Protocolo de atención integral del consumo nocivo de alcohol, tabaco y otras drogas

Objectives

Provide an evidence-informed, public-health response to harmful alcohol, tobacco and other drug use across Ecuador’s National Health System, reducing acute harms, dependence, disability and preventable mortality while improving quality of life, rehabilitation, social reintegration and healthy lifestyles.[1][2][3]The guideline frames substance use as a health issue with medical, psychological, social, economic, cultural and family consequences, and applies gender, generational, rights-based and culturally responsive perspectives.[4][1][5]

• Strengthen health promotion, prevention, early identification, brief intervention, treatment, rehabilitation, harm and risk reduction, and continuity of care for people affected by harmful substance use.[6][2][7]
• Prioritise prevention of alcohol, tobacco and psychoactive-substance use among pregnant women, children and adolescents.[8][2]
• Provide professionals with technical, evidence-based instruments for comprehensive assessment, management, follow-up, referral and counter-referral according to level of care.[9][2]
• Support abstinence where appropriate, or risk and harm reduction where abstinence is not immediately achievable, through individual therapeutic agreements and personalised treatment plans.[10][11]
• Promote social, educational, occupational and family reintegration, including sustained autonomy after treatment.[12][13][14]

Implementation

Deliver an integrated, stepped care pathway beginning in primary care and linking outpatient, intensive outpatient, residential, hospital, emergency and specialised services.[15][16][17]Care is based on interdisciplinary assessment of substance-use patterns, comorbidity, risks, social circumstances, family support and treatment response, with the intensity and setting adjusted to individual needs.[18][19][16]

• Identify harmful use and dependence through clinical history, examination and validated tools, including the Alcohol Use Disorders Identification Test, Alcohol, Smoking and Substance Involvement Screening Test, Clinical Institute Withdrawal Assessment for Alcohol scale, revised version, CAGE, Munich Alcoholism Test and Fagerström test.[20][21][22][23]
• Provide first-level care through detection, initial management, motivation, brief intervention, harm reduction, patient and family information, and referral when specialist support is required.[15][24][25]
• Deliver second-level care as the main setting for diagnostic assessment, detoxification, individual therapeutic planning, rehabilitation and coordinated social reintegration.[15][26]
• Provide third-level and hospital care for severe intoxication, withdrawal, major comorbidity or complications, including specialist detoxification units, therapeutic communities, intensive care and emergency stabilisation where clinically necessary.[15][16][27]
• Use referral and counter-referral across levels of care, with the referring professional retaining responsibility for follow-up after specialised assessment or treatment.[2][15][17]
• Apply substance-specific clinical management, including supportive emergency care for acute intoxication; severity-based alcohol-withdrawal care using the revised Clinical Institute Withdrawal Assessment for Alcohol scale; tobacco cessation through behavioural support and appropriate pharmacotherapy; and psychological treatment, relapse prevention and rehabilitation for cannabis, cocaine, stimulant and benzodiazepine-related disorders.[28][29][30][31][32][33]
• Provide outpatient and intensive outpatient treatment through medically, psychologically and socially informed plans, including individual, group, family, occupational and community interventions.[34][35][36]
• Use residential treatment for people whose needs cannot be met through less intensive services, particularly where there is substantial functional deterioration, insufficient family or social support, or repeated unsuccessful attempts to stop use.[16][37]
• Engage users and families as active participants through therapeutic agreements, family therapy, multifamily sessions, support networks, life-project planning and reintegration activities.[38][39][40]
• Coordinate implementation through the Ministry of Public Health, specialised Alcohol and Other Drugs Treatment Centres, the Ministry of Economic and Social Inclusion, hospitals, community actors, educational institutions and labour-sector partners.[9][12][13][17]
• Maintain clinical records, interdisciplinary case reviews, treatment-stage assessments, patient follow-up and technical and economic progress reports using approved mechanisms and outcome or impact indicators.[27][41][17][42]
• Mobilise periodic project disbursements through approved timetables and justify expenditure or investment with supporting documentation; no monetary budget or funding allocation is specified in the supplied material.[43]

