Users of psychoactive substances: challenges to nursing care in the Family Health Strategy

Objective: to analyze the nursing care provided to users of psychoactive substances in the Family Health Strategy. Method: a descriptive and qualitative study carried out with seven nurses from the Family Health Strategy of Juiz de Fora, Minas Gerais. Data was obtained through interviews guided by a semi-structured script and the Thematic Content Analysis was used for its treatment. Results: the care provided by the interviewees is based on spontaneous demand, without active search strategies, with the valorization of practices guided by the medicalization of the person and the referral to specialized services. The inclusion of the family in the rehabilitation process, immediate care, and therapeutic listening were mentioned as strategies that can be adopted for an integral assistance. The challenges mentioned referred to the lack of training in mental health, the fragmentation of knowledge about the specialty, the absence of training, and the patient’s desire to participate in the treatment. Final considerations and implications for the practice: the nurses reported insufficient care to ensure comprehensive care permeated by a lack of knowledge and skills to deal with this public, which leads to referral to specialized services as the main intervention, reinforcing the need to train these professionals.


INTRODUCTION
Drugs are psychoactive substances (PAS) that cause different effects depending on the type and characteristics of the user and the environment. It is important to note that the effects of drugs on the body depend -in addition to the type used -on the circumstances of use. The alterations are triggered by the effects on the brain, and for this reason they are called psychoactive, and can occur by exacerbating or repressing the level of sensations, consciousness, and/or emotions. There is a broad discussion about the classification of these substances. The consensus is that drugs can have light or heavy use, when they become harmful and dangerous. However, judicially, in Brazil, there are licit and illicit drugs. 1 In 2018, it was estimated that about 269 million people, equivalent to 5.4% of the population between the ages of 15 and 64, used some type of drug in the previous year. In the period from 2009 to 2018, there was a 28% increase in drug use, and in that same period, the prevalence of use increased by 12%. Furthermore, around 35.6 million people suffered from drug use disorders, characterizing harmful use with severe health consequences to the point of needing treatment. 2 This type of use causes a loss of bonds with repercussions in various segments of the individual's life, including social interaction. 3 The problem of the use of these substances is related to its unfolding effects on the health of the user and society. It is known that the use of PAS, besides reducing immunity, can lead the user to exposure to risky situations and behaviors, increasing the potential for disease acquisition. Moreover, the need to maintain the routine use of substances can trigger a series of behaviors that leave them at the margins of society, amplifying the discrimination and stigma to these people, such as sexual activity in exchange for any amount or petty crimes. 4,5 In December 2011, Ordinance No. 3088 of the Ministry of Health established the Psychosocial Care Network (PSCN) composed of various services and sectors of society, making feasible the creation, expansion, and articulation of health care points for people in psychological distress and with needs arising from the use of crack cocaine, alcohol, and other drugs. Through territorial services, it seeks to meet the social and health demands of this population through comprehensive, qualified, and humanized care. 6,7 In this sense, it is hoped that the health services are prepared to assist this population through intersectoral articulation.
In this scenario, the Family Health Strategy (FHS) is inserted, the gateway to the Unified Health System (UHS), aiming to provide care, ensure access, completeness, and coordination of care to individuals and families living in its area of operation, leading to specialized assistance when necessary. Among the health professionals who work in the FHS, it is up to the nurse -as well as the other professionals on the team -to monitor and maintain contact with users of the service, recognize the problems related to the use of PAS, and develop care and prevention actions aimed at reducing health problems. 7,8 It is added that, as a member of the FHS team, the nurse has the following attributions, which interface with the care of PAS users, among others: to provide care to all members of the community in an integral, individualized, family or social group manner through spontaneous, programmatic and/or collective actions; to guarantee humanized care, including the embracement of users, qualified listening and the establishment of bonds; to foresee flows of the Health Care Networks (HCN) and to provide nursing consultations, group activities and referrals to other services. 9 Users of PAS seek Primary Health Care (PHC), via FHS, not with complaints of harmful use of alcohol or other drugs, mostly, but for other health problems, often resulting from the use of PAS itself. 6,7 In this context, the Harm Reduction Program (HR) instituted by the Ministry of Health (MH) is inserted, based on the principle of ethics and care, highlighting actions that should be developed in the FHS such as: conducting health education groups, therapeutic listening and conversation circles that meet what the National Policy of Primary Care recommends regarding the nurse's duties. [8][9][10] Through the embracement and holistic view, the nurse, during the care not only of the user, but also of his family, must be able to detect means that will help the recovery and the physical and mental well-being of PAS users and facilitate referrals and specialized care, even when they seek the health unit outside of scheduled appointments or activities. 8,10 Similarly, these practices should value how the user presents himself, aiming to improve his accessibility to health services and, in this sense, fragmented actions guided by the biomedical model are not enough. In this understanding, the reception of the PAS user is not just a procedure; therefore, it cannot be scheduled for later. Reception demands a set of articulated actions of the services involving users and their families, staff, and managers of specialized services. The FHS, as an instrument that organizes and coordinates care, offers generalist care, 9 however, when faced with health problems related to the use of PAS, the conduct of professionals should consider this issue as a complex phenomenon that requires integrated and intersectoral responses. 8,10 Nevertheless, the trajectory of these users is faced with several difficulties in their reception, treatment and the relationship between professional-patient, because, most of the time, the lack of training and professional training does not allow them to provide qualified care. From these considerations, the guiding question of the study was elaborated: how is the nursing care given to psychoactive substances users in the Family Health Strategy scenario? And as an objective: to analyze the nursing care provided to users of psychoactive substances in the Family Health Strategy.

