RESULTSThis is a time of consolidation of the psychosocial model, with expansion of the health care network and inversion of the funding for community services with a strong emphasis on the area of crack cocaine and other drugs. Mental health is an underfunded area within the chronically underfunded Brazilian Unified Health System. The governance model constrains the progress of essential services, which creates the need for the incorporation of a process of regionalization of the management. The mechanisms of assessment are not incorporated into the health policy in the bureaucratic field. METHODSThis is a qualitative and evaluative study about the official regulations of the Brazilian mental health care system. We have carried out a review and analysis of the guiding documents of the current mental health policy at the Federal context, which consolidate the Brazilian psychosocial model, from 2009 to 2014, including Laws, Conferences, Decrees, Ordinances, and Technical Reports of the Ministry of Health (MS). We have incorporated documents from before the study period, as they still structure the Policy and are a reference for current documents.Altogether, we have analyzed five Ordinances, two Decrees, two Conference Reports, one Resolution, one Technical Report, and one electronic database.

1. Telha Norte

The material has been organized and analyzed from the definition of the model and the trinomial Funding-Governance-Assessment, used as axes for understanding the current stage of the mental health policy. FundingThe focus of the funding in the area of mental health follows the trend of countries with consolidated health systems, which prioritize community health services, being endorsed by the instances of social control. However, the World Health Organization advises that investment in mental health should be approximately 5% of the health budget, as a result of its prevalence and the impact in the health care. The Brazilian Government spends only 2.3% of the total health budget in actions for mental health.

This value increases slightly if we consider mental health in primary care and the Family Health Support Centers (NASF), which are not referred to in the studies analyzed. This datum shows that the real growth does not reflect the percentage, which has not increased and needs to be reviewed for the consolidation of the model. Mental health is underfunded within an underfunded system.The last National Conference on Mental Health shows a concern to ensure adequate funding for the provision and maintenance of substitute services, increasingly proposing federal control of the money applied. Although the responsibility for the funding is interfederative, the impact of the federal underfunding has given to the cities a strangulation of the public expenditure. There are no reliable sources that define the percentage of the expenditure of States and cities on specific programs and services for mental health, a fact that is worthy of research studies and assessments.Inserted in this context, the PCPV has no budget allocation to fulfill its goals, according to its article 6. The funds allocated to the cities, in the “fund-to-fund” model, consist of three blocks: management of the SUS, medium and high complexity, and investment, pertaining specifically to the construction of new units of the Program.The values for the payment of the services vary according to their complexity. Recently, the Ministry of Health has increased the value allocated to the type III CAPS in little more than 30% of the value of the monthly cost.

This change represents an attempt to impute a necessary change to the care model, increasing the still scarce type III CAPS in the country; however, we can see a prioritization of the services related to PCPV.The type III CAPS for AD (alcohol and other drugs), advocated by the program, receive 25% more than the same service for any other typology, therefore inducing the opening of fifty-nine units since the beginning of the Program. Ordinance 131 regulates the funding for “therapeutic communities” using a series of policies concerning the structure, staff, and ways to join them. We highlight that this care point is already one of the biggest and most expensive parts of the Program, working against Law 10,216, which highlights inconsistencies in the regulatory standards.It is clear the need for studies on the assessment and cost-effectiveness of the services offered. Furthermore, the prioritization regarding the investment block and the increased funding indicates the induction of a model and reflects the current focus of the policy, which has the PCPV as the central program and the therapeutic communities as protagonists. CONCLUSIONThe mental health care model advocated by the Brazilian Ministry of Health has been slowly advancing in several aspects and creating urgent demands for its consolidation. The model has assumed, since 2010, the area of crack cocaine and other drugs as a priority focus. In all documents, that line of action is emphasized, being always present in the mental health policy.

The PCPV assumes a role of great importance at this moment of the mental health policy, determining some anachronism in relation to the model and the funding. We are not only contrasting the focus of the program, which, as we have discussed, has the admission as expected result, but we are also thinking about the financial impact within a reality of chronic underfunding of the health, and mental health as a technical area.The increase in the total budget of the health area would entail in the densification of services and offers; however, without a change in the organizational process, this growth would lose power because of a fragmented organizational and irrational logic, as we have analyzed. The debate about governance and organization of mental health services, in this perspective, is an agenda that must enter the program of mental health and social control policy makers. The funding of the area needs to expand its relative percentage, since demand tends to increase, given the undergoing demographic transition.The assessment has shown to be a subject that is not present in the practices of the bureaucratic field. There is a gap between the studies on the evaluative-academic field and their incorporation as what could move the model forward.

