Como tornar
eficaz a política de álcool e
drogas nos diversos níveis
Prof. Dr. Ronaldo Laranjeira
UNIAD-UNIFESP
Resumo
• 1 – Políticas do álcool baseadas em
evidências científicas
• 2 – Príncipios do tratamento
efetivo
Alcohol, No Ordinary
Commodity: Research and
Public Policy
Sponsored by:
The World Health Organization
and
The Society for the Study of Addiction (UK)
The findings and conclusions represent the consensus views of its 15 authors,
none of whom received either direct or indirect support for their participation
from the sponsoring organizations or any other organization that might
represent a conflict of interest.
Prevention Strategies
Reviewed and Evaluated
•
•
•
•
•
•
•
Regulating Physical Availability
Pricing and Taxation
Altering the Drinking Context
Education and Persuasion
Regulating Alcohol Promotion
Drinking-Driving Countermeasures
Treatment and Early Intervention
Ratings of 32 Policy-relevant Prevention
Strategies and Interventions
1) Evidence of Effectiveness – the quality of
scientific information
2) Breadth of Research Support – quantity and
consistency of the evidence
3) Tested Across Cultures, e.,g. countries, regions,
subgroups
4) Cost to Implement and Sustain – monetary and
other costs
aRating
Scale: 0, +, ++, +++, (?)
b Rating Scale: Low, Moderate, High
Taxation
Strategy or
Intervention
Alcohol
Taxes
Effectiveness
+++
XResearch Cultural
Support Testing
+++
+++
Cost
Low
Target
Group
General
Population
Regulating Physical Availability
Strategy or
Intervention
Total ban on sales
XEffectiveness Research Cultural
Support Testing
+++
+++
++
Cost
Target Group
High
General
Population
High Risk
Group
General
Population
General
Population
Minimum legal
purchase age
Rationing
+++
+++
++
Low
++
++
++
High
Government
monopoly of retail
sales
Hours and days of
sale restrictions
Restrictions on
density of outlets
Server liability
+++
+++
++
Low
++
++
++
Low
++
+++
++
Low
+++
+
+
Low
Different
availability by
alcohol strength
++
++
+
Low
General
Population
General
Population
High Risk
Group
General
Population
Modifying the Drinking Context
XStrategy or
Effective- Research Cultural
Intervention
ness
Support Testing
Outlet policy to not
+
+++
++
serve intoxicated
patrons
Training bar staff
+
+
+
and managers to
prevent and better
manage aggression
Voluntary codes of
O
+
+
bar practice
Enforcement of on++
+
++
premise
regulations and
legal requirements
Community
++
++
+
mobilization
Cost
Target Group
Moderate
High Risk
Group
Moderate
High Risk
Group
Low
High Risk
Group
High Risk
Group
High
High
General
Population
Modifying the Drinking Context
Many prevention measures seek to limit drinking in
the contexts or environments where alcohol is
typically sold and consumed (e.g., bars and
restaurants).
The most effective options involve:
• enforcement of serving regulations
• increasing the legal liability of bar staff and
owners for the actions of those they serve.
Responsible Beverage Service
(RBS) programs
• Focus on attitudes, knowledge, skills, and
practices of persons involved in serving alcoholic
beverages on licensed premises
• If supported by actual changes in the serving
policies of licensed establishments and reinforced
by local police, RBS training can reduce heavy
consumption and high risk drinking
Drinking-Driving Countermeasures
Strategy or
Intervention
Sobriety check
points
Random breath
testing (RBT)
Lowered BAC
Limits
Administrative
license
suspension
Low BAC for
young drivers
(“zero
tolerance”)
Graduated
licensing for
novice drivers
Designated
drivers and ride
services
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+++
++
+
Moderate
+++
+++
++
Low
++
++
++
Moderate
+++
++
+
Low
High Risk
Group
++
++
++
Low
High Risk
Group
O
+
+
Moderate
High Risk
Group
Cost
Target Group
Moderate
General
Population
General
Population
General
Population
Harmful
Drinkers
Education and Persuasion
Strategy or
Intervention
Alcohol
education in
schools
College
student
education
Public service
messages
Warning
labels
Effectiveness
O
XResearch Cultural
Support Testing
+++
++
O
+
+
O
+++
++
O
+
+
Cost
High
High
Target
Group
High Risk
Group
High Risk
Group
Moderate General
Population
Low
General
Population
Education and Persuasion Strategies
• School-based alcohol education programs have been found to increase
knowledge and change attitudes toward alcohol and other substances,
but actual substance use remains unaffected.
