New fix for the war on drugs

Por­tu­gal’s rad­i­cal pol­icy in fo­cus

The Guardian Weekly - - Front page -

When the drugs came, they hit all at once. It was the 1980s, and by the time one in 10 peo­ple had slipped into the depths of heroin use – bankers, uni­ver­sity stu­dents, car­pen­ters, so­cialites, min­ers – Por­tu­gal was in a state of panic. Ál­varo Pereira was work­ing as a fam­ily doc­tor in Ol­hão in south­ern Por­tu­gal. “Peo­ple were in­ject­ing them­selves in the street, in pub­lic squares, in gar­dens,” he told me. “At that time, not a day passed when there wasn’t a rob­bery at a local busi­ness, or a mug­ging.”

The cri­sis be­gan in the south. The 1980s were a pros­per­ous time in Ol­hão, a fish­ing town 50km west of the Span­ish bor­der. Coastal wa­ters filled fish­er­men’s nets from the Gulf of Cádiz to Morocco, tourism was grow­ing and cur­rency flowed through­out the south­ern Al­garve re­gion. But by the end of the decade, heroin be­gan wash­ing up on Ol­hão’s shores. Overnight, Pereira’s beloved slice of the Al­garve coast be­came one of the drug cap­i­tals of Eu­rope: one in ev­ery 100 Por­tuguese was bat­tling a prob­lem­atic heroin ad­dic­tion at that time, but the num­ber was even higher in the south. Head­lines in the local press raised the alarm about over­dose deaths and ris­ing crime. The rate of HIV in­fec­tion in Por­tu­gal be­came the high­est in the Euro­pean Union. Pereira re­called des­per­ate pa­tients and fam­i­lies beat­ing a path to his door, ter­ri­fied, be­wil­dered, beg­ging for help. “I got in­volved,” he said, “only be­cause I was ig­no­rant.”

In truth, there was a lot of ig­no­rance back then. Forty years of au­thor­i­tar­ian rule un­der the regime es­tab­lished by An­tónio Salazar in 1933 had sup­pressed ed­u­ca­tion, weak­ened in­sti­tu­tions and low­ered the school-leav­ing age, in a strat­egy in­tended to keep the pop­u­la­tion docile. The coun­try was closed to the out­side world; peo­ple missed out on the ex­per­i­men­ta­tion and mind-ex­pand­ing cul­ture of the 1960s. When the regime ended abruptly in a mil­i­tary coup in 1974, Por­tu­gal was sud­denly opened to new mar­kets and in­flu­ences. Un­der the old regime, Coca-Cola was banned and own­ing a cig­a­rette lighter re­quired a li­cence. When mar­i­juana and then heroin be­gan flood­ing in, the coun­try was ut­terly un­pre­pared.

Pereira tack­led the grow­ing wave of ad­dic­tion the only way he knew how: one pa­tient at a time. A stu­dent in her 20s who still lived with her par­ents might have her fam­ily in­volved in her re­cov­ery; a mid­dle-aged man, es­tranged from his wife and liv­ing on the street, faced dif­fer­ent risks and needed a dif­fer­ent kind of sup­port. Pereira im­pro­vised, call­ing on in­sti­tu­tions and in­di­vid­u­als in the com­mu­nity to lend a hand.

In 2001, nearly two decades into Pereira’s ac­ci­den­tal spe­cial­i­sa­tion in ad­dic­tion, Por­tu­gal be­came the first coun­try to de­crim­i­nalise the pos­ses­sion and con­sump­tion of all il­licit sub­stances. Rather than be­ing ar­rested, those caught with a per­sonal sup­ply might be given a warn­ing, a small fine, or told to ap­pear be­fore a local com­mis­sion – a doc­tor, a lawyer and a so­cial worker – about treat­ment, harm re­duc­tion, and the sup­port ser­vices that were avail­able to them.

The opi­oid cri­sis soon sta­bilised, and the en­su­ing years saw dra­matic drops in prob­lem­atic drug use, HIV and hep­ati­tis in­fec­tion rates, over­dose deaths, drug-re­lated crime and in­car­cer­a­tion rates. HIV in­fec­tion plum­meted from an all-time high in 2000 of 104.2 new cases per mil­lion to 4.2 cases per mil­lion in 2015. The data be­hind these changes has been stud­ied and cited as ev­i­dence by harm­re­duc­tion move­ments around the globe. It’s mis­lead­ing, how­ever, to credit these pos­i­tive re­sults en­tirely to a change in law.

