How Portugal is dealing with its drug crisis
In the 1990s, Portugal, like the United States today, was ravaged by an opioid epidemic so severe that Lisbon was dubbed the "heroin capital" of Europe. Portugal, however, has emerged from its crisis thanks to an innovative statute that entered into effect in 2001.
The law decriminalized the use and possession of up to 10 days' worth of narcotics or other substances for personal use, with the support of psychologists and other health-care professionals. (Dealers are still imprisoned.) Users who are caught by police are taken before a local three-person commission for the dissuasion of drug addiction, which is normally made up of a lawyer and any combination of a physician, psychologist, social worker, or other health-care professional with competence in drug addiction.
The commission determines whether the person is addicted and, if so, recommends therapy. Individuals who are not addicted may receive a warning or a fee. If the individual agrees to obtain help—an information session, motivational interview, or brief intervention—targeted to his or her pattern of drug use, the commission can decide to defer execution of these sanctions for six months. The case is closed if this occurs and the person does not appear before the commission again within the six-month timeframe.
The so-called Portugal model of shifting from a criminal to a public health strategy has yielded spectacular benefits. According to a New York Times investigation, the number of heroin users in Portugal has decreased from approximately 100,000 before the law to only 25,000 today. Portugal presently has the lowest drug-related death rate in Western Europe, with a rate that is a tenth of that of the United Kingdom and a fiftyth of that of the United States. The frequency of HIV cases linked to injectable drug use has dropped by nearly 90%. Delegates from the United States and other countries, including Amanda Clinton, PhD, senior director for international affairs at the American Psychological Association, visit the model on a regular basis.
"You can't work with people who are frightened of getting arrested and going to jail," says Francisco Miranda Rodrigues, president of the Ordem dos Psicólogos Portugueses. "It's impossible to have a successful health program if people are concealing their illness."
The need of harm reduction is emphasized.
According to psychologist Domingos Duran, chief of the treatment division of the government's Serviço de Intervenço nos Comportamentos Aditivos e nas Dependências, the Portuguese paradigm is founded on humanism, which sees persons with drug problems as people with illnesses. "By doing so, you may place the person in the context of health interventions rather than judicial actions," he explains.
When a dissuasion commission sends someone to treatment, they usually go to the country's national health service, which provides comprehensive outpatient treatment that meets the person's medical, psychological, and social requirements. The treatment team, led by a physician or psychologist, provides all services at one location to improve access to care. "For example, we don't have methadone clinics," Duran explains. "In this integrated paradigm, we have methadone in all of the public centers."
Harm reduction is the focus for those who aren't ready or reluctant to seek therapy. As a result, psychologists frequently leave their workplaces to provide care to drug users who require it. Rita Lopes, a psychologist with the voluntary organization Crescer, for example, spends her days traveling set routes throughout Lisbon in one of two vans. These mobile outreach teams, which include a psychologist, a nurse, a doctor, and a social worker, offer psychological support, exchange used syringes for clean ones, distribute condoms, and encourage drug users and other vulnerable populations to seek treatment at shelters, hospitals, and treatment centers.
Each year, the teams' 1,200 patients are encouraged to move at their own pace. "If they don't want to quit using drugs, that's fine with us," Lopes says. "We will assist them if they so desire." She emphasizes that the transportable units serve as a bridge to treatment. The primary purpose is to establish a rapport with drug users. "You can't achieve anything without a connection," she explains. "We build relationships first, then we serve individuals."
Other psychologists are in charge of harm-reduction initiatives. Hugo Amaral Faria, for example, is the program manager for a mobile methadone program conducted by the Ares do Pinhal Association for Social Inclusion in Lisbon.
The mobile units, which are staffed by a doctor who consults with patients and dispenses medication, a nurse, and two psychosocial technicians—non-university-educated specialists who provide teaching on themes like safer drug consumption and safe sex—visit five locations across Lisbon each day. Staff members check for infectious diseases, exchange needles, provide condoms, and distribute methadone, as well as medications for mental illnesses, HIV, and hepatitis. The program is described as "low-threshold," which means that participants are not obliged to abstain from drugs in order to benefit from its services. At least once a week, Faria and the other psychologists and social workers visit the mobile units to check on participants who are unable or unable to visit the Ares do Pinhal office. Each psychologist and social worker is in charge of roughly 100 patients who may require assistance in obtaining housing or referral to a substance addiction treatment program.
"It's not therapy," Faria clarifies, "but psychological assistance." The purpose is to empower individuals and assist them in achieving autonomy, whether that means assisting someone in obtaining an identification card to aid in their reintegration into society or assisting them in traveling to a hospital for HIV treatment. Participants can also get regular medical and psychosocial assessments, as well as a better understanding of their health status and access to community health and social services.
According to Faria, this harm-reduction strategy is paying off. For example, when the program began three decades ago, 55 percent of its participants were HIV-positive. Currently, only 13% are. And, as Faria points out, the mobile units do more than merely boost members' health. Staff members monitor infectious disease patients' medicine intake and thereby ensure treatment adherence, which helps to protect public health.
Now, the Portuguese Psychologists' Organization (Ordem dos Psicólogos Portugueses) is launching a series of trainings to help more psychologists in Portugal—both in the public and private sectors—prevent and cure addiction to opioids and other narcotics. The trainings will begin with a general overview of drug addiction before focusing on concerns specific to opioids, alcohol, and other substances. The goal, according to Rodrigues, is to expand the principles of the Portuguese model beyond substance abuse professionals and beyond the big towns of Lisbon and Porto. The trainings, which are set to begin in October, will blend e-learning and live group sessions across the country. "This is our approach of disseminating a successful model," he explains.
The Ordem dos Psicólogos Portugueses, as well as more than two dozen other national and regional psychological groups, have signed a memorandum of understanding with the APA. These memorandums of understanding spell out mutual objectives and bind the parties to regular contact and consideration of cooperative operations. Visit http://www.apa.org/.../2018/04/portuguese-psychologists.aspx for more information about the APA's relationship with its Portuguese equivalent.