FAMILY OF USERS OF PSYCHOACTIVE SUBSTANCES IN SEARCH OF CARE* FAMILIARES DE USUÁRIOS DE SUBSTÂNCIAS PSICOATIVAS EM BUSCA DE CUIDADO FAMILIARES DE USUARIOS DE SUSTANCIAS PSICOACTIVAS EN BUSCA DE CUIDADO

Objective: to describe the experiences of family members of psychoactive substance users in search of care in the psychosocial care network. Method: this is a quantitative, exploratory, and cross-sectional study, with 29 family members of users of psychoactive substances hospitalized with physical trauma, reported to an information and toxicological assistance center, using a semi-structured script and home interviews. Data were compiled in an electronic spreadsheet using Microsoft Office Excel 10.0 software and analyzed using simple descriptive statistics. Results: it is revealed that family members lived, on average, for 20.8 years with domestic addictive behavior, especially the use of alcohol, in a scenario of short periods of relapse and abstinence and high intrafamily and social violence. There was high access to emergency hospital services and low access and link to primary care and community-based services. After hospitalization due to trauma, 15 family members (51.7%) reported a decrease in addictive behavior, on average, for 30 days. Conclusion: it is concluded that the opportunity to stop the cycle of addiction and continuity of care, focusing on psychosocial care and family arrangement, did not happen in the investigated families. Descriptors: Health Services; Social Support; Health Services Accessibility; Substance-Related Disorders; Public Health Nursing; Family Health.

Understanding public policies and social relations associated with the increased consumption of psychoactive substances in urban spaces in one of the great issues nowadays, and the complexity of the dimensions related to abuse (biological, psychological, social, cultural) demands varied options for the use prevention and care for the user, which combine integrated interventions based on a cognitive-behavioral and self-help type, drug treatment and social reintegration strategies for the drug users and their family members, usually codependents, with the available provision of care services. [1][2] The Psychosocial Care Network was established, within the scope of the Unified Health System (SUS), based on services to assist people with mental suffering or disorder and with needs resulting from the use of psychoactive substances. The network is guided by the creation, expansion and articulation of health care support, with an emphasis on care in territorial and communitybased services, consisting of elements in the spheres of primary health care, specialized psychosocial care, urgency and emergency care, temporary housing, hospital care, deinstitutionalization strategies and psychosocial rehabilitation. [3][4] In this context, the Psychosocial Care Network can be understood as an assistance network focused on community care associated with the health and social services network, always considering that the provision of care to people who have problems resulting from the use of alcohol and other psychoactive substances must be based on out-of-hospital psychosocial care arrangements. Among the spaces and strategies for coping with the abuse of psychoactive substances in health, a referral is made to Primary Health Care, Specialized Psychosocial Care, Urgent and Emergency Care, Temporary Housing and Hospital Care. [4][5][6] In the prevention and care strategies scenario, family members are invited to actively participate in the implementation of unique therapeutic projects for people with needs resulting from the use of psychoactive substances, as they are privileged actors to provide better care conditions. There are concerns about how and when people seek help for their health problems or demands, which has been increasingly present in studies on the planning, organization, and evaluation of assistance services. [7][8][9][10] Studies on support for families of users of psychoactive substances considered the family environment to be very stressful, both for the user and for family members, and the strengthening of families to experience this routine depends on the support of friends, neighbors and professionals in the social and health fields. 11 The Family Health Strategy (FHS), in the scope of Primary Health Care, became the policy that induces changes in care models, support to the health care process, in the territorial scope, for their care centered on user embracement and bonding, which is responsible for coordinating care and continuity of care, focusing on the family arrangement. 12 Based on these references, the experiences of family members of psychoactive substances users seeking care in the psychosocial care network were outlined as a matter of study, considering the importance of the provision of services, accessibility, and continuity of care.
• To describe the experiences of family members of users of psychoactive substances searching for care in the psychosocial care network. This is an exploratory and cross-sectional study, conducted through home interviews with family members of users of psychoactive substances as key informants and analyzers of the care provided to the family member who uses the Psychosocial Care Network strategies, in an intentional sample.
