inebria 2009 newcastle upon tyne

EFF/PAI-PAD/USP-RP-2009EFF/PAI-PAD/USP-RP-2009 11

INEBRIA 2009INEBRIA 2009Newcastle upon TyneNewcastle upon Tyne

Brazilian alcohol and drugs policy Brazilian alcohol and drugs policy of the Ministry of Health and of the Ministry of Health and

SBIRT implementationSBIRT implementation

Erikson F. Furtado, MD, PhD – Assist. Prof.USP – University of São Paulo

FMRP – School of Medicine of Ribeirão PretoDept. Neuroscience and Behavior


ObjectiveObjective

To present an overview of the To present an overview of the present developments of the present developments of the Brazilian public policy for alcohol Brazilian public policy for alcohol and drugs and its relation to SBIRT and drugs and its relation to SBIRT implementation in the public implementation in the public health system.health system.


• Population (2009) – 191 millions (mostly urban)

• Federative Republic, 5 regions, 26 States (01 FD)

• Municipalities - 5,564

• Territory: 8.5 mln sq km (aprox. 22 inh/sqkm)

• GNP (2008) US$ 1,991 bi

• Per capita GNP (2008) - US$ 10,325

• HDI Rank (2006) - 70th (0.807)

Brazil: Country Profile


Health Policy in Brazil

• Epidemic diseases – Dengue, Tuberculosis, Aids-STD• Neonatal deaths• Chronic diseases - risk factors

• Cancer, cardiovascular diseases, diabetes• Obesity• Violence and vehicle accidents• Alcohol and Drug abuseAlcohol and Drug abuse• Health costs• Community participation• Management of health services and health system.

Health Policy – Challenges

Human Development IndexHuman Development Index



Health Policy in Brazil

Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006

Health Budget and ExpendituresTotal Health Budget in R$ Billions – Federal, State and County.

Brazil, 2000-2005


Health Policy in BrazilContext: Epidemiologic Transition - Violence

Standardized Mortality Rate by Violence (Assault and Homicide) per 100.000 habitants, Region, Brazil, 1980 - 2004

Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Saúde Brasil 2006 : uma análise da situação de saúde no Brasil. Brasília : Ministério da Saúde, 2006. 620 p. : il. – (Série G. Estatística e Informação em Saúde) http://portal.saude.gov.br/portal/arquivos/pdf/saude_brasil_2006.pdf


Per Capita Alcohol ConsumptionPer Capita Alcohol Consumption


Alcohol and Injury in Emergency Departments


Alcohol and Car AccidentsAlcohol and Car Accidents 53% car crash victims attending the 53% car crash victims attending the

emergency room – HC-Sao Paulo emergency room – HC-Sao Paulo (mostly, young 15-29 ya males)(mostly, young 15-29 ya males)

Mortality due by fatal car accidents Mortality due by fatal car accidents responds for 28% of all external responds for 28% of all external causes (about 30,000 deaths/year)causes (about 30,000 deaths/year)

High BAC found among 96.8% of High BAC found among 96.8% of necropsies of fatal victims (IML-SP)necropsies of fatal victims (IML-SP)

About 50% positive AUDIT in ERAbout 50% positive AUDIT in ERSource: Report of the Brazilian Ministry of Health - 2003


Prevalence of alcohol dependencePrevalence of alcohol dependence


Alcohol abuse among university students from a Alcohol abuse among university students from a medical schoolmedical school

20,0015,0010,005,000,00Score total AUDIT

80

60

40

20

0

Freq

uenc

y

Mean = 4.8 SD = 4.4 N = 464

Cut-off pointAudit ≥ 8

23.5%

Binge Drinking33.3%


State

Liver disease – MalesLiver disease – Males ((CasesCases / 100.000) / 100.000)

Region of Ribeirão Preto = 75,5

Mortality by TB and comorbiditiesMortality by TB and comorbidities

Condition NTB treatment

pNone (n;%) Some (n;%)