• Approaches that address values clarification, self-esteem, general
social skills, and “alternatives” approaches that provide activities
inconsistent with alcohol use (e.g., sports) are equally ineffective.
• Programs that include both resistance skills training and normative
education (which attempts to correct adolescents’ tendency to
overestimate the number of their peers who drink) have modest effects
that are short-lived unless accompanied by ongoing booster sessions.
• Programs that include both individual-level education and family- or
community-level interventions may not be sufficient to delay the
initiation of drinking, or to sustain a small reduction in drinking
beyond the operation of the program.
Summary: Education and
Persuasion Strategies
• The impact of education and persuasion programs tends to
be small at best.
• When positive effects are found, they do not persist.
• Among the hundreds of studies, only two show significant
lasting effects (after 3 years), and the significance of these
is questionable when reanalyzed (Foxcroft et al. 2003).
• The time is past for arguments on behalf of substituting
education for other, more effective approaches.
• If educational approaches are to be used, they should be
implemented within the framework of broader
environmental interventions that address availability of
alcohol.
Regulating Alcohol Promotion
Strategy or EffectiveIntervention
ness
Advertising
++
bans
Advertising
?
content controls
Research
Support
++
XCultural
Testing
++
O
O
Cost
Low
Moderate
Target
Group
General
Population
General
Population
Regulating alcohol promotion
• The marketing of alcohol is a global industry.
• Alcohol brands are advertised through television, radio,
print, point-of-sale promotions, and the Internet.
• Exposure to repeated high-level alcohol promotion
inculcates pro-drinking attitudes and increases the
likelihood of heavier drinking.
• Alcohol advertising predisposes minors to drinking well
before legal age of purchase.
• Advertising has been found to promote and reinforce
perceptions of drinking as positive, glamorous, and
relatively risk-free.
Regulating alcohol promotion
Legislation restricting alcohol advertising
• A well-established precaution used by
governments throughout the world, despite
opposition from the alcoholic beverage industry.
• Findings suggest that while the restrictions have
not achieved a major reduction in drinking and
related harms in the short-term, countries with
greater restrictions on advertising have less
drinking and fewer alcohol-related problems
(Saffer, 1991).
Regulating alcohol promotion
Industry Self-regulation Codes
• Self-regulation tends to be fragile and largely
ineffective.
• These codes may work best where the media,
advertising, and alcohol industries are all
involved, and an independent body has powers to
approve or veto advertisements, rule on
complaints, and impose sanctions.
• Few countries currently have all these
components.
Treatment and Early Intervention
Strategy or
Intervention
Brief
intervention
with at-risk
drinkers
Alcohol
problems
treatment
Mutual
help/selfhelp
attendance
Mandatory
treatment of
repeat
drinkingdrivers
Effectiveness
++
Research
Support
+++
XCultural
Testing
+++
+
+++
+++
High
Harmful
Drinkers
+
+
++
Low
Harmful
Drinkers
+
++
+
Moderate
Harmful
Drinkers
Cost
Moderate
Target
Group
High Risk
Group
Melhores Práticas
• Idade mínima para a
compra de álcool
• Monopólio
governamental para a
venda de álcool
• Restrições de horário
para a venda de álcool
• Restrições a densidade
de bares
• Taxação álcool
• Sobriety check points
• Diminuir BAC limits
• Suspenção
administrativa de
cartas de motorista
• Intervenção Breve
Piores Práticas
• Código voluntário de
prática em bares
• Promover atividades
sem álcool
• Educação sobre álcool
nas escolas
• Educação nas
universidades
• Propaganda contra o
álcool
• Warning labels
• Motorista alternativo
ou taxi para
alcoolizados
Evolving Views of Alcohol Policy: Optimism
• Opportunities for effective, evidence-based
alcohol policies are more available than ever to
better serve the public good.
