- 22 Oct 18
Hot Press saw first-hand how Portugal has managed to cut its drug OD rate from over 300 to 23
The reviews were universally rave last night for The Hardest Hit, Philly McMahon's documentary on the way people with addiction issues are treated - or not treated - in Ireland.
The Dublin GAA star, who tragically lost his brother John to heroin in 2012, took to the streets of Dublin and Limerick to see how the cities are dealing with their respective drug problems.
What he discovered were services shorn of resources, and people being criminalised for what are essentially health reasons. Some of the most poignant and incisive observations were made by those with past and present addiction issues. Philly was accompanied on a trip to Lisbon by the CEO of the Ana Liffey Drug Project, Tony Duffin, where he saw first-hand how, since going the decriminalisation route in 2001, Portugal has seen yearly overdose deaths fall from 300 to 23; problematic drug use half; and HIV infection rates similarly plummet. Stuart Clark was also in Lisbon recently and filed this report, which explains precisely what they're doing right there, and why Ireland urgently needs to go the same decrim route...
"We haven’t stopped the war on drugs, we’ve stopped the war on people.” Dr. Nuno Capaz is explaining the philosophy behind Portugal’s health-based ‘treat don’t punish’ drug laws, which have seen overdose deaths fall from 300 in 2001 to 23 last year. In that same period, the number of problem drug users has been halved from 100,000 to 50,000; intravenous drug use as a factor in new HIV cases has plummeted from 60% to 6%; and heroin use among the prison population is down from 14% to 3%.
With official government stats like that, it’s no wonder that Portugal has become such an important reference point for progressive drug policy.
“We’ve had delegations visiting us from all over the world including Ireland, Canada and Norway, where they’re introducing their own version of decriminalisation,” resumes Capaz, an amiable fortysomething whose hipsterish demeanour belies the fact that he’s Vice-President of the Lisbon Drug Addiction Dissuasion Commission. More commonly known as the CDT, it’s where 4,000 people caught with drugs for personal use were sent last year, instead of to court. Following an initial assessment in the organisation’s nondescript suburban offices, they were obliged to return, to meet a panel comprising of a lawyer, a psychologist and a social worker.
“People are apprehensive about coming here, but we’re not trying to punish them,” Nuno stresses. “Because we’re part of the Ministry of Health we’re not a threatening structure. We don’t moralise, and we offer advice rather than instruction. It’s the person who’s been decriminalised, not the drug, which remains illegal. The assessment determines whether they’re a recreational user or a drug addict because the law applies differently to them. In between the two, there’s a huge grey area of more or less problematic cases.
“We always try to discover if people have problems other than the use of an illicit substance,” he adds, “whether it’s an early dropout from school, a long-term unemployment situation, someone who uses alcohol as well as drugs, someone who has family problems, an illegal immigrant with no paperwork and residence status acquired, we can put them in contact with the relevant services to ensure that their problem doesn’t develop into an even bigger problem. This early intervention means that only 15% of people present to the Dissuasion Commission more than once.”
REDUCE THE STIGMA
The term ‘for personal use’ is defined in Portugal as what you might reasonably be expected to consume in a 10-day period. The permitted amounts aren’t overly generous with 0.1 gram of LSD; one gram of heroin, methadone, MDMA or amphetamine; two grams of cocaine; five grams of cannabis resin and 25 grams of cannabis leaves/flowers/fruited doms the thresholds that have to be crossed before the criminal justice system gets involved.
“Drug dealers still go to jail but if a guy has, say, six grams of hashish on him, the courts will often refer them back to us,” Nuno notes.
“For decriminalisation to work, it requires common sense and discretion. One of the things I normally recommend to regular cannabis users is, ‘Try not to smoke for two or three weeks. See what it’s like not to be under its effect. Maybe you’ll think differently about it’. The cost to the state of sending somebody to court is €480 as opposed to €230 for attending the Dissuasion Commission. We saw 4,000 people last year in this office, which is a saving of €1 million and the outcome is better too.”