Diabetes 44 23(52.3) 21(47.7) .05

Cancer 6 4(66.7) 2(33.3) .05

COPD 39 23(59) 16(41) .05

HIV 15 11(73.3) 4(26.7) .005

Smoking 64 39(60.9) 25(39.1) .05

Alcoholism 142 82(57.7) 60(42.3) .01

Lindoso et al., Rev Saude Publica 42(5), 2008


%


• Health professionals don't assess risk patterns of alcohol use

• Patients with problematic alcohol use are discriminated

• Risk groups are not routinely assessed

Fabbri , Laprega & Furtado , Rev Saude Publica 41(6), 2007.

N = 450

N = 100 (22%)

Only 9% identifiedBy GO clinicians

Alcohol use by pregnant womenAlcohol use by pregnant women

1616

Americas: Alcohol – risk factor Nr. 01Americas: Alcohol – risk factor Nr. 01

Source: Monteiro, M. G. Alcohol y atencion primaria de la salud. OPS, 2008Source: Monteiro, M. G. Alcohol y atencion primaria de la salud. OPS, 2008

Frequency of inpatient admissionsFrequency of inpatient admissions

In-patient admissions - In-patient admissions - 20082008

Alcohol Dependence 57,789

Alcoholic Liver

Disease14,188

Total 71,977



StructureStructure

CAPS-AD

Emergency Room Outpatient MH Clinics

General Hospital

Family Health Program Psychiatric Hospitals

Detoxification GH

Basic Care (PHC) AOD Health Care System


AOD Psychosocial Centers by Regions (N=212)

73%

4722%

105%

5325%

9545%

North

Northeast

Southeast

South

Central-West

Brazilian Regions

North

South

Southeast

Northeast

Central-West

Argentina

Bolivia

Peru

Datasus Tabwin/Access 09-15-2009

AOD Psychosocial CentersAOD Psychosocial Centers

Short hospitalization wards: 4Short hospitalization wards: 4


CAPS-AD Distribution – 2009CAPS-AD Distribution – 2009

Cumulative number of CAPS by yearCumulative number of CAPS by year



Health Policy in BrazilFamily Health Care Program

Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006

Family Health Teams – PHC levelFamily Health Teams – PHC level


Urgency AOD Policy PlanUrgency AOD Policy Plan


New AOD beds in general hospital wardsNew AOD beds in general hospital wards


AOD Policy - ChronologyAOD Policy - Chronology

2003 – Basic Guidelines for a 2003 – Basic Guidelines for a National Public Policy for Alcohol National Public Policy for Alcohol and Drugs, Prevention, Treatment and Drugs, Prevention, Treatment and Health Promotionand Health Promotion– First insertion of Brief InterventionsFirst insertion of Brief Interventions


BRASILIA DECLARATION ON ALCOHOL BRASILIA DECLARATION ON ALCOHOL PUBLIC POLICIES, 2005 - PAHOPUBLIC POLICIES, 2005 - PAHO

RecommendationsRecommendations Preventing and reducing alcohol consumption-related Preventing and reducing alcohol consumption-related

harms be considered a public health priority for action in harms be considered a public health priority for action in all countries of the Americas.all countries of the Americas.

Regional and national strategies be developed, Regional and national strategies be developed, incorporating culturally appropriate evidence-based incorporating culturally appropriate evidence-based approaches to reduce alcohol consumption related harm.approaches to reduce alcohol consumption related harm.

These strategies are supported by improved information These strategies are supported by improved information systems and further scientific studies on the impact of systems and further scientific studies on the impact of alcohol and the effects of alcohol policies in the national alcohol and the effects of alcohol policies in the national and cultural contexts of the countries in the Americas.and cultural contexts of the countries in the Americas.


