RESEARCH ARTICLES

Focus group as a strategy for the prevention of alcoholism relapse

Janaina Rocha Soares^I; Marilurde Donato^II; Sheila Nascimento Pereira de Farias^III; Maria Yvone Chaves Mauro^IV; Elaine Franco dos Santos Araujo^V; Liane Gack Ghelman^VI

ABSTRACT: This study focused on health problems identified by means of a focus group as a reason for relapse prevention in alcoholism. The objectives were to survey and analyze the consequences or health problems that lead to relapse prevention of alcoholism. This is a descriptive study, using the focus group. The subjects were 31 clients from 18 to 65 years of age, attended by the City Department of Health and Civil Defense-RJ and Center for Studies, Research and Reference on Alcoholism and Addiction between July and September 2009. A total of 38% responded that the reasons that lead alcoholics to prevent relapse were: tuberculosis, hypertension, Diabetes Mellitus, cardiovascular and psychiatric problems. Based on the results, the implementation of damageand health problem reduction and the fostering of specialized treatment are necessary.

Keyword: Alcoholism; relapse; focus group; collective health.

INTRODUCTION

Man discovered the fermentation process more than 10,000 years ago, thus obtaining the first alcoholic beverages. More than 5,000 years ago, the Sumerians and Assyrians produced a fermented beverage, based on cereals, using the grain malting process, in the same way as it is done today¹.

Until the 18^th century, drinks were produced by craft producers, with a low alcohol percentage, as they were fermented. As from the British Industrial Revolution, in the 19^th century, the production gained industrial dimensions, in large quantities and with higher alcohol percentages. Thus, drinks consumed during meals as a less contaminated source of water, at the time, were not treated appropriately, became stronger and sold at a low cost, favoring the access to a larger number of people².

In 1977, with the development of research in this area, experts from the World Health Organization (WHO) defined two main diagnostic categories of alcoholism: abuse and dependence, conceptualized as a change in the patients’ physical, mental and/or social aspects, whose causal nexus was the excessive alcohol intake, causing disability³. Then, the disease model was accepted by highly prestigious groups like WHO which, in 1978, started to conceptualize alcoholism as the Alcohol Dependence Syndrome.

Alcohol consumption imposes unwanted and extremely costly problems on societies all over the world, which affect individuals across their lifetime4. Alcohol is part of the social context because it is globally accepted and its initiation starts in childhood or adolescence, stimulated by the family members⁵.

According to WHO, beer is the most consumed drink per capita in Brazil, with 54 liters/year, followed by cachaça with 12 liters/year, wine with 1.8 liters/year. Between the 1970’s and 1990’s, Brazil presented a 74.5% growth in the consumption of alcoholic beverages. The cachaça production in 2002 amounted to 1.3 billion liters, 14.8 million of which were exported, besides a production of 2.3 liters of wine in 2000⁶.

In the health context, the International Classification of Diseases and Related Health Problems (ICD-10) defines the Alcohol Dependence Syndrome as a set of behavioral, cognitive and physiological phenomena developed based on the consumption of a psychoactive substance, typically associated with the uncontrollable desire to use the drug, with the difficulty to maintain the consumption under control, with the continuous use despite its dangerous consequences, with the greater priority of drugs use to the detriment of other activities and obligations, with increased tolerance of the drug and, sometimes, with a state of physical abstinence⁷.

In the 1980’s, a behavioral maintenance program was developed for use in the treatment of problems caused by addiction, based on complete abstinence of the substance the individual uses (abstinence from alcohol use for example), or the maintenance of programs to regulate individual behaviors, which consisted in the abstinence from or moderate use of the psychoactive substance, whose model was called Relapse Prevention (RP)⁸.

For the same authors, relapse refers to a collapse or setback in a person’s attempt to change or modify any target behavior. Based on the social learning theory, relapse prevention is a self-control program that adds behavioral skills training procedures, cognitive interventions and lifestyle changes.

Therefore, relapse cannot only be understood as the return to the substance abuse pattern, but also as the process in which indicators appear before the patient’s return to the substance use⁹.