Portugal’s drug laws were radically overhauled in response to the heroin epidemic of the late 1990s, which had started a decade earlier with middle-class students in Lisbon – drug-taking was regarded as an almost intellectual celebration of the death of the country’s Franco-like dictator, Antonio Salazar - and quickly spread to other parts of the country.
“It needed a drugs epidemic and a financial crisis – ‘Is what we’re doing cost effective?’ – to convince politicians from all sides to take action,” Nuno Capaz reflects. “Every family, rich and poor, was affected. People were openly injecting in the streets. Not far from here you had a drug slum, Casal Ventoso, where thousands were living in tents and holes in the ground. Every day there were overdoses and people being found passed out, with maggots in their wounds. The feeling was, ‘Let’s try this, because it can’t make things any worse’. And, of course, it’s made things hugely better.”
Portugal’s heroin-using community is an ageing one – “I’d estimate that the majority of people with addiction issues are over 40”, Nuno notes – with fewer young people getting hooked.
“When one person stops, it means that four or five people in their family or social circle are no longer directly exposed to heroin and are less likely to start using it themselves,” he reasons.
To work as effectively as they do, Portugal’s drug laws require the full support of their three police forces – the paramilitary Guarda Nacional Republicana, who mainly operate in larger cities; the civilian Polícia de Seguranca Pública, who are the ones most likely to nab you for having a wrap of MDMA; and the Polícia Judiciára, who concentrate on murders and other serious criminal cases.
“The police catch somebody, they send them to us, job more or less done,” Nuno says. “Because they’re not worried about incriminating themselves, people are more likely to tell the police where they got their drugs, which has led to an increase in the amount of drugs seized.”
In conclusion, Nuno says: “What we’ve learned – and there’s endless research on this that I can show you – is that if you reduce the stigma surrounding drug use, people are far more willing to seek treatment.”
SAFE INJECTING ROOM
The oft-heard mantra of people opposed to drug decriminalisation in Ireland is that it’s a first step towards full legalisation. Not, so, says one of the architects of Portugal’s drug laws, Manuel Cardoso.
“There is no appetite for legalisation, apart from medicinal cannabis,” says the second in command at the General-Directorate for Intervention on Addictive Behaviours and Dependencies. “The police are very comfortable with our policy. Their attitude is that drug users are sick, not criminals. They have a really good relationship with the Dissuasion Commission and work with them to explain to officers what we’re looking to achieve.”
Thirteen different government ministries have come together to tackle all addictive behaviours, which interestingly, given the debate we’re currently having about it here, includes gambling. As for the cost, as Manuel Cardoso points out: “The extra spending in some areas is offset by savings in others.”
The ‘democratic’ nature of heroin addiction is evident when we rendezvous with the Mobile Low Threshold Programme bus, as it parks up under a flyover around half a mile from Nuno Capaz’s office. The first dozen people in the queue to get their 20ml of maintenance methadone from the cheery nurse include an attractive young woman in her 20s who steps out of a newish BMW, a slightly older woman who we’re told works in a local bakery, a studenty type with a scruffy briefcase, and a man carrying a few meagre personal possessions who appears to be a rough sleeper. After getting their methadone, they all quickly go their separate ways again, with no signs of people congregating or dealing. There’s a police station 50 metres down the road, but the drug worker we talk to can’t remember the last time they took a professional interest in the bus.
As drug use evolves, so do the harm-reduction responses employed by the likes of IN Mouraria, a drop-in facility serving a working-class community close to the city-centre, which is run with evangelical zeal by Adriana Curado.
“Crack cocaine has overtaken heroin as the main drug that people inject and smoke in this area,” she tells us. “We’ve secured private funding to hand out clean crack pipes to some of the 80 clients we see every day. When you smoke rock cocaine, your lips crack and there’s blood, which can lead to HIV and Hepatitis C infection if the pipe is shared. It also reduces scarring on the lungs, which is a major problem.”