The inclusion of 29 family members of users of psychoactive substances in the study resulted from the hospitalization of people with a medical diagnosis of physical trauma associated with intoxication due to psychoactive substances abuse reported to the Poison Control Center of the Hospital Universitário Regional de Maringá, between April and September 2014. Physical trauma associated with intoxication by psychoactive substances abuse has been considered as a sentinel event in a program for epidemiological surveillance and monitoring of the repercussions of the use of psychoactive substances on family health and of access to public policy provisions on psychoactive substances. 13 For the selection of the study sample, the intoxication report forms for psychoactive substances were checked to identify cases of physical trauma associated with intoxication due to psychoactive substances. Initially, 171 reports of psychoactive substances intoxication were found, of which, 100 were associated with physical trauma, 63 were residents of the municipality of Maringá, 49 had family ties and 29 family members agreed to participate in the research. It is highlighted that, for the registration data, the first contact to the family member was made through a telephone call to invite to participate in the study, with the scheduling of a home interview, up to 60 days after the occurrence of the trauma. At home, care was taken to ensure METHOD OBJECTIVE INTRODUCTION that the interview was held in a private place to preserve the confidentiality of information provided by the family member, avoiding embarrassment for the family member and the user.
The data collection instrument was a semistructured script, with questions for the characterization of the research participants, aspects related to the abuse of psychoactive substances throughout the family's life and the services to seek help, accessed by the family member and/or user of psychoactive substances. Data were collected in a home interview, recorded in full on a digital device, with prior authorization from research participants, in a single meeting, with an average time of 70 minutes, using the narrative approach.
In the step after collection, data exploration was carried out, compiling them in an electronic spreadsheet in Microsoft Office Excel 10.0 software and analyzing them using simple descriptive statistics (absolute and relative frequencies The elements associated with the abuse of psychoactive substances and which marked the experience of families are shown in table 2. It was shown that 22 family members believed that the reason to begin the use of psychoactive substances was motivated by living with other users of psychoactive substances, in the family or the neighborhood, and in 16 families, the family addictive behavior was reported. Repeated violence in childhood was found in 12 users, and 22 family members referred to the current family violence and aggressive user behavior. The long period using psychoactive substances was marked by phases of abstinence, relapses and living with social violence; seventeen users were never able to go for more than six months without using drugs and twenty-four had some physical trauma before the current hospitalization: physical aggression (10); fall (9) and road accident (5).
It is described, in table 3, the occurrence of physical trauma and access to services of the Emergency Care Network. In the hospital service, it was found that the average hospital stay was 4.9 days and the assistance provided to the user was assessed as good/excellent by 22 family members. After hospital discharge, 15 users were referred to community-based services: Basic Health Unit (14) and Psychosocial Care Center for Alcohol and Drugs (01).
It was found that fifteen family members reported turning point or decreased addictive behavior to a controlled pattern of use after hospital discharge for about 30 days, with a decrease in family conflicts and an opportunity to approach treatment.

 The mental health network services accessed by family members seeking help
It is pointed out that, although the average time using psychoactive substances was 20.8 years, the time to recognize the harm from use and dependence by families was, on average, 4.1 years and, after recognition of the severity of the individual and family condition, 16 families said they immediately started "seeking help" in the public health system, but 13 did not access the services, stating that users refused to accept treatment.
However, it was reported by 18 (62.1%) family members, who were in a constant search of strategies to stop/reduce harm from the abuse of psychoactive substances by the user. Community-based health and social services were accessed by these families, such as the Basic Health Unit (01 -3.4%), the Psychosocial Care Center for Alcohol and Drugs (05 -17.2%) and the Social Assistance Reference Center (02 -6.9%), but, above all, care services in hospitalization and user embracement, such as the psychiatric hospital (10 -34.5%), the therapeutic community (11 -37.9%) and general hospital (01 -3.4%), besides nongovernment services: church (03 -10.3%) and mutual aid groups (04 -13.8%).