Por­tu­gal’s re­mark­able re­cov­ery, and the fact that it has held steady through sev­eral changes in gov­ern­ment – in­clud­ing con­ser­va­tive lead­ers who would have pre­ferred to re­turn to the US-style war on drugs – could not have hap­pened with­out an enor­mous cul­tural shift, and a change in how the coun­try viewed drugs, ad­dic­tion – and it­self. In many ways, the law was merely a re­flec­tion of trans­for­ma­tions that were al­ready hap­pen­ing in clin­ics, in phar­ma­cies and around kitchen ta­bles across the coun­try. The of­fi­cial pol­icy of de­crim­i­nal­i­sa­tion made it far eas­ier for a broad range of ser­vices (health, psy­chi­a­try, em­ploy­ment, hous­ing, etc), that had been strug­gling to pool their re­sources and ex­per­tise, to work to­gether more ef­fec­tively to serve their com­mu­ni­ties.

The lan­guage be­gan to shift, too. Those who had been re­ferred to sneer­ingly as dro­ga­dos (junkies) – be­came known more broadly, more sym­pa­thet­i­cally, and more ac­cu­rately, as “peo­ple who use drugs” or “peo­ple with ad­dic­tion dis­or­ders”. This, too, was cru­cial.

It is im­por­tant to note that Por­tu­gal sta­bilised its opi­oid cri­sis, but it didn’t make it dis­ap­pear. While drug-re­lated death, in­car­cer­a­tion and in­fec­tion rates plum­meted, the coun­try still had to deal with the health com­pli­ca­tions of long-term prob­lem­atic drug use. Dis­eases in­clud­ing hep­ati­tis C, cir­rho­sis and liver can­cer are a bur­den on a health sys­tem

that is still strug­gling to re­cover from re­ces­sion and cut­backs. In this way, Por­tu­gal’s story serves as a warn­ing of chal­lenges yet to come.

De­spite en­thu­si­as­tic in­ter­na­tional re­ac­tions to Por­tu­gal’s suc­cess, local harm-re­duc­tion ad­vo­cates have been frus­trated by what they see as stag­na­tion and in­ac­tion since de­crim­i­nal­i­sa­tion came into ef­fect. They crit­i­cise the state for drag­ging its feet on es­tab­lish­ing su­per­vised in­jec­tion sites and drug con­sump­tion fa­cil­i­ties; for fail­ing to make the anti-over­dose med­i­ca­tion nalox­one more read­ily avail­able; for not im­ple­ment­ing nee­dle-ex­change pro­grammes in pris­ons. Where, they ask, is the coura­geous spirit and bold lead­er­ship that pushed the coun­try to de­crim­i­nalise drugs in the first place?

In the early days of Por­tu­gal’s panic, when Pereira’s beloved Ol­hão be­gan fall­ing apart in front of him, the state’s first in­stinct was to at­tack. Drugs were de­nounced as evil, drug users were de­monised, and prox­im­ity to ei­ther was crim­i­nally and spir­i­tu­ally pun­ish­able. The Por­tuguese gov­ern­ment launched a se­ries of na­tional anti-drug cam­paigns that were less “Just Say No” and more “Drugs Are Satan”.

In­for­mal treat­ment ap­proaches and ex­per­i­ments were rushed into use through­out the coun­try, as doc­tors, psy­chi­a­trists and phar­ma­cists worked in­de­pen­dently to deal with the flood of drugde­pen­dency dis­or­ders at their doors, some­times risk­ing os­tracism or ar­rest to do what they be­lieved was best for their pa­tients.

In 1977, in the north of the coun­try, psy­chi­a­trist Eduíno Lopes pi­o­neered a methadone pro­gramme at the Cen­tro da Boav­ista in Porto. Lopes was the first doc­tor in con­ti­nen­tal Eu­rope to ex­per­i­ment with sub­sti­tu­tion ther­apy, fly­ing in methadone pow­der from Bos­ton, un­der the aus­pices of the Min­istry of Jus­tice, rather than the Min­istry of Health. His ef­forts met with a vi­cious pub­lic back­lash and the dis­ap­proval of his peers, who con­sid­ered methadone ther­apy noth­ing more than state­spon­sored drug ad­dic­tion.