The services offered to clients by IN Mouraria range from HIV testing, Hepatitis C treatment and liasing on their behalf with the courts to free snacks, wi-fi access and the use of a photocopier. Going forward, they’re keen to operate a safe injecting room, and have bought the next-door building in anticipation of being given that particular green light.
“There was a discussion on the radio recently about heroin and crack cocaine, and lots of our neighbours rang in to say positive things about us,” Adriana enthuses. “If local people have health problems that don’t require going to the doctor, we let them see our nurse. This is a resource for the whole community.”
A SENSE OF SELF-WORTH
The desire to prevent drug addiction, rather than to maintain or cure it, hasn’t been abandoned, with 1.3 million Portuguese kids receiving on-going drug education at school. As a result, there’s been a steady decrease in illicit drug use among adolescents, since 2003.
Precisely how Portugal has managed to reduce its annual overdose deaths from 300 to 23 – we average one a day in Ireland with half the population – is a question I put to Dr. Pedro Marques Catita, the impressively named clinical psychologist who oversees the Xabregas Integrated Response Centre in eastern Lisbon. Opened in 1997, they currently have 1,122 patients in therapy, 500 of who are on methadone maintenance programmes.
“If people can’t or won’t give up taking drugs, you have to reduce the risk,” Dr. Catita begins. “One example of that is encouraging them to smoke rather than inject heroin, which is much, much safer. Pre-2001, 80% injected. Now, it’s 10% injecting.”
That noise you can hear is the howls of NIMBY-ish Irish politicians going ape at the thought of the Department of Health recommending that injecting users should start smoking their heroin instead. But it works. “It requires a leap of faith from politicians, doctors, law enforcement and healthcare workers alike,” Dr. Catita acknowledges. “The real challenge is to give people decent lives, which means jobs or meaningful training, somewhere with a front door that they can lock and call home. It’s crucial to have a sense of self-worth.
“Outreach work is an important part of reducing harm. We can’t just sit here waiting for them to come to us. We have street teams to find the people falling through the cracks. They can’t see the light at the end of the tunnel because they’re not in the tunnel yet. We don’t make them feel a bad person if their attempts to come off drugs fail the first time, the second time, the third time. We’ll try again.
“They might get it right the sixth time. There’s no guilt or punishment for not succeeding. We encourage rather than belittle. A colleague of mine gives clients a diploma saying, ‘I’ve completed my treatment for Hepatitis C’. They’re so proud of it. It might be the only diploma they ever get.
“We start work immediately with them as out-patients,” Dr. Catita adds. “It can take a month to get into a therapeutic community: we can do a lot with a client in that month. It’s not dead time. They can use heroin until the day of their admission into the community, then we put them on methadone. We don’t have the same ongoing debate about whether methadone maintenance works. We accept that it does, but Portugal also has 1,200 detox beds. It’s important to have the fullest range of options and services that join up. It’s a very safe space that they spend 12-18 months in. Afterwards, we offer them whatever psychological or psychiatric support they need. There’s no magic wand; we can’t cure everyone, but there are tailored responses.
“Some referrals come from the Dissuasion Commission, some from youth services. They can be reluctant. ‘We don’t have a problem, we don’t need to be here’. That’s okay. We let them know that whenever they want to come back, they can. We open a file and wait for them. I compare it to being overweight: ‘I’ll start the diet tomorrow’. It only works when they’re ready.”
Whilst justifiably proud of what Xabregas and similar centres are achieving, Dr. Catita isn’t resting on his laurels.
“Twenty-three overdose deaths a year is still too many,” he asserts. “Realistically, you’ll never get it down to zero but we should be aiming for single figures. There is always more that can be done.”
Asked what that ‘more’ comprises of, Dr. Catita says: “When the recession hit in 2010, the government cut the money for employers to take people on who are recovering from addiction. They need jobs in order to be able to rebuild their family ties. It also reduces the risk of them resorting to criminality. Street teams are not allowed to administer Naloxone, the medication used to block the effects of opioids. If they find someone lying unconscious who’s overdosed, they have to wait for a doctor to administer it. During that time, somebody could die. It’s now available in inhaler form and has no side-effects or other medical uses, so you could give it to street teams to take out with them.”