The aim of this study is to understand the essential aspects for a successful treatment for crack dependency, based on the speech of users. This is a descriptive study, using a qualitative approach. Interviews were conducted with 39 crack users who were assisted in a social protection program for drug users. In order to understand the narratives, the content analysis technique was used and the theoretical framework was based on Bardin. Aspects that were mentioned as important were undergoing voluntary treatment and spirituality, categories that can be grouped as individual aspects, as well as increasing the list of activities, supply of settings protected from drugs and professional qualification with socio-productive inclusion, as institutional aspects. These demands must be considered for a better understanding of what is needed for a successful treatment, and contemplated by public policies targeted at this issue.Key words: Crack cocaine; Dependency; Treatment; Drug user.

IntroductionDrug consumption dates back to remote times and involves cultural, religious, economic, political and social issues. In different cultures, societies and eras, man always consumed licit or illicit drugs. In the majority of times, this did not constitute problems nor reasons for social alarm, as they were consumed with diverse purposes and understood as a cultural and human manifestation.As the years went by, it was possible to notice that both the type and the form of drug utilization started to vary. When a psychoactive substance is identified, different forms to reach the desired effects are discovered, and the substance becomes one more market product in our society. In recent decades, drug consumption has assumed worrying dimensions, with severe consequences to the individual, his family and community, negatively affecting different interfaces of daily life.The increase in drug use is not only associated with the culture of consumption and instant pleasure, but also with the vulnerability situation that has been experienced mainly by socially disadvantaged classes.

It is considered that a large portion of society lives permanently threatened by the instability of their life conditions and by social exclusion. The status of social misery and lack of political support have made new survival strategies emerge, and this instability favors the ever-growing entrance of youths into the world of drug trafficking.Crack cocaine consumption emerged in Brazil at the end of the 1980s. This phenomenon suffered a quick expansion, mainly among the population under major social vulnerability.

According to Bastos and Bertoni, the majority of users of crack cocaine and/or similar substances are young men with a low level of schooling who are living on the streets and do not have a permanent job or a regular income. Therefore, they form a socially vulnerable group.According to Pulcherio, crack cocaine is a drug with great power to make the person become dependent. It is largely associated with criminality, involvement in illicit acts to maintain consumption, like theft and robbery, and participation in drug trafficking. In spite of its severe consequences, the current knowledge about the use of this substance is still not sufficient, neither to provide efficient assistance for people in harmful drug use, nor to guide public prevention policies.In view of the challenge of overcoming crack cocaine dependence, research has been developed to verify the efficacy of different therapeutic approaches. Due to the complexity of the harmful use of this drug, Kessler and Pechansky argue that treatment over long periods guarantees better results, and it should offer spaces protected from the substance. Pulcherio adds that, besides being long, treatment for crack cocaine dependence should have a multidisciplinary approach, considering clinical, familial, social and legal aspects. Pinho et al believe that the therapeutic proposal must be adequate to the user’s age, sex, ethnicity and culture, meeting the subject’s different needs.Among the therapeutic approaches, Cognitive Behavioral Therapy focuses on the recovery of social skills, and its goal is abstinence.

This approach produces good results in people who do not present severe consequences deriving from crack cocaine use. Relapse Prevention has provided motivational techniques to restructure cognitions and modify drug-use behaviors. With its well-structured techniques, it has been presenting good results in the treatment for dependence.,Replacing the hegemonic models of treatment, which have a moral and legal character, the psychosocial approaches value the offer of hearing and embracement spaces for the phenomenon of drugs.

In this perspective, offering assistance at public spaces for drug users without imposing abstinence or permanence in the service is a great challenge and an important tool in the treatment.Although crack cocaine stands out in scientific publications, it is still necessary to advance more in relation to the treatment for its dependence. Even with different therapeutic approaches, crack cocaine users are more likely to abandon the treatment and, therefore, are not successful. Some factors can be highlighted, such as problems with the law, poor coping skills, family history of mental disorder, associated alcohol use disorder, among others.On the other hand, studies that aim to assess the efficacy of different approaches have not investigated users’ demands in the treatment process. Thus, the present study aimed to understand, based on the users’ discourse, their fundamental needs for a successful treatment. The desire to undergo treatment: voluntariness and willpowerThis category describes the extent to which the research participants consider important having the desire to undergo treatment.

