Socio-economic deprivation is associated with drug dependence, but not drug use (von Sydow, et al., 2002). It is also clear that countries with a lower level of social inequality and greater social cohesion have smaller populations of problem drug users per head of population. Thus, addressing poverty and social inequality over the long term will have a significant impact on levels of problem drug use. (Civil Society Forum on Drugs - Recommendations to the EU Member States and to the European Commission regarding the new EU Drugs Strategy and Action Plan, 2012, p. 7)
In the present climate, designing effective drug policies, adapted to the real needs of people, implies adopting a much broader perspective of problematic drug use than treating it purely as a health issue. The change in paradigm, from a perspective that considered drug users as criminals, to one focussing primary on the health issues that underlie “addiction”, represented an important turning point for implementing comprehensive measures in the drug field. This was made possible in Portugal, thanks to the Decriminalisation Model, implemented in 2000, which definitely opened the door to more comprehensive and non-judgemental intervention services such as harm reduction and outreach work. Results so far could hardly be more positive. Portugal has seen a reduction in the prevalence of HIV among injecting drug users, while the number of people accused of drug-use, and rates of problematic use, have also declined. The country has become an example of best practice in the drug field. Although these results are a cause for national pride, especially among professionals, drug-user representatives, researchers, and politicians who have a genuine interest in this area, the “resounding success” of these drug policies cannot be exclusively attributed to drug-specific public health responses or decriminalisation of drug-use. Social benefits, reintegration, housing and employment programs that support the most vulnerable, were crucial for implementing integrated and comprehensive strategies in this area. Also, the success of Portuguese drug policies cannot be fully understood without considering macro-social indicators such as poverty levels, employment rates and broader political ideologies concerning the role of the state in mitigating social inequality.
It is with great concern, these days, that we are witnessing a strange paradox in social policies: On the one hand, according to economic indicators such as the Gini Index, the crisis is affecting the poorest and most vulnerable, since we are seeing an alarming growth in the gap between lowest and highest incomes, and a sharp rise in unemployment rates. On the other hand, social benefits are being cut, which mean that hundreds of people are actually losing social support - this being, in some cases, the only financial support they have. This paradox means that we are tragically seeing an ideological change among our decision-makers, in terms of how they percieve the role of the State as an enabler of social justice, while the State withdraws from using redistributive measures and from supporting those who are first in line to be affected by the financial crisis.
Concerning this ideological and economic shift in the accepted model of social intervention, APDES considers that today, it is not enough merely to support programs that focus mainly on health prevention and harm reduction. It´s not enough to categorise drug users as "addicted". Today more than ever, we need to address poverty, exclusion, and stigma, when we talk about drug use. More than ever, we have a duty to advocate for human rights, and address problematic drug use as a profound problem of social inequality which is not likely to be resolved through stopgap measures.
APDES has been actively advocating for the need to once and for all consider drug users as citizens, citizens who in problematic cases tend to live in poor conditions, unsupported, and viewed (by a society in which only the fittest survive), as a different kind of human being and blameworthy for their life situation. APDES rejects stigmatisation and discrimination against drug use and drug users. In this way, APDES has drafted recommendations which were delivered last July to the Portuguese Parliament, addressing pragmatic measures that need to be urgently adopted in order to prevent irreversible consequences - both for drug users, and for society in general. More recently, we also appraised an important Portuguese document, the National Plan for Reducing Addictive Behaviors and Dependences (Plano Nacional para a Redução dos Comportamentos Aditivos e das Dependências, PNRCAD), that sets out a prioritised action plan for the Portuguese government for the period between 2013 and 2020. in respect of dependence behaviors such as illicit drugs, alcohol and gambling. Even though, in terms of drug use, APDES agrees with the document's main thrust, there were issues - addressed inadequately or not at all - that we considered to be of unquestionable importance in planning intervention and strategies on drug use. We highlight two of the considerations, documented by APDES:
First, the PNRCAD gave insufficient coverage to current Portuguese social and economic conditions. Without such a socio-economic context, drug use intervention is bound to contribute to the pathologisation of drug use, promoting stopgap measures which isolate the use of drugs from social inequality and poverty. This is a very dangerous position, since it is only to likely to bolster government arguments legitimising their abdication from their role of promoting social justice and equality.
The second consideration focuses mainly on the failure to seek input from Civil Society and Drug Users' Representatives in the definition of the main priorities. Many harm reduction services, especially outreach interventions in Portugal, have been developed by NGOs active in the field. In addition, the National and International networks which many of them have developed, can make a significant contribution to developing and evaluating comprehensive policies.
These, and other APDES recommendations and comments, were sent to the Intervention Services on Addictive Behaviours and Dependencies (SICAD), the Government agency with responsibility for the plan and the Portuguese Governmental authority on dependence behaviors, in order to provide important information for the roll-out of comprehensive and efficient drug policies in the future.
The Portuguese Model of Decriminalisation was founded on humanist and pragmatic principles, and its success is today being jeopardised by the idea that intervention focussed solely on health can be effective - as if problematic drug use was just a disease, divorced from social opportunities and rights. More than ever, we have to understand that human dignity, respect, social justice and equality cannot be achieved with charity!
Now more than ever, we have to rescue the real principles underpinning the Portuguese Model of Decriminalisation; otherwise, we will be passive spectators, while the phenomenon of drug use comes to be considered a problem “treatable” by repressive and coercive measures.
Helena Moura, APDES, Portugal
· Centro de Vigilância Epidemiológica Doenças Transmissíveis (2000). SIDA. A situação em Portugal a 31 de Dezembro de 1999 (AIDS. The Situation in Portugal in Decembre 31, 1999). Instituto Nacional de Saúde. http://repositorio.insa.pt/bitstream/10400.18/1605/1/Documento%20SIDA_119%20%2831.12.1999%29.pdf
· Civil Society Forum on Drugs (2012). Recommendations to the EU Member States and to the European Commission regarding the new EU Drugs Strategy and Action Plan.
· Unidade de Referência e Vigilância Epidemiológica (2013). Infeção VIH/SIDA: a situação em Portugal a 31 de dezembro de 2012 (VIH/AIDS. The Situation in Portugal in Decembre 31, 2012). Instituto Nacional de Saúde Doutor Ricardo Jorge, IP http://repositorio.insa.pt/bitstream/10400.18/1622/3/Relatorio_SIDA_2012_WEB.pdf
 Note that in 1999, drug use was the main transmission category corresponding to 60.1% (N= 547) of the population infected in that year (Centro de Vigilância Epidemiológica Doenças Transmissíveis, 2000). In 2012, only 10% (N= 776) of the HIV cases detected were associated to drug use (Unidade de Referência e Vigilância Epidemiológica, 2013). Although it’s noticeable the impact showed by this evidence, it’s important to analyze these data with precaution, since the screening and testing of HIV, has suffered major changes all over the years, being progressively more inclusive of other transmission categories. Without information considering the number of positive tests vs. the number of tests conducted in each category, we have to be cautious.