FACTORS THAT INTERFERE IN PATIENT COMPLIANCE WITH CHEMICAL DEPENDENCE TREATMENT : HEALTH PROFESSIONALS

Exploratory, qualitative research performed at a Psychosocial Care Center for Alcohol and Other Drugs in the metropolitan area of the city of Curitiba, Paraná, Brazil, from March to April 2013. This study aimed to identify health professionals’ perceptions on the factors that interfere in patient compliance with chemical dependence treatments. All health professionals from the Care Center participated in the research (9). Data were collected by means of semi-structured interviews and analyzed by Minayo’s Qualitative Data Interpretation, resulting in two categories: drug users’ intrinsic factors for treatment compliance, which entailed motivational influences, use of medication, and the type of psychoactive substance; and drug users’ extrinsic factors for treatment compliance, which included influences from the family, socioeconomics, and healthcare services. It could therefore be concluded that the identification of such factors may well aid in identifying more appropriate therapeutic intervention planning, in an attempt to increase both compliance and quality of life.


INTRODUCTION
Estimates from the United Nations Office on Drugs and Crime show that approximately 243 million people, a number corresponding to 5% of the population, consume illicit psychoactive substances, and of these, 0.6% develop a dependency to these substances, 1 causing an intense impact on their personal, family, social, and professional lives. 2,3hemical dependency is characterized as a chronic and multicausal disease expressed as the combination of physiological, behavioral, and cognitive phenomena resulting from the use of psychoactive substances, commonly associated with losses in various realms of one's own personal life. 3In an attempt to bring this medical condition under control, treatment for chemical dependence requires multiple psychotherapeutic and social interventions, counting on a multidisciplinary team that considers the individual in his/her totality, seeking both the individual's rehabilitation and his/her social reinsertion. 4][10] After the beginning of treatment, a patient's continuance is characterized as difficult to achieve; as the drug users face obstacles of lapses and relapses, few are able to remain abstinent and comply with the treatment. 4,6his perspective can be seen in a study developed at the Psychosocial Care Center for Alcohol and Other Drugs (CAPS AD) from the state of Piauí, carried out with 227 chemically dependent patients who were undergoing treatment, which explained that 56.8% (n=129) of the patients abandoned the treatment. 6This scenario has also been proven internationally, as it is estimated that between 20% and 70% of individuals that begin psychosocial treatment never actually finish. 11eanwhile, another study conducted in Spain revealed that, among 57 chemically dependent patients who were undergoing treatment at a rehabilitation center, 52.9% abandoned the treatment within a period of up to six months. 12ue to its magnitude, the non-compliance with treatment constitutes a public health problem that is responsible for many various forms of damage caused to one's own individual life and to family members, who are directly involved in the worsening of the disorder, the strain on the family, the inevitable hospitalizations, and the increase in the cost of healthcare services. 13t is believed that investigating this theme can lead to reflection and reorientation in professional practices in healthcare, through the construction, production, and development of knowledge concerning the factors that directly interfere in drug users' compliance with treatment, in an attempt to boost patient compliance and quality of life.Therefore, this study aimed to identify healthcare professionals' perspectives on the factors that interfere in drug users' compliance with treatment.

METHODOLOGY
The present work is an exploratory qualitative study conducted in a CAPS AD, located in the metropolitan region of the city of Curitiba, Paraná, Brazil.This healthcare service provides medical care, from Monday to Friday, for alcohol and drug users who are of 18 years of age or older.
All of the healthcare professionals from this center participated in this study, totaling nine participants: social worker (one), nurse (two), psychologist (two), general clinician (one), psychiatrist (one), occupational therapist (one), and nursing technician (one).The inclusion criteria to participate in this study were: be a member of a multidisciplinary mental health team and develop healthcare actions directly with the patient.
The participants were recruited during the weekly meetings of the multidisciplinary staff, an occasion in which all of the professionals gathered to discuss the clinical cases, the planning of activities, and structural questions.After agreement to participate, the interviewees were scheduled, considering the participant's preferred date and time.
The data were collected from April to May 2013, by means of a semi-structured interview, with the following guiding question: "what are the factors that benefit and hinder drug users' treatment compliance in a CAPS AD?" The interviews were recorded on a digital device and conducted individually in a location made available by the unit's administrative staff.
This study used the proposal of qualitative interpretation of data set forth by Minayo to perform the analysis, following the three proposed phases: ordering, classification, and final analysis of the data.The ordering of the data consisted of the transcription of collected audio material, the re-reading of the material, and the organization of the reports in an ordered manner.The classification phase of the data was conducted through the detailed reading of the collected material, aimed at comprehending the core ideas.In the end, the final analysis consisted of the interlinking of the findings and the theoretical foundations, which provided the basis of the thematic categories of this study.

