The lengthy read: Because it decriminalised all drugs in 2001, Portugal has witnessed dramatic drops in overdoses, Aids infection and drug-related crime

When the drugs came, they hit all at one time. It had been the 80s, and when one out of 10 people had tucked in to the depths of heroin use bankers, college students, carpenters, socialites, miners Portugal is at a condition of panic.

lvaro Pereira was being employed as a household physician in Olho in southern Portugal. People were injecting themselves on the street, in public places squares, in gardens, he explained. At that point, not really a day passed when there wasnt a robbery in a local company, or perhaps a mugging.

The crisis started within the south. The 80s were a booming amount of time in Olho, an angling town 31 miles west from the Spanish border. Seaside waters filled fishermens nets in the Gulf of Cdiz to The other agents, tourism was growing, and currency ran through the southern Algarve region. But through the finish from the decade, heroin started dish washing on Olhos shores. Overnight, Pereiras beloved slice from the Algarve coast grew to become among the drug capitals of Europe: one out of every 100 Portuguese was battling a problematic heroin addiction in those days, however the number being greater within the south. Headlines from our press elevated the alarm about overdose deaths and rising crime. The speed of Aids infection in Portugal grew to become the greatest within the Eu. Pereira remembered desperate patients and families beating a way to his door, afraid, bewildered, pleading for help. I got involved, he stated, only since i was ignorant.

In reality, there is lots of ignorance in those days. 40 years of authoritarian rule underneath the regime established by Antnio Salazar in 1933 had covered up education, weakened institutions and decreased the college-departing age, inside a strategy meant to keep your population docile. The nation was closed towards the outdoors world people overlooked the experimentation and mind-expanding culture from the 1960s. Once the regime ended abruptly inside a military coup in 1974, Portugal was all of a sudden opened up to untouched markets and influences. Underneath the old regime, Coca-Cola was banned and having a cigarette lighter needed a licence. When marijuana after which heroin started flooding in, the nation was absolutely unprepared.

Pereira tackled the growing wave of addiction the only method he understood how: one patient at any given time. Students in her own 20s who still resided together with her parents may have her family involved with her recovery a middle-aged man, estranged from his wife and living in the pub, faced different risks and needed another type of support. Pereira improvised, contacting institutions and people locally to help.

In 2001, nearly 2 decades into Pereiras accidental specialisation in addiction, Portugal grew to become the very first country to decriminalise the possession and use of all illicit substances. Instead of being arrested, individuals caught having a personal supply might obtain a warning, a little fine, or told to look before a nearby commission a physician, an attorney along with a social worker about treatment, harm reduction, and also the support services which were at hand.

The opioid crisis soon stabilised, and also the ensuing years saw dramatic drops in problematic drug abuse, Aids and hepatitis infection rates, overdose deaths, drug-related crime and incarceration rates. Aids infection plummeted from your all-time full of 2000 of 104.2 new cases per million to 4.2 cases per million in 2015. The information behind these changes continues to be studied and reported as evidence by harm-reduction movements around the world. Its misleading, however, to credit these good results entirely to a general change in law.

Portugals outstanding recovery, cheap it’s held steady through several alterations in government including conservative leaders who’d have preferred to go back to the united states-style fight against drugs couldn’t have happened with no enormous cultural shift, and a general change in the way the country viewed drugs, addiction and itself. In lots of ways, what the law states was just an expression of transformations which were already happening in clinics, in pharmacies and around kitchen tables across the nation. The state policy of decriminalisation managed to get far simpler for any wide range of services (health, psychiatry, employment, housing etc) that were battling to pool their sources and expertise, to operate together better for everyone their communities.

The word what started to shift, too. Individuals who was simply known sneeringly as drogados (junkies) grew to become known more broadly, more sympathetically, and much more precisely, as people using drugs or people with addiction disorders. This, too, was crucial.

You should observe that Portugal stabilised its opioid crisis, however it didnt allow it to be disappear. While drug-related dying, incarceration and infection rates plummeted, the nation still had to handle the health problems of lengthy-term problematic drug abuse. Illnesses including hepatitis C, cirrhosis and liver cancer really are a burden on the health system that’s still battling to recuperate from recession and cutbacks. In this manner, Portugals story works as a warning of challenges yet in the future.

Despite enthusiastic international reactions to Portugals success, local harm-reduction advocates happen to be annoyed by the things they see as stagnation and inaction since decriminalisation arrived to effect. They criticise the condition for dragging its ft on creating supervised injection sites and drug consumption facilities for failing to help make the anti-overdose medication naloxone more designed for not applying needle-exchange programmes in prisons. Where, they ask, may be the courageous spirit and bold leadership that pressed the nation to decriminalise drugs to begin with?