The literature was confirmed by the characteristics of the users studied for sex, age, and marital status. Male users of psychoactive substances are 2.4 times more likely than women to be victims of trauma and are more predisposed to risky behaviors. Considering the particularities of the studied group, users and families who are typical of social vulnerability: unemployed; family addictive behavior and living with the use of psychoactive substances in the family and the neighborhood.  It is known that alcohol, due to the easy access and the social appreciation that this drug represents in society, is present in family contexts and its use by one family member can stimulate the other and the greater the number of alcohol DISCUSSION users in the home, the greater the risk of negative impacts in the family. 17 The strong association between family history of drug use and drug abuse in youth and adulthood, with an intergenerational pattern of aggravation and inclusion of other types of drugs in the family, can provide an expansion of using harmful drug use in the family. 18 It is pointed by the elements associated with the abuse of psychoactive substances in the experience of families, as contexts of family and social violence and living with addictive family behavior, that the circulation of psychoactive substances, in most families, reaches intergenerational standards, with decades of coexistence with drug abuse and their repercussions and a pattern of interruption of care, although there is the discontinuity of use, with periods of abstinence and relapse. 9 Intrafamily violence, expressed as aggressive behavior and aggravated by behavioral changes resulting from drug intoxication and social violence, with repeated episodes of road accidents, falls and physical aggression in the outdoors environment, impair the well-being of members of families.
In these episodes, it can be assumed by the easy access to the pre-hospital emergency care on the day of the event and the time between the search of care and the provision of service, evaluated by the family members as positive, that the component of pre-hospital is in line with the guidelines for care for people in urgencies and emergencies and people with disorders due to the use of psychoactive substances, considering that the majority also had a clinical condition compatible with acute intoxication by psychoactive substances, having the aggressiveness as the main sign. Users construct evaluation criteria associated with their value judgments, and their perception is complex, as it is affected by various factors such as previous health care experiences, in which conditions they happened and their current health status. 11,13 Concerning the severity of drug use, an expanded object of this study, it is inferred that all users had a relevant relationship with the drug and harm to health, comprising subjective, family, organic, social, economic and cultural aspects, which accompany a radical transformation of the family, changing the individual's relations with himself, with others and with life. The abuse of psychoactive substances was a chronic condition in the family, however, signs of worsening of this condition, such as the uncontrolled pattern and binge drinking, were strongly related violence, aggression and repeated trauma and violence. 15,17 This harmful use cycle was repeated in the experiences of abstinence and relapse that can be attributed to experiential contexts, such as the addict's awareness of the addictive problem, the rescue of family bonds, recovery of self-esteem, avoiding environments that favor the drug use or involvement in religious practices. However, it is shown that the crucial links to the abstinence experience were interpersonal support networks, made up of family members and new friends, the involvement as collaborators in the recovery of other drug addicts, as well as the link with health services and professionals. 9,15 Relapse is defined as a return to the use of psychoactive substances after a period of abstinence, associating it to the lack of family support -not verified in this studyand to the lack of appropriate professional monitoring.
It is believed that the period of hospitalization, for the treatment of trauma, seemed to be an important moment in the individual's life, which favors the cessation of drug use and provides a period of abstinence or controlled pattern of use after hospital discharge, since the majority of users showed signs and symptoms of abstinence during the days of hospitalization and was managed clinically in the hospital to reduce this event. Family members reported an improvement in addictive behavior in the month following hospital discharge, with a decrease in the use of psychoactive substances and the consequent decrease in family conflicts.
