Do the recent structural changes to Portuguese harm reduction services threaten the stability and integrity of the country’s system? Our local EDPI partner, APDES, guides readers through this issue.
Recent developments in the structural features of Portuguese addiction agencies warrant careful consideration. Firstly, in 2011, a legal decree (no. 124/2011, of December 29th) abolished (by merger) the Institute for Drugs and Addiction (IDT) and the Service for Intervention in Addictive Behaviours and Addiction (SICAD), transferring responsibility for this work to the Regional Health Authorities (ARS I.P.) and General Inspection for Health Activities (IGAS). In practice, this means that drug equipment ceased to be administered directly by the Health Ministry via an autonomous dedicated agency (IDT I.P.), and this work was absorbed into a larger agency within the National Health Service, the General Direction of Health. Secondly, in the context of the National Plan for Mental Health (2007-2016), some important steps have been taken towards the effective integration of work on addictive behaviours, within the mental health area. APDES took an active part in the public discussions of the workin party evaluating the state of mental health in Portugal. The essential elements of that contribution are explored here.
What does the change of structures bring with it?
In order to fully understand the first change, we need first to have a look backwards: Over the last three decades, Portugal has gone through a process of refinement and specialisation which led to the creation of quality services – among them, the IDT – characterised by a remarkable degree of integration and complementarity. Obviously, there was still considerable room for improvement, but the abolition of IDT meant the loss of a sizeable bank of accumulated expertise relating to living with dependency. The autonomy of this organisation reflected not only its dedicated nature, but also the inevitable complexity of responses in this field. The marked international success of the Portuguese Model on Drugs is not, certainly, unconnected to this level of autonomy, specialisation and territorial integration, which together allowed a truly comprehensive approach to the problem.
Much more then a mental health issue
Regarding the mental health context of drug use, there are disagreements. As we know, if the massive abuse of drugs is a recent phenomenon in human history, although drug use is an anthropological constant, this compels us to take one important sociological fact into consideration: the drug problem is rooted in a complex combination of bio/psychosocial factors, in which the social dimension plays an important role. So, its classification as a mental health issue is reductive, dangerous and contributes to the pathologisation of consumption. In addition, the phenomena of stigma and social marginalisation – factors adversely affecting the health of the individual – contribute significantly to increased risks associated with drug use, creating a threat to public health (e.g., contagion risk of infections such as HIV, viral hepatitis or tuberculosis; or the risk of death from overdose). Besides, as scientifically established, the majority of individuals who contact with drugs, whether legal or illegal, are non-problematic. So, to categorise the use of these substances as psycholgically aberrant behaviour means ignoring the considerable part of the population which benefits from specialised harm reduction interventions, outside the mental health framework.
Greater commitment on harm reduction measures needed
Although we recognise that the document, in essence, is in line with the intention to maintain the long-standing interventionist model, in practice, APDES’ intervention experience leads us to raise concerns about what is a clear political plan to dilute responses to addictive behaviour – with particular consequences for harm reduction. A greater commitment to harm reduction measures should take a form which reflects its political importance. The scientific evidence clearly shows that harm reduction represents good value for money, so that it warrants autonomous status within drug policy. This is particularly true of treatment and prevention, which are clearly distinguished from the theoretical point of view, from fieldwork and intervention strategies.
Overall, APDES is worried about the reclassification that has been made of the drug phenomenon in national public policies, and the lack of consultation with the intended beneficiaries of these policies, who should be the most important actors in an evaluation process within a comprehensive policy model. Finally, APDES is concerned about what seems to be a retrograde step in the categorisation of people who use drugs, who first went from being considered “criminal” to being considered “sick” and, more recently, from “sick” to “citizen”.
Marta Pinto, Maria João Oliveira, Soraia Teles/APDES