LEAP OF FAITH
One of those street teams is headed up by Marta Correia, a clinical psychologist in her early twenties, and Joao Faninha, a 57-year peer worker who was addicted to heroin himself for over thirty years. “I was a good student from a middle-class family who played basketball, but Salazar died and everybody thought, ‘Hey, let’s try new things!’” says Joao who, having started off volunteering with them, was recently added to the Crescer community-based intervention organisation payroll.
Marta and Joao are based in Bairro Quinta Cabrinha, a crumbling tower-block complex – think pre-demolition Ballymun - in an area of Lisbon where intravenous crack cocaine and heroin use remains rife. It’s their job to track and help the people, who either through choice or their lifestyles being too haphazard, are unable to attend clinics like Pedro Marques Caita’s one.
First on their daily drive-round is Santa Clara, an even more dilapidated estate where Joao recently discovered a middle-aged man dead from an overdose. They take us into a patch of wooded wasteland behind some flats where we find 15 people in various states of intoxication sitting under tarpaulins strung between tree branches.
The stench of urine and faeces is startling, as is the carpet of bloodied syringes, crack pipes and other drugs detritus that Marta and Joao start picking up with scoopers. Also opened and discarded are dozens of the safe injecting and smoking packs that the pair hand out every day. The other overriding smell is of charred wood, the result of a botched council attempt to eradicate the camp, which is normally a no-go area for their workers who are happy to let the Crescer street teams take care of the day-to-day cleaning up of drug paraphernalia.
“One of the people we’ve just seen has asked if we can arrange for a doctor to come and visit them here tomorrow,” Marta tells me after we leave. “One day a week we bring a nurse with us. Everybody has a different story to tell. One of the women is from quite a rich family, and there’s a man who spends three months working down south in Almodovar and then comes back and spends all of his money on heroin before going back again. We’d love to be able to carry Naloxone with us but we’re not allowed. The drug laws in Portugal are good, but they’re not perfect.”
Next up is Casal Ventoso, the former drug slum mentioned by Nuno Capaz, which is still home to a community of 20-30 mainly rough-sleeping intravenous drug users, who are mostly in their forties, but look a good twenty years older. Once again, Marta is asked to organise a doctor’s visit by a man with destroyed teeth, who gives us a big gummy grin and says, “Welcome!”
Elsewhere on their rounds, we get to meet a Cape Verdean sex worker in her early thirties who tells us about her mother OD-ing and, more happily, her son who recently landed himself a job in Belfast; and a slightly older guy with half-a-dozen surgical staples in his head who gives us a history lesson on Vasco de Gama and the other great Portuguese explorers. Both ask for clean tin foil before wandering off to presumably smoke their heroin or crack.
By the time we return to base, Marta and Joao have collected well over 100 syringes, which are immediately taken to the incinerator.
“Lisbon’s first safe drug consumption room is opening close to here later in the year,” Marta says. “The heroin and crack users you met today are very excited, as are we because it will save lives. These are the most vulnerable of the vulnerable. If we can’t get them into treatment, we can at least keep them alive.”
It’s important to note that we already have drop-in centres, street teams, needle exchanges and other progressive harm reduction strategies like encouraging heroin users to smoke rather than inject here in Ireland. What we’re lacking, of course, is that vital last piece of the puzzle.
No one I meet in Portugal believes decriminalisation to be a silver bullet, but it is by far and away the best option if you want to significantly reduce drug deaths. Instead of taking the word of a rock journalist, you might prefer to read the recent United Nations report, which urges members to: “Commit to treating people who use drugs with support and care, rather than punishment. UNAIDS believes that this objective can only be achieved by implementing alternatives to criminalisation, such as decriminalisation and stopping incarceration of people for consumption and possession of drugs for personal use.”
Let’s make that leap of faith here in Ireland too...