INEBRIA 2009
Newcastle upon Tyne
Brazilian alcohol and drugs policy
of the Ministry of Health and
SBIRT implementation
Erikson F. Furtado, MD, PhD – Assist. Prof.
USP – University of São Paulo
FMRP – School of Medicine of Ribeirão Preto
Dept. Neuroscience and Behavior
EFF/PAI-PAD/USP-RP-2009
1
Objective

To present an overview of the present
developments of the Brazilian public
policy for alcohol and drugs and its
relation to SBIRT implementation in
the public health system.
EFF/PAI-PAD/USP-RP-2009
2
Brazil: Country Profile
• 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)
EFF/PAI-PAD/USP-RP-2009
3
Health Policy in Brazil
Health Policy – Challenges
• Epidemic diseases – Dengue, Tuberculosis, Aids-STD
• Neonatal deaths
• Chronic diseases - risk factors
• Cancer, cardiovascular diseases, diabetes
• Obesity
• Violence and vehicle accidents
• Alcohol and Drug abuse
• Health costs
• Community participation
• Management of health services and health system.
EFF/PAI-PAD/USP-RP-2009
44
Human Development Index
EFF/PAI-PAD/USP-RP-2009
5
Health Policy in Brazil
Health Budget and Expenditures
Total Health Budget in R$ Billions – Federal, State and County.
Brazil, 2000-2005
EFF/PAI-PAD/USP-RP-2009
Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006
66
Health Policy in Brazil
Context: Epidemiologic Transition - Violence
Standardized Mortality Rate by Violence (Assault and Homicide) per 100.000
habitants, Region, Brazil, 1980 - 2004
EFF/PAI-PAD/USP-RP-2009
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
77
Per Capita Alcohol Consumption
EFF/PAI-PAD/USP-RP-2009
8
Alcohol and Injury in Emergency Departments
EFF/PAI-PAD/USP-RP-2009
9
Alcohol and Car Accidents




53% car crash victims attending the
emergency room – HC-Sao Paulo
(mostly, young 15-29 ya males)
Mortality due by fatal car accidents
responds for 28% of all external causes
(about 30,000 deaths/year)
High BAC found among 96.8% of
necropsies of fatal victims (IML-SP)
About 50% positive
AUDIT
in ER
Source: Report
of the Brazilian
Ministry of Health - 2003
EFF/PAI-PAD/USP-RP-2009
10
Prevalence of alcohol dependence
EFF/PAI-PAD/USP-RP-2009
11
Alcohol abuse among university students from a
medical school
80
Binge Drinking
33.3%
Cut-off point
Audit ≥ 8
Frequency
60
40
23.5%
20
0
0,00
5,00
10,00
15,00
20,00
Score total AUDIT
EFF/PAI-PAD/USP-RP-2009
Mean = 4.8 SD = 4.4 N = 464
12
Liver disease – Males
(Cases / 100.000)
State
Region of Ribeirão Preto = 75,5
EFF/PAI-PAD/USP-RP-2009
13
Mortality by TB and comorbidities
Condition
N
Diabetes
TB treatment
p
None (n;%)
Some (n;%)
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
EFF/PAI-PAD/USP-RP-2009
14
Alcohol use by pregnant women
• Health professionals don't
assess risk patterns of
alcohol use
• Patients with problematic
alcohol use are
discriminated
• Risk groups are not
routinely assessed
N = 450
N = 100 (22%)
Only 9% identified
By GO clinicians
Fabbri , Laprega & Furtado , Rev Saude Publica 41(6), 2007.
EFF/PAI-PAD/USP-RP-2009
15
Americas: Alcohol – risk factor Nr. 01
Source: Monteiro, M. G. Alcohol y atencion primaria de la salud. OPS, 2008
16
Frequency of inpatient admissions
In-patient admissions 2008
Alcohol
Dependence
57,789
Alcoholic
Liver Disease
14,188
Total
71,977
EFF/PAI-PAD/USP-RP-2009
17
Structure
Basic Care (PHC)
AOD Health Care System
Emergency Room
Family Health Program
CAPS-AD
General Hospital
EFF/PAI-PAD/USP-RP-2009
Outpatient MH Clinics
Psychiatric Hospitals
Detoxification GH
18
AOD Psychosocial Centers
Short hospitalization wards: 4
Datasus Tabwin/Access 09-15-2009
EFF/PAI-PAD/USP-RP-2009
19
CAPS-AD Distribution – 2009
EFF/PAI-PAD/USP-RP-2009
20
Cumulative number of CAPS by year
EFF/PAI-PAD/USP-RP-2009
21
Health Policy in Brazil
Family Health Care Program
EFF/PAI-PAD/USP-RP-2009
Brasil, Ministério da Saúde. Painel de Indicadores do SUS, Brasília. Ano I, No. I, agosto 2006
22
22
Family Health Teams – PHC level
EFF/PAI-PAD/USP-RP-2009
23
Urgency AOD Policy Plan
EFF/PAI-PAD/USP-RP-2009
24
New AOD beds in general hospital wards
EFF/PAI-PAD/USP-RP-2009
25
AOD Policy - Chronology