Thus, this study was focused on the sequelae or health problems as a motive for alcoholism relapse prevention. The objectives were to survey the sequelae or health problems as a motive for the prevention of alcoholism relapse and to analyze the sequelae or health problems as a motive for the prevention of alcoholism relapse. 

LITERATURE REVIEW

Alcoholism is a chronic-degenerative disease characterized by the feeling of compulsion to continuously consume alcohol, in any amount and situation, leading to physical, psychological, family and social problems, to a greater or lesser extent, with the possibility to evolve to death if the patient does not submit to a treatment that leads to the rehabilitation from the disease¹⁰.

Alcoholism is a progressive disorder that depends on biological and cultural factors, which will determine how the individual will relate to the alcohol¹¹. There are two globally known definitions of alcoholism: the first includes any use of alcoholic beverage that causes damage to any individual; and the second is a chronic disorder of conduct, manifested by repeated alcohol intake¹².

Alcoholics start their consumption as social drinkers, at around the age of 20 years; in the third decade of life, they evolve to the category of binge drinkers, with physical consequences related to the alcohol; finally, in the second half of the third decade of life, the alcohol dependence syndrome develops¹³.In this late phase of alcoholism, in which they drink uncontrolledly, they end up losing their job, are hospitalized, ashamed, try to isolate themselves, culminating in physical and emotional degradation, turning them into manipulators of the family which, feeling guilty in view of the situation, hide the fact and, by doing so, facilitates the addiction⁵.

Alcoholics can be socially faced as ill or as individuals with personality disorders. That demonstrates the presence of the stigma that will feed this attribute associated to them, thus maintaining their position as alcohol addicts which, in many cases, leads to non-adherence to alcoholism treatment and to successive relapses¹⁴.

There can be two types of alcoholics: in type 1, alcoholism has a late start, slow evolution, better prognosis, less complications and psychopathological comorbidity. The alcoholics consume alcohol in a lighter form but the progression to dependence is fast, developing a feeling of guilt and health complications; impulsiveness and anti-social personality traits, on the other hand, are less frequent. In type 2, alcoholism starts early; there exists a genetic predisposition and rapid evolution, plus psychopathological comorbidities and a worse prognosis. In both types, abstinence difficulties are frequent, as well as involvement in fights and confusions, but type 2 alcoholics are more impulsive and antisocial¹⁵.

Relapse prevention is aimed at enabling the patients to learn to foresee and deal with the problem, allowing them to develop skills to interrupt the evolution of a renewed use, avoiding the relapse16.
Maintaining abstinence implies accepting that the recovery process is long and rests on setbacks and mishaps and that, therefore, a high level of alert and knowledge is needed about the internal (thoughts, feelings) and external (risk situations) signs that signal the danger of a relapse¹⁷, besides information on earlier (social, psychological and demographic) events that can be used in the prediction of future relapses⁹.

Based on the above, it is inferred that the alcoholics’ main problem is not to stop consuming alcoholic beverages, but to go back to drinking as, more than achieving complete abstinence, it requires a change in their personality and life habits⁵. 

METHODOLOGY

A descriptive study with a quantitative-qualitative approach was undertaken. The focus group was used as the data collection technique, which permitted the identification and analysis of the sequelae or health problems that motivated the clients to prevent the alcoholism relapse. The study subjects were 31 randomly selected clients, between 18 and 65 years of age, attended by the Rio de Janeiro City Department of Health and Civil Defense (SMSDC-RJ) and the Center for Studies, Research and Reference on Alcoholism and Addiction (CEPRAL/HESFA/UFRJ) between July and September 2009. The focus group sessions took place at the City Department of Health and at CEPRAL. The data were analyzed in the light of the specialized literature.

The first institution mentioned above was selected because it consists of a set of actions to reduce the impact of abuse and addiction to alcohol and other drugs in the work environment and, consequently, in society, aiming to improve the quality of life and work of the public servant in the City of Rio de Janeiro (PCRJ).

The second institution mentioned is an Academic Program of Universidade Federal do Rio de Janeiro (UFRJ) focused on integrated care to users with use, abuse and addiction problems to alcohol and other drugs. The care activities involve multiprofessional and interdisciplinary attendance, either individually or in groups of clients and their relatives.