• Alcohol policies that limit access to alcoholic
beverages, increase the price of alcohol, and
enforce laws and regulations through deterrence,
are likely to reduce the harm linked to specific
drinking patterns and per capita consumption.
• Alcohol problems can be minimized or prevented
using a coordinated, systematic policy response.
CONCLUSIONS
• The difference between good and bad alcohol policy is not
an abstraction, but very often a matter of life and death.
• Research has the capacity to indicate which strategies are
likely to succeed in their public health intentions, and
which are likely to be less effective or even useless,
diversionary, and a waste of resources.
• Opportunities for evidence-based alcohol policies that
better serve the public good are more available than ever.
• There are still too many instances of policy vacuums filled
by unevaluated or ineffective strategies and interventions.
• Because alcohol is no ordinary commodity, the public has
a right to expect a more enlightened, evidence-based
approach to alcohol policy.
13 Princípios do Tratamento
Efetivo
NIDA
Princípios Tratamento Efetivo
1
Nenhum tratamento é
efetivo para todos os
pacientes
Princípios Tratamento Efetivo
2
O Tratamento necessita
ser facilmente disponível
Princípios Tratamento Efetivo
3
Tratamento deve atender
às várias necessidades e
não somente ao uso
drogas
Princípios Tratamento Efetivo
4
O tratamento necessita
ser continuamente
avaliado e modificado de
acordo com as
necessidades.
Princípios Tratamento Efetivo
5
Permanecer em
tratamento por período
adequado é fundamental
para a efetividade
Princípios Tratamento Efetivo
6
Aconselhamento e outras
técnicas
comportamentais são
fundamentais para o
tratamento
Princípios Tratamento Efetivo
7
Medicamentos são
importantes,
principalmente quando
combinados com terapia
Princípios Tratamento Efetivo
8
A comorbidade deveria
ser tratada de uma forma
integrada
Princípios Tratamento Efetivo
9
Desintoxicação é só o
começo do tratamento
Princípios Tratamento Efetivo
10
O tratamento não
necessita ser voluntário
para ser efetivo
Princípios Tratamento Efetivo
11
A possibilidade de uso
de drogas deve ser
monitorada
Princípios Tratamento Efetivo
12
Avaliação sobre HIV,
hepatites B e C e
aconselhamento para
evitar esses riscos
Princípios Tratamento Efetivo
13
Recuperação é um
processo longo e muitas
vezes necessita vários
episódios de tratamento
CRECHES
ORIENTAÇÃO
VOCACIONAL
ABORDAGENS
VOLTADAS À FAMÍLIA
PROCESSO DE ENTRADA
E AVALIAÇÃO
ALBERGAGEM &
TRANSPORTE
ORIENTAÇÃO
FINANCEIRA
ASSESSORIA &
PLANO DE
MONITORAMENTO
PSICOTERAPIA TRATAMENTO (USO DE DROGAS)
EQUIPE MULTIDISCIPLINAR
FARMACOTERAPIA
SERVIÇOS
DE SAÚDE MENTAL
OUTROS SERVIÇOS
MÉDICOS
CUIDADOS CONTÍNUOS
ABORDAGENS
EDUCACIONAIS
APÓIO JURÍDICO
ORIENTAÇÃO E
DIAGNÓSTICO
PARA DST-AIDS
Os melhores programas de tratamento provêm uma combinação de terapias e outros serviços para satisfazer as
necessidades do paciente. FONTE: NIDA.