/ Dependência Química / Dependência Química: Prevenção e Tratamento
Data: 25/05/2018 ás 13:27

Dependência Química: Prevenção e Tratamento

A história da dependência química acontece desde o início da humanidade, embora a atenção à essa condição só tenha ocorrido no último século. Dependência química é o uso frequente e exagerado da droga, com ruptura dos vínculos afetivos e sociais, é a perda da liberdade de dizer não à droga à qual o organismo se adaptou, seja droga lícita ou ilícita.

Segundo o dicionário Aurélio, droga é “qualquer substância capaz de modificar a função dos organismos vivos, resultando em mudanças fisiológicas ou de comportamento”. Na definição da OMS é “qualquer produto, lícito ou ilícito que afeta o funcionamento mental e corporal do indivíduo e que pode causar intoxicação ou dependência”.

As drogas são classificadas em três categorias, de acordo com a sua ação no sistema nervoso: Depressores do Sistema Nervoso Central, englobando o álcool, benzodiazepínicos, inalantes, opiáceos naturais, sintéticos e semissintéticos; estimulantes do Sistema Nervoso Central, englobando anfetaminas, cocaína e seus derivados; e ainda os Perturbadores do Sistema Nervoso Central, onde encontra-se vegetais (mescalina, maconha, psilocibina, trombeteira) e sintéticos (LSD, ecstasy).

Precede a Dependência, o fenômeno conhecido como tolerância, no qual o organismo sempre pede uma quantidade maior da droga para obter o efeito de prazer antes obtido com menor quantidade. Tal fenômeno é devido à sobrecarga dos sistemas enzimáticos do fígado, principalmente o citocromo P450 que desempenha uma função adaptativa, transformando produtos estranhos ao organismo em substâncias menos ativas.

No Brasil, segundo estatísticas, 10% da população adulta é acometida pelo alcoolismo e 2% é dependente de outras drogas. Não incluindo o tabagismo, pois se assim fosse, teríamos o número assustador de um dependente para cada dois habitantes (Busnello). Temos, portanto, um quadro preocupante e merecedor de atenção na Saúde Mental.

Nos últimos anos, devido ao aumento da incidência da enfermidade, muito se tem explorado para tentar compreender a gênese da dependência química, assim como criar mecanismos eficazes de prevenção.

O sujeito propenso ao uso de drogas, segundo a OMS, é uma pessoa sem informação adequada sobre os efeitos da droga; com saúde deficiente; insatisfeito com sua qualidade de vida (falta ou excesso); com personalidade deficientemente integrada; com fácil acesso às drogas. Segundo Zaitter, o vício tem início sob quatro aspectos principais:

  • Problemas emocionais – 65%
  • Curiosidade – 20%
  • Exibicionismo ou autoafirmação – 10%
  • Problemas mentais – 5%

Segundo Hawkins, quatro elementos têm se mostrado protetores contra a adicção: forte ligação com os pais; compromisso escolar; envolvimento regular em atividades religiosas; crença em normas e valores da sociedade.

É uma patologia que atinge todas as classes sociais e todo tipo de família. Porque algumas famílias são bem-sucedidas na criação de seus filhos, evitando assim a adicção e outras não? Segundo Baurind (1968), os pais são classificados em quatro categorias: pais competentes, pais autoritários, pais negligentes e pais ausentes. Os pais competentes demonstram confiança em si próprios, como pais e como pessoas. São confortadores e afetuosos mas estabelecem limites e padrões de conduta. Disciplinam os filhos quando esses padrões são rompidos, explicando a lógica da disciplina e tendem a não utilizar força física como punição. Exercem a autoridade sem serem autoritários. Seus filhos tendem a ser maduros, independentes, autoconfiantes e com autoestima elevada. Os pais autoritários são os que dizem aos filhos o que fazer sem explicar as razões, estabelecem padrões de conduta rígidos sem levar em conta a necessidade dos filhos, consideram a obediência uma virtude absoluta, quando os padrões são rompidos a punição é insensata e sem explicação, não encorajam discussões. Seus filhos tendem a apresentar baixa autoestima e dependência. Os pais negligentes são inseguros como educadores, geralmente são afetivos e calorosos mas exercem pouco controle, como se tivessem medo de serem autoritários, organizam a família como uma pseudodemocracia abdicando do poder de decisão e responsabilidade. Seus filhos tendem a ser inseguros, imaturos e dependentes. Já os pais ausentes manifestam rejeição através da ausência de atenção e afeto, privando a criança de limites definidos e do alimento afetivo necessário para o reconhecimento de sua própria existência. Seus filhos têm dificuldades no convívio social e é comum encontrar esse tipo de característica nos adolescentes usuários de drogas.