2003 – Basic Guidelines for a National
Public Policy for Alcohol and Drugs,
Prevention, Treatment and Health
Promotion
– First insertion of Brief Interventions
EFF/PAI-PAD/USP-RP-2009
26
BRASILIA DECLARATION ON ALCOHOL
PUBLIC POLICIES, 2005 - PAHO
Recommendations



Preventing and reducing alcohol consumption-related harms be
considered a public health priority for action in all countries of
the Americas.
Regional and national strategies be developed, incorporating
culturally appropriate evidence-based approaches to reduce
alcohol consumption related harm.
These strategies are supported by improved information
systems and further scientific studies on the impact of alcohol
and the effects of alcohol policies in the national and cultural
contexts of the countries in the Americas.
EFF/PAI-PAD/USP-RP-2009
27
BRASILIA DECLARATION ON ALCOHOL
PUBLIC POLICIES, 2005


Alcohol policies whose effectiveness has been
established by scientific research are implemented
and evaluated in all countries of the Americas.
Priority areas of action need to include: heavy
drinking occasions, overall alcohol consumption,
women (including pregnant women), indigenous
peoples, youth, other vulnerable populations,
violence, intentional and unintentional injuries,
underage drinking and alcohol use disorders.
EFF/PAI-PAD/USP-RP-2009
28
Recent Brazilian effectiveness studies


SBIRT among ER patients:
– Segatto, Rev Psiq Clínica,
2008.

– Kerr-Côrrea, Alcohol Alcohol,
2008

SBIRT among Firemen
periodical health evaluation:
– Ronzani, Est Psicologia
(Natal), 2007.
SBIRT among university
students:
SBIRT among adolescents
attending a community health
clinic:
– De Micheli, Rev Assoc Médica
Bras, 2004

SBIRT among imprisoned
adolescents :
– Andretta, Est Psicologia
(Campinas), 2008
29
Implementation Process
EFF/PAI-PAD/USP-RP-2009
30
Trained Health Professionals
PAI-PAD:
Trainings
Network
Supervision
Evaluation
EFF/PAI-PAD/USP-RP-2009
31
Stigma is a barrier
69(7):1080-1084, 2009
EFF/PAI-PAD/USP-RP-2009
32
Changing attitudes after training

SBIRT knowledge
after training
correlates with
reduction of
alcohol
expectancies
– N = 185;
– r = 0.215;
– P < 0,005
EFF/PAI-PAD/USP-RP-2009
33
Implementation process


2008 Ministry of Health, three metropolitan
areas pilot project for SBIRT implementation
in the Family Health Program and the matricial
support teams.
2009 Annual plan, Alcohol and Drugs
Coordination, State of São Paulo
– Extending the PAI-PAD couverture of SBIRT
training for all 17 regional health departments,
reaching the total population of the state (~41mi).
EFF/PAI-PAD/USP-RP-2009
34
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.
EFF/PAI-PAD/USP-RP-2009
35
35