Why Scotland can ill afford to ignore Portugal’s ground-breaking war on drugs

Illegal drugs in abandoned factory.
Illegal drugs in abandoned factory.
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By a make-shift shack on a wasteland in Bairro da Picheleira, in Lisbon, a man holds out his bloody arms and gestures to me to douse them with water. He has spotted the outreach team from Crescer – one of Portugal’s many drugs agencies – making their way down the hill, and staggered over, fresh from injecting, to drop his dirty needle in one of their trademark red and yellow buckets.

On either side of the path, the ground is a mosaic of drugs-related paraphernalia: brightly coloured spoons, tiny plastic bottles, empty packets of citric acid and condoms, which are used as tourniquets more than prophylactics.

Hilltown area. Picture: John Devlin

Hilltown area. Picture: John Devlin

The detritus comes from the many kits the outreach workers hand out every day and looks, from a distance, like 100,000 Christmas crackers have been pulled, their contents disgorged. I take the water from the man and pour it over his arms; as he rubs off the still-flowing blood, the track marks become visible.

Behind me, the owner of the shack has emerged from behind some hanging blankets. He is carrying a plastic bottle full of hypodermics; he cuts round the top and spills the needles on to the ground. Argentina, a peer worker, picks them up them one by one and places them in the bin, while psychologist Patricia Cabral hands him clean needle kits and foils (for smokers) and tries to encourage him to sort out a new identity card. “Every day, he says he will come; every day he does not,” she says.

Further down the hill, we approach another 3D jigsaw of crates and a wizened face appears in the doorway. It is the face of Pablo*, an artist who lives in a house nearby, but uses this precarious structure as a studio. A totem pole featuring a bearded man, a monkey and a snake stands sentinel outside. “Pablo has been here for years,” Cabral says. “He makes art in the ‘studio’, but he lets others in to take their drugs.” The shack is divided in two: half for smokers, half for injecters. “We know he will sell some of the needle kits and the foil we give him, but we accept that because it means they will reach the users we don’t see.”

As a visitor accustomed to a more punitive approach towards Class A drugs, it is curious to witness this open-air injection site, known for trafficking as well as consumption, accepted as part of the Lisbon landscape in much the same way as the Castelo de São Jorge. But it is the lack of moral judgment, more even than the headline-grabbing decriminalisation, that defines the country’s much-lauded drugs policy.

Adriana Curado, project co-ordinator at GAT.

Adriana Curado, project co-ordinator at GAT.

Every year, agencies like Crescer are inundated with requests from journalists and politicians desperate to know how Portugal did it; how it rescued itself from the drugs epidemic of the 80s and 90s, reduced its death toll, and turned itself into a world leader in recovery and harm reduction.

As the country with the highest number of drugs deaths in the EU, Scotland is desperate for answers. In the same period, its mortality rate has risen from 369 to 1,187 – more than 30 times that of a country with almost double its population.

The proportion of people affected by drugs in Scotland now stands at 1.1 per cent – higher than in Portugal at the height of its crisis.

One oft-quoted statistic is that twice as many people died drugs-related deaths in Dundee last year (66 out of a population of 148,000) than in the whole of Portugal. Dundee and Lisbon: two cities with stunning waterfronts, one on the Tay, the other on the Tagus. Two cities keen to market themselves as tourist destinations, both with visible drugs problems. Why should the death tolls be so very different? And what can Dundee, and the rest of Scotland, learn from Portugal’s success?

The first thing that strikes me when I arrive in Lisbon is the mind-boggling panoply of drugs-related organisations and approaches. The Porto-based NGO APDES has set up dozens of interviews across the two cities. Over four days, I will visit policy-makers, treatment centres, harm reduction centres and employability programmes. I will go out with three outreach teams and spend time in both low-threshold methadone dispensing vans and the country’s first mobile safer consumption unit; and even then I will only have scratched the surface.

The second thing that strikes me is how seamlessly all these organisations appear to fit together. Despite their many differences in approach and funding structures, each one appears to understand its place in the whole. They are bound together by a shared ethos . At the centre of Portugal’s drugs policy is a belief in users as individuals, with a range of interconnecting problems – childhood trauma, unemployment, mental health, homelessness – which must be tackled holistically rather than in isolation.

