Abordagem da dependencia de substancias psicoativas na adolescencia: reflexao etica para a enfermagem

El uso indiscriminado de drogas entre los jovenes aumenta progresivamente en Brasil y en el mundo. Este estudio tuvo como objetivo reflejar sobre el abordaje etico de la enfermeria en la atencion a adolescentes usuarios de drogas licitas e ilicitas. Se trata de un estudio teorico de caracter reflexivo, basado en una revision bibliografica de tipo narrativa, utilizandose de libros y articulos cientificos. Emergieron reflexiones sobre la dependencia de sustancias psicoactivas en expansion en la adolescencia, que culminaron en la discusion sobre el abordaje etico de la enfermeria junto al adolescente usuario de drogas. El enfermero puede priorizar una asistencia direccionada a la promocion de la salud del adolescente en una perspectiva emancipadora del joven en la prevencion del consumo de drogas. Se concluyo que las enfermeras deben realizar un enfoque etico a los adolescentes dependientes, considerando su contexto y su subjetividad.


INTRODUCTION
Nowadays, the indiscriminate use of legal and illegal drugs steadily grows among the youth from different social classes in Brazil and worldwide.This is a complex issue that entails huge damage in the private and public areas, which has motivated several studies in Latin America about its impact on health and modern society.
The problem of toxic or drug addiction or, as suggested by the World Health Organization (WHO), the use of substances that cause dependence on psychoactive substances, is complex, no matter what viewpoint is adopted: for doctors and psychologists, for politicians and sociologists.Drugs are understood as those substances that cause drug addiction, that is, intoxication and habit and/or chemical dependency and which, due to their psychological and behavioral effects, are harmful to the individual and to society 1 .
In a multicenter study concerning the perspective of family members and people that were close to illegal drug users about risk and protective factors, treatment services, policies and laws related to the use of illegal drugs, family members and people that were close to illegal drug users were recruited in seven Latin America countries (Brazil, Colombia, Costa Rica, Ecuador, Guatemala, Honduras and Mexico).Most participants opted for psychosocial and not genetic or biological factors to explain the cause of drug use issues, and considered family and government members as the primarily responsible for the prevention of drug use.The religious institutions were often mentioned within the context of access to treatment for drug users, with the embarrassment about drugs use, costs, and insufficient treatment options as the main obstacles for treatment 2 .
A study was undertaken in the 107 biggest Brazilian cities to estimate the predominant use of illegal drugs, alcohol, tobacco, and non-medical psychotropic medications.The use of alcohol, with 68.7%, was close to Chile with 70.8%; the use of tobacco was 41.1%, less than in the United States with 70.5%; the use of marijuana was 6.9%, close to Colombia with 5.4% and below the United States with 34.2%.The use of cocaine corresponded to 2.3%, which was less than in the United States with 11.2%; while 5.8% used solvents, much less than in the United Kingdom with 20.0%.Stimulant use was found in 1.5% and benzodiazepines in 3.3% 3 .
The results of this research showed that legal drugs, such as alcohol and tobacco, are the most serious problems of public health.The Brazilian reality of drug use, although similar to that in other countries, has peculiarities that need to be observed in the development of prevention programs and in the implementation of appropriate public policies in the field of psychotropic drugs 3 .
These studies reveal that legal and illegal drug use involves the participation of families, religious organizations, schools, Governments and society as a whole, with the development of effective strategies to prevent the use and the expansion of access to rehabilitation treatments for drug addicts as the main challenges.
According to WHO, adolescents are those people between 10 and 19 years of age, whilst the Child and Adolescent Statute defines adolescents as those aged between 12 and 18.At first, this period of life is shown as a category linked to age, biological development and body ability; however, it is during this period that subjective changes occur, such as behavioral, intellectual and social changes 4 .
Due to the fact that drug use among adolescents has become a public health issue, it requires specialized care and a holistic approach to adolescents, because it involves dealing with their different issues and changes, including the consideration of their view about themselves and the world 5 .Given this scenario, the role of nurses can be highlighted in the development of actions directed at young people.
Nurses should act to reduce the increasing demand of drug users and to provide specific scientific and technological knowledge that contributes to the resolution of use and abuse issues in Latin America, based on a multidimensional view of the problem, which will help them to understand it 6 .
Also, the need to ethically reflect on professional nursing practice's performance can be highlighted when faced with drug use and abuse among adolescents, since the care provided should not be limited to programs aimed at timely care delivery, without taking into consideration the adolescents' comprehensive development.
Assuming that nursing staff often works with adolescents and that they are usually not prepared to act in an ethical manner in cases involving drug use, the present study is aimed at contributing to the reflection about this reality, in order to promote the overcoming of these limitations.Therefore, it presents theoretical and conceptual discussions about the ethical performance of professional nurses in providing care to adolescents who are users of legal or illegal drugs.
Within this perspective, the present study was developed based on the discussions that took place in the subject Ethics and Bioethics in Health, offered in the Graduate Nursing Program at Universidade Federal do Rio Grande do Norte (PGENFUFRN).
The study is aimed at reflecting about professional nursing practice's ethical approach in providing care to adolescents who use legal and illegal drugs.It is important in the sense of raising awareness or developing critical thinking that is capable of overcoming any obstacles professionals face in this area as a result of complex issues involving addiction to psychoactive substances and reality.

