Harm reduction in primary healthcare: an integrative review of care strategies

1 Universidade Federal do Piauí, Departamento de Enfermagem, Teresina, PI, Brazil. ABSTRACT Objective: To analyze the evidence available in the literature on harm reduction actions developed by primary healthcare. Method: Integrative literature review carried out in the databases MEDLINE, CINAHL, SCOPUS, Web of ScienceTM and LILACS. Results: Seventeen (17) primary studies published from 2008 to 2017 were included in this review. Care strategies for harm reduction included maintenance treatment with methadone, therapy with opioid agonists, needle and syringe distribution programs and the creation of rooms for supervised drug consumption. Health professionals were essential for consolidating inclusion strategies, possessing skills to listen without judgment and prejudice. Conclusion: Harm reduction care strategies have been disseminated in different countries and healthcare levels, aiming toward safe practice and quality, effective and risk-free care actions.


INTRODUCTION
The use/abuse of drugs has become a real public health problem nowadays, not only demanding the attention of public policies focused on the subject, but also demanding an organized and articulated elaboration of actions, strategies and specialized services to a resolute performance from the entire Brazilian Unified Health System (SUS -Sistema Único de Saúde) (1) . Thus, parallel to this issue, the abusive use of these substances is associated with increased crime and antisocial attitudes when the psychosocial implications are not seen in an overall context of the problem. Thus, drug use becomes a challenge for the Family Health Strategy (FHS), especially the aspects which encompass care and the comprehensive health promotion of drug users (2) .
In line with the principle of comprehensive care, there was recognition of the expanding coverage and performance of the FHS team to offer care based on prevention, rehabilitation, approach and application of Harm Reduction (HR) strategies in order to minimize the consequences of drug abuse to users. HR goes far beyond the simple exchange of syringes and needles, constituting a set of activities and measures which not only aim to reduce the harmful effects of drugs on the body, but also work towards the social inclusion and citizenship of those who are marginalized, promoting self-care of drug addicts by distributing condoms to prevent Sexually Transmitted Infections (STIs), in guidance regarding substitution of heavy substances by others with less adverse effects, stimulating individuals to adhere to vaccines against Hepatitis B and Tetanus, as well as providing opportunities and helping drug users access health actions and services (3) .
Thus, HR policy proposes to reduce the harmful effects caused by undue drug use, both for the individual who uses them and for the society in which they are inserted. It needs to be kept in mind that the total suppression of such substances is made impossible by the strong presence which has constituted their consumption throughout human history, and so it is indispensable to formulate new devices or strategies which establish ways to reduce and consequently minimize the damages caused by abusive consumption. In addition, it is necessary to consider new ways of tackling the indiscriminate use of drugs, whether they are of a legal or illegal nature, as uncontrolled use of these substances can cause various physical, psychological and social complications and disorders which not only affect the user, but reach the entire family and social conjuncture (4) .
Thus, it is important to work with the users' uniqueness in order to outline strategic plans for promoting their lives, giving them the freedom and capacity to become co--responsible and protagonists of their own actions (5) . It is worth highlighting the need to establish an articulated care network involving all individuals and social and organizational segments of the territory, whether public or private, in sharing care actions which complement each other so as to promote inclusion in the most diverse sectors, fully aligning all comprehensive actions (1) .
Regarding the adversities related to inserting HR actions in Primary Health Care (PHC) services, it is observed that HR has gone through periods of non-acceptance, resistance and affirmation throughout its history and construction. Several reasons reflect the difficulties in its implementation as an effective and legitimate practice in the field of drugs, such as: questions regarding chemical dependency as a disease; types of use and right; respect for individual choices; and mainly in relation to the ways of assisting users of alcohol and other drugs (6) .
Due to the various factors associated with drug abuse and the large proportion and extent of its effects on humanity, HR policy is part of a global challenge facing numerous social, political, legal and ethical barriers, composing with the different sectors, health institutions and services (5) . In view of this, this study aims to analyze the scientific evidence available in the published literature about the strategies used by PHC for HR in crack, alcohol and other drug users.