Of course other countries make the same claims; but in Portugal the philosophy does appear to be at the heart of the system. All the drop-in services and outreach teams are made up of a range of professionals: doctors, nurses, psychologists, social workers and peer workers – people with lived experience of drugs use, who are crucial in building trust with those wary of “do-gooders”.

“We understand that poverty, mental health and drug use are all linked and that many drug users find it difficult to attend appointments in different places so we offer as much as we can under one roof,” says Adriana Curado, project manager at GAT – an activist organisation for those living with HIV.

Curado is taking me on a tour of IN-Mouraria, GAT’s low-threshold harm reduction centre in Lisbon. Its outside walls are decorated with a futuristic black and white mural, its internal walls with posters reading: “No More War on Drugs.”

IN-Mouraria has an area for socialising, a small office for private interviews, facilities to test for HIV, Hep C and TB, a computer where clients can fill out benefits forms, a counter full of clean needles, foils and crack pipes, a stock of shower gel and toothpaste, which clients can take to nearby public showers, and a room full of second-hand clothes. It sees 70 people a day and serves sandwiches from 5-8pm. It is, in short, a soup kitchen, benefits office and health clinic rolled into one.

GAT is also spearheading a pilot safe consumption project in an adjacent building. The pilot project, involving 40 users, is being run in advance of two fixed sites opening in the city next year. Safer consumption rooms are a source of great controversy in Scotland. Glasgow City Council would like to open one in the city centre to tackle spiralling HIV rates, but can’t because drugs policy is reserved to Westminster and Westminster has said No. Though it has been legally possible in Portugal since 2001, the local authorities have dragged their heels. Lisbon City Council is acting now because the crash in 2008 led to a relapse among some ageing heroin users and a slight spike in deaths. It is also funding the mobile safer consumption unit which began operating in April.

“The drug user comes in and sits here,” says Curado, gesturing towards a steel counter where needles and other equipment are set out like toiletries. “Sometimes people prefer to inject in private, but mostly we will stay with them. We can give them advice; help them find a vein in a safe part of the body. The only thing we cannot do is help them inject.”

Curado is no PR officer. She complains about budget cuts and the government’s failure (so far) to give outreach workers Naloxone – the antidote to a heroin overdose. They are allowed to take it on the safer consumption van – the first time this has ever happened – but it is not yet provided in other settings.

“We have anyway. We order it in from Spain and other countries as disobedience,” Curado says. What would happen if the authorities found out? “Oh, they already know,” she shrugs.

In the drop-in centre, peer worker Jo Santa Maria tells me he wishes GAT had been around when he started taking drugs in the 80s. A wilful boy, who smoked and drank, he left school at 15 to work in construction. “I was earning so much money,” he says. “More than my mum and dad put together.” He followed a well-worn route from cannabis to smoking heroin to injecting it.

Then a friend encouraged him to try a speedball: a mix of heroin and cocaine taken intravenously. “Thus began my tragic career,” Santa Maria says. “Over 13 years, I lost everything: my home, my job, my family.”

Those were the years when everyone seemed to be on drugs. The years of Casal Ventoso: a vast open-air market where people like Santa Maria came to buy and consume, and never left.

Casal Ventoso was pulled down in 1999, its inhabitants decanted to projects like Bairro Quinto do Carbrinho – a series of Duplo blocks in clashing colours; like Balamory on acid. But it has left a painful scar. Everyone I meet mentions it. They conjure up a scene of Bosch-like horror; the Garden of Earthly Delights cum The Fall of the Damned into Hell. A place where you might stumble over corpses; a place where souls were lost.

It’s not clear exactly when Santa Maria began to get his life together; but the catalysts were becoming an activist and encountering GAT. And having a baby too, although not immediately. His son with a fellow addict (now his wife) was given medication to prevent the transmission of HIV. He was born Hep C, which was cured after treatment .

Santa Maria, too, was also cleared of Hep C and started working for GAT. Now his wife and son work there too. He still uses cannabis, but not heroin. “I feel I have a normal life,” he says. “I don’t have all the cravings and anxiety I had when I used other drugs. I took MDMA for the first time recently, but I informed myself about the risks first. I just wish I’d had access to such information in the 80s,”

Elsa Maia is also haunted by the Casal Ventoso years. The daughter of a doctor and a teacher, she was never tempted to try anything other than cannabis, but others were. Three of her friends died of overdoses while she was a teenager. Back then, heroin use cut across all classes. One fatality was the daughter of the justice minister.