METHOD
This is a theoretical and reflective study, based on a narrative literature review.As sources of information, some book chapters related to adolescence, bioethics and drug addiction, and mainly scientific articles from electronic journals about adolescence and chemical dependency were used, which were indexed in the Scientific Electronic Library Online (SciELO Brazil) and in the Nursing Database (BDENF), based on the application of the following descriptors: professional nursing practice; illegal drugs; disorders related to drug use; bioethics.
The stages for the development of this study involved: initially, the identification and finding of a theoretical framework that covered the topic bioethics and drug addiction during adolescence.After this, the relevant information related to the study were registered and archived, resulting in the reading and critical analysis, and also in the drafting of this article.In the analysis, books and articles that matched this study's objectives were used.
Two articles in Scielo Brasil and 26 in BDENF were found when using the descriptors professional nursing practice, illegal drugs and disorders related to substance abuse.Of the 28 articles found in this search, 12 were used in this study.
The descriptor bioethics did not provide articles when crossed with illegal drugs and disorders related to substance abuse but, when crossed with the descriptor professional nursing practice, 59 articles were found in BDENF and 28 in Scielo Brasil.However, the articles found in this search were not used because they were not directly related to the topic drug addiction during adolescence.
Based on the reading and synthesis, as well as the summaries of the material used, two lines of analysis and reflection were formed: Reflections about growing addiction to psychoactive substances among adolescents and Professional nursing practices' ethical approach to drug-using adolescents.

Reflections about growing addiction to psychoactive substances among adolescents
Drug use by the youth should be understood in its current complexity, since drug is merchandise for export and import which is linked to the interests of large international corporations involved with legal drugs and to drug trafficking.Therefore, it has been studied from the epidemiological point of view, generally describing the frequency of use and type of drugs used by some groups of young people, grouped by the similarity of the situation in which they are and rarely by social class similarity 7 .
Most people who are users of legal and illegal drugs are adolescents and youth.Although the social class they belong to can determine the type of drugs these people use, given the price range that basically depends on the level of purity and the type of drug, it is known that addiction to psychoactive substances is present in all layers of society and is an expanding event with damaging and fatal consequences.
In a study undertaken in Rio de Janeiro, alcohol is the psychoactive substance adolescents most use.Among the 702 people studied between the age of 13 and 21, approximately 6% have already had contact with illegal drugs 8 .According to national and international research, the relationship between use and abuse of alcohol and illegal drugs and criminality is very close 9 .
The following question remains: does the use and/or abuse of alcohol and illegal drugs lead to criminal behavior or, rather, do adolescents with behavioral issues have more chances of using drugs, which maintain and contribute to the increase of criminal activities?
The causes of the interface between addiction to psychoactive substances, violence and juvenile criminality, although present, are not completely understood, since they involve a broader view on the impact of legal and illegal drugs among adolescents in health and society.
In order to represent the context of the situation, it is important to remember that there are international drug trafficking networks, large sources of production for the distribution and consumption market.In all relations, some figures were mentioned to indicate the extent of the problem, in an attempt to quantify it.People killed by drugs, substances seized, people arrested, drug addicted people undertaking treatment are, however, simple indicators and samples of only a very small part of the problem 1 .
In this context, adolescents are subject to influence from unhealthy habits and behaviors, and are faced with several changes, becoming vulnerable to the impact of social, technological and marketing movements.Therefore, a number of factors are associated to trying legal and illegal drugs or not 10 .
Drug use is usually related to subjective and behavioral characteristics of adolescence, such as the feeling of questioning, impetuosity, idealism and omnipotence.In this sense, some studies 3,6,8,9,10 about this phase have discussed the association between drug use and other problems, such as the practice of unsafe sex and unwanted pregnancy, highlighting the role of the family in this process.
Drug use can also interfere in unsafe sexual practices among adolescents, making them more vulnerable to sexually transmitted diseases, STD/HIV/AIDS and unplanned pregnancy.The use of drugs affects adolescents' sexual health because it leads to having sexual relations with strangers, without the proper use of preservatives, besides favoring the sharing of contaminated materials and creating serious family problems.