METHOD
This is a descriptive study, with a qualitative approach, developed within the scope of the Integrative Project (IP) of teaching-research between the School of Medical and Health Nursing care for drug users Militão LF, Santos LI, Cordeiro GFT, Sousa KHJF, Peres MAA, Peters AA Sciences (Suprema) and the Municipal Health Department of the Juiz de Fora Municipal Government -Minas Gerais.
This project integrates one of the components of the curricular structure of health courses in the educational institution. Its purpose is to contribute to the integrated training of health professionals through the experience of students in different communities through insertion in Primary Health Care Units (PHCU). Each PHCU has approximately three FHS teams composed of a doctor, a nurse, a nursing technician, and Community Health Agents (CHAs), with only one team being the reference for monitoring students due to the lack of physical space in these locations.
To be part of the research, the reference team that accompanies students in the field of practice was selected. The inclusion criterion was: being a nurse on the IP's reference team. Those on probation, on leave for any reason, or on vacation were excluded. The sample was composed of seven nurses working in the FHS.
Data collection was performed between October and December 2019 through interviews directed by a semi-structured script prepared by the authors with guiding questions, encompassing the following themes: characteristics of Nursing care, preparation and challenges to assist SPA users. The interviews were conducted by the researchers themselves in a room reserved for this purpose, outside working hours and after previous scheduling by phone, recorded on an electronic device, lasting approximately 30 minutes.
In order to maintain greater trustworthiness, the researchers transcribed the interviews immediately after they were conducted and then made them available for the participants to read, so that they could freely omit any information or add anything that might contribute to the proposed study.
Thematic Content Analysis was used 11 as a technique for data treatment. Three chronological poles were followed: preanalysis, from floating readings, performing the organization and recognition of the data; exploration of the material through which the coding of the data and the identification of the nuclei of meaning according to the proposed objectives were performed; and treatment and interpretation of the results achieved mediated by the available literature on the subject.
The ethical precepts for research involving human beings were respected, and the research protocol was approved by the Research Ethics Committee (Opinion no. 3,535,543/2019). All participants signed the Informed Consent Form, and prior consent was obtained from the setting institution to conduct the study. Anonymity was guaranteed through a pseudonym indicated by the letter "N" for nurses with the numeric sequence in which the interviews occurred (N1, N2 etc.).

RESULTS
Seven nurses participated in this research, with training time ranging from 6 to 32 years. All professionals were specialists in some area: 5 in FHS, 1 in Intensive Care Unit and 1 in Women's Health.
Through the analysis of the material, it was possible to identify the following thematic categories: Characterization of nursing care to users of psychoactive substances in the Family Health Strategy and Unpreparedness and challenges for the production of care, in the Family Health Strategy, to users of psychoactive substances.