The data were collected after approval of the research project by the Research Ethics Committee (CEP) of the Rio de Janeiro City Department of Health and Civil Defense, on March 2nd 2009 – CAAE: 0019.0.314.000-09,under protocol 25/09; and by the CEP at Anna Nery School of Nursing (EEAN)/HESFA/UFRJ, under protocol 031/2007, as part of the community service project called The problems related to the use, abuse and addiction to alcohol and other drugs in community health.
To safeguard the clients’ anonymity, their discourse was identified with the letter P – participant – followed by the number indicating their order of inclusion in the study: P1, P2...

RESULTS ANDDISCUSSION

Among the results the clients attended at the SMSDC-RJ and CEPRAL obtained, representing 23(38%) recording units (RU) identified in the focus group discussion, one of the motives stands out that lead the alcoholics to alcoholism relapse prevention – the sequelae or health problems deriving from the alcohol abuse registered in the focus group.

Excessive alcohol consumption is related to the morbidity and mortality of more than 30 illnesses¹⁸. As regards the forms of exposure, the acute form is associated with traffic accidents, homicides, suicides, falls, burns and drowning; the chronic form with the prolonged use of large amounts of alcohol, leading to liver cirrhosis, alcohol dependence, cerebrovascular diseases, tumors of the lip, oral cavity, pharynx, larynx, esophagus and liver, gastritis, esophageal varicose veins, acute and chronic pancreatitis, diabetes mellitus, tuberculosis, pneumonia and influenza¹⁹.

In Brazil, between 1998 and 2002, according to the Ministry of Health’s Mortality Information System (SIM), the mortality coefficient due to Alcohol Dependence (AD) in the male group corresponded to 5.8 deaths/100,000 men, with statistically significant differences (p<0.00001) per age range, ranging from 0.4 for the group from 15 to 24 years to a maximum of 16.0 for the group from 45 to 54 and dropping to 7.6 in the group aged 75 years and older²⁰.

In the same period, the female group revealed 0.6 deaths/100,000 women, ranging from 0.0 in the group from 15 to 24 to a maximum of 1.5 in the group from 45 to 64 years, dropping to 1.0 in the group aged 75 years and older, showing also statistically significant differences (p<0.00001). The ratio between the male and female coefficients corresponded to 9.2, with smaller differences in the extreme ages of young and elder elderly people²⁰.

Main Illnesses

The main illnesses the alcoholism causes, according to the authors cited, were confirmed in the following testimonies:

[...]I almost destroyed myself and today, I am treated for the diseases that came with the beverage. (P3)

[...]I am diabetic and hypertensive due to the beverage. (P13)

[...]I got hypertensive because of the alcohol. (P20)

It is highlighted that not only alcoholism can cause these diseases, but also lighter alcohol consumption, mainly in cases of genetic predisposition, viral infections and vitamin B1 (Thiamine) deficiency21. The lack of this vitamin, metabolized in the liver, was mentioned in one statement:

Because of my health… I got so skinny… I took vitamin many years. (P5)

Alcohol is a toxic substance and its consumption by itself is already considered a disease that causes countless harmful consequences, mainly if consumed over a long period, like in the case of the study participants, whose testimonies confirm that, until today, even abstinent, they are treated for the sequelae of alcoholism, which are not always recognized or reported as being provoked by alcohol abuse.

One of the participants mentioned hypertension and diabetes as diseases that came with the alcohol abuse. As regards arterial hypertension, alcohol restriction is indicated, which reduces the systolic pressure by 2-4 mmHg^22,23. Concerning the diabetes, it is known that alcohol abuse results in vasodilation, which favors peripheral glucose collection through the blood; as well as insulin insufficiency through the pancreas, resulting in alcoholic diabetes, which can be overcome in case of abstinence²⁴.

It should be highlighted that a study developed about the diabetic foot and associated factors evidenced that 17.5% of its patients consume alcohol, that is, a number almost three times higher than in people who do not consume this substance²⁵.