Study deSign
This is an integrative literature review. This method makes it possible to gather and synthesize scientific evidence in a systematic and orderly manner, representing an instrument for deepening knowledge about the investigated topic and enables synthesis of multiple published studies and general conclusions regarding an area under study (7).
The study design was based on six distinct stages: elaborating the research question; peer search and sample selection; defining the information to be extracted from the selected articles; information analysis; interpreting results and synthesizing the knowledge (8) .
The research question to guide the search was formulated from the acronym PICo, defining "Users of crack, alcohol and other drugs" as the Population, "Risk and harm reduction" as the phenomenon of Interest, and "Primary Health Care" as the COntext. Thus, the structured question was: What is the evidence related to the strategies used by PHC for HR in users of crack, alcohol and other drugs?

data collection
The bibliographic survey was independently conducted by two reviewers in April 2018 by consulting the following electronic databases: Medical Literature Analysis and Retrieval System Online (MEDLINE via PUBMED ® ), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Web Of Science TM , Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS) and Base de dados da enfermagem (BDENF) via the Virtual Health Library.

P AND I AND Co
Legend: CD -Controlled descriptor; NCD -Non-controlled descriptor.

Selection criteria
Primary studies which highlighted the strategies used by PHC for HR, published in the period from 2005 to 2017 and without language restriction were included. The exclusion criteria were editorials, theoretical reflections, experience reports and reviews, dissertations, monographs, theses, summaries in the annals of events and duplicates found in more than one database.
The decision for the time frame was based on the publication year of Ordinance 1.028/2005, which deals with the implementation of actions aimed at social and health HR resulting from the use of products, substances or drugs which cause dependence (9) .
There were 228 publications initially identified. Next, 67 potentially eligible studies for inclusion were pre-selected after reading the titles and abstracts. After the exclusion of 50 articles (12 for constituting a literature review and 38 for duplicity), the sample consisted of 17 articles. Figure 1 shows the search, selection and inclusion of studies. The recommendations proposed by the Oxford Center for Evidence-based Medicine were used to assess the methodological quality of the included studies, which considers: 1A -systematic review of randomized controlled clinical trials; 1B -randomized controlled clinical trial with a narrow confidence interval; 1C -therapeutic results of the "all-or--nothing" type; 2A -systematic review of cohort studies; 2B -cohort study (including randomized clinical trial of lesser quality); 2C -observation of therapeutic results or ecological studies; 3A -systematic review of case-control studies; 3B -case-control study; 4 -case reports (including cohort or lower quality case-control); 5 -expert opinion without critical evaluation (10) .
An instrument for collecting and synthesizing the data was used for the purpose of analyzing the selected articles in full, prepared by the authors themselves in order to extract, organize and summarize the information and facilitate forming the database. The topics of interest addressed in the instrument were: study identification (main author, journal and year of publication), methodological aspects (design), main results, and evidence level. The results were descriptively analyzed, and then organized into a chart which describes the main strategies adopted for harm reduction.

RESULTS
The sample consisted of 17 articles. There was a greater number of publications in 2015, with 6 (35.29%) articles approaching the HR actions developed by PHC. The database with the largest number of selected articles was MEDLINE with 9 (52.94%) publications, while there was a considerable number of publications in the Harm Reduction Journal with 4 (23.52%). Regarding the language, there was a prevalence of the English language with 15 (88.23%) articles published and only 2 (11.76%) in Portuguese. For the evidence level, a higher frequency of articles with a 2C assessment was observed in 16 (94.11%) studies.
Among the care strategies for HR, there was a prevalence of Methadone Maintenance Treatment (MMT) in 3 (17.64%) studies, followed by needle and syringe distribution programs with 2 (11.76%) articles. The synthesis of knowledge is presented in Chart 2.   (20) Qualitative study.
A multidisciplinary team developed the reception and inclusion of homeless people to citizenship and health services. It promoted educational and informative actions, in addition to make possible artistic and recreational activities.
Nursing students as drivers in HR through a technical approach to health counseling, with a focus on changing behaviors.

