It’s April in Porto, Portugal, and I’m with a group of other journalists visiting an open-air drug use site in a ruined farmhouse building outside the city. 

A drug user, 49-year-old Carolina Padua, tells me how her serious addiction to heroin has been stabilized for many years now, thanks to easily accessible, government-provided methadone treatment. 

Standing in the sunshine amid the remains of the ruined building, Sérgio Rodrigues, a founder of CASO (Consumidores Associados Sobrevivem Organizadosthe drug users association in Portugal) tells me how he moderates his own drug use. Having also moved off injection drugs thanks to a year and a half on government-provided methadone, Rodrigues now smokes heroin irregularly.

With pride, Rodrigues shows me a photo of his five-year-old son, who is never exposed to drug use. He explains that when his son is older he hopes to tell him about the harmful effects drugs can have. “But the reality, not like a poster.” Rodrigues  hopes that realistic knowledge and the example of a father living a full and “beautiful” life will help inoculate his son against problematic use. The idea that you can distinguish between problematic and unproblematic use of any substance seems to me to be a crucial part of the Portugal paradigm I’ve come here to learn about.

Open-air drug use site in Porto, Portugal. Credit: Carlyn Zwarenstein

Those in the harm reduction world know Portugal as a harm reduction Mecca: renowned for its 2001 legislation that decriminalized possession of small amounts of substances—including “hard” drugs like heroin and cocaine—and prioritized the health and human rights of people who use drugs over punishing them for it. 

I have traveled here from Canada, where one person is dying roughly every two hours from an opioid-involved overdose, to attend Harm Reduction International’s 26th global conference, and to learn about Portugal’s own radical experiment. 

Back in the city, I find myself in an enormous conference room, surrounded by policy makers, doctors and researchers from some 90 countries around the world. They see harm reduction measures as fundamental to achieving the UN’s goal of eliminating AIDS by 2030 (Portugal is one of the few nations on track to meet its goal) as well as dramatically reducing rates of viral hepatitis and tuberculosis. 

In a side meeting to the main event, I hear drug users from Mexico, the United Kingdom, France and Spain discuss the dangers of treating all drug use as a disorder. 

Michele Bachelet, the UN High Commissioner for Human Rights and former president of Chile, moves me with her speech at the opening ceremonies:

“Decriminalization in Portugal,” she says, “was based on humanism, courage, evidence base and participation.” Officially, the four pillars were actually pragmatism, humanism, participation and evidence, but her point is taken: these are hardly the priorities that ground policies relating to substance use in North America, and much of the world. That’s why I’m hereto learn how we can do better. 

I start by learning about Portugal, and Porto, itself. 

Portugal

Porto, like the rest of the country, was hit with extraordinarily high rates of open and injection drug use and addiction in the mid 1970s. The dictatorship of António de Oliveira Salazar had just fallen, finally opening Portugal to a Europe that had more gradually adapted to responsible drug use through the 1960s. In short order, one in eight adults in Portugal became addicted to heroin.

Through the 1980s, viral hepatitis and eventually HIV became serious problems, with AIDS deaths peaking in 1996 with 561 deaths. 

In response to this multifaceted public health crisis, the government set up its first needle exchange program in 1993 and, in 2001, took the radical approach of decriminalizing possession of small amounts of all substances, including heroin, methamphetamines and cocaine. 

Portugal was not the first country to do so: Uruguay did it back in 1974. But Portugal took the crucial step of pairing its decriminalization with other measures intended to reduce the harms associated with drug use. These included everything from easy, same-day access to methadone maintenance treatment to distribution of drug paraphernalia like syringes and crack pipes.

Through this policy, substance use was substantially (though not entirely) shifted from the criminal justice realm to that of health care and social services. 

Rui de Carvalho de Araújo Moreira, the mayor of Porto, stresses the importance of this radical shift: from drug use falling under the Ministry of Justice to it falling under the Ministry of Health. “Those of you who live in countries where you haven’t done that, please do. It is fundamental,” he tells conference participants at the opening plenary.

And Portugal has the statistics to prove it. 

According to UNAIDS, the percentage of new HIV infections in Portugal dropped 45 percent between 2010 and 2016. Portugal did not keep comparable statistics on new HIV infections before 2000, but if compared to the ’80s and ’90s, when the World Health Organization says that Portugal had one of the highest rates in Europe for its population size, the drop would be far more significant. 