Characterization of nursing care provided to users of psychoactive substances in the Family Health Strategy
The following excerpts reveal how nurses welcome and approach people with problems related to the use and abuse of PAS who seek health care in the FHS. This care is based on spontaneous demand, without active search strategies, with the valorization of practices oriented by the medicalization of the patient and the referral to specialized services. Despite this, some initiatives towards a mental health care are perceived, considering the particularities of this user, among them, the inclusion of the family in the psychosocial rehabilitation process, the immediate care, and the exercise of therapeutic listening, as observed in the following statements.
[...]We treat them as a priority, we always give them more attention, we go ahead of them so that they don't stay there. Generally, they come with a family member at the reception, and the family already talks to them, and tells them about the case (N5).
[...]What we try to do are mental health groups, we try to do weaning from medications, in this case, in patients that use some psychotropic medication and in these specific patients that are dependent, we, of course, try to include the family in their recovery, we try to find a clinic and refer them as soon as possible. [...] we also try to treat him with medications according to the complaint (N6). There is, on the part of these nurses, the recognition that their approach is not yet sufficient to meet this user integrally, being classified as incipient in the face of the needs that alcohol and other drugs users have, which one participant also attributes to the problems of staff dimensioning to meet this demand:

Unpreparedness and challenges for the production of care, in the Family Health Strategy, to users of psychoactive substances
According to the reports, the factors related to the difficulties and challenges in the Nursing care to PAS users, in the investigated FHS teams, are directly related to the lack of specialization/ training in mental health, the fragmentation of knowledge about the specialty, and the lack of professional training.
Participants reveal that there is an urgent need to organize territorial services to prepare and train these nurses who are part of the multi-professional FHS team to fully assist PAS users who come to the teams with some type of associated health problem. The following statements illustrate these conditions.
In these ten years as a nurse, working also with family health, I see mental health as a great difficulty. I am not very good with mental health, because, besides the absence of a psychiatrist, I feel this difficulty for the user to understand how important it is to be in treatment [...] (N1).
I lack the professional profile to be working with these patients. It is not the specialty that I would choose to work in, never. I don't like this specialty, I have difficulty working with psychiatric patients, this is since college and since the internship, I always had difficulty working with these patients and, at work, daily, I also perceive this great difficulty. And today, our great challenge with these patients is because they also go through other degrees of dependency on drugs, alcohol, and in general, they use these substances as well, and we don't have much structure to assist these patients, and they come when they want, generally, when they are already in their worst state and come here wanting medicine immediately (N4).
It was also observed that, in addition to the barriers inherent to professional know-how, there are aspects inherent to patients that constitute barriers to the effectiveness of nursing care, such as "wanting". Sometimes, PAS users do not have the will or desire to participate in the rehabilitation process, which eventually leads to abandoning treatment, as highlighted in the statements below. [

One of the biggest challenges is treatment adherence, is not having individual psychotherapy, because it is a treatment that I think would be very good for the patient (N7).
Another point mentioned by the nurses, which greatly intervenes in the rehabilitation of the PAS user, is the participation of the family during the process, being decisive for a good adherence of the patient to treatment, according to the following statements. The patient's will is the first point. The family also involved in wanting to help, to be with him, to add, this is the kickoff [...] (N3).