BRASILIA DECLARATION ON ALCOHOL BRASILIA DECLARATION ON ALCOHOL PUBLIC POLICIES, 2005PUBLIC POLICIES, 2005

Alcohol policies whose effectiveness has been Alcohol policies whose effectiveness has been established by scientific research are established by scientific research are implemented and evaluated in all countries of implemented and evaluated in all countries of the Americas.the Americas.

Priority areas of action need to include: heavy Priority areas of action need to include: heavy drinking occasions, overall alcohol consumption, drinking occasions, overall alcohol consumption, women (including pregnant women), indigenous women (including pregnant women), indigenous peoples, youth, other vulnerable populations, peoples, youth, other vulnerable populations, violence, intentional and unintentional injuries, violence, intentional and unintentional injuries, underage drinking and alcohol use disorders.underage drinking and alcohol use disorders.


2929

Recent Brazilian effectiveness studiesRecent Brazilian effectiveness studies

SBIRT among ER SBIRT among ER patients: patients: – Segatto, Rev Psiq Segatto, Rev Psiq

Clínica, 2008.Clínica, 2008. SBIRT among Firemen SBIRT among Firemen

periodical health periodical health evaluation:evaluation:– Ronzani, Est Psicologia Ronzani, Est Psicologia

(Natal), 2007.(Natal), 2007.

SBIRT among university SBIRT among university students: students: – Kerr-Côrrea, Alcohol Kerr-Côrrea, Alcohol

Alcohol, 2008Alcohol, 2008 SBIRT among adolescents SBIRT among adolescents

attending a community attending a community health clinic: health clinic: – De Micheli, Rev Assoc De Micheli, Rev Assoc

Médica Bras, 2004Médica Bras, 2004 SBIRT among imprisoned SBIRT among imprisoned

adolescents :adolescents :– Andretta, Est Psicologia Andretta, Est Psicologia

(Campinas), 2008(Campinas), 2008


Implementation ProcessImplementation Process


Trained Health ProfessionalsTrained Health Professionals

PAI-PAD:PAI-PAD:

TrainingsTrainings

NetworkNetwork

SupervisionSupervision

EvaluationEvaluation

Stigma is a barrierStigma is a barrier


69(7):1080-1084, 2009


Changing attitudes after trainingChanging attitudes after training

SBIRT SBIRT knowledge after knowledge after training training correlates with correlates with reduction of reduction of alcohol alcohol expectanciesexpectancies– N = 185; N = 185; – rr = 0.215; = 0.215; – P < 0,005P < 0,005

Implementation processImplementation process 2008 Ministry of Health, three metropolitan 2008 Ministry of Health, three metropolitan

areas pilot project for SBIRT implementation areas pilot project for SBIRT implementation in the Family Health Program and the in the Family Health Program and the matricial support teams.matricial support teams.

2009 Annual plan, Alcohol and Drugs 2009 Annual plan, Alcohol and Drugs Coordination, State of São PauloCoordination, State of São Paulo– Extending the PAI-PAD couverture of SBIRT Extending the PAI-PAD couverture of SBIRT

training for all 17 regional health departments, training for all 17 regional health departments, reaching the total population of the state (~41mi).reaching the total population of the state (~41mi).



References

Brasil. Ministério da Saúde. As Causas Sociais das Iniqüidades em Saúde no Brasil. Relatório Final da Comissão Nacional sobre Determinantes Sociais da Saúde (CNDSS). Brasília. 2008.

Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006.

Cornwall, A., Shankland, A. Engaging citizens: Lessons from building Brazil’s national health system. Social Science & Medicine 66 (2008) 2173 – 2184.

Barreto, ML, Aquino, R. Recent Positive Developments in the Brazilian Health System. American Journal of Public Health. January 2009, Vol 99, No. 1.

Camargo, KR. Celebrating the 20th Anniversary of Ulysses Guimarães’ Rebirth of Brazilian Democracy and the Creation of National Health Care System. American Journal of Public Health. January 2009, Vol 99, No. 1.

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