Between 1984 and 1997, a study about hospitalizations due to tuberculosis in the state of São Paulo indicated the main motives: bad general condition, alcoholism and cachexia²⁶. In this study, alcoholism appears as a complicating factor due to the fact that the individual does not take the medication established in the disease treatment scheme, choosing the drink; or uses the medication and alcohol, annulling the effect of the first.

The risk factors for the occurrence of tuberculosis, in a study undertaken in Rio Grande do Sul, revealed that, among the 610 patients treated between 1989 and 1994, 134 (22%) patients were alcohol addicts²⁷, showing alcoholism as a risk factor for the appearance of tuberculosis. In another study, carried out in 2002 in São Paulo, a survey identified the profile of patients who died due to tuberculosis, indicating that 64% of these patients were alcoholics²⁸.

The percentages are relevant because they confirm the association between tuberculosis and alcoholism, a fact that can also be verified in health centers and treatment clinics in the city of Rio de Janeiro, during the nursing care routine for alcoholics, many of them showing tuberculosis as a comorbidity of alcohol abuse, which the participants confirmed, as illustrated by the following testimonies:  

[...]I had tuberculosis twice. (P9)

My motivation was because I had tuberculosis and almost died. (P10)

It started because I had tuberculosis. (P22)

At the only municipal health center in the city of Rio de Janeiro, which attends to these clients, most of the internal forwarding occurs through the pneumology sector, followed by the medical clinic, in view of diseases like tuberculosis and hypertension/alcoholic diabetes, respectively. Therefore, the health professionals adopted the conduct of forwarding the clients to those clinics, simultaneously with the forwarding to those services that receive cases of alcoholism and drug addiction, contributing to the reduction of the treatment abandonment rate in these diseases.

Cardiovascular problems

Alcohol consumption can be partially responsible for cardiovascular problems. In this respect, in which the subjects addressed are alcoholics (binge drinkers), it is considered that the harm the alcohol causes should be carefully evaluated, especially because cardiologic emergency situations are not rare during care delivery to alcoholics who are undergoing treatment in specialized health programs²⁹. The following testimonies address this question:

I do relapse prevention because I got full of heart problems. (P26)

I decided to do prevention because my heart couldn’t handle it. (P31)

Chronic alcoholism is a highly prevalent entity that can condition a heart disease, which is initially asymptomatic, but as a result of continuous consumption contributes to the progressive deterioration of the myocardial function³⁰.

Alcoholic abstinence permits symptomatic improvement though, as the only form to achieve the regression of the alcoholic myocardiopathy³⁰.

I am afraid of relapse because the degradation process was very big. (P15)

The degradation was very big. (P18)

Neuropsychiatric disorders

The alcoholics’ sequelae and health problems include mental disorders, which can occur independently of their genetic predisposition. In that sense, in a study that related alcohol to psychiatric disorders, it was identified that alcohol is responsible for central nervous system (CNS) disorders, such as epilepsy and multiple sclerosis. These testimonies confirm this:

[...]I got motivated because I had some [epilepsy] attacks.  (P1)

[...]the [epilepsy] attacks made me think of the relapse.  (P3)

[...]the epilepsy made me want to remain abstinent. (P13)

As perceived, the main reason for relapse prevention were the epilepsy attacks deriving from the alcoholism, which cause panic in the alcoholics out of fear of dying or getting stigmatized as mental patients. Alcohol abuse is directly associated with functional and neuropathological alterations related to epilepsy. The epileptic crises can happen due to alcohol intoxication, as one of the main triggers of ionic and neurotransmitter changes in the CNS²⁵.

The possibility of manifesting mental disorders was considered if they continued their binge drinking, and some testimonies stated the following:

[...]I had psychiatric disorders due to the abuse and hereditariness. (P14)

[...]I am afraid of returning, due to the [psychiatric] disease. (P18)

[...]the psychiatric internment made me quit... (P21)

[...]I spent six months on the streets begging due to the [psychiatric] disease. (P22)

There is evidence that the intermittent use of legal or illegal psychoactive substances, even in small doses, can lead to health problems in patients with severe mental disorders, with worse consequences than those that affect mental patients who do not use any kind of drug^31-33. Thus, health professionals who attend to alcoholic patients with mental disorders need to establish differences between the psychiatric disease and the alcohol dependence, which allow them to establish a correct diagnosis and the treatment criteria for each case.