DISCUSSION
The results motivate discussions about the challenges faced by nurses in the FHS to assist users of PAS. The care provided to this person in the FHS, according to the participants' reports, is insufficient to be configured as a service directed to the abandonment of PAS use. The speeches of the participants in this study reveal the adoption of a conduct based on prohibitionist care practices and focused on abstinence, which may be one of the reasons for the low adherence of PAS users to the rehabilitation process, since nurses no longer act based on the needs of users from a perspective of reducing harm.
The nurse professionals of the FHS teams surveyed provide care focused on the use of medications, advocating the repetition of prescriptions by the physician and bringing, as a subject of approaches to patients, the use and effects of drugs, moving Nursing care for drug users Militão LF, Santos LI, Cordeiro GFT, Sousa KHJF, Peres MAA, Peters AA away from psychosocial care, which should guide the practices in the services that make up the PSCC.
This care focused on the complaint-conduct, medicalization and referral of these patients to specialized units may be a reflection of the training process and unpreparedness for the care of the PAS user. Added to this, the absence of a continuing education policy may be contributing to this scenario of fragmented health practices. The investment in the process of formation and work in health is a key premise of the continuing education process. It is understood that focusing the production of care on abandonment or even abstinence is a widely debated issue in the field of health care for this public. This type of care reduces the possibilities of recognizing the subject and his limits/difficulties of adherence and falls much more into prohibition than in the construction of autonomy and possibilities of living with drugs, reducing harm.
However, the interviewees recognize that Nursing care should be provided through the reception, which, according to the literature, is configured as a technology that favors the construction of a bond with the subject through qualified listening, enabling the identification of priorities and access to health services, facilitating the construction of the Single Therapeutic Project (STP). Thus, it is believed that the unpreparedness of these professionals, in terms of knowledge and skills on the subject, is a condition that greatly impacts their care practice. Thus, the appropriate professional attitude makes the other feel valued, besides showing that the service is open to meet their experiences and sufferings. 7,10 In the analysis of the material, it was observed, through the nurses' speeches, difficulties in dealing with the PAS user, either due to lack of training and continuing education, insecurity, overload or for not believing in their motivation for treatment and success. It is worth mentioning that the treatment outcome may be unsatisfactory due to the obstacles reported by nurses or even due to their desire for the patient to stop using drugs, which reduces their expectations and intervention possibilities. However, what is observed is that the treatment based on psychosocial rehabilitation and harm reduction sometimes does not even happen. This right is denied to users of PAS, which goes against the precepts of UHS and the very legislation of mental health in the country in which the right to care should be ensured to all people. 12,13 Thus, when it comes to the care of PAS users, the fact that they seek the health service in search of medicine should be seen as a reason to bring them closer to the assistance, to the health team, which must be prepared to perform the reception and capture this user for rehabilitation, and there are even political strategies for this, such as the Family Health Support Centers (FHSC) composed of different professionals who support the FHS in specialized cases. The speech of some nurses shows total unpreparedness to meet this spontaneous demand for which public health policies recommend community care, including the family. 13 FHSC should work in an articulated and integrated manner with the FHS teams so that it is possible to provide a comprehensive care. It is considered the direction for the logic of matrix support in the perspective of integration among the teams in the development of technical-pedagogical and clinical-supportive activities. The matrix support in mental health in the FHS is the cornerstone to ensure the organizational arrangement, because the teams work with the sharing of cases, ensuring the co-responsibility of care among health professionals, users, and families. 13 Thus, among the care offers to the PAS user that should be proposed by the FHS team, the following stand out: the embracement with active and therapeutic listening with emphasis on communication skills through dialogue without pre-judgments and discrimination; the active search and identification of individuals with needs related to the use of PAS as the difficulties in establishing social ties; the situational diagnosis about the territorial tools for the establishment of partnerships for the benefit of care; the articulation with the other points of PSCN, in particular, the Psychosocial Care Centers (PSCC) and the positive reinforcement of the individual and collective victories and achievements in the rehabilitation process. 9,14 Another relevant finding is the lack of knowledge about the role of the nurse in the FHS when faced with a situation involving users of PAS, as evidenced in the speeches. Feeling understood and respected in their psychosocial needs creates an atmosphere of self-confidence, stimulating the user's self-competence to explore their problems and find possible solutions for them. This user presents suffering that cannot be measured, involving moral issues, and, from then on, the professional believes that he cannot help him, because his work is centered in legal and prohibitionist guidelines that lead to a carelessness. [13][14][15] However, this user needs to be heard, which requires a therapeutic relationship through active listening, which will allow the elaboration of a therapeutic project focused on the biopsychosocial needs of the user. 8 For this, a qualified reception and the absorption of the user by the service are imperative, which was not mentioned by the nurses, who informed that the medical team bases its assistance only on the renewal of prescriptions and the referral to specialized services. [13][14][15] Among the competencies of the nurse in the FHS is the development of actions to promote and prevent diseases with a focus on the development of autonomy through actions that promote social reintegration, harm reduction and health maintenance with the goal of developing comprehensive care that impacts the health situation and the autonomy of people. 9,14,16 However, in the performance of the FHS team professionals investigated, the focus is mainly on addressing the problem when it has already occurred and when its consequences, both for the family and for the user, are already having negative repercussions in their lives.
Thus, the nursing professionals who work in the FHS devices are professionals who should have the ability to recognize the needs arising from the use of PAS so that they can provide favorable moments, both individually and collectively, to provide guidance and develop HR strategies, such as health education and prevention of risks and physical and biological damage, such as rapid testing for Sexually Transmitted Infections (STIs), Nursing care for drug users Militão LF, Santos LI, Cordeiro GFT, Sousa KHJF, Peres MAA, Peters AA guidance on their risks, prevention of gynecological diseases and unwanted pregnancy. 17 The innovation of nursing care in mental health is part of the autonomous exercise of the profession and requires technical and scientific knowledge to overcome the biomedical model and the stigmas in relation to PAS users in mental distress and their families, aiming at the transformation of care practices for the understanding of comprehensive care in territorial health devices. In this sense, soft technologies of care, conceptualized as technologies of relationships involving bonding, embracement, autonomy, responsibility, and management, are a way to ensure effective work processes for nursing in the FHS scenario. 8,16 The results showed, besides the lack of professional preparation to work with PAS users, insecurities in their conduct due to the absence of the psychiatrist, lack of knowledge and training on the topic of drugs. This is due to the lack of this theme in undergraduate curricula in nursing, being considered indispensable in the training of nurses in order to offer qualified care to this population and their families, and the lack of structure in the PHCU. 18 These factors reflect in the fragility of the work process of the team and, consequently, as reported by the nurses, in the lack of adherence of users of PAS to treatment.
It was noticed that most nurses have not been trained to work with PAS users, a fact that, in addition to affecting the care, also hinders the very attraction of the user to the service, which ultimately contributes to the existence of late care and often of greater complexity. Such challenges are continuously related to insecurity due to lack of preparation and professional qualification, inadequate conditions of care structure, stigma, lack of knowledge about the PSCN and fragmentations in the process of interdisciplinary work. 19 Nurses still have, as the main methods of practice, curative medicine and drug treatment models, being, most of the time, referred that the referral of the patient for medical treatment or specialized consultation is the only way to provide assistance to PAS users. However, it is necessary to understand that mental health care should act within the PSCN, which considers the clarified multi-professional work among professionals and care agencies as the guiding axis of mental health practice.
Thus, it is worth mentioning that, despite the use of the expression "treatment" by nurses in their statements, in the scenario of assistance to the PAS user, it is not considered that talking about "treatment of mental illness" is the exclusive domain of the psychiatrist or other professional department. For this, nurses need to identify themselves as part of this process and take responsibility for shared care with the multidisciplinary team and the user's family. Therefore, a careful critical reflection is needed on the reports of nurses about why there is still resistance on the part of PAS users to adhere to psychosocial rehabilitation in the FHS.
The strengthening of soft technologies as a practice of nursing care in this scenario, as a method to embrace integrality and humanization, which have the assumption of producing reciprocal relationships and interaction through the reception, the bond, cooperation and active listening between professional and user of health services, needs to reach the PAS user, who is also a unique subject, in his particularities, with the right to receive extramural care and to be the protagonist in his care process. 20,21 Thus, the training of professionals in the theme should be considered from the academic training in Nursing 18 and health services as part of the team's work process through continuing education. 22 Therefore, it is essential that all professionals be trained to assist people who use and abuse PAS and their families with a view to transforming nursing practices and the growing reality of social problems that stem from this abuse, breaking up families, generating violences and other psychosocial damage. [18][19][20]