In the first times of Portugals panic, when Pereiras beloved Olho started failing before him, the states first instinct ended up being to attack. Drugs were denounced as evil, drug users were demonised, and closeness either to was criminally and spiritually punishable. The Portuguese government launched a number of national anti-drug campaigns which were less Just Say No and much more Drugs Are Satan.

Informal treatment approaches and experiments were rushed into use through the country, as doctors, psychiatrists, and pharmacists labored individually to handle the ton of drug-dependency disorders in their doorways, sometimes risking ostracism or arrest to complete the things they believed was perfect for their sufferers.

In 1977, in northern the nation, mental health specialist Eduno Lopes pioneered a methadone programme in the Centro da Boavista in Porto. Lopes was the very first physician in continental Europe to test out substitution therapy, flying in methadone powder from Boston, underneath the auspices from the Secretary of state for Justice, as opposed to the Secretary of state for Health. His efforts met having a vicious public backlash and also the disapproval of his peers, who considered methadone therapy simply condition-backed substance abuse.

In Lisbon, Odette Ferreira, a skilled pharmacist and pioneering Aids investigator, began an unofficial needle-exchange programme to deal with the growing Aids crisis. She received dying threats from drug dealers, and legal threats from politicians. Ferreira who’s now in her own 90s, but still has enough swagger to hold off lengthy fake eyelashes and red leather in a mid-day meeting began offering clean syringes in the center of Europes greatest open-air drug market, within the Casal Ventoso neighbourhood of Lisbon. She collected donations of clothing, soap, razors, condoms, fruit and sandwiches, and distributed these to users. When dealers reacted with hostility, she clicked back: Dont wreck havoc on me. You need to do your work, and Ill do mine. She then bullied the Portuguese Association of Pharmacies into running the countrys and even the worlds first national needle-exchange programme.

A flurry of costly private clinics and free, belief-based facilities emerged, promising detoxes and miracle cures, however the first public drug-treatment center operated by the Secretary of state for Health the Centro das Taipas in Lisbon didn’t begin operating until 1987. Tight on sources in Olho, Pereira sent a couple of patients for treatment, although he didn’t accept the abstinence-based approach used at Taipas. First you get rid of the drug, after which, with psychiatric therapy, you plug in the crack, stated Pereira. There wasn’t any scientific evidence to exhibit this works also it didnt.

Also, he sent patients to Lopess methadone programme in Porto, and located that some responded well. But Porto what food was in another finish of the nation. He desired to try methadone for his patients, however the Secretary of state for Health hadnt yet approved it to be used. To obtain around that, Pereira sometimes requested a nurse to sneak methadone to him within the boot of his vehicle.

Pereiras work treating patients for addiction eventually caught the interest from the Secretary of state for Health. They heard there is a wild man within the Algarve who ran their own, he stated, having a slow smile. Now 68, he’s sprightly and charming, by having an sports build, thick and wavy white-colored hair that bounces as he walks, a gravelly drawl along with a bottomless reserve of heat. They came lower to locate me in the clinic and suggested which i open cure center, he stated. He asked a friend from in a family practice within the next town to join him a youthful local physician named Joo Goulo.

Goulo would be a 20-year-old medical student as he was offered his first hit of heroin. He declined while he didnt understand what it had been. When he finished school, got his licence and started practising medicine in a health center within the southern town of Faro, it had been everywhere. Like Pereira, he accidentally wound up specialising for substance abuse.

A nurse hands out methadone to addicts in Lisbon. Photograph: Horacio Villalobos/Corbis via Getty Images

The two young colleagues joined forces to open southern Portugals first CAT in 1988. (These kinds of centres have used different names and acronyms over the years, but are still commonly referred to as Centros de Atendimento a Toxicodependentes, or CATs.) Local residents were vehemently opposed, and the doctors were improvising treatments as they went along. The following month, Pereira and Goulo opened a second CAT in Olho, 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 Portugals 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 wasnt legitimate for the state to punish users, he told me in his office at the University of Lisbons 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 werent immediately adopted, but they did not go unnoticed.

In 1997, after 10 years of running the CAT in Faro, Goulo was invited to help design and lead a national drug strategy. He assembled a team of experts to study potential solutions to Portugals 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, Goulo is Portugals drug czar. 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. Goulo is also decriminalisations busiest global ambassador. He travels almost non-stop, invited again and again to present the successes of Portugals harm-reduction experiment to authorities around the world, from Norway to Brazil, which are dealing with desperate situations in their own countries.

