1 Como tornar eficaz a política de álcool e drogas nos diversos níveis Prof. Marcelo Alessandro Rigotti
2 Resumo 1 Políticas do álcool baseadas em evidências científicas 2 Príncipios do tratamento efetivo
3 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.
4 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
5 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 a Rating Scale: 0, +, ++, +++, (?) b Rating Scale: Low, Moderate, High
6 Taxation Strategy or Intervention Effectiveness Research Support X- Cultural Testing Cost Target Group Alcohol Taxes Low General Population
7 Regulating Physical Availability Strategy or Effectiveness Research X- Cultural Cost Target Group Intervention Support Testing Total ban on sales High General Population Minimum legal purchase age Low High Risk Group Rationing High General Population Government monopoly of retail Low General Population sales Hours and days of sale restrictions Low General Population Restrictions on density of outlets Low General Population Server liability Low High Risk Group Different availability by alcohol strength Low General Population
8 Modifying the Drinking Context Strategy or Intervention Outlet policy to not serve intoxicated patrons Training bar staff and managers to prevent and better manage aggression Voluntary codes of bar practice Enforcement of onpremise regulations and legal requirements Community mobilization Effectiveness X- Cultural Testing Research Cost Support Moderate High Risk Group Target Group Moderate High Risk Group O + + Low High Risk Group High High Risk Group High General Population
9 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.
10 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
11 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 X- Cultural Testing Cost Target Group Moderate General Population Moderate General Population Low General Population Moderate Harmful Drinkers Low High Risk Group Low High Risk Group O + + Moderate High Risk Group
12 Education and Persuasion Strategy or Intervention Alcohol education in schools College student education Public service messages Warning labels Effectiveness X- Cultural Testing Research Support Cost Target Group O High High Risk Group O + + High High Risk Group O Moderate General Population O + + Low General Population
13 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.
14 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.
15 Regulating Alcohol Promotion Strategy or Intervention Advertising bans Advertising content controls Effectiveness Research Support X- Cultural Testing Cost Target Group Low General Population? O O Moderate General Population
16 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.
17 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).
18 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.
19 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 X- Cultural Testing Research Support Cost Target Group Moderate High Risk Group High Harmful Drinkers Low Harmful Drinkers Moderate Harmful Drinkers
20 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
21 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
22 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.
23 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.
24 13 Princípios do Tratamento Efetivo NIDA
25 Princípios Tratamento Efetivo 1 Nenhum tratamento é efetivo para todos os pacientes
26 Princípios Tratamento Efetivo 2 O Tratamento necessita ser facilmente disponível
27 Princípios Tratamento Efetivo 3 Tratamento deve atender às várias necessidades e não somente ao uso drogas
28 Princípios Tratamento Efetivo 4 O tratamento necessita ser continuamente avaliado e modificado de acordo com as necessidades.
29 Princípios Tratamento Efetivo 5 Permanecer em tratamento por período adequado é fundamental para a efetividade
30 Princípios Tratamento Efetivo 6 Aconselhamento e outras técnicas comportamentais são fundamentais para o tratamento
31 Princípios Tratamento Efetivo 7 Medicamentos são importantes, principalmente quando combinados com terapia
32 Princípios Tratamento Efetivo 8 A comorbidade deveria ser tratada de uma forma integrada
33 Princípios Tratamento Efetivo 9 Desintoxicação é só o começo do tratamento
34 Princípios Tratamento Efetivo 10 O tratamento não necessita ser voluntário para ser efetivo
35 Princípios Tratamento Efetivo 11 A possibilidade de uso de drogas deve ser monitorada
36 Princípios Tratamento Efetivo 12 Avaliação sobre HIV, hepatites B e C e aconselhamento para evitar esses riscos
37 Princípios Tratamento Efetivo 13 Recuperação é um processo longo e muitas vezes necessita vários episódios de tratamento
38 ABORDAGENS VOLTADAS À FAMÍLIA ALBERGAGEM & TRANSPORTE ASSESSORIA & PSICOTERAPIA CRECHES PROCESSO DE ENTRADA E AVALIAÇÃO PLANO DE TRATAMENTO MONITORAMENTO (USO DE DROGAS) ORIENTAÇÃO VOCACIONAL SERVIÇOS DE SAÚDE MENTAL ORIENTAÇÃO FINANCEIRA EQUIPE MULTIDISCIPLINAR FARMACOTERAPIA OUTROS SERVIÇOS MÉDICOS APÓIO JURÍDICO CUIDADOS CONTÍNUOS ORIENTAÇÃO E DIAGNÓSTICO PARA DST-AIDS ABORDAGENS EDUCACIONAIS Os melhores programas de tratamento provêm uma combinação de terapias e outros serviços para satisfazer as necessidades do paciente. FONTE: NIDA.