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE
The assistance to users of PAS has a well-structured service network with interconnected services, which, theoretically, should offer a quality and resolute care, however, it was observed that there are major failures in relation to the insertion of the user in the system to look at the experience of nurses of the FHS teams investigated.
The greatest difficulty that was perceived is in relation to the reception by the nurses. This is a limited assistance in dealing with the PAS user due to the lack of training and/or information about chemical dependency, justifying its limitation with the difficulties of physical structure, work overload, and the need for a mental health professional in PHC.
The interviewed nurses still have, as their main focus of practice, the biomedical treatments models, centered on cure and complaint-drug, being, most of the times, referred that the referral of the patient for medical treatment or specialized consultation is the only way to provide assistance to this public. It is believed, therefore, that the shortcomings in the training process limit the scope of action of these professionals, since they are leaders of a team, but do not have sufficient knowledge and skills to direct the assistance with a view to comprehensive care to the PAS user.
Thus, one of the great challenges for Nursing today is to realize that the use of PAS has become an epidemic and that it is as harmful to public health as other chronic non-communicable diseases that receive its attention. It is necessary, therefore, that nurses develop strategies for care, training, sensitizing, and qualifying themselves to provide quality and resolute care.
Regarding the limitations of this study, the small sample size may have influenced the inferences of the researchers of this study, since it reveals a small portion of professionals from FHS teams in the municipality investigated, limiting the ability to generalize the findings. However, the results of this study incorporate the knowledge of professionals who already work in the assistance, as well as add to the training of professionals who will work in the assistance to PAS users and their families in territorial health services.
Nursing care for drug users Militão LF, Santos LI, Cordeiro GFT, Sousa KHJF, Peres MAA, Peters AA Thus, taken as a tool that makes scientific knowledge possible, this study can encourage discussions, in academic and institutional spheres, about the training needs of professionals, particularly in the area of nursing, stimulating the construction of psychosocial care, through a critical, reflective, ethical and empowered posture, with a view to harm reduction, rather than prohibition.