[…] patients who come here by judicial order will most likely not comply with the treatment, because it is something that is not done on their own accord (P5).
The use of medication is a factor that influences treatment compliance, since some of the drug users have the illusion that by simply using medication they will be able to achieve rehabilitation and thus fail to comply with the rest of the proposed activities.However, medical treatment is only one of the many therapeutic resources and must be complemented with strategies for behavioral changes and therapeutic life planning: Compliance with medication is not the problem, because they think that they will only achieve rehabilitation if they use medication.However, this is not true, because motivation and behavioral changes are more important (S2).

The first thing they ask for when they come for treatment is medication. […] This is a problem, because we always need to educate the patients that the medication treatment is only an aid and not the treatment itself. The treatment also requires a process of behavioral change and a different project of life (S4).
The type of psychoactive substance consumed directly influences treatment compliance, given that users of multiple drugs and crack comply with treatment less than do those who are addicted to alcohol.The low compliance on the part of crack users is possibly related to the effects caused in one's body and the intense addiction, which generates: The users of multiple drugs, especially crack users, have difficulty complying with treatment.The users who are addicted only to alcohol comply more easily, as they are people with a more chronic disease, who have suffered more, and who are older (P2).

The crack user rarely complies with treatment, few actually comply. Possibly because of the anxiety, as they do not know how to deal with the addiction or even because of the effects that the substance causes in the organism. The alcohol user complies more with the treatment (P8).
This research project was approved by the Research Ethics Committee, Healthcare Sciences Sector of the Federal University of Paraná (UFPR), logged under protocol number 904.029.10.03; CAAE: 0825.0.000.091-10.It should be noted that the ethical precepts were safeguarded, in accordance with Resolution 466/2012 from the Brazilian National Health Council.Therefore, the privacy and anonymity of the identity of the participants were protected through the codification by the letter P, plus a numeral with no direct correlation to the order of the interviews.

RESULTS
In the analysis of the transcriptions of the interviews applied to the professionals of the CAPS AD staff, for the drug users to begin treatment, specific intrinsic and extrinsic factors arose, which were organized in two categories, as described below.

Drug users' intrinsic factors for treatment compliance
The aspects considered intrinsic to the drug user him/herself interfere directly in treatment compliance, with motivation representing one of the most important factors for the facilitation of the patient's rehabilitation and treatment: He/she has to want it, the main factor is the individual's will to participate or not in the treatment.When the patient does not feel that he/she needs treatment, for his/ her own health, for his/her own life, there is no way to comply with the treatment.

[…] Many begin treatment and, after one or two weeks, give up. Chemical dependence is like that. A lack of motivation is a hindrance to compliance (P1). […] many factors interfere with compliance, but the main factor is the lack of motivation for treatment. […] This is the major hindrance to drug users' compliance (P2).
Reaffirming the importance of motivation, the participants emphasized that patients that begin the treatment only because of external influences, such as pressure from family and friends, clinical comorbidities, and judicial orders, have difficulty in complying with the treatment, since they do not feel motivated:

Drug users' extrinsic factors for treatment compliance
The influence of the family proved to be unanimous from the participants of this study's point of view, contributing negatively to the non-evolution of the patient's treatment in two aspects: when the family is overprotective and does not hold the drug user responsible for his/her acts, and when they are absent: The family interferes in the treatment in two bad ways, when they do not collaborate or when they collaborate too much.Generally, the overprotective family acts in such a way that the drug user does not assume his/her responsibilities.However, the patient needs to assume responsibility for having fallen into drugs alone and that he/ she can overcome this problem.In other cases, the patient is homeless and with no conditions to maintain his/her treatment without help from the family.Both neglect and overprotection hinder the user from getting better and cause the user to give up on the treatment (P2).
The role of the family is essential to the drug user's rehabilitation and treatment compliance, be that by motivation or by participating in the treatment through family meetings and other such mediums.Moreover, the absence of this support, often stemming from an overbearing family, favors the patient's common non-compliance with the treatment: When family members participate in the family group and maintain telephone contact with the staff, compliance is much higher than for those patients who arrive alone, without family support.[…] This abandonment happens many times because the family is tired, can't handle the situation anymore, and no longer wants to know about the patient (P1).