Chemical dependency in adolescents
The use of illegal drugs by a family member who lives at home is a factor associated to teenage pregnancy, regardless of other relevant factors, such as the mother's age at first pregnancy, the inappropriate use of contraceptive methods and low education level of the parents 10,11 .
On the other hand, in a context of low family income and low level of education of the parents, the desire to undertake a university course acts as a protection against pregnancy before the age of 18 among public school students 10,11 .
Concerning this problem, the area of collective health is opposed to the hegemonic model of war against drugs, while it critically adopts the alternative model of damage reduction, as it offers ways to produce emancipatory educational actions 7 .
It is believed that, if stimulated by appropriate methods, young people from different social classes express responses that show strengthening and strategies to overcome the problems that affect them.Emancipatory educational responses can be developed with young people in primary healthcare to provide the understanding about the basis of drug use, thus increasing their capacity to join on the path towards political and collective solutions 7 .
In Brazil, adopted by actions, services and collective health policies, this emancipatory concept is supported by the development of autonomy among adolescents and young people, through the establishment of a civic awareness concerning addiction to psychoactive substances.Thus, the mere discussion about the harm caused by each type of drug is overcome, involving institutions such as families, schools, churches and the community.
In this line of thought, the role of parents and the family environment in the relation adolescents have with alcohol and other drugs, as facilitators of actions or trigger of problems, can be highlighted.The inclusion of family systems in prevention and treatment interventions is reflected in facing the drug problem, since it provides control of the factors predisposing to greater chances of starting and continuing drug 8 use.
The pedagogical dynamics focused on personal empowerment is considered a necessary exercise for each family member, as it leads to the strengthening of the intentions to perform practices related to drug use.The ability of adult family members to question their own habits encourages the acquisition of new identities and acculturation of practices the adolescents' family members view as good examples 12 .
The role of the school as the formation basis is related to the education, citizenship and locus of behavior and personality expressions, as well as the formation of habits, being a privileged space for the development of prevention programs and public policies 8 .
It should be emphasized that, although the participation of social institutions is encouraged and important in such a chaotic scenario as drugs use among adolescents, it should not replace the role of the Government which, in turn, cannot act separately from the international dynamics in the fight against drugs and narcotics production, export, import, distribution, sale and consumption networks.This dynamic should unite and involve a network of supportive collaboration between countries, with the ethical commitment to change the current scenario of profitable streams generated by the addiction to psychoactive substances.

Ethical approach to drug-using adolescents by professional nursing practice
The ethical dimension involves the whole drug process: dissemination, consumption, prevention, therapeutic performance and rehabilitation.Beyond the ethical dimension, there are other equally important and interrelated dimensions (socioeconomic, psychological, medical/pharmaceutical, political and legislative).Given the illegal and immoral profit made with drugs, a commitment of ethical responsibility is required from particular, educational and institutional fields in order to repress and discourage drugs use.As a result, the ethical problem unites all other dimensions and stages of a rehabilitation program 1 .
Given the fact that drugs, due to their illegal and destructive nature, are immoral for harming human life values, the ethical reflection concerning their impact and influence on society and humanity is imperative.In this perspective, individual and collective co-responsibilities complete each other in a supportive commitment among nations and people all over the world towards change.
Drug addiction cannot be eradicated without the commitment of all citizens, civil and religious institutions, families, school and media for an education of values, above all, values of life, health and people.It is not possible to stop drug consumption by nurturing a culture that is hedonistic, individualist and lacking support and transcending values.Without cultivating the meaning of holiness and of the inviolability and transcending life within the family and school, life results in disorder and despair 1 .
On the other hand, it is not possible to continue fighting the causes of all social unrest by appealing to affective integration, the parents' educational co-participation in the family, and by moving the policies intto a different direction that favors the disintegration and dissolution of marital and family commitments.The mere control of everyday life cannot be used in the fight against drug use without being linked to the full motivations that inspire the values of life, responsibility and solidarity, through a view of the divine inside the human being, the Homo sacer 1 .

