Portugal: Success in harm reduction
INTERVIEW/JOÃO GOULÃO
In 1999, Portugal broke new ground by enacting legislation that decriminalized all drug use. Ten years later, the results are there for all to see, results of a change that João Goulão, president of the do Instituto da Droga e Toxicodependência (The Drugs and Chemical Addiction Institute) IDT, believes show the law has been instrumental in solving the problem of drug abuse, and crucial for bringing legislation into harmony with practices and people.
A family doctor, Goulão was condecorated by the president of the Portuguese Republic, but he says he is always ready for to roll up his sleeves and get out in the field. At 55, he is a candidate for the Presidency of the European Drugs Observatory, but that has not clowded his sobriety about the work at hand.
In an exclusive interview to Comunidad Segura, Goulão discusses the workings and the structure of the institution that he presides over, that has set a world-wide example of success. For him, drug use is closely associated to self-esteem. “If we could restore drug addicts their human dignity, we would be able to demand something in return. But to make demands of addicts who are enslaved by their addiction is senseless,” he said.
Portugal is a model in drug decriminalization. What is the goal of this policy?
The advantages of this measure were, on the one hand, to lower the misguivings that drug users had in approaching the health care system for fear of being turned over to the police, and on the other, to bring about greater harmony between the law and the practices of the people subject to the law. Harm reduction professionals, for example, who conducted needle exchanges before the decriminalization were, as government employees, compelled to notify authorities of the fact the users were commiting a crime, and worse, were aiding the continuation of that criminal behavior.
Why decriminalize all drugs, instead of a few?
The distinction between light and heavy drugs makes less and less sense, and already from the 90’s it made little sense scientifically. There are drugs with different levels of danger, but these levels are changing. The plants have undergone genetic alterations, they have been manipulated, and in some cases the content of the active substance has increased by 15 to 10 times, as have the psico-gênic effects that these substances cause.
That means that the distinction makes little sense. I have seen people who are heavily addicted to so-called light drugs, and people using so-called heavy drugs in reasonably light ways. The issue has more to do with the relationship each person establishes with the substance than with what the substance itself is. That is what led us to decriminalize all substances.
Results have been positive...
We adopted dissuasion as a mechanism, but I would not like to exaggerate the effects of decriminalization. I think decriminalization has been very good because it has allowed for greater harmony, allowing for drug addicts to approach us without running the risk of being denounced.
On the other hand, I think the positive results that we attained with respect to drug use in Portugal has to be credtied to the investments we made in treatment, prevention, harm reduction and social insertion, all of which benefited from decrimninalization. There are other European societies that, while not decriminalizing, have seen similar results.
How do the IDT services work?
We use a comprehensive approach that includes psychology and social aspects, we use multi-disciplinary teams, made up of psychiatrists and doctors who are general practitioners, who have been specially trained in this field, as well as psychologists and social service workers.
The IDT has approximately 1,600 professionals acros the country. General management, planning, training and international relations are all headquartered in Lisbon. Our call center VIDA is located in Lisbon, as is our cientific magazine Toxicodependências and the Documentation Center.
We have five regional delegations and each of them manages operations units that are divided by territory. The administration is quite de-centralized. The IDT service, that belongs to the Ministry of Health, is dedicated above all to reducing the demand for drugs – which includes prevention, treatment, harm reduction, social re-insertion and dissuasion.
Is Portugal’s National Health System is prepared to face the demands of the Portuguese drug policy?
Our national care system covers the national territory through a number of operating units. First among these we have the Comprehensive Response Centers (CRI), that are 23 in number across the nation, and we also have approximately 60 treatment centers in outpatient services that offer treatment for free to all.
We also have inpatient care for brief hospitalizations –for 10 to 15 days- for detox. There are also three units of free long term hospitalizations, where people stay for a year on average.
We also have a network with approximately 60 private therapy units that are managed by NGOs, and where we cover 80% of treatment costs. The remaining 20% are left to the patient, his or her family or in the event that these expenses cannot be paid for, they can be covered by social security.
The fourth type of unit that we have are the three units for alcoholcs in the north, center and south – Oporto, Coimbra and Lisboa – that joined the IDT in 2006 when the institute took over certain responsibilities in the alchohol abuse.