“My mother had a colleague from a very wealthy family who started selling silver cups,” says Maia who now works in the international relations division of policy body SICAD. “It turned out her son was an addict who’d started stealing and she was trying to help him.”

Portugal’s drugs epidemic was rooted in its history. Under dictator António de Oliveira Salazar, the country was very closed. “Our news was controlled by the state,” Maia says. “We missed out on flower power and the student riots.”

At the same time, it was a country with a high level of emigration and a number of colonies. Many of its men were sent out as soldiers to South America, Asia and Africa. As a doctor, Maia’s father spent some time in Mozambique.

When Salazar died in 1970, things moved very quickly. Portugal agreed to give up its colonies, so settlers and soldiers, who had used cannabis abroad, moved home. Gangsters moved in. Portugal was suddenly awash with drugs, but unlike other countries, where the increase in drugs use had been gradual, it had no policy or structures to deal with the consequences. “Very quickly there was no difference between recreational and problematic drugs use. And we had all the comorbidities that went with addiction too: HIV, and the onset of Aids, TB and all the different types of hepatitis,” Maia says.

“By the 90s, around 1 per cent of the population or 100,000 people was using heroin. It was almost impossible to find a family which hadn’t been touched by it.”

Portugal’s drug problem became a domestic obsession and an international embarrassment. Something had to be done. In 1999, a socialist government led by Antonio Guterres – now general secretary of the UN – came into power. Guterres invited a panel of medical, legal and academic experts to come up with new ways of thinking.

The result was a radical two-pronged strategy. The first involved decriminalisation. Under the new law, possession of small amounts of illegal substances – enough for ten days’ consumption – would become a civil rather than a criminal offence, to be dealt with by newly created Commissions for Dissuasion. These commissions have the power to refer users to treatment centres and to impose sanctions such as fines and community service on those unwilling to attend.

The decision to decriminalise caused international controversy, but in Portugal it was readily accepted. “What you have to understand is how desperate everyone was for change,” Maia says.

“I lived near Casal Ventoso and I remember participating in some of the public consultations. On the one hand you had the mother of a huge family complaining that all her kids were already using, on the other shop-owners saying: ‘We are being threatened’.”

The other less sensational, but arguably more important change was the adoption of an integrated approach encompassing prevention, treatment and harm reduction. “We realised we needed to look at each person as an individual in need of care and treatment; as an individual who is part of society and not an outsider,” Maia says.

In the intervening years, a political consensus has formed around this approach. In the UK, where drugs policy is a political football, the country has bounced from recovery to harm reduction and back again. But Portugal’s drugs strategy has survived both left-wing and right governments. Sure, there have been arguments over funding and the structure of organisations. But the basic principle – that drug use is a health rather than a criminal justice issue – appears to be inviolable.

So what impact has it had? Well, it hasn’t eradicated drug use. You can still see dealers and users in open air sites like the one in Pescheleira and on the city centre streets. Out in Porto with a team from Medicos de Mundo, I climbed some steps off the busy Rua Mouzinho da Silveira, with its thronged restaurants and artisan delicatessens. They led up to a hidden courtyard where a dozen addicts were smoking and injecting. In one corner, there was so much smoke it caught in my throat. Bent over their gear, the huddled users barely looked up as the team handed over new foils .

In fact, some claim there has been a slight rise in drug consumption. But drugs-related deaths and rates of HIV infection have plummeted, and there has been an increased uptake in treatment. Such details speak for themselves . So too do stories like Argentina’s.

Argentina is a long-term cocaine user who spent ten years living on the streets in one of the areas the Crescer outreach team visits. Last Christmas, the organisation found her a flat through its Housing First initiative.

As we drive from stop to stop, she enthuses about her new home. “Muito lindo, muito lindo,” she cries excitedly. “Very beautiful.” Argentina talks about her fridge and her microwave, and how she hasn’t taken cocaine for two months now. She still needs support, but her new job gives her structure. “I like being out with the team,” she says, “because then I worry about work and not about drugs.”