Down in Lis­bon, Odette Fer­reira, an ex­pe­ri­enced phar­ma­cist and pi­o­neer­ing HIV re­searcher, started an un­of­fi­cial nee­dle-ex­change pro­gramme to ad­dress the grow­ing Aids cri­sis. She re­ceived death threats from drug deal­ers, and le­gal threats from politi­cians. Fer­reira – who is now in her 90s, and still has enough swag­ger to carry off fake eye­lashes and red leather at a mid­day meet­ing – started giv­ing away clean sy­ringes in the mid­dle of Eu­rope’s big­gest open-air drug mar­ket, in the Casal Ven­toso neigh­bour­hood of the city. She col­lected do­na­tions of cloth­ing, soap, ra­zors, condoms, fruit and sand­wiches, and dis­trib­uted them to users. When deal­ers re­acted with hos­til­ity, she snapped back: “Don’t mess with me. You do your job, and I’ll do mine.” She then bul­lied the Por­tuguese As­so­ci­a­tion of Phar­ma­cies into run­ning the coun­try’s – and in­deed the world’s – first na­tional nee­dle-ex­change pro­gramme.

A flurry of ex­pen­sive pri­vate clin­ics and free, faith-based fa­cil­i­ties emerged, promis­ing detoxes and mir­a­cle cures, but the first pub­lic drugtreat­ment cen­tre run by the Min­istry of Health – the Cen­tro das Taipas in Lis­bon – did not be­gin op­er­at­ing un­til 1987. Strapped for re­sources in Ol­hão, Pereira sent a few pa­tients for treat­ment, al­though he did not agree with the ab­sti­nence-based ap­proach used at Taipas. “First you take away the drug, and then, with psy­chother­apy, you plug up the crack,” said Pereira. There was no sci­en­tific ev­i­dence to show that this would work – and it didn’t.

He also sent pa­tients to Lopes’s methadone pro­gramme in Porto, and found that some re­sponded well. But Porto was at the other end of the coun­try. He wanted to try methadone

for his pa­tients, but the Min­istry of Health hadn’t yet ap­proved it for use. To get around that, Pereira some­times asked a nurse to sneak methadone to him in the boot of his car.

Pereira’s work treat­ing pa­tients for ad­dic­tion even­tu­ally caught the at­ten­tion of the Min­istry of Health. “They heard there was a crazy man in the Al­garve who was work­ing on his own,” he said, with a slow smile. Now 68, he is sprightly and charm­ing, with an ath­letic build, thick and wavy white hair that bounces when he walks, a grav­elly drawl and a bot­tom­less re­serve of warmth. “They came down to find me at the clinic and pro­posed that I open a treat­ment cen­tre,” he said. He in­vited a col­league from a fam­ily prac­tice in the next town over to join him – a young local doc­tor named João Goulão.

Goulão was a 20-year-old med­i­cal stu­dent when he was of­fered his first hit of heroin. He de­clined be­cause he didn’t know what it was. By the time he fin­ished school, got his li­cence and be­gan prac­tis­ing medicine at a health cen­tre in the south­ern city of Faro, it was ev­ery­where. Like Pereira, he ac­ci­den­tally ended up spe­cial­is­ing in treat­ing drug ad­dic­tion.

The two young col­leagues joined forces to open south­ern Por­tu­gal’s first CAT in 1988. (These kinds of cen­tres have used dif­fer­ent names over the years, but are com­monly re­ferred to as Cen­tros de Atendi­mento aT oxi co de­pen­dent es, or CATs .) Local res­i­dents were ve­he­mently op­posed, and the doc­tors were im­pro­vis­ing treat­ments as they went along. The fol­low­ing month, Pereira and Goulão opened a sec­ond CAT in Ol­hão, and other fam­ily doc­tors opened more in the north and central re­gions, form­ing a loose network. It had be­come clear to a grow­ing num­ber of prac­ti­tion­ers that the most ef­fec­tive re­sponse to ad­dic­tion had to be per­sonal, and rooted in com­mu­ni­ties. Treat­ment was still small-scale, local and largely ad hoc.