Além do desenvolvimento e criação adequada, é no mínimo irresponsável negar o papel da exposição do indivíduo ao ambiente como elemento influenciador ao estabelecimento da adicção. A mídia enquanto “mãe substituta” pode modificar comportamentos. Estudos mostram que nos Estados Unidos, uma criança entre 6 e 17 anos gasta 18.000 horas exposta à televisão e 12.000 horas na sala de aula. Em média, a TV nos EUA veicula por ano 14.000 propagandas com referência sexual, 2.000h com referência a bebidas alcoólicas e 1.000h com referência a assassinatos, estupros e assaltos. Um adolescente ouve rádio, em média, 18,5h durante a semana e 12,8h durante o fim de semana. Em revistas, carros são os primeiros, cigarros os segundos produtos mais anunciados. Bebidas alcoólicas também são muito divulgadas. Em Washington, 1988, uma pesquisa mostrou que crianças entre 8 a 12 anos conseguiam lembrar de mais nomes comerciais de bebidas do que de presidentes americanos.

Várias abordagens psicológicas tentam explicar a dependência química por diversos fatores. Nenhuma delas consegue explicar tal fenômeno na sua totalidade. Talvez, a forma mais compreensível seja a complementação que uma teoria pode ser à outra. Deve-se compreender a Dependência Química considerando as teorias como includentes e complementares e não excludentes.

A Psicanálise contribui para a compreensão da gênese dessa condição com algumas hipóteses. São elas: teoria das gratificações narcísicas, teoria da oralidade, teoria das perversões, e teoria das relações maníacas.

Não pretendo explorar profundamente cada uma das teorias, mas superficialmente informá-las.

Teoria da Gratificação Narcísica: -Freud, em 1897 escreveu "... comecei a compreender que a masturbação é o grande hábito, o vício primário, e que é somente como seu sucedâneo e substituto dela que outros vícios - álcool, morfina, tabaco, etc. - adquirem existência. “ -Enfatizava a possibilidade de, através das substâncias psicoativas, alguém conseguir prazer, sem a necessidade da colaboração de outra pessoa. Simmel (1930) endossa tal pensamento ao afirmar que " as mães dos toxicômanos, não raro, são sedutoras e superindulgentes enquanto mãe nutrícia, retirando, elas mesmas, um prazer auto erótico do amamentar", concorda Knight(1937) acrescentando que: "elas procuram aplacar o bebê satisfazendo-o constantemente, de modo que o desmame eventual da criança só poderá significar traição da mãe”. Desta forma a etapa da separação com posterior individuação (Mahler,1975) seria comprometida, favorecendo-lhes o envolvimento futuro com as drogas.

Para Rosenfeld (1960) os bebês seriam portadores de inveja primária do seio materno, o que leva o indivíduo, a precocemente preterir o seio em favor de seu próprio polegar. A droga, nesta perspectiva, seria um substituto deste polegar.

Em 1987, Olievenstein e seus colaboradores, concentraram seus estudos na questão da falta. Segundo estes autores, há a possibilidade do sentimento da falta propiciado pela maternagem inadequada se sobrepor ao prazer narcísico associado às drogas. As mães insuficientemente boas gerariam um estado de crônica falta. Uma falta descomunal e jamais saciável. Nessa perspectiva, o depender de drogas seria o resultado do deslocamento deste sentimento de falta para um objeto, com a vantagem de este ser alcançável em qualquer esquina do mundo.

Teoria da Oralidade: Freud (1905) destacou a presença de fixações orais em dependentes químicos. Escreveu em seus três ensaios sobre a teoria da sexualidade: "...da importância erógena da região labial, constitucionalmente determinada. Se esta importância persistir, estas crianças quando crescerem, tornar-se-ão epicuros do beijo, inclinar-se-ão ao beijo pervertido, ou, se do sexo masculino, terão poderoso motivo para beber e fumar."