It is with the outreach teams that the humanity at the core of Portugal’s drugs policy is most palpable. Parked under a flyover near the Praa de Espanha, the city’s mobile methadone unit could pass for an ice cream van, albeit with the drugs handed out openly through the hatch, as opposed to under the counter a la Glasgow in the 1980s.

The early evening clientele is a mixed bunch: those prematurely aged by long-term use knock back their methadone from plastic shot glasses alongside professionals stopping off on their way home from work.

One woman arrives on the back of her partner’s scooter. She is wearing a long floral skirt and stilettos. Removing her helmet, she shakes out her hair, as if filming a shampoo ad; then she swigs her methadone, gets back on the bike and va va vooms into the distance.

The methadone van is a low-threshold service aimed at those who might fall foul of mainstream services. Users do not have to prove they are clean to register, nor will they be sanctioned if they fail to turn up several days in a row. Most importantly, with a doctor on board, it is possible for a user to start taking the methadone on their first visit.

There is an important social aspect to all the outreach services too. Gaggles of homeless, isolated men cluster round APDES’ GiruGaia (Around Gaia) van, hungry for conversation, at every stop on its route through the city.

Social worker Joana Vilares, who works alongside nurse Nuno Lourinho, is tiny, but manages the men like the landlady of a rowdy boozer, allowing them to lift her up as a demonstration of their strength, encouraging their chat, and diffusing any hint of tension with semi-flirtatious humour.

At the first stop, Vilares pets a toddler perched on her mother’s hip; at another she laughs when a man castigates her for not giving him a kiss before closing the van door in preparation for moving on. “Shame. On. Me,” she says in English for my benefit.

Vilares knows the man’s story. He was a former Porto football player who lost his career to his addiction and a leg to a car accident. On being introduced to me, another regular – Manuel – reveals he was once married to one of the country’s most famous news presenters. In the car she and Lourinho google the glamorous presenter’s picture to show me what she looks like. “Do you believe him?” I ask. “He is not the sort of person who generally makes things up,” she says.

Manuel, 56, has been coming to the van for methadone for two years; after decades of addiction, he now consumes just a tiny amount of heroin and cocaine. He has a job at a beachfront bar, is clear of Hep C and has reconnected with his estranged son who works nearby. “I like coming here,” he says. “It has changed everything.”

What Fiona*, the mother of a Scottish user, would give for a touch of that humanity. Sitting 1,800 miles away in Dundee, she tells me of her desperate struggle to get her son David back on the methadone programme after he failed to pick up his prescription. “He had blood clots and fatigue and was suffering the symptoms of withdrawal so he missed several days in a row,” says Fiona, who gave up her work to look after David’s son, Ryan. “But the danger of taking drug users off the methadone is that they will go looking for street drugs and that those street drugs will kill them.”

David was already known to services so there was no reason he shouldn’t have been able to start again immediately on a lower dose; but it took her months of wrangling to sort out. “I worry about David dying every day. The worst is when I wake up at 3am and wonder what he is doing,” she says.

Fiona was part of the Dundee Drugs Commission, a body of experts tasked with looking at what could be done to tackle the city’s drugs deaths toll. The commission discovered almost all of Dundee’s drug users were being funnelled through one NHS service: the Integrated Substance Misuse Services (ISMS), which is stretched and focused almost entirely on the prescribing of methadone. The commission also found there was little collaboration between ISMS and the city’s myriad third sector and community organisations, to the point that it seemed to believe there was no alternative service to which patients could be referred or discharged.

As a result, there were only 22 planned discharges from ISMS last year and 452 unplanned discharges (where users have simply fallen out of the programme). A greater proportion of those who died drugs-related deaths were in treatment than in other parts of Scotland.

“Dealing with drug users has become a specialism,” says Andy Perkins, director of the Figure 8 consultancy contracted to run the commission. “Because there are medical issues with prescribing, ISMS sees itself as the only organisation that can deal with this population. It’s partly territorial, partly that they don’t trust anyone else. But the idea that it’s a speciality leads mental health services to turn people away. They say: ‘Oh no – we can’t help you. You need to be seen by the drugs service’.”

It’s not just mental health services that are the problem. Fiona recalls the stress of trying to sort out David’s benefits. “He was in crisis and wanted to stop his joint claim with his partner, so I put him in a B&B, got him his own bank account and took him to the benefits office,” she says.