As for drug use prevention campaigns, how does the IDT work?
We work very intensively in prevention and it has been our policy to stop using huge campaigns of great visibility, because scientific analysis shows they are very cost ineffective. We chose instead selective strategies that target specific groups with small projects that are more intensive and go on for longer periods of time, while closely monitored and evaluated.
Our priority are youths and children at risk, the family members of people with chemical addictions and youths who are out of school, and finally, youths in night life. Our interventions are developed by our own teams and by non governmental bodies and plans or professionals who work in the fields of prevention, security and health.
How were these sectors selected?
We have a program called the National Comprehensive Response Plan that was created at first based on a diagnosis of of the entire national territory, that was as detailed as possible.
Every one of the Comprehensive Response Centers developed their own diagnosis that included the participation of all the relevant bodies in the region, such as city hall, security forces, schools, social security, after this problems and community resources were evaluated.
Through this program we have been able to optimise the resources at our disposal and we are able to be much more precise about our goals. In a small country like Portugal there are regional specificities that differ wildly – we cannot embark on large national campaigns because the problems we find in Lisobon have nothing to do with the problems that arise in the interior, for example.
What are the dissuasion commissions?
The Dissuasion Commissions are three people decision taking bodies that employ a lawyer, a psicologist and a social worker – who are in turn supported by a technical team. If someone is caught using or carrying illegal substance that exceeds the quantity stipulated for use of a single person for 10 days, this person will be sent to the regional Dissuasion Commission within 3 days. The user will then undergo a clinical diagnosis to decide whether it is a case of addiction or recreational use.
There are no penalties for first time offenders. Those who are considered addicts will be invited to go to a treatment center. If the offender does not accept treatment and is caught a second time, he or she will be subject to penalties.
What types of penalties?
Drug users may be sentenced to do community work, or barred from going to certain bars at night, or loseing their right to bear a gun, or even losing security benefits. In the majority of cases, users accept treatment and begin the road to recovery.
If the offender is just an occasional or recreational drug user, the offender will be directed to a service that will have him or her discuss issues related to personal development, sexuality, self-care among other topics.
This has been the path taken by a number of people who had never even admitted to drug addiction, especially in the case of cannabis users who are the majority of users sent to Dissuasion Commissions. Today cannabis users are a mere 10% of our patients.
There has been significant change in public opinion with respect to drug addiction in Portugal. How do you see this change, is it a success?
Yes. I would say that the policy was adopted when the nation was ready for it, although there were politicians who claimed the country would become a haven for drug traffikers. 10 years later none of that happened. Of course we have had to face challenges, but we have been able to consolidate our teams in such a way as to respond to all these issues. We have been able to reach out to practically the entire population through street interventions, which we were able to do through triage, providing medical care and the necessary guidance.
How do you see the recent measure in the United Kingdom that offers free heroin to addicts?
To offer addicts heroin is substance therapy. It goes a step beyond what we do with Methadone. Methadone has its advantages, because it is a opium derivative and although users continue addicted, it does not cause psychotropic effects of comparable intensity and acuteness. The provision of addicts with methadone is compatible with an active professional, social and family life. Now similar programs that use heroin have been used in cases when methadone has failed, and it involves high social investment. I do not think such a program would fit our needs in Portugal at the moment.
Do you think the Portuguese model could be transferred to Latin America?
I think so, but solutions cannot be simply transplanted. I think that some of our measure may inspire others, but they would have to be adapted to local realities.
In my opinion, harm reduction policies have always been based on the supposition that they raise ideological divergences. The state decides that whether citizens want to or not, can or cannot stop using drugs, they merit being invested in.
In my view the Portuguese state’s position is appropriate, it has always maintained that people must be invited to stop using drugs. There is one tenet that is often ignored: one cannot entreat someone to use their will power when they are completely denied their human dignity, it makes no sense. If we can return users their human dignity first we will eventually get to a point in which we can demand something in return. But to go to drug addicts who are slaves to their addiction and make demands is senseless.
Translated by Lis Horta Moriconi
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