These social movements take time, Goulo told me. The fact that this happened across the board in a conservative society such as ours had some impact. If the heroin epidemic had affected only Portugals lower classes or racialised minorities, and not the middle or upper classes, he doubts the conversation around drugs, addiction and harm reduction would have taken shape in the same way. There was a point whenyou could not find a single Portuguese family that wasnt affected. Every family had their addict, or addicts. This was universal in a way that the society felt: We have to do something.

Portugals policy rests on three pillars: one, that theres no such thing as a soft or hard drug, only healthy and unhealthy relationships with drugs; two, that an individuals 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, Goulo 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 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 dont you go shave off that beard? You cant give up on yourself, man. Thats when its 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 Joo, a compact man with blue eyes who was rigorous in going over the details and nuances of what I was learning. Joo 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 doesnt go well, there is the risk that that person will feel too ashamed to return to the drop-in centre. Then we lose them, and thats not what we want to do, Joo said. I want them to come back when they relapse. Failure was part of the treatment process, he told me. And he would know.

Joo is a marijuana-legalisation activist, open about being HIV-positive, and after being absent for part of his sons 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 dont have that right now, but I do have some good cocaine. Joo 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 werent 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.

Addicts waiting for methadone at a drug treatment project in Lisbon. Photograph: Horacio Villalobos/Corbis via Getty Images

In the mornings, I followed the centres street teams out to the fringes of Lisbon. I met Raquel and Sareia their slim forms swimming in the large hi-vis vests they wear on their shifts who worked with Crescer na Maior, a harm-reduction NGO. Six occasions per week, they loaded up a sizable white-colored van with consuming water, wet wipes, mitts, boxes of tinfoil and piles of condition-issued drug kits: eco-friendly plastic pouches with single-use areas of filtered water, citric acidity, a little metal tray to cook, gauze, filter along with a clean syringe. Portugal doesn’t yet have supervised injection sites (although there’s legislation to permit them, several tries to open one have started to nothing), so, Raquel and Sareia explained, they visit outdoors-air sites where they are fully aware people visit buy and employ. Both of them are trained psychologists, but in the roads they’re known simply because the needle girls.

Good mid-day! Raquel known as out cheerily, once we walked across a apparently abandoned lot within an area known as Cruz Vermelha. Street team! People materialised using their hiding places like some strange form of whack-a-mole, poking their heads out of the holes within the wall where they’d attended smoke or skyrocket. My needle women, one lady cooed for them tenderly. How are you currently, my loves? Most made polite conversation, updating the employees on their own health struggles, love lives, immigration woes or housing needs. One lady said excitedly she’d be returning to Angola to cope with her mothers estate, that they was searching toward the modification of scenery. Another man said excitedly he’d got his online girlfriends visa approved for any visit. Does she know youre still using? Sareia requested. The person looked sheepish.

I start methadone tomorrow, another man stated proudly. He was supported by his beaming girlfriend, and waved a hot goodbye towards the women because they handed him a square of foil.

Within the foggy northern town of Porto, peer support workers from Caso a connection operated by as well as for drug users and former users, the only real unique in Portugal meet each week in a noisy coffee shop. They are available here every Tuesday morning to lower espressos, fresh pastries and toasted sandwiches, and also to talk the challenges, debate drug policy (which, ten years . 5 following the law arrived to effect, was still being confusing for a lot of) and argue, using the warm rowdiness that’s sign of individuals the northern region. After I requested them the things they considered Portugals proceed to treat drug users as sick people looking for help, instead of as crooks, they scoffed. Sick? We dont say sick up here. Were not sick.

I had been told this over and over within the north: considering substance abuse simply when it comes to health insurance and disease was too reductive. Many people can make use of drugs for a long time with no major disruption to their own personal or professional relationships. It just grew to become an issue, they explained, if this grew to become a problem.

Caso was based on Apdes, an improvement NGO having a concentrate on harm reduction and empowerment, including programmes aimed toward recreational users. Their award-winning Check!n project has for a long time setup frequent festivals, bars and parties to check substances for dangers. I had been told more often than once when drugs were legalised, not only decriminalised, then these substances could be held towards the same rigorous quality and safety standards as food, drink and medicine.