“As we walked in, he saw the words ‘universal credit’ and went white. He said: ‘I can’t do this’ because he was frightened of having to cope with daily life. I managed to convince him. I said: ‘Look, just take a deep breath and ask the question’ and he did and it was sorted out – but that was with me by his side. What happens to those who have nobody?”

Chair of the commission Robert Peat says the ISMS focus on prescribing means there is little time for outreach initiatives. “That’s why we should be using the third sector more. You don’t need a nurse or a social worker for that type of work. You need support workers who will treat the user with kindness and compassion.”

Nationally, the Scottish Government has set up a task force, headed by Professor Catriona Matheson, which is looking at the Misuse of Drugs Act 1971 and gathering evidence on good practice elsewhere. Last year, much of the debate focused on the safer consumption rooms, with SNP MPs calling for decriminalisation or a one-off exemption to allow it to happen. But many of those who work in the sector believe there is plenty that could done without Westminster’s help.

The commission hopes the Scottish government and the Dundee Partnership will act on its recommendations. “ If the city wants to attract people, it needs to be a good place for those who live here,” Peat says. “Everyone must be valued.”

Portugal’s drugs policy is not perfect. As Curado points out the government has been slow to fund both Naxolene and the safer drugs consumption rooms. Many working on the front line would also like to see the introduction of drug-testing facilities.

At a semi-derelict property in Porto, I meet Rui Coimbra Morais, president of CASO, the local drug users’ union. With his grey beard, thick-set glasses and rakish scarf, there is a touch of Jeff Goldblum to Morais, who must be a thorn in the side of those trying to sell the Portuguese model to the world.

Morais is a former heroin addict. He still smokes it occasionally. He would continue to inject “on special occasions” if he could, but he no longer has any veins he can inject into. “Injecting heroin gives me a sense of unity I cannot achieve with any other substance,” he tells me. “It brings the broken pieces back together.” In its place, he takes MDMA or snorts cocaine about once a month.

Morais’s biggest gripe with Portugal’s drugs strategy is the Commission of Dissuasion which he has appeared before several times. “It is better than going to court,” he says , “but it is still patronising. It is saying to people: ‘You don’t know how to take care of yourself.’ It also encourages game-playing. If I go to the psychologist because I want my life to change that’s one thing, but if the police or the Commission of Dissuasion sends me, I am going because I don’t want to pay a fine.”

The irony is that Morais and the secretary of his local Commission for Dissuasion see each other regularly when they drop their children off at the same nursery. “She treats me like everyone else,” he says. “But making people appear before a committee, it is stigmatising – I would not like to see Scotland replicating this.”

Morais insists that, despite the spin, stigma is woven throughout the system. “If there is no stigma, then why are psychologists who work with outreach teams paid so much less than those who work in hospitals?” he demands. And he is impatient with the various governments for not progressing from decriminalisation to regulation.

So, is the Portuguese system not all it’s cracked up to be? “Oh I’m playing devil’s advocate,” Morais says. “When I go to conferences and see what other countries are doing, I’m glad I live here.”

When I look at what’s happening with drugs deaths here, I wish I lived there. Or at least I wish we could tap into some of Portugal’s vision.

Imagine a Scotland where drugs policy wasn’t prey to the whims of each new government; where no-one spoke dismissively of being “parked” on methadone and where the most vulnerable had easy access to the support they required.

Fiona often imagines what life might have been like for her son if he had been given more support. David, now in his late 30s, started struggling emotionally when his father died. He became addicted to over-the-counter painkillers and began using cannabis. His transition from soft to hard drugs came when he was placed in a hostel after serving a short prison sentence.

Fiona believes there were lots of moments where wrap-around support – or even just someone who listened – might have pushed him further towards recovery. She would like to see more outreach work, and the forging of one-to-one relationships with long-term users. “If you have someone to talk to and are treated with kindness, everything else will follow,” she says.

While she lobbies for change, she has to bear the pain of losing the essence of the son she once knew and the worry of trying to keep what is left of him alive. “There was so much joy in having David and seeing him develop and knowing that he was – IS – such a good person, although I don’t see so much of that side of him any more,” she says.

“He is stuck in a hole now. I just want someone to reach in and pull him out.”

*Some names have been changed