Daphne Bramham: Harm reduction just one part of Portugal's war on drugs

Although the focus of Portugal's drug strategy is treatment and recovery, it does fund harm-reduction programs including outreach teams.

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In the 1990s, Portugal was in the throes of a national crisis, averaging 360 drug overdose deaths a year in a country of 10 million. Today, it has one of Europe’s lowest rates of drug, alcohol and tobacco use and the number of overdose deaths in 2016 was 26. In a weeklong series from Portugal, Vancouver Sun columnist Daphne Bramham looks at the lessons to be learned from the country’s radical approach to addiction treatment. 

LISBON, Portugal — It’s only after being assured that there are no police around that a wan, skinny heroin addict emerges from a shack that’s been cobbled together from spare boards and cardboard.

The shack is surrounded by discarded drug paraphernalia — but no needles. It’s on a dry hillside, below a government housing project and not too far from the national cemetery where for centuries Lisbon’s most powerful citizens have been laid to rest.

The addict’s name is Jose. He doesn’t give a last name. He brightens at the sight of social worker Andreia Alves and nurse Rita Abrantes. The outreach team is here to check on Jose and about a dozen other addicts who hunker here and they bring supplies aimed at reducing the harms associated with his drug use.

That includes syringes of different gauges — smaller ones for users who inject in their legs and groin, bigger ones for use on arms, legs and neck — and packages of distilled water and citric acid. The water and citric acid are used to dissolve heroin.

Abrantes rips a length of aluminum foil off a roll and hands it to him. Later, Jose will use it to cook and then smoke his heroin.

The outreach workers ask him how he’s doing. Can they help in any way? Does he know about the methadone van that makes the rounds? Does he need to see a doctor? During their conversation, Jose tells them it’s his birthday.

As evening sets in, we sing Happy Birthday in English. While we sing, his roommate huddles behind the shack beside a pile of used wrappers. He couldn’t wait to use one of the clean syringes to inject his drugs.

It is the saddest birthday I’ve ever witnessed.

The outreach team of social worker Andreia Alves (left) and nurse Rita Abrantes visit a shantytown to provide basic harm-reduction supplies to addicts and help motivate them to seek treatment. Daphne Bramham / PNG

Earlier, the outreach team was barely out of the van when an older man with deep wrinkles and no teeth approached, asking for aluminum foil.

He told the strangers with them that these workers were “very good.”

“They come here every day to help raise people up and give them what they need,” he said, tapping his heart before meandering away.

“Sometimes we are the only people who they talk to who don’t use drugs or sell drugs,” Alves said. “They do have friends, but it’s always about the drugs.”

Although the focus of Portugal’s national drug strategy is treatment and recovery, it does fund harm-reduction programs including outreach teams like this one. Like everything else in the strategy, the results have been impressive. Through education and prevention, there has been a sharp drop in injection drug use. Now, there are an estimated 33,290, high-risk, opioid users, down from an estimated 100,000 in the late 1990s.

Infection rates for HIV/AIDS and hepatitis have also fallen. The most recent data indicate that HIV diagnoses related to injection drug use dropped from nearly 500 in 2006 to 30 in 2016. Despite that decline, 1.35 million syringes were distributed in 2016 through programs like this one.

As we carried on down the worn path, Alves and Abrantes pointed out horses grazing in the distance. But then they quickly reminded us to keep our heads down and watch for used needles. At a bend, two junkies appeared startled at the sound of our approach.

Police come here often looking for drugs, drug users and dealers. Depending on the officer, some make arrests and confiscate drugs. At the police station, if they’re found to have only enough for personal use, police will write them a summons to appear the following day at the Commission for Dissuasion of Drug Use, where they’ll be offered a fast track to help.

But sometimes, they say, officers threaten them, demanding information about their dealers in exchange for not arresting them.

Assured by the outreach workers that none of us was with the police, one man dug two handfuls of used syringes out of a bag and dropped them into the bright yellow bucket that Alves carries.

Antonio runs what he calls a safe injection site in a Lisbon shantytown. The methadone user and former heroin addict says he’s doing the other addicts a favour by looking out for them when they’re using or high. Daphne Bramham / PNG

A neatly dressed man came up the path as they talked. Antonio was returning from another, larger shack down in the valley. A 20-year methadone user and former heroin user, he has fashioned what he calls a supervised injection site. It’s a surprisingly tidy inside, despite scrounged couches and ornaments including a toy — one of Disney’s 1,001 Dalmatians — that stands guard at the entrance.

Until this past summer, Portugal had no official, supervised injection sites. In July, three pilot projects were launched — two in Lisbon and one in Porto, the second largest city.

Antonio regards himself as a bit of a hero.