The first of­fi­cial call to change Por­tu­gal’s drug laws came from Rui Pereira, a for­mer con­sti­tu­tional court judge who un­der­took an over­haul of the pe­nal code in 1996. He found the prac­tice of jail­ing peo­ple for tak­ing drugs to be coun­ter­pro­duc­tive and un­eth­i­cal. “My thought right off the bat was that it wasn’t le­git­i­mate for the state to pun­ish users,” he told me in his of­fice at the Uni­ver­sity of Lis­bon’s school of law. At that time, about half of the peo­ple in prison were there for drug-re­lated rea­sons, and the epi­demic, he said, was thought to be “an ir­re­solv­able prob­lem”. He rec­om­mended that drug use be dis­cour­aged with­out im­pos­ing penal­ties, or fur­ther alien­at­ing users. His pro­pos­als weren’t im­me­di­ately adopted, but they did not go un­no­ticed.

In 1997, after 10 years of run­ning the CAT in Faro, Goulão was in­vited to help de­sign and lead a na­tional drug strat­egy. He as­sem­bled a team of ex­perts to study po­ten­tial so­lu­tions to Por­tu­gal’s drug prob­lem. The re­sult­ing rec­om­men­da­tions, in­clud­ing the full de­crim­i­nal­i­sa­tion of drug use, were pre­sented in 1999, ap­proved by the coun­cil of min­is­ters in 2000, and a new na­tional plan of ac­tion came into ef­fect in 2001.

To­day, Goulão is Por­tu­gal’s drug tsar. He has been the lodestar through­out eight al­ter­nat­ing con­ser­va­tive and pro­gres­sive ad­min­is­tra­tions; through heated stand­offs with law­mak­ers and lob­by­ists; through shifts in sci­en­tific un­der­stand­ing of ad­dic­tion and in cul­tural tol­er­ance for drug use; through aus­ter­ity cuts, and through a global pol­icy cli­mate that only very re­cently be­came slightly less hos­tile. Goulão is also de­crim­i­nal­i­sa­tion’ s busiest global am­bas­sador. He trav­els al­most non-stop, in­vited again and again to present the suc­cesses of Por­tu­gal’s harm-re­duc­tion ex­per­i­ment to au­thor­i­ties around the world, from Nor­way to Brazil, which are deal­ing with des­per­ate sit­u­a­tions in their own coun­tries.

Por­tu­gal’s pol­icy rests on three pil­lars: one, that there’s no such thing as a soft or hard drug, only healthy and un­healthy re­la­tion­ships with drugs; two, that an in­di­vid­ual’s un­healthy re­la­tion­ship with drugs of­ten con­ceals frayed re­la­tion­ships with loved ones, with the world around them, and with them­selves; and three, that the erad­i­ca­tion of all drugs is an im­pos­si­ble goal.

“The na­tional pol­icy is to treat each in­di­vid­ual dif­fer­ently,” Goulão told me. “The se­cret is for us to be present.”

A drop-in cen­tre called IN-Mouraria sits un­ob­tru­sively in a lively, rapidly gen­tri­fy­ing neigh­bour­hood of Lis­bon, a long­time en­clave of marginalised com­mu­ni­ties. From 2pm to 4pm, the cen­tre pro­vides ser­vices to un­doc­u­mented mi­grants and refugees; from 5pm to 8pm, they open their doors to drug users. A staff of psy­chol­o­gists, doc­tors and peer sup­port work­ers (them­selves for­mer drug users) of­fer clean nee­dles, pre-cut squares of foil, crack kits, sand­wiches, cof­fee, clean cloth­ing, toi­letries, rapid HIV test­ing, and con­sul­ta­tions – all free and anonymous.

On the day I vis­ited, young peo­ple stood around wait­ing for HIV test re­sults while oth­ers played cards, com­plained about po­lice ha­rass­ment, tried on out­fits, traded ad­vice on liv­ing sit­u­a­tions, watched movies and gave pep talks to one an­other. They var­ied in age, re­li­gion, eth­nic­ity and gen­der iden­tity, and came from all over the coun­try and all over the world. When a slen­der, older man emerged from the bath­room, un­recog­nis­able after hav­ing shaved his

‘The na­tional pol­icy is to treat each in­di­vid­ual dif­fer­ently. The se­cret is for us to be present’

beard off, an en­er­getic young man who had been flip­ping through mag­a­zines threw up his arms and cheered. He then turned to a quiet man sit­ting on my other side, his beard lush and dark hair curl­ing from un­der his cap, and said: “What about you? Why don’t you go shave off that beard? You can’t give up on your­self, man. That’s when it’s all over.” The bearded man cracked a smile.