When abstinent, alcoholics get aware of the harm the beverage causes and are able to perceive the level of degradation of their health and the need to seek treatment, not only for the alcoholism but also for the resulting diseases.

Among the reasons that lead the alcoholics to alcoholism relapse prevention, the sequelae or health problems deriving from alcohol abuse stand out. Thus, it is perceived that fighting the problem requires a consensus that goes far beyond what health services can offer.

CONCLUSION

Alcohol may be the eldest psychoactive substance humanity uses and, as a result of the changes in society in general, people have started to consume alcohol and more frequently, leading to the occurrence of physical, mental, social and family complications related to excessive alcohol consumption.

The study reveals that alcohol is a contributing factor and often triggers a series of organic diseases. Alcoholism is considered a disease, with an intense and progressive degradation process that can introduce secondary diseases, due to its devastating power.

And alcoholics need to experience all of these feelings to perceive the physical and mental problems and harm the alcoholism entails as, after feeling that they lost control over the situation, the desire emerges to quit drinking and seek help. Therefore, individuals look for help not only for their alcoholism, but also for its sequelae.

In view of the above, it is clear that a long road lies ahead for those who deal with alcoholism issues, especially relapse prevention, considering that they need to be trained and updated on the theme to be able to deliver high-quality care to the alcoholics, with the reduction of damage and health problems and the encouragement to accomplish the recommended treatment as targets.

REFERENCES

1. Carvalho LG. Produção de cerveja. Rede de Tecnologia do Rio de Janeiro /Serviço Brasileiro de Respostas Técnicas [Internet]. 2007 [citado em 10 mar2014]; Available at:
http://www.sbrt.ibict.br/dossie-tecnico/downloadsDT/NTc=

2. Ramos SP, Bertolote JM. Alcoolismo hoje. 3ª ed. Porto Alegre (RS): Artes Médicas;1997.

3. Thierney LM Jr. Diagnóstico e tratamento. São Paulo: Atheneu; 1995.

4. Ministério da Saúde (Br). A política do Ministério da Saúde para atenção integral a usuários de álcool e outras drogas. Brasília (DF): Ministério da Saúde; 2003.

5. Mendes R. Patologia do trabalho. 2ª ed. São Paulo: Atheneu; 2005.

6. Galduróz JCF, Caetano R. Epidemiologia do uso de álcool no Brasil. Rev Bras Psiquiatria. 2004; 26 (Suppl 1):S3-6.

7. Organização Mundial de Saúde. Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde – CID-10 [Internet] [citado em 12mar2014]. Available at: http://www.datasus.gov.br/cid10/v2008/cid10.htm

8. Marlatt A, Gordon J. Determinants of relapse: implications for the maintenance of behavior change In DavidsonPO, Davidson SM, editors. Behavioral medicine: changing health lifestyles. New York: Bruner/Mazel; 1980.

9. Marlatt A, Donovan DM. Relapse prevention: maintenance strategies in the treatment of addictive behaviors. 2ª ed. New York: The Guilford Press; 2008.

10. Donato M.Reinserção do trabalhador alcoolista no contexto laboral: a percepção do enfermeiro do trabalho[tese de doutorado] Rio de Janeiro:Universidade Federal do Rio de Janeiro; 2002.

11. Giglioti A, Bessa MA. Alcohol dependence syndrome: diagnostic criteria. Rev Bras Psiquiatria. 2004;  26 (Suppl) 1:03.

12. Ramirez LM, Quirantes M, Alberto J, Perez M, Jose A. Pesquisaje de alcoholismo en un área de salud. Rev Cuba Med Gen Integra, 2006; 22 (2).

13. Laranjeira R, Pinsky I. O alcoolismo hoje. 3ª ed. Porto Alegre (RS): Artes Médicas, 1998.

14. Campos GM, Ferreira RF. A importância da legitimação social na (re)construção da identidade de um alcoolista. Estud psicol. 2007;24 (2): 215-25.