“I’m not afraid of the police. I have nothing to fear because I’m doing things that nobody else does. I explain to the police that it’s better to inject here than near a school or at a public park. And, I’ve already sent five people to institutions to get better.”

He picks up used needles and when he finds toys, he sells them to local kids for the equivalent of a Canadian quarter. It helps supplement the $640 he receives each month in social assistance.

A so-called “safe injection site” in a Lisbon shantytown is operated by Antonio, a methadone user and former heroin addict. Daphne Bramham / PNG

At 64, Antonio said he’s lost too many friends — most of them during the heroin overdose epidemic in the 1990s. It scared him clean. For how long isn’t clear. At one point, he said 20 years, at another 30.

“I hate heroin. Even the smell of it makes me puke,” he said.

For Antonio, clean means getting a daily dose of methadone. He can’t get it from a clinic and bring it home because doctors fear that he’ll sell it in this shantytown. Instead, Antonio goes every day to the mobile dispensing van that cruises the neighbourhood on a regular schedule.

“One more year, I’m going to stay on it,” he said. “I’m going to quit next summer.”

It’s a fitting epitaph for more than a few addicts.

Although Alves and Abrantes offer to get people into detox, treatment and recovery, they admit that long waiting times often keep users from getting into residential care. In 2016, there were 27,834 people in treatment with 2,090 of them first-time entrants.

“If you want to pay, you could go tomorrow,” said Alves. “Everybody who doesn’t pay waits two or more months. But you can go to the central treatment centre in the meantime.

“There is also a shelter where they have activities and you can stay there and have professional help. And, you can go to the methadone program.”

If users ask for help and provide their names and ages, the team makes the connections to the services the next day and will even drive the users to where they need to be.

“In the past, there were a lot of tents here. But that’s changed since they (the government) started to provide methadone and to create shelters where people can go inside even if they use drugs outside,” Alves said.

Before 2001, when drug use was decriminalized, the shelters were only for people who weren’t users.

At the outreach workers’ first stop of the night, we met only six men. Women — other than the outreach workers — don’t come here.

Less than 20 years ago, Lisbon was known as the junkie capital of the world because it was home to the largest illicit drug market in Europe.

A homeless addict uses a syringe to shoot up outside his tent in the Casal Ventoso slum in Lisbon in 2000. The shantytown has since been demolished, with new housing (under construction at left) for its 1,200 residents. Gael Cornier / PNG

In the city’s Casal Ventoso, a shantytown that attracted up to 5,000 people a day, even grandmothers sold heroin. Portugal’s national drug policy coordinator, João Goulão, recalls seeing one elderly woman handing heroin to addicts out her window along with bowls of chicken soup.

One in every 10,000 Portuguese used heroin and overdose deaths were deemed to be of epidemic proportion, with 360 dying from overdoses annually. Frequently, bodies were found in Casal Ventoso when dawn broke.

The drug crisis had its roots in war. Just as American soldiers came home from Vietnam addicted, so did Portuguese soldiers who had been fighting colonial wars in Angola, Guinea-Bissau and Mozambique.

Goulão, a family physician, led an 11-person committee that convinced the government that radical change was needed.

“There were many differences of opinion,” Goulão said. “But our main guidance was humanistic and respect for the dignity of people using drugs.”

Since almost every family had personal experience with addiction, citizens needed little convincing that addiction was an illness and that addicts needed help, not jail.

Casal Ventoso was bulldozed. Nearby, the government built social housing units in apartment towers for the shantytown’s residents who weren’t addicts.

Cres Car, the non-profit organization that Alves and Abrantes work for, is on the ground floor of one of them, providing a wide range of services that include counselling for addictions and family problems, help with finding employment and housing, and specialty services to those sleeping rough. It also provides them with an address and phone number so that they qualify for welfare.

Cres Car used to have a needle exchange program, but residents complained when addicts were shooting up in the underground parking lot half a block away. So it no longer hands out needles and syringes from its office.

As a steady stream of people came and went, a little girl rode by on a pink bike. A couple of little boys ran shouting along the concrete that separates one highrise from another, delighting in the sound of their voice echoing in the concrete cavern.

A few doors down from Cres Car, mothers with babies in arms drank espresso and exchanged gossip at the two cafés.

And above it all? Grandmothers looked down from their windows — the informal enforcers of public order.


Twitter: @daphnebramham

the war

Day 1:World comes to study Portugal’s grand experiment.

Day 2:Dissuasion commission aims to set users straight.

Day 3:Life today for drug addicts in Portugal.

Day 4: Outreach workers have a long-term goal.

Day 5:Harm reduction just a piece of the puzzle.

Day 6:Treatment centres abound; so do waiting lists.

Day 7:Applying the Portuguese model to B.C.