation of those to whom the practice is directed in order to promote improvements towards the effective response to the needs raised.

DISCUSSION
The construction of HR practices, as affirmed by the anti-prohibitionist social movement which seeks criticism and the transformation of social and health inequalities, is still a huge challenge in health and particularly in PHC, as it requires that those involved in the practices be familiar with critical, progressive and humanistic references, capable of encouraging the rescue of extraclinical dimensions which are usually separated from healthcare.However, we noted a progressive expansion of knowledge fields which take HR as the practice objective; in addition to public health and psychiatry, there is a growing presence of psychology, collective health, social sciences, anthropology, social work and critical criminology, which favors broadening the reach of HR towards the issues that are on the basis of drug use (8) .
Collective health encourages expanding EHR practices, promoting articulation of problems arising from drug abuse with social totality.We sought to recognize the reality of services, the organization of territories and the prior knowledge of those involved about the drug phenomenon.
The workers were initially strangers to the proposed activity, mainly because they feel uncomfortable talking about the daily practices of PHC in a critical way.This discomfort was stronger when the discussion about the work process at the FHS was proposed at the beginning of the workshops.However, as the workshops unfolded, the workers felt more comfortable, especially to present their afflictions and anxieties about the limitations of their work, exposing a fragmented work process, as well as multifactorial-based training in service.
By exposing the weaknesses of the work process in the area of drugs, the participants denounced an unfamiliarity www.ee.usp.br/reeuspEmancipatory drug practices: building projects with Primary Healthcare workers Rev Esc Enferm USP • 2019;53:e03528 in the PHC workers with the issues in the drug production, distribution and consumption chain.What can be seen from the participation of the majority of those involved in the workshops is that the participants had an understanding of the complexity of drug issues but could not theoretically envision how the social totality shapes the social determination of drug use.Moreover, it was not known how to act in facing this understanding of the work object that is taken by PHC, which is generally directed to pathologies.The same complaint is made in the HR program evaluation process of the city of São Paulo, in which they found that workers directly involved in providing care to people who use drugs were not aligned with the HR model, and there is little clarity as to the objectives and relevance of the activities they performed (13) .
In the course of the developed educational process and of constructing the propositions of practices through an analysis of the expressed statements, it was observed that the workers increased their understanding of the social determination perspective of harmful drug use, as well as the EHR concepts and needs in health.They also demonstrated knowledge on the territories and limitations of current practices of PHC and its services, so they could see a change in their practices and organization of services, even if they needed to face numerous organizational and vocational training barriers.
Another limitation that greatly concerned workers was regarding the construction of these practices themselves.Workers reported great difficulty in articulating their work with other healthcare network institutions, such as CAPS AD, sometimes reporting the presence of a pragmatic view on drugs, which would make it difficult to consolidate partnerships to carry out projects which do not pathologize the user or demand behavior change.
It is also worth considering that the challenges of implementing HR strategies in Brazil are not only in the daily practice, they go beyond the training and performance of professionals.Such challenges are considered to be mainly in political resistance, because even with the implementation of the Policy on Comprehensive Attention to Users of Alcohol and Other Drugs, there is still a limitation on the part of political managers to raise awareness to support and direct resources to HR actions.This lack of support culminates in the suspension and termination of projects and programs in this area (14) .
These barriers are marked by tendencies which do not fully recognize HR policy, pointing at a lack of scientific evidence which validates HR practices, while in fact what exists are moral values which do not allow acceptance of drug use as a necessity.There are also partial acceptance movements guided by "risky behavior", with an intentionality which is revealed to be a reduction in the transmission of diseases, reaching abstinence of the substance (15) .
There is still little scientific production in this area overall.In particular, when it comes to work that follows the framework adopted by this research, most studies address the use of alcohol and drugs by the risk category, disregarding, or giving little importance or fragmenting the social dimension into factors, so that when we verify the presence of the "social", it is often a hazy thing that appears as something in the background, something which can influence an accentuation of dependence or be considered one of the protective factors.In this context, the social class situation is not essential; on the contrary, the user is considered responsible for their choices and for changing habits to acquire a healthy condition.
However, one should consider the strategies used by such studies to effectively implement practices on drugs.The use of community-based intervention design is notable in international literature, which has been shown to be powerful for incorporating evidence-based practices that address local public health concerns.We highlight programs such as: Communities That Care (CTC), which is a program that seeks to identify high risk factors and weakened protective factors for behaviors that are considered problematic among adolescents in the community.The program steps encourage participation and engagement of the community and local leaders in choosing the best program to be implemented to respond to the "risk" and underscore the importance of engaging parents, schools and other community actors (mayor, chief of police, school superintendent, merchants, and religion, among other members) as determinants for smooth implementation of the actions and to obtain positive results in the reduction of risk factors (16) .
When such actions are considered in the context of public health, a critical framework is assumed which breaks from moral values in recognizing HR practices (8) , and the pragmatic HR perspective adds transformative potential which seeks the emancipation and strengthening of social groups, so the EHR is proposed to guide practices and policies.
Practices based on the perspective of EHR built through an emancipatory educational process are configured as political practices by proposing collective care which seeks to meet the health needs of service users, which means going beyond individual and punctual care, and also further providing understanding of the health work process and greater appropriation of the object of this process (7) .Thus, it is considered that the developed process responds to the referenced EHR by focusing on the care of collectivities, ensuring the creation of critical-political spaces for encouraging those involved in the actions.

CONCLUSION
The process developed through emancipatory workshops increased the participants' repertoire on healthcare in the drug area, culminating in a proposal of critical practices supported by the collective health framework, adapted to the reality of PHC.
Although the study has limitations such as reduced attendance of workers at meetings due to workload, workers being enrolled in more than one training and workers involved in work scale coverage, the emancipatory workshops enabled workers to be positioned in the health production process and assume contradictions of the work processes present in the service in which they work.Thus, they have been instrumentalized to engage in elaborating work plans which identify the health needs of the territory, as well as to build and implement the tools to respond to those needs.
It was critical in this process to understand that the drug problem is social and that health sector action involves tools that go beyond individual clinical practices and public health propositions around behavioral changes.
However, much remains to be worked on and built in this area.There are still many fears among workers regarding the decision making of changes in health practices.These are fears arising from disciplinary work processes, which hinder the space and the possibilities of developing creative and critical work.As seen in the literature and ratified by those involved in the study, there are few constructed projects which seek to identify the social problems that cause distress to those attended by health facilities, let alone propose actions which in fact reduce harm and suffering, and more boldly bring together workers and residents of the region around joint actions to confront social problems that are the basis of suffering.
Frequent interaction with the collective health framework is recommended as being necessary in order to seek transformations in the service culture, as well as to encourage scientific publication of critical works on the PHC work process in order to pressure the construction of public policies that promote effective changes in the way services are organized.
It can be affirmed that this study illustrates emancipatory work perspectives, while helping professionals find themselves in the work process, thereby enabling a reduction in suffering.