15. Ribeiro MS, Ribeiro LC, Souza GFS, Antunes MG, Oliveira LN. Avaliação dos Tipos 1 e 2 de alcoolismo de Cloninger em homens participantes de um programa de tratamento ambulatorial. Rev Psiquiatr Clín.2008; 35 (2): 39-48.

16. Mathias ACR, Cruz MS. Benefícios de técnicas cognitivo comportamentais em terapia de grupo para uso indevido do álcool e drogas. Jornal Bras Psiq. 2007; 56 (2) 140-2.

17. Trigo M. Terapia para a prevenção da recaída na dependência de substâncias: os modelos de Alan Marlatt e de Terence Gorski. Aplicações à nicotino-dependência. Rev Port Clin Geral. 2006; 22: 299-328.

18. Marín-León L, Oliveira HB, Botega NJ. Mortalidade por dependência de álcool no Brasil: 1998 - 2002.Psicol Estud. 2007;12(1):115-21.

19. Holman CD, English DR, Milne E, Winter MG. Meta-analysis of alcohol and all-cause mortality: A validation of NHMRC recommendations. Medical Journal of Austrália. 1996; 5;164(3):141-5.

20. Ministério da Saúde (Br).Informações de saúde estatísticas vitais: mortalidade; informações demográficas e socioeconômicas. Brasília (DF): Ministério da Saúde; 2004.

21. Andrade AG, Oliveira LG. Álcool e suas conseqüências: uma abordagem multiconceitual. São Paulo: Manole; 2009.

22. Amoedo C, Passarelli JO, Borelli FAO, Souza MG. S. Tratamento não medicamentoso da hipertensão arterial. In: Nobre F, Serrano CV, orgs. Tratado de cardiologia da SOCESP. São Paulo: Manole; 2005. p. 453-63.

23. Bloch KV, Rodrigues CS, Fiszman R. Epidemiologia dos fatores de risco para hipertensão arterial – uma revisão crítica da literatura brasileira. Rev Bras Hipertensão. 2006;13(2):134-43.

24. Baron AD. Insulin and vasculature-old actors, new roles. J Investig Med. 1996; 44:406-12.

25. Santos MSD, Veloso TMG. Alcoolismo: representações sociais elaboradas por alcoolistas em tratamento e por seus familiares. Interface Comum Saúde Educ. 2008;12:619-34.

26. Nogueira PA. Internações por tuberculose no Estado de São Paulo [tese de livre docência]. São Paulo: Universidade de São Paulo; 1997.

27. Picon PD, Bassanesi SL, Caramori MLA, Ferreira RLT, Jarczewski CC, Vieira PRB. Fatores de risco para a recidiva da tuberculose. J Bras Pneumol. 2007; 33:572-8.

28. Foppa M, Fuchs FD, Duncan BB. Álcool e doença aterosclerótica. Arq Bras Cardiol. 2001; 76:165-70.

29. Oliveira ER, Luis MAV. Distúrbios psiquiátricos relacionados ao álcool associados a diagnósticos de clínica médica e/ou intervenções cirúrgicas, atendidos num hospital geral.  Rev Latino-AmEnfermagem. 1997;5 (esp):51-7.

30. Gonçalves AM, Correia AM, Falcão LM, Ravara AL. Miocardiopatia alcoólica: significado clínico e prognóstico. Revista SPMI. 2005;12(2): 89-101.

31. Drake RE, Osher FC, Wallach MA. Alcohol use and abuse in schizophrenia:a prospective community study. The Journal Nervous and Mental Disease. 1989; 177:408-14.

32. Felipe ICV, Gomes AMT. Consumo de álcool acadêmicos da área de saúde: implicações para prática profissional. Rev enferm UERJ. 2014; 22: 35-41.

33. Soares JR, Farias SNP, Donato M, Mauro MYC, Araújo EFS, Ghelman LG. A importância da família no processo de prevenção da recaída no alcoolismo. Rev enferm UERJ. 2014; 22: (prelo)