Chemical dependency in adolescents
The life of the Homo sacer is found at the crossing between the ability to kill and the inability to sacrifice: the life that cannot be sacrificed and can be killed is the sacred life.The separation between humanitarian and political currently experienced is the extreme stage of the detachment between human rights and citizenship rights.The humanitarian, when separated from the political, can only reproduce the isolation of sacred life sovereignty is based on, and the field, that is, the pure space of exception, which is the bio-political paradigm for which it cannot find a solution 13 .
In the social, political and media-related imaginary of the western world, the established paradox between the cult of hedonism and transcendental sacred human being, as well as the paradox between family integration and stimulus to marital lack of commitment negatively affect the advancement towards changes in the global picture of drugs use, due to the devaluation of the inviolability of human life.
Therefore, the eradication of drug-related conflicts takes form in the lack of fragile, punctual and selfish motivations of people in an individual scope, and of countries in a collective scope; and in the rise of an ethical global dimension, in which the rational Homo sapiens cannot overtake the Homo sacer, so as not to violate his divinity.
Immersed in this ethical debate, some challenges should be overcome in relation to the holistic healthcare provided to adolescents in their operational aspects, such as: the recognition of their specific healthcare needs; the performance of professional nursing teams concerning adolescent healthcare with a family focus; in addition to ethical issues concerning care related to this phase of life.
The frameworks for the evaluation of ethical issues related to the care provided to adolescents involve the moral development of adolescents and nursing teams; the cognitive capacity; the autonomy and the values held by adolescents, healthcare professionals and families 7 .
Concerning decision making, adolescents are seen differently, in accordance with their moral maturity, full-age health and legal capacity.They are able to decide about their health if they can understand the information received, analyze the consequences of their possible choices, and judge the information according to their values, beliefs and projects 7 .
Therefore, the ethical issues of adolescents are related to their interaction and ability to make decisions about the care provided by nurses and their teams, which is adjusted as a result of cognitive and behavioral transformations they experience and supported by moral values and ability.Similarly, the approach of professional nursing teams is based on technical/scientific, care-related and legal documents.
Due to the fact that adolescents are immersed in the formation of their identity, and are often experiencing dramatic situations, an approach needs to be developed to support adolescents in collective health, so that nursing actions should be based on a process that offers space for dialogue, both with the group and nurses as educators for self-care.It is essential that nurses who work with this phase of life in their daily practice are aware of the importance of providing healthcare from a holistic perspective, taking into consideration not only the physical transformations of adolescents, but also their expectations in the condition of maturing individuals 5,10 .
Concerning adolescence, nurses' reflections about professional confidentiality and the actual autonomy of adolescents are essential due to their drug addiction, which can indicate a compromised clinical condition and change to their ability to decide about a rehabilitation treatment.The higher the level of chemical dependency, the more affected an individual's conscious decision making ability and autonomy will be.
Nurses are educators to enhance awareness about the harm drugs cause to health, they should respect and provide care to human beings and prioritize prevention work, with care delivery that may go beyond healthcare institutions.Therefore, they need to intervene through institutions in order to promote adolescents' health and prevent the use of legal and illegal drugs, acting with other healthcare professionals and social levels, raising awareness about the cause and consequences of using psychoactive substances.The challenge is to develop educational and awareness-raising activities, which cover the valuation of these adolescents' meaning of life 14,15 .
In this sense, nurses should use an approach to adolescent drug use that is based on integrality and ethics, seeing them as human beings who are part of a social, family and educational environment.This approach, which considers the subjectivity of these maturing individuals, who are in a condition of personal and moral fragility caused by drug use, should involve families, schools, rehabilitation institutions and the community.
As educators, nurses should prioritize the approach to adolescent health promotion, based on an emancipatory perspective, which emphasizes their coresponsibility and participation in the fight against and prevention of drug use.In order to exercise this broad role, it is necessary to articulate in a cross-sectorial and interdisciplinary manner.

FINAL CONSIDERATIONS
Drug use by adolescents need to be understood in its entirety, considering social, economic, cultural, family-related and ethical aspects.In this sense, the present study showed that the responsibility for these individuals should not only be attributed to the Government or to the family.The addiction to psychoactive drugs among adolescents is currently a serious public health issue and both the problem and its aggravating factors are associated with other conflicts in this phase, such as violence, criminality, unplanned pregnancy, unsafe sex practices and the spread of STD/AIDS.
To stop the expansion of drugs, communication is needed among the various sectors of society, which can promote health prevention and promotion actions through public policies; international cooperation among countries, aimed at promoting a dynamic that is able to control the international networks that distribute narcotics all over the world, as well as support to families facing this type of problem with their young members.
In this perspective, the reflection about the professional nursing practice's ethical approach in providing care to adolescents who are users of legal and illegal drugs is important to enhance the awareness about and development of critical thinking, able to overcome possible obstacles these professionals face when confronted with complex issues involving drug use.In this ethical approach, the rescue of moral and personal values is emphasized, as well as the adolescents' ability to decide about their rehabilitation treatment, involving intersectoriality and interdisciplinarity.