Considering the importance of these periods of abstinence for actions or implementation of a therapeutic project, with a focus on harm reduction/cessation of drug addiction, continuity of care, focused on primary health care and specialized psychosocial care, as well as the family unit, coordinated by the Family Health Strategy, it would represent an opportunity to break the cycle of addicition. 4,6,12 The Family Health Strategy, with its territorial and cultural immersion, facilitates work on family and social relationships, the exploration of therapeutic bonds and the use of community resources. 12 The family can be a protective or risk factor for the use of psychoactive substances in the relapse prevention phase. The best communication with families would be to intensify information about the health status of the family member and the appropriate treatment. Besides, the relationship with health professionals should come from proper care and interest in family health, explanations about doubts (signs, symptoms, grievances), being able to build a bond from that moment. 10,19 Most users were referred to the continuity of care and intervention in basic health units, but assistance in these units focused on physical changes related to trauma, such as wound treatment and evaluation of treatment based on medications, without relating them to psychosocial problems. The care provided in these units should mean a moment centered on the family dimension and opportune to the empowerment of the family, aimed at facing drug abuse in community-based services, avoiding the relapse use pattern and traumas. 20 Patterns of drug use can be changed by health interventions, however, the critical factors in abstinence are not only related to treatment or even personal adaptation, but the severity of dependence and the actions proposed in treatment. The increased risk of relapse is proportional to the time of intervention or the professional approach. [9][10] The extension of mental health care to primary care consists of a strategy of expanding access and the teams' ability to identify and solve problems in the face of mental health needs, which are usually accompanied by other clinical demands, which should not be neglected. Besides, meeting these needs reduces the stigma of mental disorder, allowing the detection of risk factors and the contextualization of demand where the user lives, contributing to more effective clinical and social results. 19 Concerning the search of social and health services, in some families in this research, the lack of motivation to seek help from outside the family was based mainly on the user's refusal to accept treatment, on the belief in spontaneous cessation and on drug abuse as a condition of marginality and not as a mental disorder. It is believed, although they did not seek outside help, based on the narratives, that they relied on other family members, friends, neighbors, and coworkers, setting up an informal support network.
It is highlighted that, although there is a psychosocial care network with established guidelines and objectives, the paths took by drug users and their families in search of therapeutic care do not necessarily follow predetermined schemes or flows. Their choices express individual and collective subjective constructions about the illness process and ways of treatment, forged under the influence of different factors and contexts. These choices will define actions that, step by step, will constitute a certain path or trajectory. 10 It is indicated that, although there are care protocols and flowcharts well established by the care network in Maringá, individuals can outline their unique paths to the official system, through their choices, based on their own needs, conceptions, stigmas and social determinants. It was observed, in this regard, a "preference" for hospital care and the narrative of assumptions of the hospital-model prevailing over the psychosocial model, with most families seeking admission to exclusively psychiatric hospitals. This narrative of the use of hospital contradicts what was advocated for the Health Care and Support Network for Alcohol and Drugs [4][5][6] The external support network for families was composed mainly of inpatient care services, still with the exclusion paradigm of the individual with a mental disorder, through assistance focused on the hospital, as well as therapeutic communities and the general hospital, although these were mentioned less frequently. When considering the principles of health care at the community level, the attributes of primary health care and that the municipality studied has adequate coverage in the family health strategy, it is possible to judge that few families elected community-based services and institutions as supporters of the coping with drug abuse process in the family. 21,22 It is highlighted by some international researchers, the issue of the link to mental health services and care as a crucial aspect, once resources alone do not guarantee equal accessibility of these services, that is, the need and access tend to vary inversely. The concept of access includes both the geographic-spatial perspective, as well as the resoluteness of the actions, which is decisive for the users' confidence in the help/care that will be provided by the health service. 18,23 Also, most families were unaware of community-based services and used only those providing emergency in health care, psychiatric emergencies, and psychiatric hospitals. Family access to health services could represent the opportunity for health professionals to plan actions aimed at preventing drug use and planning a reduction in the impacts of harmful use in the family context. 7,10 It is noteworthy that there was no report from family members on the care provided by community health workers nor from other Family Health Strategy workers. This fact may indicate a lack of knowledge about the reality of families in the territory or who are served by public services. It is noticed that the action of these professionals would be to subsidize the choice of appropriate strategies that guarantee access to users at an opportune time and continuously, providing a link with the team of health professionals and, consequently, adherence to the proposed treatment. 10,24 The absence of a link in Primary Health Care and other public services of low and medium complexity may have contributed to families seeking services of high complexity, such as emergency rooms, psychiatric emergency and psychiatric hospital, looking for assistance for the severe consequences of psychoactive substance abuse, not just for repeated physical trauma. It is warned, however, that the emergency care/hospitalization process does not allow the establishment of a therapeutic bond, as users access these services for episodic problems and, after resolving the complaint, they are discharged, get better and remain without follow-up care related to the abuse of psychoactive substances.