DISCUSSION
HR is one of the main intervention methods for people who use alcohol and other drugs. Therefore, it presents a diversity of strategies to achieve the established purpose for each user. It is noteworthy that each drug user has unique and peculiar characteristics, requiring specific interventions and care for each situation.
The studies included in this review demonstrate that the theme has been gaining prominence among researchers and importance in all healthcare contexts, especially in PHC in order to reduce the damage caused by the use of psychoactive substances, with alcohol and other drugs among them.
There was a higher prevalence of MMT as a HR strategy, and with that important descriptions of this medication were evidenced. Methadone is a synthetic, long-acting opioid which binds to opioid receptors in the body, exponentially reducing symptoms caused by abstinence and improving patients' physical and mental conditions. Another described strategy which was associated with reducing HIV and Hepatitis C infection indicators was the provision of syringe and needle exchange services, and information to the target community, minimizing the risk of transmitting these diseases (14)(15)27) .
MMT was also used in Iranian prisons, standing out as a positive method for decreasing injection drug use, shared practices, overdose mortality, as well as preventing abstinence syndrome and inhibiting crimes which were initiated by drug abuse. Thus, the treatment provided drug users with the opportunity to improve their quality of life and social reintegration (15) .
Moreover, a study performed in Canada referenced MMT in a very unusual way, introducing some characteristics which potentially hindered the performance of HR practices in its context (27) . In this sense, it was pointed out that stigma, prejudice, social and structural restrictions, and the homelessness of drug users are barriers to access MMT. Even if HR practice occurred systematically, it would not be enough to deal with health inequalities when considering the social disparities in which the drug user is inserted (18,27) .
Thus, the potential of Opioid Agonist Therapy (OAT) and a Needle and Syringe Program (NSP) was confirmed by providing improvements in health and self-care, reduced viral and bacterial infections rates (HIV and Hepatitis C), crime, stress, overdose cases, and consequently the mortality of drug users (11,17) .
In one study, the use of buprenorphine in treating opioid dependence and consequently in HR is highlighted. This therapeutic method represents the best detoxification process when compared to traditional opioid detoxification and has minimal abstinence symptoms. In addition, it is more effective when compared to methadone. However, its side effects and long-term effects are still unknown (26) .
Another significant intervention was the creation of Supervised Drug Consumption Rooms (SDCR), which can be defined as a "health center" supervised by professionals, where users can use drugs in safer and more hygienic conditions. This practice is also aimed to reduce the transmission of infectious diseases, as well as to perform wound treatment. Therefore, SDCRs have the essence of attracting people with chronic drug use who mostly have increased potential for developing pathologies. Thus, patient/user interaction with health professionals becomes easier with this approach, favoring a scenario for adequate care provision and alternative options for better quality of life for users (12) .
Thus, HR practices favor a positive environment for establishing links between the professionals involved and the users of the service. This applicability additionally results in the development of proposals in health education, techniques, and hygienic measures, as well as enabling a better direction to access specialized health care (12)(13)18) .
An approach outlined for the economic and social context was demonstrated through the participants' perception in a study related to treatment modalities based on abstinence, since the experiences of homelessness and their exposures caused by alcohol abuse were described. The reports pointed out that abstinence-based goals were not always considered desired or attainable. Thus, pharmacological treatment using naltrexone and behavioral interventions focused on the patient were performed holistically. The evidence found in the study permeated the conclusion that some basic needs are indispensable to the user, such as the provision of housing, healthcare, consistent therapeutic relationships and HR services integrated into the community (16) .
A study conducted in Vancouver considered patient reports about the relevance of HR hospital interventions for people who use drugs, such as supervised drug consumption services and opioid-assisted treatment as an alternative to improve hospital care retention, promote care centered on the patient, and reduce adverse health outcomes among people who use drugs (13) .
In Brazil, HR is based on the perspective of establishing bonds of trust with users, something which opposes the compulsory hospitalization model for treating chemical dependency. Thus, PHC makes the care path under the HR aspect favorable, as this program often occurs actively in the territory where there is direct contact with the user; and the harm reducers are often residents of that territory, which favors care development (20)(21) .