Teoria das Relações Maníacas : Sob o efeito das substâncias psicoativas, o indivíduo experimenta sensações de enaltecimento pessoal, com consequente reforço da onipotência, fato que sempre chamou a atenção dos vários psicanalistas, que tentaram melhor entender a psicodinâmica dos dependentes químicos. Assim é que Freud (1917,1927) destacou a relação entre a elação alcóolica e a mania. Para Rosenfeld (1960) "a toxicomania intimamente se relaciona à doença maníaco-depressiva, conquanto não lhe seja idêntica... o ego dos toxicômanos é fraco e não dispõe de força para suportar o peso da depressão e, por isso, recorre, com facilidade, aos mecanismos maníacos, mas só alcança a reação maníaca com o auxílio das drogas ...Caracteristicamente defendem-se com idealizações, identificações com o objeto ideal e o controle onipotente dos objetos".

Clark (1919) direcionou sua atenção para a importância do exame da relação entre depressão e dependência química. Nisto foi seguido por uma infinidade de outros pesquisadores que tiveram sempre o desafio de tentar separar qual condição determinaria a outra.

Seja, no entanto, mania ou depressão, do ponto de vista destas contribuições, estas seriam condições prévias, onde o uso de substâncias psicoativas apareceria como subproduto.

Teoria das Perversões: Desde 1912, (Freud) a psicanálise estuda a relação da dependência química de uma forma geral, e do alcoolismo em especial, com fantasias homossexuais. Para Freud o álcool seria capaz de levantar as inibições e desfazer o trabalho da sublimação. Em consequência disto a libido homossexual se liberaria.

Abraham (1908) concorda com isso, sustentando que o comportamento, muitas vezes criminoso, de alcoolistas se daria devido a liberação, pelo álcool, de perversões como o sadismo e o masoquismo.

A Dependência química é uma doença crônica com danos lentos e irreversíveis física e psicologicamente. No DSM-IV-TR (Diagnostic and Statistical manual of mental disorders) aparece como transtornos relacionados a substâncias.

Cada classe de drogas conduzirá, no decorrer do tempo, a diferentes danos pois afetará diferentes sistemas de neurotransmissores.

Robinson e Berridge (1993) estudaram os diversos efeitos das drogas no organismo e concluíram que substancias psicoestimulantes levam a uma concentração maior de dopamina no núcleo accumbens resultando em um comportamento psicótico com alucinações e delírios.

Alterações comportamentais como agressividade exacerbada, comportamento antissocial e perda de memória, perda de valores morais e éticos são implicações comuns do abuso de substâncias.

Ernest Simmel (1947) afirma que o supereu é solúvel em álcool, ou seja, o superego do alcoolista, sob o abuso da substância, se torna menos permeável à censura, perdendo referências morais e éticas.

As mudanças comportamentais do adicto ocorrem na esfera biopsicossocial. Na esfera física podem se evidenciar episódios amnésicos, sintomas de abstinência, acidentes frequentes, reações tóxicas agudas (vômitos, estado confessional, convulsões, dores abdominais), preocupação excessiva com a saúde geral. No âmbito escolar pode-se observar queda no rendimento escolar, aumento do número de faltas, dificuldade de memória e concentração, problemas disciplinares. Em áreas legais nota-se maior incidência de acidentes/ multas de trânsito, amigos com história criminal, atividades criminais. Na atuação familiar: conflitos pais/filhos, afastamento das atividades da família, desaparecimento de dinheiro ou objetos da casa. E ainda é possível constatação através de evidências laboratoriais, como a exemplo, pode-se dosar na urina até um certo tempo após o uso, que varia de acordo com a droga. Assim: cocaína – presente na urina de 8 a 48h. Opiáceos – presentes até 84h. Maconha – de 7 a 34 dias depois do consumo.

Frequentemente os familiares protelam ou utilizam-se do mecanismo de defesa de negação para não aceitar a possibilidade de ter um de seus membros envolvidos com drogas.

Dependendo do tempo de uso e da instalação da dependência química, muitas vezes o único tratamento possível é a internação clínica, a qual, na maior parte das vezes é involuntária num primeiro momento.

De acordo com a Federação Brasileira de Comunidades terapêuticas (FEBRACT), no estado de São Paulo, há filiação de 46 instituições, entretanto, por não ser um órgão de filiação obrigatória, é estimado a existência de um número bem maior, sem contar as clínicas e hospitais médicos especializados no tratamento da dependência química.

Escolher uma instituição que ofereça uma proposta terapêutica eficaz, que tenha instalações adequadas com profissionais devidamente treinados e ofereça uma estrutura real de trabalho terapêutico e reinserção social é, para os familiares leigos do tema e surpresos pelo acometimento da doença, um desafio que muitas vezes premedita o fracasso do objetivo a que se propõe uma internação para reabilitação.