Dur­ing my vis­its over the course of a month, I got to know some of the peer sup­port work­ers, in­clud­ing João, a com­pact man with blue eyes who was rig­or­ous in go­ing over the de­tails and nu­ances of what I was learn­ing. João wanted to be sure I un­der­stood their role at the drop-in cen­tre was not to force any­one to stop us­ing, but to help min­imise the risks users were ex­posed to.

“Our ob­jec­tive is not to steer peo­ple to treat­ment – they have to want it,” he told me. But even when they do want to stop us­ing, he con­tin­ued, hav­ing sup­port work­ers ac­com­pany them to ap­point­ments and treat­ment fa­cil­i­ties can feel like a bur­den on the user – and if the treat­ment doesn’t go well, there is the risk that per­son will feel too ashamed to re­turn to the drop-in cen­tre. “Then we lose them, and that’s not what we want to do,” João said. “I want them to come back when they re­lapse.” Fail­ure was part of the treat­ment process, he told me. And he would know.

João is a mar­i­juana-le­gal­i­sa­tion ac­tivist, open about be­ing HIV-pos­i­tive, and after be­ing ab­sent for part of his son’s youth, he is de­light­ing in his new role as a grand­fa­ther. He had stopped do­ing speed­balls (mix­tures of cocaine and opi­ates) after sev­eral painful, failed treat­ment at­tempts, each more de­struc­tive than the last. He long used cannabis as a form of ther­apy – methadone did not work for him, nor did any of the in­pa­tient treat­ment pro­grammes he tried – but the cruel hypocrisy of de­crim­i­nal­i­sa­tion meant that al­though smok­ing weed was not a crim­i­nal of­fence, pur­chas­ing it was. His last and worst re­lapse came when he went to buy mar­i­juana from his usual dealer and was told: “I don’t have that right now, but I do have some good cocaine.” João said no thanks and drove away, but soon found him­self head­ing to a cash ma­chine, and then back to the dealer. After this re­lapse, he em­barked on a new re­la­tion­ship, and started his own busi­ness. At one point he had more than 30 em­ploy­ees. Then the fi­nan­cial cri­sis hit. “Clients weren’t pay­ing, and cred­i­tors started knock­ing on my door,” he told me. “Within six months I had burned through ev­ery­thing I had built up over four or five years.”

In the morn­ings, I fol­lowed the cen­tre’s street teams out to the fringes of Lis­bon. I met hi-vis-clad Raquel and Sareia, who worked with Crescer na Maior, a harm-re­duc­tion NGO. Six times a week, they loaded up a large white van with drinking water, wet wipes, gloves, boxes of tin­foil and piles of state-is­sued drug kits: green plas­tic pouches with sin­gle-use serv­ings of fil­tered water, cit­ric acid, a small metal tray for cook­ing, gauze, fil­ter and a clean sy­ringe. Por­tu­gal does not yet have any su­per­vised in­jec­tion sites (al­though there is leg­is­la­tion to al­low them, sev­eral at­tempts to open one have come to noth­ing), so they go out to the open-air sites where they know peo­ple go to buy and use. Both are trained psy­chol­o­gists, but out in the streets they are known sim­ply as the “nee­dle girls”.

“Good af­ter­noon!” Raquel called out cheer­ily, as we walked across a seem­ingly aban­doned lot in an area called Cruz Ver­melha. “Street team!” Peo­ple ma­te­ri­alised from their hid­ing places like some strange ver­sion of whack-a-mole, pok­ing their heads out from the holes in the wall where they had gone to smoke or shoot up. “My nee­dle girls,” one wo­man cooed to them ten­derly. “How are you, my loves?” Most made po­lite con­ver­sa­tion, up­dat­ing the work­ers on their health strug­gles, love lives, im­mi­gra­tion woes or hous­ing needs. One wo­man told them she would be go­ing back to An­gola to deal with her mother’s es­tate, that she was look­ing for­ward to the change of scenery. An­other man told them he had man­aged to get his on­line girl­friend’s visa ap­proved for a visit. “Does she know you’re still us­ing?” Sareia asked. The man looked sheep­ish.