However, it is clear there are many weaknesses in training Primary Health Care professionals to work with the demands of drug users. Professionals generally only develop reception restricted to screening, the initial arrival of the patient and are subsequently concerned with referring them to specialized mental health services. Thus, care networks appear as possibilities for offers to users of alcohol and other drugs, depending on the complexity of the cases. The offerings range from street care provided by health professionals, to specific care at the Basic Health Units (UBS) with scheduled care or spontaneous demand (21) .
A peculiar characteristic of HR is evidenced through the representativeness of the actions developed by professionals who work at the Street Clinic (Consultório na Rua), presenting users with a new possibility of care. This service initially occurs on the street where the users are, and involves educational activities on health problems, self-care, food, hygiene, sexuality, and damage caused by the excessive use of drugs (20) . "HR is not only attractive from a human point of view, but it is also less costly and more efficient when compared to traditional approaches, making it an international movement" (28) .
As a result, HR in primary care emerges with a plurality of actions to benefit alcohol and other drug users. Thus, it is worth highlighting a study which pointed out the contribution of "Recovery Coaches" (RCs) as having a valuable role in primary care by favoring behavior changes, promoting social support, helping in the recovery and realization of shared experiences among users. However, challenges in this approach were also evidenced, as patients reported discomfort when they had to ask for help from professionals, lack of clarity in the assignments of RCs and tension within the service team (23) .
PHC in Iran has demonstrated potential in developing HR policy by having a significant number of Health Centers to provide services to drug users, carrying out HR activities and referrals to specialists when necessary. It is noted that this policy aimed to reduce the rate of demand for drug use in the community through a program which managed to win the trust of the population and an effective integration with mental health programs (24) .
In contrast, a study on the perception of professionals in the context of alcohol users reports that total abstinence would be the solution for alcoholism.
An absence of using the HR concept was highlighted, although it is central to the current policy guidelines regarding care to the problematic use of alcohol and other drugs. However, the professionals justify their attitudes by mentioning that the Family Health Teams (ESF) are prejudiced against these users and that they are not properly prepared to provide adequate care to these clients, and that they simply refer them to the Psychosocial Care Center for treatment of alcohol and other drug users (CAPSad) (25) .
A study in Brazil corroborates the idea of providing an educational program which reinforces the systematic of alcohol use and other psychoactive substances to be part of the undergraduate nursing curriculum. Positive results were found in the work with patients with alcoholism problems when evaluating students' attitudes and knowledge after a Brief Intervention Training (BIT) program for alcohol-related problems. Thus, it is clear that educational interventions significantly favor changes in the attitudes and beliefs of professionals who will provide care for vulnerable groups (22) .
On the other hand, there is still a need for HR proposals in PHC services when considering users of performance and image enhancing drugs (PIEDs), as they are used without any supervision by a health professional. These drugs are usually obtained illegally and can introduce a series of complications ranging from the administration of injectables being potentially responsible for infections due to the reuse of needles, and sharing vials with these substances (19) .
Thus, the focus of Primary Health Care on providing care to drug users should be guided by the reception logic, prioritizing the ethics of care through HR strategies. Therefore, health professionals are essential for consolidating inclusion strategies, and skills such as knowing how to listen without judgment and prejudice, seeking possibilities of differentiated care for each service circumstance (20)(21) .
The limitations of this study are related to the absence of Brazilian studies which describe the actions of professionals in the Family Health Strategy with an HR approach in their daily work. Thus, additional research is necessary to support the HR strategies to be developed by professionals in Primary Health Care, specifically by the FHS.

CONCLUSION
This study presented a synthesis of evidence related to actions aimed at HR for drug users in the context of health and its social and economic aspects. Policy interventions and the control of drug abuse are part of an ongoing process which has been progressively becoming a public health problem. It was found that HR has been implemented in several countries, each with its own peculiarity, as it depends on the specificity of each region from the habits of the population to their life demands, as well as their cultural particularities.
Thus, it was possible to verify that HR surpasses the limits of a policy when going through new possibilities in life, offering varied alternatives of resources aimed at treatment, and it also enables minimizing prejudices related to drug users.