In Portugal, Harm Reduction plays a crucial role when the needs of people who use drugs are at play but there are still a lot to advocate for. Article by Ximene Rego from APDES (Portugal).
In Portugal, Harm Reduction (HR) plays a crucial role when the needs of people who use drugs (PWUD) are at play. In 2000, a paradigm shift was set in motion due to the law that decriminalised the private and/or public use, possession, and acquisition of all psychoactive substances for personal use, thus eliminating the distinction between hard and soft drugs. Shortly after, in 2001, HR interventions were regulated. This event contributed to the multiplication of outreach teams and abstinence ceased to be the only therapeutic alternative. Ever since, HR services have been provided by NGOs and funded and monitored by State bodies.
Unlike policies that clearly reinforce individual freedom and the right of an informed choice, the policies that fall strictly within the health sphere – or whose absence would pose obvious challenges in terms of public health and/or social order – tend to face little or no opposition. This mirrors how the notion of drug use as something in the pathological scope is well assimilated by Portuguese society and political affairs. For instance, the national coverage of Opioid Substitution Treatment seems wide and stable – despite some territories (such Barcelos and Setúbal) failing to make low-threshold programmes available. The same can be said about needle and syringe programmes, although again with some limitations – the lack of these services in prison contexts being possibly among the most dramatic. Recent major developments, to name a few, include the broadening of hepatitis C treatment for all PWUD, the PrEP approval, and the legalisation of medical marijuana.
Meanwhile, elementary aspects in the scope of low-threshold HR services go unnoticed or are dependent of the “goodwill” of outreach teams. It is worth mentioning that there is no naloxone prescription for outpatient use in Portugal, either among outreach teams or peers, since it remains an exclusive of hospitals and medical emergency services. Tailored programmes aimed at poly-drug use are scarce, especially those targeting vulnerable PWUD. Safe crack use kits are (nearly) unavailable and education for safer practices on alcohol use is generally overlooked. Gender-sensitive programs are virtually nonexistent. Issues like double stigma for being a woman who uses drugs or for being a pregnant woman or mother who uses drugs – and the fact that they are more likely to suffer institutional violence – are grey areas. Portugal is a country with a tradition of festivals organised in outdoor, non-urban, and often isolated territories and the majority of these events lack the presence of HR outreach teams and/or other medical support services.
Political opposition, and perhaps social hesitation, tends to arise fiercely when HR policies go beyond pathology and highlight the well-being aspects of drug use phenomena, ignoring the fact that health is a very broad concept. Two measures of particular relevance – and among the most controversial in Portugal – have been in standby for 17 years: drug checking services and safe consumption rooms. The Decree-Law number 183/2001 (November 29th, 2001), which regulates, as mentioned above, the national HR policy, has failed in the concrete implementation of the aforementioned measures.
Drug checking services – designated by the said Decree-Law as “contact and information points” aimed at providing adequate information on the composition and effects of drugs – are legally framed and foreseen (despite its experimental character) by the legislation, with the main goal of providing the integrated analysis of psychoactive substances (which involves laboratory analysis) and also counselling in terms of HR practices. However, this same law does not define its operating conditions, leaving HR teams unprotected as regards to the handling and transport of samples. In addition, the lack of funding is one of the main obstacles to its permanent implementation, hindering the continuous and regular establishment of said services. As in others domains, drug checking depends on the perseverance of civil society. This year, drug checking services were made available at some Portuguese summer festivals by Check!n, a HR team of APDES, and also by Kosmicare at Boom Festival – without State funding, but with the adequate issued licenses.
As for drug consumption rooms, they haven’t been implemented yet, despite countless activism actions, international evidence-based studies, and public debate. Drug consumption rooms have been a prospect in Portuguese law since 2001; however – and since they are perceived as local mechanisms to address the drug use phenomenon – they are dependent on the municipal authorities’ will. The good news is that – in contrast with Porto – the Lisbon municipal authorities approved the creation of three consumptions rooms that will (hopefully) be operating in Lisbon by the end of 2018. The implementation of these services might influence Porto’s municipal authorities’ willingness.
Yet, the most ambitious challenge is to promote a debate that places the drug use phenomena in the Human Rights realm, thus favouring the respect for the principles of individual freedom and the right to an informed choice. HR is one of the cornerstones of Portuguese drug policy and certainly the most suitable to do so. Meanwhile, civil society emphasise the need to consolidate the on-going paradigm shift – namely by strengthening the notions of health that are broad enough to consider well-being and not solely pathology, which obviously is a poor concept when it comes to empowering PWUD.
Ximene Rego, APDES