In spite of Portugals tangible results, other nations happen to be unwilling to follow. The Portuguese started seriously thinking about decriminalisation in 1998, rigtht after the very first United nations General Set up Special Session around the Global Drug Problem (UNgass). High-level UNgass conferences are convened every ten years to create drug insurance policy for all member states, addressing trends in addiction, infection, money washing, trafficking and cartel violence. In the first session that the slogan was A drug-free world: are going to it Latin American member states tight on a radical rethinking from the fight against drugs, but every effort to look at alternative models (for example decriminalisation) was blocked. When from the next session, in 2008, worldwide drug abuse and violence associated with the drug trade had vastly elevated. An remarkable session was held last year, however it was largely a disappointment the end result document didnt mention harm reduction once.

Despite the fact that letdown, 2016 created numerous promising other developments: Chile and Australia opened up their first medical cannabis clubs following a lead of countless others, four more US states introduced medical cannabis, and 4 more legalised recreational cannabis Denmark opened up the worlds largest drug consumption facility, and France opened up its first Nigeria suggested legalising medical cannabis Canada outlined a plan to legalise recreational cannabis across the country and also to open more supervised injection sites and Ghana announced it might decriminalise all personal drug abuse.

The greatest alternation in global attitudes and policy continues to be the momentum behind cannabis legalisation. Local activists have pressed Goulo to consider a stance on controlling cannabis and legalising its purchase in Portugal for a long time, he’s responded the time wasnt right. Legalising just one substance would call into question the building blocks of Portugals drug and harm-reduction philosophy. When the drugs arent the issue, if the issue is the connection with drugs, if there isnt any such factor like a hard or perhaps a soft drug, and when all illicit substances should be treated equally, he contended, then shouldnt all drugs be legalised and controlled?

Massive worldwide cultural shifts in considering drugs and addiction are necessary to make method for decriminalisation and legalisation globally. In america, the White-colored House has continued to be unwilling to address what drug policy reform advocates have termed an addiction to punishment. But when conservative, isolationist, Catholic Portugal could transform right into a country where same-sex marriage and abortion are legal, where drug abuse is decriminalised, a wider transfer of attitudes appears possible elsewhere. But, because the harm-reduction adage goes: one must want the modification to make it.

When Pereira first opened up the kitty in Olho, he faced vociferous opposition from residents they worried by using more drogados will come more crime. However the opposite happened. Several weeks later, one neighbour found ask Pereiras forgiveness. She hadnt realized it at that time, but there was three drug dealers on her behalf street when their local clientele stopped buying, they packed up and left.

The Kitty building is a colorless, brown two-floor block, with offices upstairs as well as an open waiting area, bathrooms, storage and clinics lower below. The doorways open at 8.30am, 7 days per week, all year round. Patients wander in during the day for appointments, to talk, to kill time, to clean, or to get their weekly way to obtain methadone doses. They attempted to shut the kitty for Xmas Day twelve months, but patients requested it stay open. For many, estranged from family members and adrift from the form of home, this is actually the nearest factor theyve reached community and normality.

Its not only about administering methadone, Pereira explained. You need to conserve a relationship.

Inside a back room, rows of little canisters with blueberry-flavoured methadone doses were arranged, each labelled having a patients name and knowledge. The Olho CAT regularly services about 400 people, however that number can double throughout the summer time several weeks, when periodic workers and vacationers arrived at town. Anybody undergoing treatment elsewhere in the united states, or perhaps outdoors Portugal, might have their prescription sent to the kitty, making the Algarve a perfect harm-reduction holiday destination.

After lunch in a restaurant of an old CAT worker, the physician required me to go to another of his projects a specific favourite. His decades of dealing with addiction disorders had trained him some training, and that he put his accrued understanding into designing a unique rehab facility around the borders of Olho: the Unidade de Desabituao, or Dishabituation Center. Several such UDs, because they are known, have opened up in other regions of the nation, however this center was created to focus on the specific conditions and requires from the south.

A man receives clean syringes after being given methadone at a clinic in Lisbon. Photograph: Horacio Villalobos/Corbis via Getty Images

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, theres 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 dont 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 centres parking lot: You need to change almost everything. He cackled at his own joke and stepped out of his car.

The glass doors at the entrance slid open to a facility that was bright and clean without feeling overwhelmingly institutional. Doctors and administrators offices were up a sweeping staircase ahead. Women at the front desk nodded their hellos, and Pereira greeted them warmly: Good afternoon, my darlings.

The Olho centre was built for just under 3m (2.6m), 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 dont 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. Wed 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, even if it was more than a dozen times.

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, its like I always say: I may be a doctor, but nobodys perfect.

A longer version of this piece appears on Research and travel with this piece were thanks to the Matthew Power Literary Reporting Award

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