Há, entretanto, alguns critérios que devem ser levados em conta, na escolha de uma instituição adequada. Os familiares devem preceder uma visita antes de uma escolha definitiva, quando se observa itens básicos como instalações e acomodações para o interno, higiene, estrutura de lazer, presença de profissionais diversos da área de saúde tais como psicólogos, psicanalistas, terapeutas, assistente social, monitores, professor de educação física, médico psiquiatra e médico clínico geral, possibilidades e recursos de atendimento a emergências clínicas, plano e rotina diária de atividades, cardápio diferenciado para dietas hipocalóricas ou hipoglicemias, programas de ressocialização na etapa final da internação, programa de assistência familiar e acompanhamento pós-internação. São critérios que determinam ou não o sucesso do tratamento.

A maioria das instituições fundamentam seus projetos terapêuticos nos passos das Irmandades Anônimas, o que tem se mostrado muito eficiente e eficaz para o sucesso do tratamento.

O primeiro momento do interno, geralmente conturbado e de maior vigilância é a desintoxicação. Nessa etapa diversos fenômenos físicos se manifestam na síndrome de abstinência. O paciente geralmente estará mais irritadiço e agressivo e deverá ser acompanhado por um médico clínico geral ou psiquiatra. O uso de neurolépticos pode abrandar os sintomas de desconforto da síndrome de abstinência e assegurar a integridade física do paciente, geralmente prescritos pelo médico psiquiatra. Uma segunda etapa deverá ser firmada no objetivo da sensibilização e conscientização concentrada num número maior de atendimentos psicológicos e psicanalíticos individuais e grupais. A terceira etapa é a de reabilitação, na qual objetiva-se a mudança comportamental e o planejamento para o futuro. Na fase seguinte, a ressocialização, assistido por profissionais, o interno deverá ser reinserido gradualmente no seu mundo e consolidar as mudanças comportamentais. A última etapa é o acompanhamento do paciente no seu mundo. Paralelamente ao trabalho com o interno, a família poderá ser assistida e orientada quanto a atendimentos psicoterapêuticos familiares com o propósito de gerar mudanças que quebrem o padrão de co-dependência inconscientemente instalado nos cuidadores. É um trabalho de preparação para a reinserção futura do membro internado. Não existe um tempo determinado para cada etapa do tratamento, entretanto a singularidade do indivíduo, a complexidade da patologia e estruturação familiar deverão ser consideradas na determinação do tempo de duração de cada etapa.

As instituições terapêuticas para dependentes químicos têm uma ampla gama de atividades que podem ser psicoterapia individual e grupal, psicanálise individual e grupo analise, grupos de reflexão, grupos de AA e NA, grupos de partilha de sentimentos, palestras, vídeo terapia, educação física, artes marciais, laborterapia, grupos de práticas espirituais, etc...

O objetivo da internação é a priori, a quebra de padrão de abuso da substância, mas também uma preparação para a reinserção do indivíduo na sociedade, no exercício da sua cidadania e do seu papel familiar, conscientizando o de sua enfermidade e de sua cronicidade e colocando-o na posição de responsável pela manutenção constante da sua recuperação.

Findado o período de internação, faz-se importante a manutenção do tratamento através da assistência psicoterapêutica ou psicanalítica, dos grupos de apoio externos para o indivíduo e familiares, assim como acompanhamento psiquiátrico periódico.

A terapia medicamentosa poderá ser eficaz durante e pós-internação. Poderá ser o uso de neurolépticos para contenção dos impulsos e da compulsão ou também o uso de drogas aversivas específicas para o alcoolismo. Embora o Dissulfiram tenha sido, no passado, usado por muitos profissionais no combate ao alcoolismo, mostrou-se com o tempo, perigosa e obsoleta. Hoje, a indústria farmacêutica oferece a naltrexona e o acamprosato no tratamento de alcoolismo. Não se tem uma evidência concreta da eficácia dessas drogas, os dados até então encontrados são inconsistentes.

A manutenção da recuperação tende a ser bem-sucedida quando orientada por profissionais experientes, mas outros fatores têm se mostrado relevantes nesse processo, tais como o apoio e o acolhimento familiar; a criação de um ambiente propício à expressão de sentimentos e à pedidos de ajuda, quando necessários; a valorização do indivíduo e o respeito pelos seus direitos e liberdade e a estimulação à responsabilidade do indivíduo pelos seus atos.

A dependência química é uma doença crônica que leva o caos à estrutura familiar e que pode ser destrutiva e autodestrutiva, portanto requer tratamento especializado e participação de todos os membros cuidadores.


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