“I start methadone to­mor­row,” an­other man said proudly. He was ac­com­pa­nied by his beam­ing girl­friend, and waved a warm good­bye to the girls as they handed him a square of foil.

In the foggy north­ern city of Porto, peer sup­port work­ers from Caso – an as­so­ci­a­tion run by and for drug users and for­mer users, the only one of its kind in Por­tu­gal – meet ev­ery week at a noisy cafe. They come here ev­ery Tues­day morn­ing to down espres­sos, fresh pas­tries and toasted sand­wiches, and to talk out the chal­lenges, de­bate drug pol­icy (which, a decade and a half after the law came into ef­fect, was still con­fus­ing for many) and ar­gue, with the warm row­di­ness typ­i­cal of those in the north­ern re­gion. When I asked them what they thought of Por­tu­gal’s move to treat drug users as sick peo­ple in need of help, rather than as crim­i­nals, they scoffed. “Sick? We don’t say ‘sick’ up here. We’re not sick.”

I was told this again and again in the north: think­ing of drug ad­dic­tion sim­ply in terms of health and dis­ease was too re­duc­tive. Some peo­ple are able to use drugs for years with­out any ma­jor dis­rup­tion to their per­sonal or pro­fes­sional re­la­tion­ships. It only be­came a prob­lem, they told me, when it be­came a prob­lem.

Caso was sup­ported by Apdes, a de­vel­op­ment NGO with a fo­cus on harm re­duc­tion and em­pow­er­ment, in­clud­ing pro­grammes geared to­ward recre­ational users. Their award-win­ning Check!n project has for years set up shop at fes­ti­vals, bars and par­ties to test sub­stances for dan­gers. I was told more than once that if drugs were le­galised, not just de­crim­i­nalised, then these sub­stances would be held to the same rig­or­ous qual­ity and safety stan­dards as food, drink and med­i­ca­tion.

In spite of Por­tu­gal’s tan­gi­ble re­sults, other coun­tries have been re­luc­tant to fol­low. The Por­tuguese be­gan se­ri­ously con­sid­er­ing de­crim­i­nal­i­sa­tion in 1998, im­me­di­ately fol­low­ing the first UN Gen­eral As­sem­bly Spe­cial Ses­sion on the Global Drug Prob­lem (UN­gass). High-level UN­gass meet­ings are con­vened ev­ery 10 years to set drug pol­icy for all mem­ber states, ad­dress­ing trends in ad­dic­tion, in­fec­tion, money laun­der­ing, traf­fick­ing and car­tel vi­o­lence. At the first ses­sion – for which the slo­gan was “A drug-free world: we can do it” – Latin Amer­i­can mem­ber states pressed for a rad­i­cal re­think­ing of the war on drugs, but ev­ery ef­fort to ex­am­ine al­ter­na­tive mod­els (such as de­crim­i­nal­i­sa­tion) was blocked. By the time of the next ses­sion, in 2008, world­wide drug use and vi­o­lence re­lated to the drug trade had vastly in­creased. An ex­tra­or­di­nary ses­sion was held last year, but it was largely a dis­ap­point­ment – the out­come doc­u­ment didn’t men­tion “harm re­duc­tion” once.

De­spite that let­down, 2016 pro­duced a num­ber of promis­ing de­vel­op­ments: Chile and Aus­tralia opened their first med­i­cal cannabis clubs; fol­low­ing the lead of sev­eral oth­ers, four more US states in­tro­duced med­i­cal cannabis, and four more le­galised recre­ational cannabis; Den­mark opened the world’s largest drug con­sump­tion fa­cil­ity, and France opened its first; South Africa pro­posed le­gal­is­ing med­i­cal cannabis; Canada out­lined a plan to le­galise recre­ational cannabis na­tion­ally and to open more su­per­vised in­jec­tion sites; and Ghana an­nounced it would de­crim­i­nalise all per­sonal use.