Monitoring & Evaluation

The guideline combines programme-level oversight with extensive patient-level assessment, follow-up and referral mechanisms for harmful use of alcohol, tobacco and other drugs. It does not establish a single document-wide indicator framework, reporting timetable, surveillance system, audit process or independent accountability structure, although it specifies clinical scoring, service records, technical reporting and multidisciplinary review in several areas.[9][17][43]

• Use structured screening and diagnostic instruments, including the Alcohol Use Disorders Identification Test, Alcohol, Smoking and Substance Involvement Screening Test, CAGE questionnaire, Munich Alcoholism Test, Fagerström test and International Classification of Diseases, tenth revision, to identify hazardous use, dependence, withdrawal and related disorders.[20][21][38][22]
• Apply Clinical Institute Withdrawal Assessment for Alcohol Scale, revised scoring to classify alcohol-withdrawal severity, guide pharmacological treatment and determine escalation of care; hospitalised patients may require assessments three times daily or at eight-hour intervals, while some detoxification protocols require hourly reassessment after cessation.[44][29][45][46]
• Monitor acute intoxication through observations of consciousness, airway and respiratory status, vital signs, blood glucose, hydration, temperature, urine output, haemodynamic status and targeted laboratory investigations; the frequency varies by presentation, including four-hourly observation for hospitalised ethanol-intoxication cases and 15-to-30-minute vital-sign monitoring for delirium tremens.[28][47][48]
• Maintain integrated follow-up, referral and counter-referral across levels of care, with first-level professionals responsible for monitoring after referral and specialised services reassessing modality or returning patients to lower-intensity psychological and social-integration support when recovery is favourable.[2][15][17]
• Review treatment progress through therapeutic agreements, diaries, family information, multidisciplinary case discussion, reassessment of therapeutic objectives and adjustment of interventions when required.[10][11][39]
• Conduct systematic reassessment in outpatient and intensive outpatient psychological treatment, with progression between phases determined by achievement of phase objectives.[36]Residential programmes use technical-team reviews, weekly case-analysis meetings, community assemblies and, where feasible, follow-up outcome studies.[37][49][50][41]
• Track post-residential social reintegration through educational performance reports, employment follow-up, family follow-up, social assessments and monitoring of autonomy in housing, schooling, work and social relationships.[12][51][13][52]
• Require specialised treatment centres to maintain updated clinical records and patient-registration instruments, submit technical and economic progress reports using approved formats, and include outcome and impact indicators in those reports.[43][53]
• Require house operators to submit monthly activity reports to Technical Coordination, alongside maintenance of clinical histories, professional reports, observations and institutional contact records.[42][54][55]
• Use participation agreements and signed therapeutic commitments to support individual, family and centre responsibilities; centres are expected to communicate achievements and difficulties periodically.[56][40][57]

Costing & Financing

Costing information is limited. No overall programme budget, costed implementation plan, funding-gap estimate, resource-mobilisation target or economic assumption is specified for the guideline.[6][16][17]The clearest financing provisions concern universal free State health services, coverage of tobacco-cessation treatment, periodic project disbursements and documentation of expenditure.[5][58][43]

• Provide universal, free State health services at all levels, including necessary diagnosis, treatment, medicines and rehabilitation.[5]
• Recognise tobacco use as creating high public-health costs, estimated at approximately 15% of health expenditure in Latin America, without a monetary value, country-specific estimate or methodology in the supplied material.[59]
• Include effective tobacco-dependence medication and counselling as covered benefits in public and private health plans, and allocate sufficient resources to cessation-support systems.[58]
• Consider public-sector availability, insurance coverage and patient costs when selecting smoking-cessation medicines, but no medicine prices or reimbursement levels are provided.[60]
• Provide periodic fund disbursements for approved projects through technical coordination in accordance with an approved timetable, and justify prior expenditure or investment with supporting documentation.[43]
• Mobilise materials and logistical support for prevention activities through public and private institutions, formal and informal organisations, educational communities and community actors.[61]
• Resource specialised treatment services through identified staffing and infrastructure requirements, including clinical, psychological, nursing, social-work, occupational-therapy, pharmacy, hospital and intensive-care capacities, but without costings or allocations.[16][12][42][55]
• Note that benzodiazepine use qualitatively increases the cost of interventions, consultations and diagnostic examinations, while providing no financial estimate.[33]