Some families motivate the patient to remain in treatment, and others think it is not necessary. This interferes in compliance, since, if the patients have no support, they end up losing their will to continue the treatment (P9).
For the family to play an effective role in the treatment of the family member, the family must be aware of the fact that chemical dependence is characterized as a chronic disease and that it requires treatment, since many family members still see this disorder as a lack of morality and a show of irresponsibility.
The family is a central factor in treatment compliance, it must understand that chemical dependence is a disease and that it has a treatment; also that it plays an essential role and must participate in all of the moments of treatment, if not, compliance will be low (P3).Some family members do not know how to deal with the patient and do not understand that chemical dependence is a disease; thus, they see it as "shame".When the family members understand that dependence is a disease, they come more often to the CAPS AD and participate more, while those that do not understand this tend to maintain their distance from the treatment (P5).
In addition to the participation of the family member in the institution, the help and organization from the family become necessary, especially as regards changes in one's lifestyle so that the drug user puts behavioral changes into action:

[…] For example, a patient who is still unaware of his/her chemical dependence, who is still ambivalent regarding the question of drugs, will have a great need for the organization of family and friends that live with him, so that he/she can change his/her behavior. The family will play a fundamental role in motivating him/ her […] The lack of this family arrangement causes the patient to continue with the same behavior, with the same habits, resulting in relapses and abandonment of the treatment (P4).
The socioeconomic conditions are factors that are intimately related to one's non-compliance with treatment, given that some patients cannot take a day off from work, as they must maintain the family income; or even because they do not have the financial means to pay for transport to the CAPS AD:

Approximately 90% of the patients work in constructions or informally, earn money on a day-to-day basis, and have no fixed income. If they go to the CAPS AD every day, they will not be able to work (P8).
The environment is a factor that interferes in treatment compliance, for example, many patients live with other drug users or near drug dealers and places where drugs are consumed, favoring their daily contact with these substances: structure that we make available is not comfortable, if the patients arrived in a beautiful, pleasant environment, with bigger rooms, more appropriate materials to work with, they would surely be more motivated.[…] On rainy days, the patients do not come, because they know that the CAPS AD floods.I can't gather a therapeutic group in the living space, because it smells moldy, is very humid, and does not give the feeling of a place for treatment (P1).
[…] there is no emergency clinic, a good infirmary where we can treat the more serious patients and perform detox procedures.The physical structure and the working conditions are precarious.[…] We don't have cars to make home visits, there are not enough human resources.We are unable to give all the technical support, because we do not have an adequate infrastructure, nor human resources and materials (P2).
In the CAPS AD, there are some healthcare professionals who do not like to work in the field of chemical dependence and who are not properly trained for this, which directly interferes in the quality of the medical care provided and in the patient's compliance with the treatment.

The training of professionals and the skills necessary to work with this field interfere in patient compliance. […] We work with a staff of professionals that do not like to work with mental health, who do not want mental health, and this interferes in the manner of acting, advising, and intervening (P1).
[…] I think that there should be some sort of training to work in this field, we get here with no experience, this would benefit the treatment (P8).

DISCUSSION
Healthcare professionals have identified multiple factors that interfere in treatment compliance, in accordance with the literature, upon revealing that treatment compliance is a multicausal process that involves the drug user in his/her totality.Consequently, the biological, behavioral, and socioeconomic determinants, as well as those referent to the treatment service, interfere directly in the patient's treatment compliance. 15mong the aspects considered to be intrinsic for drug users, motivation, the propelling force for one's change in behavior and rehabilitation, was cited by the participants as one of the main predictive factors for treatment compliance.This motivation in the realm of chemical dependence is based on the model proposed by Prochaska and DiClemente, which stems Patients that live in contexts where drugs are consumed, that have a family member that lives with them or a neighbor that consumes drugs, will rarely be able to comply with the treatment, because at any moment someone may offer or call them to use drugs.In the home visits, we observed the social context in which the patient is inserted and many live in homes that are practically drug havens [places where drug users consume drugs], how can we expect compliance from a patient who lives in a drug haven?(P1).
[…] the context in which the chemically dependent patient lives interferes, if he/she lives near a bar, a drug trafficker, which are there every day convincing him/her to use it, compliance tends to be low (P3).
Healthcare services favor treatment compliance, beginning from the initial embracement of the drug user in the institution, without the use of violence or prejudice, with the establishment of a tie between the professional and the patient.Without this tie, the patients do not comply with the treatment and do not return to the medical services:

The initial embracement facilitates the connection with the patient, […] this depends on the manner in which the embracement is performed, on empathy, and on how the professionals present themselves to the patient. […]
Many times, the patients are used to being treated with violence and prejudice, and if we use this here, there will also be a break in ties with the patient (P1).
The chemically dependent patient has problems with relationships, has problems in relating to others, and this affects the ties that he had with the institution and with the CAPS AD staff.If there are no ties between the patient and the professional, the patient will not return (P4).
With the influence of the precarious infrastructure of the CAPS AD, many patients do not feel motivated to carry out treatment, since there is a lack of instructors to develop abilities; the environment is small, unpleasant, moldy, and humid; there is a lack of adequate materials; there is a lack of emergency rooms and adequate infirmaries to provide medical care to more serious patients; there is a lack of cars to make home visits; there is a lack of human resources and materials, among other factors: In the conditions that we work in, there is no way to invest in patient treatment […] we do not have instructors, a craftsman who can teach them to develop a different ability, […] because the more activities we can offer, the more the patient will do the handicrafts.[…] The sense of the need for a better structure to aid in the rehabilitation process. 6,8,9,15,18This is because the family is characterized as a system made up of beliefs, values, and skills that guide their actions in providing care, embracement, prevention, and health promotion, especially in the disease rehabilitation process. 19nother study carried out in a CAPS AD in Campo Grande, Mato Grosso do Sul, Brazil, with 125 drug users found that the participation of two or more family members in the treatment has direct repercussions on the consolidation of the patient's treatment compliance (57.9%).The participation of the family in the therapeutic project increases the commitment of the family in their changes in their own daily habits and ways of living, in which drugs are not present. 8y contrast, without the support of the family, drug users tend to present difficulty in tolerating problems from their daily lives and in staying motivated to continue their treatment. 4The absence of the family appears to be related to the drug user's own relationship with the drug itself, which favors his/her isolation from social and family environments, from the family nucleus to the entire extension of the family, which results in a distancing and in the breaking of ties between the family and the drug user. 18s regards the socioeconomic factors that influence the drug user's treatment compliance, the participants referred to the difficulty in conciliating work with the treatment, as well as financial difficulties.It is well-known that many drug users are fired from the jobs, as the action of drug consumption occupies the core function of their lives at the expense of other activities.As a consequence, they begin to work informally and/or sporadically. 10n this sense, one study developed in Juiz de Fora, Minas Gerais, Brazil, which aimed to assess the factors associated with compliance with a therapy program including 300 alcoholics, indicated that the professionals with no employment ties had difficulty in continuing the healthcare service routines over a long period of time. 20his fact appears to be related to the absence of formal full time work and a monthly income, which makes the patient miss treatment sessions to go to work and sustain the family income.
As regards the environment, the literature reports that the social medium plays a crucial role in the process of the chemically dependent patient's relapses and compliance with the treatment.When social aid is offered positively, it becomes a predictive factor for abstinence over the long term.However, when there is a tumultuous interpersonal relationship, social pressure, and recurring exposure to the drug, the probability of a relapse and abandonment of the treatment increases. 5egarding the interference of healthcare services in treatment compliance, one study conducted with 12 healthcare from the premise that drug users pass through diverse stages of motivation and readiness to change their problem behavior. 4n this model, drug users should seek treatment when they are aware of their drug consumption problem and engage in specific actions aimed at achieving abstinence. 4However, individuals often begin treatment without the awareness of their dependence and are ambivalent to the need for rehabilitation.As a result, they encounter great difficulty in engaging in therapeutic programs from the center, leading to low levels of treatment compliance. 4,16onfirming this outlook, one study, carried out with 103 adolescent drug users undergoing psychotherapeutic treatment in Porto Alegre, Rio Grande do Sul, Brazil, explained that the majority of participants that did not comply with treatment (69.3%) were found to be at a motivational stage of precontemplation, in other words, they were unaware of their own impotence when facing their addiction and did not believe they had problems resulting their drug use. 16o achieve an effective rehabilitation, the drug user must initially have a cognitive awareness of the need for treatment and, later, a proper behavioral condition.Clearly, the search for treatment resulting from external influences presents a challenge to healthcare professionals, given that the changes commonly require a commitment that is primarily internal, not external. 