The big­gest change in global at­ti­tudes and pol­icy has been the mo­men­tum be­hind cannabis le­gal­i­sa­tion. Local ac­tivists have pressed Goulão to take a stance on reg­u­lat­ing cannabis and le­gal­is­ing its sale in Por­tu­gal; for years, he has re­sponded that the time wasn’t right. Le­gal­is­ing a sin­gle sub­stance would call into ques­tion the foun­da­tion of Por­tu­gal’s drug and harm-re­duc­tion phi­los­o­phy. If the drugs aren’t the prob­lem, if the prob­lem is the re­la­tion­ship with drugs, if there’s no such thing as a hard or a soft drug, and if all il­licit sub­stances are to be treated equally, he ar­gued, then shouldn’t all drugs be le­galised and reg­u­lated?

Mas­sive in­ter­na­tional cul­tural shifts in think­ing about drugs and ad­dic­tion are needed to make way for de­crim­i­nal­i­sa­tion and le­gal­i­sa­tion glob­ally. In the US, the White House has re­mained re­luc­tant to ad­dress what drug pol­icy re­form ad­vo­cates have termed an “ad­dic­tion to pun­ish­ment”. But if con­ser­va­tive, iso­la­tion­ist, Catholic Por­tu­gal could transform into a coun­try where same-sex mar­riage and abor­tion are le­gal, and where drug use is de­crim­i­nalised, a broader shift in at­ti­tudes seems pos­si­ble else­where. But, as the harm-re­duc­tion adage goes: one has to want the change in or­der to make it. When Pereira first opened

the CAT in Ol­hão, he faced vo­cif­er­ous op­po­si­tion from res­i­dents. They wor­ried that with more dro­ga­dos would come more crime, but the op­po­site hap­pened. Months later, one neigh­bour came to ask Pereira’s for­give­ness. She hadn’t re­alised it at the time, but there had been three drug deal­ers on her street. When their local clien­tele stopped buy­ing, they packed up and left.

The CAT build­ing it­self is a drab, brown two­s­torey block, with of­fices up­stairs and an open wait­ing area, bath­rooms, stor­age and clin­ics down be­low. The doors open at 8.30am, seven days a week, 365 days a year. Pa­tients wan­der in through­out the day for ap­point­ments, to chat, to kill time, to wash, or to pick up their weekly sup­ply of methadone doses. They tried to close the CAT for Christ­mas Day one year, but pa­tients asked that it stay open. For some, es­tranged from loved ones and adrift from any ver­sion of home, this is the clos­est thing they’ve got to com­mu­nity and nor­mal­ity. “It’s not just about ad­min­is­ter­ing methadone,” Pereira told me. “You have to main­tain a re­la­tion­ship.”

In a back room, rows of lit­tle can­is­ters with ba­nana-flavoured methadone doses were lined up. The Ol­hão CAT reg­u­larly ser­vices about 400 peo­ple, but that num­ber can dou­ble dur­ing the sum­mer months, when sea­sonal work­ers and tourists come to town. Any­one re­ceiv­ing treat­ment else­where in the coun­try, or even out­side Por­tu­gal, can have their pre­scrip­tion sent over to the CAT, mak­ing the Al­garve an ideal harm-re­duc­tion hol­i­day des­ti­na­tion.

After lunch at a restau­rant owned by a for­mer CAT em­ployee, the doc­tor took me to visit an­other of his projects – a par­tic­u­lar favourite. His decades of work­ing with ad­dic­tion dis­or­ders had taught him some lessons, and he poured his ac­cu­mu­lated knowl­edge into de­sign­ing a spe­cial treat­ment fa­cil­ity on the out­skirts of Ol­hão: the Unidade de Desa­bit­u­ação, or Disha­bit­u­a­tion Cen­tre. Sev­eral such UDs, as they are known, have opened in other re­gions of the coun­try, but this cen­tre was de­vel­oped to cater to the par­tic­u­lar cir­cum­stances and needs of the south.

Pereira stepped down as di­rec­tor some years ago, but his re­place­ment asked him to stay on to help with day-to-day op­er­a­tions. Pereira should be re­tired by now – in­deed, he tried to – but Por­tu­gal is suf­fer­ing from an over­all short­age of health pro­fes­sion­als in the pub­lic sys­tem, and not enough young doc­tors are step­ping into this spe­cial­i­sa­tion. As his col­leagues else­where in the coun­try grow closer to their own re­tire­ments, there’s a grow­ing sense of dread that there is no one to re­place them.