This desire proves to be essential for the treatment’s success, as exemplified by the discourses below:He must have the willpower, because no treatment, no ATITUDE, no Support ATITUDE’s service can make a user quit. He must have the willpower, from the moment he is. That he feels he is away from drugs for a couple of months. You must face the reality out there. Here, inside the service, it’s ok, but when we cross the gate and step outside, abstinence knocks on our door. (Tiger’s eye, 20, female)Willpower, this is what’ll count in your treatment. I’m gonna tell you this, you must focus, you must be willing to change, you must be aware that the drug you used wanted to destroy you, you must have the willpower.

(Andalusite, 36, male). you must have the willpower to. Because if you don’t, it’s nonsense. The person must want it, the person must. There are many nice people, you must work a lot to.

Because the person becomes ignorant. (Moonstone, 27, male)It is possible to notice, in the narratives, the importance given to the decision of being in an institution and to the willingness to change their relationship with the drug, as well as maintaining their goals when they return to their social interactions. Regardless of the therapeutic approach or model, to the research participants, nothing matters if one lacks the desire to change, the desire to get out of harmful use, of compulsion. Thus, we can state that voluntariness and willpower are primordial aspects to be considered for the process to be positive, and they must be present at all stages of the treatment.According to Ruiz and Marques, compulsory hospitalization (ordered by Justice) or involuntary hospitalization (authorized by a physician) should be employed only when the individual is jeopardizing his life and other people’s. This measure should be monitored by a qualified multidisciplinary team that identifies the varied levels of dependence and the patient’s constitutional rights, and it must be integrated into other intervention proposals, at adequate places and with permanent inspections. To calm the anguish: spiritualityIn addition to voluntariness, expressed by the desire to undergo treatment, the need to strengthen spirituality was verbalized as another important aspect to facilitate the achievement of a successful treatment. Maintaining abstinence was highlighted and no specific religion was emphasized.

This perception is revealed below:I’ll tell you something. I think that the only objective to quit smoking crack is the presence of God. Because there are some crack users, that if they drink, they feel like using crack, if they drink a glass of beer, they want to use it, like this friend of mine.

He offered crack to me and it’s been 2 years since he used it for the last time. He’s been going to church. If he stops, he falls again. If he stops, he falls to the same level.

If he goes back to his friends, he relapses again. (Emerald, 21, male)The spiritual dimension, to me, as quitting worked out and I spent more than two years without using crack, to me it was the only model that worked. I don’t know to others; some people say they can quit. (Amethyst, 36, transvestite)Some studies argue that religiosity is a factor of protection against harmful drug use or for the treatment of dependence. It is important to highlight that the interviewed people had different religions and some of them did not even consider themselves religious.

They mentioned the encounter with something divine.Sanchez and Nappo, in a study carried out with former drug addicts who had used religious, non-medical resources to treat dependence, state that the positive result in the cure may be related to the interviewees’ faith in the power of their church. Arenari and Dutra discuss that religion has the potential for reversing trajectories of exclusion, mainly connected with drugs, due to its specific vocation for integrating individuals with high levels of social disengagement, unlike other systems, such as social networks and work. Thus, religion, religiosity or spirituality can be factors of protection and therapeutic resources against harmful drug use.Despite this understanding, it is important to mention that the condemnatory discourse of some churches, according to which users will only be all right through religious conversion, do not help those who do not want or cannot treat themselves in this perspective. Against craving: diversified activitiesThe crack cocaine users who were interviewed stated that, during treatment, it is necessary to develop different therapeutic activities, ranging from those directed at reflection on dependence to those related to schooling and professional qualification, and also ludic and leisure activities. They highlight that the compulsion to use crack cocaine weakens them and their mind must be busy all the time so that they are able to defeat craving:A treatment that keeps our mind busy, like a course, a distraction, a school, a tour, some kind of leisure, a group activity, something like this would be good for us, right? So that our mind is distracted and forgets, right?

Because it always comes to our mind. (Coral, 24, female)What should a good treatment have?!

I think that the group should talk less about crack. Just this, I think. (Coral, 24, female)Being dependent on crack cocaine means living around the drug. Thus, other activities are inexistent in these users’ life.