4he illusory idea of drug users that only taking medication will promote rehabilitation hinders their compliance with the rest of the proposed treatment activities.This finding is in accordance with prior literature in that it shows that the use of medication should be considered as one of the therapeutic resources that can aid in improving one's quality of life, which should be adopted together with other therapeutic modalities, such as psychotherapies, individual therapeutic plans, workshops and therapy groups, home visits, among others. 17he results showed that patients who are addicted to crack and/or multiple drugs comply less with the treatment when compared to alcohol users.Research developed in a rehabilitation unit for the chemically dependent, in the state of Paraná, Brazil, conducted with 350 drug users, highlighted that patients addicted to alcohol more often comply with the treatment, since 70% (n=135) of these were released in a better state, as compared to 38% (n=59) of those addicted to crack.This study also showed that 58% (n=89) of the crack addicts did not comply with the treatment, due to their release from the center because they had escaped, on their request, or due to indiscipline. 10ll of the participants affirmed the role of the family as a predictive factor in treatment compliance, whether benefitting or hindering it.Studies have shown that the effective functioning of the family group is directly related to compliance in the well as the influence of the healthcare service related to embracement, to the ties between the professional and the patient, the infrastructure, and the lack of training provided for healthcare professionals.
This study presents limitations concerning the perception of healthcare professionals from only one institution and from a specific reality.Nevertheless, the results made it possible to verify important aspects that interfere directly in the drug user's treatment compliance, offering subsidies for the guidance and planning of more appropriate therapeutic interventions for this clientele, aimed at increasing the patient's compliance and quality of life.professionals from a rehabilitation center in Ribeirão Preto, São Paulo, Brazil, registered the importance of the healthcare staff and of the institution in the process of treatment compliance.This study also reported that the professionals are facilitators of the drug users' compliance with the treatment through a relationship based on trust and embracement. 9oncerning the infrastructure of the service, findings from prior literature are in agreement with those from the present study as regards the low compliance, coupled with difficulties in the service infrastructure, such as: insufficient material and human resources, the difficulty to carry out home visits and the active transport of patients, as well as difficulty in organization, in turn leaving the population bereft of quality healthcare, as called for in healthcare policies. 21oreover, the lack of preparation and training of healthcare professionals to work with this type of clientele influenced the treatment.In keeping with this perspective, a bibliographic review on the Latin American production of articles regarding the compliance and non-compliance of chronic disease patients with the proposed treatment revealed that non-compliance also results from the lack of preparation and qualification on the part of the healthcare professional, characterized by: therapeutic errors and an insufficient assessment of the patient's true health scenario, difficulty in interacting with the patient, a high turnover of professionals in these healthcare services, as well as the non-recognition of the responsibility of the professional as regards treatment compliance. 21n this manner, to increase treatment compliance, what becomes imperative is the development of training programs in the field of chemical dependency for healthcare professionals, with the objective of raising professionals' awareness of the changes in conceptions regarding this disorder, as well as the acceptance of drug users as individuals that require qualified medical assistance and care.

FINAL CONSIDER ATIONS
It could therefore be concluded that the factors that interfere in drug users' treatment compliance are multiple.Among the aspects considered intrinsic for drug users, what stood out were individual motivation to undergo behavioral changes and treatment, the illusory idea that only medication will lead to rehabilitation, and the type of pyschoactive substance that caused the dependence.
Among the extrinsic aspects for drug users, the following were mentioned: the influence of the family as regards their support and the participation of the family members in the treatment and changes in the patient's lifestyle; the socioeconomic conditions referent to the influences of the social environment and the financial and working conditions; as 14