Preliminary results from Brazil ’ s first recovery housing program

Introdução: O Programa Moradia Monitorada (MM) foi iniciado em São Paulo com o objetivo de prover tratamento para transotrnos de uso de substâncias e problemas relacionados a moradia e emprego. O objetivo do presente estudo foi descrever o modelo com base nos primeiros 11 meses de operação (o programa foi lançado em junho de 2016 no Brasil). Métodos: Realizamos um estudo retrospectivo utilizando os registros de todos os indivíduos tratados no MM do Programa Recomeço desde a sua criação. Resultados: Sessenta e nove indivíduos foram incluídos. Trinta e cinco (51%) permaneceram no tratamento até o fim ou foram reinseridos socialmente com sucesso. Trinta e quatro sujeitos (49%) apresentaram recidiva durante a permanência. Destes, 16 (47%) se voluntariaram para tratamento em comunidades terapêuticas ou hospitais psiquiátricos, 8 (23,5%) escolheram permanecer apenas no tratamento ambulatorial, 6 (17.7%) retornaram para suas famílias e continuaram o tratamento em uma unidade ambulatorial próxima ao domicílio, e 4 (11.8%) descontinuaram o tratamento. Dos 35 pacientes que completaram o tratamento, 28 (80%) estavam empregados em serviço regular e 7 (20%) recebiam aposentadoria por questões clínicas e/ou psiquiátricas. Conclusão: O modelo MM pode ser um componente importante na via de cuidados integrados e é utilizado em vários países. Apesar de controverso, o uso de análise de urina para vigilância da recidiva e da recorrência parece ter um impacto positivo na adesão ao tratamento e na manutenção da abstinência. Nossos achados preliminares corroboram, com claras limitações, os resultados reportados previamente na literatura, de que os programas de MM são efetivos no tratamento da dependência química. Descritores: Crack, cocaína, transtornos relacionados ao uso de substâncias, abuso de substâncias, centros de tratamento de abuso de substâncias, dependência química, moradia monitorada. Abstract


Introduction
São Paulo is a cosmopolitan megalopolis of 12 million inhabitants and has the biggest population of crack cocaine users in Brazil. 1  improved adherence to treatment and maintenance of abstinence, longer time to relapse and higher rates of employment. 2 Residential rehabilitation is an important element of integrated care pathways. 3 Residential rehabilitation programs provide accommodation in a drug-free environment and a range of structured interventions to address drug and alcohol misuse, including abstinenceoriented interventions. 4  repository and will be made available upon request.

The RH program
The RH target group consists of subjects who are discharged from hospitals and are followed by CAPSs. All data were extracted independently by two researchers (DAC and SMMP), and any discrepancy was resolved by discussion. The following data were extracted:   As expected, in our sample there were more men than women. Even though the rates of substance abuse among women are getting closer to those observed in men, women still drink less, but they get sick earlier and more severely. [6][7][8] Differences between the two genders exist, with women presenting early physical changes due to the use of psychoactive substances that cause liver damage. 9,10 The greater physical frailty may explain why the women in our sample were younger than the men and were already in the street and unemployed.
In our sample, almost half of the women had already exchanged sex for drugs, unlike the male residents.
These data are in agreement with the literature, and this behavior may increase the risk for sexually transmitted diseases and unwanted pregnancy. 11 Another interesting fact of our research is that most of the residents asked for help by seeking health professionals, not family members. Horta et al. had already reported that family groups may be protective factors, but can also be an important risk factor for crack use, e.g., because of the shame and stigma that affects family relations. 12 In Brazil, government benefits are more easily granted if the subject has worked formally. Virtually all RH residents were not working and therefore would not have the right to apply for the government benefit.
Detoxification is well-organized in the state of São Paulo, and performed by multiple services. However, as a stand-alone treatment, detoxification appears to be ineffective, with recurrence rates as high as 80% one month after discharge. 13,14 The main reason for recurrence is premature return to an uncontrolled environment where the individual is exposed to cues that may precipitate relapse and recurrence, 14 especially in the context of other vulnerabilities, such as homelessness and unemployment. 15 Recent controlled studies have demonstrated that RH improves outcomes for substance users, 4,16 with higher rates of drug abstinence relative to standard treatments. [17][18][19][20][21][22] A clinical trial of the Johns Hopkins University School of Medicine RH program involving 83 participants was carried out. 23 Urine samples were collected twice weekly and, in the event of a positive test, the participant was removed from the RH, tested daily at a clinic and returned to the program upon submission of a drug-negative urine sample. The rate of drug abstinence after 30 days was 50% for subjects receiving reinforcement-based treatment in RH and 13% for subjects receiving standard care (p<0.001).
At six-month follow-up, 37% of the subjects who had received reinforcement-based treatment among RH participants remained abstinent compared with 20% of those who received standard care. The mean length of stay in RH was 49.5 days.
In addition, we had a high rate of employability during and after treatment at the RH program, corroborating previous studies that suggested positive results for similar supervised housing services. Figure 1 is a flow diagram explaining the process of admission and maintenance of treatment for all the subjects treated at our RH program. The program is structured to allow up to 180 days in RH and is thus considered a long-stay program. Long-stay programs are considered the best option for clients whose drug and alcohol use is long-term and rooted and who are likely to be socially excluded, unemployed, in severe housing need, lacking in life skills and facing legal problems. 4 This population makes up the majority of our service users. 1 Also, even if a resident resumes the use of crack, he is supported by the other services that compose the Restart Program, and will be reinserted in the RH program when meeting the eligibility criteria.
To be eligible for the RH program, subjects must be undertaking regular outpatient treatment. The maximum length of stay in the program is 12 months. Upon admission to the RH program, the residents' papers are regularized and they are referred to a one-week work preparation program. A collaboration between the state and private companies provides job opportunities and is monitored by a social worker. Residents are also given the opportunity to return to education. The approach to family reintegration is determined on a case-by-case basis after evaluation of family ties. During the stay, urine samples are analyzed in order to encourage abstinence, but relapse and recurrence are not absolute criteria for exclusion from the program. Each case is analyzed by a multidisciplinary team and a decision about the best treatment option is made in conjunction with the patient.
Criticism of RH programs has focused on the use of urine analysis to detect relapse and recurrence. In recent years, controversy has developed over the use of urine, blood, saliva, and breath tests to provide evidence of drug use. 24 Legal questions have already been raised about the validity of the test procedures, the reliability of the evidence obtained and the balance between the subjects' right to privacy and the need to monitor drug use. Even though laboratory methods are controversial, they seem to have a positive impact on adherence to treatment and maintenance of abstinence. 24 These preliminary findings are consistent with evidence from other countries that suggest that RH programs are effective, but the limitations of the present study must be taken into account. This was a single-center, retrospective study lacking a standard-care comparison group. Nevertheless, the RH program on which we report represents the first of its kind in Brazil. A further limitation is the lack of post-discharge follow-up data that could show the long-term effectiveness of the program. For future perspectives, clinical trials evaluating the efficacy of the RH program are necessary for a better evaluation of its clinical use, as are cost-effectiveness analyses for the future development of public health policies. We are currently implementing a prize-based contingency management treatment as part of the RH program, in order to enhance adherence to treatment and to training programs for a better insertion in the job market.