Telha Norte

Therefore, offering diversified activities is a fundamental therapeutic resource for them to experience other pleasures and meanings without the use of crack cocaine, and to help controlling craving. Therapeutic groups are important tools in the treatment for chemical dependence, but perhaps other activities that are more dynamic, creative and pleasant contribute more to the success of some users’ treatment.In order to provide comprehensive care, we need to reflect that, in the singular space of each healthcare service, the team must strive to translate and meet each complex need the individuals have. Alves adds that the diversification of programs is fundamental to embrace someone in a comprehensive way, as, with varied and diversified options of activities, the possibility of users’ participation is increased, while the tendency of selection in the follow-up on the part of the professional is reduced.Thus, we can think about care as Leonardo Boff proposes: “Providing care for someone is more than an act; it is an attitude. Therefore, it encompasses more than a moment of attention, zeal and tendance. It represents an attitude of occupation, concern, accountability and affective involvement with the other” (p.

73).The increase in the number of available activities represents, therefore, this singular and comprehensive care. It represents concern for the different demands, needs and identifications brought by the crack cocaine users who are undergoing treatment.

Against crack cocaine: a protected spaceAt some moment of the treatment for harmful crack cocaine use, a space protected from the drug becomes necessary, where the user can be sure that there will be no contact with the substance.Take him out of the street, right, not leave him on the street., how can a person spend the day here, eating, and in the evening he uses crack? Then, on the next day, he arrives here completely destroyed. (Sapphire, 26, male)A place where I can spend the night. Getting out is pure trouble. (Brazilianite, 23, female)I think that any place is ok, but not in the same city, because you know, there is the knowledge that can make a person who helps want to bring the drug inside the place, here, while in another city I think nothing happens, because you know, it is harder for you to obtain it,. (Labradorite, 29, male)The dependence clinic points that, at some moments in the therapeutic trajectory of people in harmful drug use, it becomes necessary to drive them away from their surroundings. It is fundamental to break the paradigm according to which a mental healthcare network does not need a space for inpatient treatment.In the Brazilian Psychiatric Reform, it is necessary to reflect on the importance of protected spaces that do not present the conception of long-permanence hospitalization, which segregates people who use drugs from their environment for long periods, without the construction of new life projects.

It is necessary to understand that, in the protected spaces demanded by the interviewees, care practices that support the development of skills and potentialities must be provided, strengthening autonomy and self-care, expanding protection factors that help to cope with risk situations, and including the individual in the community and, whenever possible, in the family context.In Pernambuco, some successful experiences corroborate the importance of protected spaces in the treatment of people in harmful drug use. The Casas do Meio do Caminho (CMC - Houses in the Middle of the Way), in the mental health network of Recife, and the Center for Intensive Embracement of the ATITUDE Program are examples of these experiences.The CMC emerge from the fact that the Psychosocial Care Centers (CAPS), even those which are open 24 hours a day, are not able to contain the anxiety and suffering of severe users. The CMC are complementary spaces in the healthcare network, and their function has been amplified beyond treatment, as a protection space.This amplification makes a difference in the lives of people who wish to remain abstinent, but have the substance within their reach very easily. Being certain about the possibility of remaining far from drug consumption is important to many interviewees. Towards a new project of life: professional qualification and inclusion in the job marketThis category portrays the need of professional qualification and productive inclusion in the process of maintaing the treatment of people in harmful crack cocaine use. This need emerges explicitly in the interviewees’ discourse:I think that there should be many workshops with many qualification courses, many qualification courses, and after you have attended the course, the government should refer you to a job.

When you have recovered, when you are cured, it should refer you to a job. (Garnet, 27, male)More activities, right, that were, like, vocational, which approached our motivation to go out.if we attended a course, any course, handicraft, one thing or another, it would help, if we go out already having a job, I think many groups do this. (Amethyst, 36, transvestite)An occupation, like, in the case of this one, it forms a group, we eat and sleep, for many people this is good, but for me, it could be better. An occupation, a vocational course. After attending a course, we should be referred to a job, always maintaining the mind busy, things that I used as a strategy not to smoke crack. (Topaz, 31, male)What is evident is that professional qualification needs to be an aspect of the therapeutic project; however, the interviewees themselves highlight that a course is not enough to contribute to the treatment. This qualification must be linked to inclusion in the job market.To Arenari and Dutra, when functions of responsibility are designated, even with low expectation of good results, a relationship of affective and moral “obligations” is established.

This social recognition stimulates, in the individual, the construction of viable short-run obligatory goals, breaking the destructive cycle that exclusion, together with crack cocaine consumption, can generate.In this perspective, the users stress the need of having an occupation, in addition to attending vocational courses, so that they feel integrated into society and with conditions to play their role as citizens. Thus, possibilities of socio-productive inclusion must be a concern of the government. Final remarksThis article aimed to investigate, based on users’ discourse, the fundamental aspects that are necessary for a successful treatment.