Like the United States today, Portugal in the 1990s was in the grip of an opioid epidemic so intense that Lisbon was known as the "heroin capital" of Europe. But thanks to an innovative law that went into effect in 2001, Portugal has turned its crisis around.
With the backing of psychologists and other health-care professionals, the law decriminalized the use and possession of up to 10 days' worth of narcotics or other drugs for individuals' own use. (Dealers still go to jail.) Instead of facing prison time and criminal records, users who are caught by police go before a local three-person commission for the dissuasion of drug addiction, a panel typically composed of a lawyer plus some combination of a physician, psychologist, social worker or other health-care professional with expertise in drug addiction.
The commission assesses whether the individual is addicted and suggests treatment as needed. Nonaddicted individuals may receive a warning or a fine. However, the commission can decide to suspend enforcement of these penalties for six months if the individual agrees to get help—an information session, motivational interview or brief intervention—targeted to his or her pattern of drug use. If that happens and the person doesn't appear before the commission again during the six-month period, the case is closed.
Shifting from a criminal approach to a public health one—the so-called Portugal model—has had dramatic results. According to a New York Timesopens in new window analysis, the number of heroin users in Portugal has dropped from about 100,000 before the law to just 25,000 today. Portugal now has the lowest drug-related death rate in Western Europe, with a mortality rate a tenth of Britain's and a fiftieth of the United States'. The number of HIV diagnoses caused by injection drug use has plummeted by more than 90 percent. Delegates from the United States and other nations—including APA's Amanda Clinton, PhD, senior director for international affairs—arrive regularly to see the model firsthand.
"You cannot work with people when they're afraid of being caught and going to prison," says psychologist Francisco Miranda Rodrigues, president of the Ordem dos Psicólogos Portugueses. "It's not possible to have an effective health program if people are hiding the problem."
Emphasizing harm reduction
The Portuguese model is based in humanism—seeing people with drug problems as people with an illness, says psychologist Domingos Duran, head of the treatment division of the government's Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências. "By doing that, you can put the person in the framework of health interventions, not judicial interventions," he says.
When a dissuasion commission refers someone to treatment, that person typically seeks care in the country's national health service, which offers integrated outpatient treatment that addresses the individual's physical, psychological and social needs. Led by a physician or psychologist, the treatment team provides all services at one site to increase access to care. "We don't have methadone clinics, for example," says Duran. "We have methadone in all the public centers in this framework of an integrated model."
For those who aren't ready or who are unwilling to seek treatment, the emphasis is on harm reduction. That means psychologists often leave their offices and go into the streets to bring care to the drug users who need it. For example, Rita Lopes, a psychologist with a nongovernmental organization called Crescer, spends her days in one of two vans cruising set routes in Lisbon. In addition to a psychologist, these mobile outreach teams consist of a nurse, doctor and social worker who provide psychological support, exchange used syringes for clean ones, hand out condoms and urge drug users and other vulnerable populations to take advantage of shelters, hospitals and treatment centers.
The 1,200 patients the teams serve each year are encouraged to move at their own pace. "It's OK for us if they don't want to stop using drugs," says Lopes. "If they want to, we help them." The mobile units are a bridge to treatment, she explains. The main goal is to build a relationship with drug users. "Without a relationship, you can't do anything," she says. "First we create a relationship, then we help people."
Other psychologists coordinate harm-reduction programs. Hugo Amaral Faria, for example, manages a mobile methadone program run by a nongovernmental organization called the Ares do Pinhal Association for Social Inclusion in Lisbon.
Staffed by a doctor who consults with patients and administers medication, a nurse, and two psychosocial technicians—professionals without university degrees who provide education on such topics as safer drug consumption and safe sex—the mobile units visit five spots across Lisbon each day. There the staff screen for infectious diseases, exchange needles, offer condoms and distribute methadone, along with medication for mental disorders, HIV and hepatitis. The program describes itself as "low-threshold," meaning that individuals aren't required to abstain from drugs to use its services. Faria and the other psychologists and social workers join the mobile units at least once a week to check on participants who can't or won't come into the Ares do Pinhal office. Each of the psychologists and social workers is responsible for around 100 patients, who might need help finding a place to live or a referral to a substance abuse treatment program.
"It's not therapy but psychological support," says Faria. The goal is to empower individuals and help them attain autonomy, whether that means helping someone get an identification card to help reintegrate them into society or getting them to the hospital for treatment of HIV. The organization also offers participants access to regular medical and psychosocial assessment, greater awareness of their health status and access to community health and social services.
This harm-reduction approach is paying off, says Faria. When the program first started three decades ago, for example, 55 percent of its clients were HIV-positive. Today, just 13 percent are. And the mobile units don't just improve participants' health, adds Faria. Because staff watch infectious disease patients take their medication and thus ensure treatment adherence, they also help safeguard public health.
Now the Ordem dos Psicólogos Portugueses is launching a series of trainings so that more Portuguese psychologists—both in the national health system and in the private sector—can play a role in preventing and treating addiction to opioids and other substances. The trainings will focus on drug dependence in general, then home in on issues particular to opioids, alcohol and other substances. The goal is to spread the tenets of the Portuguese model beyond substance use specialists and beyond the major cities of Lisbon and Porto, says Rodrigues. With a planned debut in October, the trainings will combine e-learning and live group sessions around the country. "This is our way of spreading a model that has results," he says.
APA has a memorandum of understanding with the Ordem dos Psicólogos Portugueses, as well as with more than two dozen other national and regional psychological associations. These memoranda of understanding lay out mutual goals and commit the partners to regular communication and consideration of joint activities. For more information about APA's collaboration with its Portuguese counterpart.