“Those of us from the Al­garve al­ways had a bit of a dif­fer­ent at­ti­tude from our col­leagues up north,” Pereira told me. “I don’t treat pa­tients. They treat them­selves. My func­tion is to help them to make the changes they need to make.” And thank good­ness there is only one change to make, he dead­panned as we pulled into the cen­tre’s car park: “You need to change al­most ev­ery­thing.” He cack­led at his own joke and stepped out of his car.

The Ol­hão cen­tre was built for just un­der €3m ($3.5m), pub­licly funded, and opened to its first pa­tients nine years ago. This fa­cil­ity, like the oth­ers, is con­nected to a web of health and so­cial re­ha­bil­i­ta­tion ser­vices. It can house up to 14 peo­ple at once: treat­ments are free, avail­able on re­fer­ral from a doc­tor or ther­a­pist, and nor­mally last be­tween eight and 14 days. When peo­ple first ar­rive, they put all of their per­sonal be­long­ings – pho­tos, mo­bile phones, ev­ery­thing – into stor­age, re­triev­able on de­par­ture.

“We be­lieve in the old maxim: ‘No news is good news,’” ex­plained Pereira. “We don’t do this to pun­ish them but to pro­tect them.” Mem­o­ries can be trig­ger­ing, and some­times fam­i­lies, friends and toxic re­la­tion­ships can be en­abling.

To the left there were in­take rooms and a padded iso­la­tion room, with clunky se­cu­rity cam­eras propped up in ev­ery cor­ner. Pa­tients each had their own suites – sim­ple, com­fort­able and pri­vate. To the right, there was a “colour” room, with a pot­tery wheel, re­cy­cled plas­tic bot­tles, paints, egg car­tons, glit­ter and other craft sup­plies. In an­other room, coloured pen­cils and easels for draw­ing. A kiln, and next to it a col­lec­tion of ex­cel­lent hand­made ash­trays. Many pa­tients re­mained heavy smok­ers.

Pa­tients were al­ways oc­cu­pied, al­ways us­ing their hands or their bod­ies or their senses, do­ing ex­er­cise or mak­ing art, al­ways fill­ing their time with some­thing. “We’d of­ten hear our pa­tients use the ex­pres­sion ‘me and my body’,” Pereira said. “As though there was a dis­so­ci­a­tion be­tween the ‘me’ and ‘my flesh’.”

To help bring the body back, there was a small gym, ex­er­cise classes, phys­io­ther­apy and a jacuzzi. And after so much de­struc­tive be­hav­iour – mess­ing up their bod­ies, their re­la­tion­ships, their lives and com­mu­ni­ties – learn­ing that they could cre­ate good and beau­ti­ful things was some­times trans­for­ma­tional.

“You know those lines on a run­ning track?” Pereira asked me. He be­lieved that ev­ery­one – how­ever im­per­fect – was ca­pa­ble of find­ing their own way, given the right sup­port. “Our love is like those lines.”

He was firm, he said, but never pun­ished or judged his pa­tients for their re­lapses or fail­ures. Pa­tients were free to leave at any time, and they were wel­come to re­turn if they needed. He of­fered no magic wand or one-size-fits-all so­lu­tion, just this daily search for bal­ance: get­ting up, hav­ing break­fast, mak­ing art, tak­ing meds, do­ing ex­er­cise, go­ing to work, go­ing to school, go­ing into the world, go­ing for­ward. Be­ing alive, he said to me more than once, can be very com­pli­cated.

“My dar­ling,” he told me, “it’s like I al­ways say: I may be a doc­tor, but no­body’s per­fect.”

A longer ver­sion of this piece ap­pears on thecom­monon­line.org. Re­search and travel for this piece were made pos­si­ble by the Matthew Power Lit­er­ary Re­port­ing Award

‘I don’t treat pa­tients – they treat them­selves. I’m here to help them make the changes they need’

Ho­ra­cio Vil­lalo­bos/Cor­bis via Getty

Long-term fix … left, a nurse hands out methadone in Lis­bon; be­low, a man re­ceives clean sy­ringes after be­ing given the drug at a clinic

Ho­ra­cio Vil­lalo­bos/Cor­bis via Getty

Get­ting bet­ter … users wait­ing at a treat­ment fa­cil­ity in Lis­bon

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