Access to non-SUS therapeutic communities, with direct payment for treatment, involves the interface of public policy deficiency, repercussions of drug abuse and family suffering because even though the families reported an impact on the family budget, they paid for the treatment, which was seen as the only resource available and with the possibility of solving the problem.
As for the bonds that need to be kept, strengthened, and broken in the care process, social and informal support needs to be maintained, as it was essential for the investigated families. It was identified in the family experience, that several people influenced the decisions about prevention and care: family members; neighbors; friends and community members. This social circle makes connections that bring people together and can be modified over time and with changes in life and becomes an aid, which can be adopted in the case of illness. 14,24 There is a need to strengthen the links that favor the care process, such as continuity of care in community-based service and a psychosocial care center for alcohol and psychoactive substances, the use of the social assistance reference center and the basic health unit need to be strengthened in the studied family groups, as they are the basis of the Psychosocial Care Network and the Drug Dependency Care and Support subsystem. 4,6 The initial care and continued use of a psychiatric hospital, the family's financial burden with the payment of "treatment" in non-SUS therapeutic communities and access to health services only in the traumatic event and clinical complications need to be weakened, due to low resolution in the face of drug abuse, as they are accessed only in times of aggravation of the case and represent a failure in public policies to fight drugs. 12,14 The present analysis represents possibilities for understanding the object under study, as it used only narratives from family members of drug users, however the family members' satisfaction or dissatisfaction must be valued and understood as a movement process towards the qualification of health care. Besides, it was possible to describe weaknesses in the identification and access to services and the family members reported being satisfied with some points of the care network, for example, when the referral and the consequent attendance to the emergency were fast, relieving the family burden.
The experience of drug abuse by these families was marked by continuity/discontinuity for short periods and addictive behavior for a long period, by a high intrafamily and social violence and by repeated traumatic events of the investigated drug user family member.
It was observed high access to emergency hospital services, and low access and link to primary and community-based services, although these are the most suitable for the continuity of care for drug users and their families. After hospitalization for trauma, 15 family members (51.7%) reported a turning point and decreased addictive behavior, on average, for 30 days, but this opportunity to break the cycle of dependence and continuity of care, focusing on psychosocial care and the family unit did not happen.
There is a need to strengthen family bonds and behaviors that favor the care process, such as access to social support networks, requiring families not to lose contact with their social environment, but there is a need to link and welcome these families into community-based services, in an articulated and resolute network of psychosocial care. Families need to be included in this network before the worsening of cases and subsequent admittance in emergency services.
Also, the assistance provided in hospitalization due to grievances associated with drug use could include in the discharge guidance a reference for the user and the family of community-based services, for continuity of care, with a focus on harm reduction/abstinence, and comprehensive care.
It is recommended to health professionals and those who work in the Psychosocial Care Network and support services for families of drug users, that they assume a comprehensive and inclusive posture, to avoid the early use of drugs, to help those already involved not to become addicted and to those already addicted to offering options to stop the drug abuse or less harmful patterns of use. Nursing, in the main perspective of professional performance, should promote access and quality user embracement for drug users and their families and strengthen practices to face the use of psychoactive substances continuously and comprehensively.
It is informed that all authors contributed equally in the design of the research project, collection, analysis and discussion of data, as well as in the writing and critical review of the content with intellectual contribution and the approval of the final version of the study.
None to declare.