By 2016, only 1.5 percent of new HIV infections in the country were associated with injection drug use. That’s in part due to the general drop in injection drug use, and also because, according to UNAIDS, some 92 percent of injection drug users in Portugal employ safe injection practices.  

APDES in Porto, Portugal provides drug testing to empower users with the knowledge of what their drugs contain. Credit: Carlyn Zwarenstein

Perhaps most startling is that drug use itself in Portugal, according to the United Nations Office on Drugs and Crime, is now well below the European average, with rates actually decreasing among young people. Youthful experimentation has by no means stopped altogether, but the stats show that fewer people are continuing to use drugs after trying them. Injection drug use in particular has declined dramatically compared to before 2001. Overdose deaths went down too, from 80 deaths from drug-related causes in 2001 down to just 16 in 2012. Porto’s chief of police tells me that open drug use has become a rare sight on city streets compared to his childhood.

Dr. Ricardo Baptista Leite is a member of parliament in Portugal, representing a center-left party. “Twenty years later, it’s not an experiment anymore,” he says of the 2001 policy. “It works, it’s here and it’s had a real impact on people’s lives.”

Baptista Leite is founder and president of UNITE, a network of parliamentarians around the world working to eradicate infectious diseases such as tuberculosis, viral hepatitis and AIDS—diseases heavily influenced by drug policy that makes injection drug use more dangerous by forcing users to hide, pushing them away from the health care system. 

He tells me that although the 2001 policy was not supported by all MPs back then, he believes that if a vote were to be held now, nobody from either left or right would vote to overturn it and return to criminalization of drug use. 

Meanwhile, illicit fentanyl and other contaminants are still sweeping the North American drug supply, claiming a staggering number of lives through overdoses. 

In Canada, the thoroughly poisonous drug supply killed some 11,500 people between 2016 and 2018. In the United States, the Centers for Disease Control believe that a gobsmacking 70,237 people died of opioid-involved overdose in 2017 alonenearly 200 people per day. That’s almost two times the number of people who died in motor vehicle accidents the same year. 

It’s not surprising that, as in Portugal, many North Americans are wondering if the War on Drugs has already been lost, and if it’s time for a different approach.

A philosophy

Harm reduction as it appears in Portugal is not just another bit of jargon or a specific initiative. It is a philosophy, backed up by evidence. 

Although there isn’t one universally accepted definition, harm reduction is basically any intervention designed to reduce the harms associated with the use of psychoactive drugs. Instead of focusing on eliminating the use of drugs among people unwilling or unable to stop, harm reduction asks what people need to use drugs as safely and healthily as possible. It aims to mitigate the impact of drug use on relationships, employment and especially healthwhile making sure that drug use does not result in violations of users’ human rights.

“The use of drugs doesn’t mean you forfeit your human rights,” says Naomi Burke-Shyne, executive director of Harm Reduction International. Yet, especially when drug use intersects with other vulnerabilities such as those relating to poverty, race, or gender, people who use drugs find that their human rights are routinely suspended. These include access to the highest possible standard of health, for example, or the right to not be arbitrarily detained.

A kit containing Naloxone, the drug that can reverse a potentially fatal opioid overdose. Handing out Naloxone kits to drug users, and their friends and family, is one form of harm reduction. Credit: James Heilman via Wikimedia Commons

That idea can be a surprisingly tough sell. At the Porto conference, Maria-Goretti Ane, African consultant for the International Drug Policy Consortium, described the wide variation in drug laws from country to country in West Africa. 

Despite many African countries now considering policy reform, politicians and opinion leaders alike are often resistant, seeing policies that focus on public health rather than punishment as “a way of encouraging people to use drugs”—a notion in direct contradiction with all the evidence we have from Portugal. It’s an attitude that is common around the world. 

In Brazil, where psychiatrist Leon Garcia works on initiatives that focus on housing and stabilizing drug users’ lives, he tells me critics say that harm reduction is “not effective, it’s a kind of incentive for drug use.” 

Dr. Garcia’s housing-focused interventions in São Paulo and other municipalities have achieved lower frequency and intensity of drug use among participants while improving overall individual and community well-being. 

Stigma

After I published a book about opioid painkillers and pain in 2016, I became belatedly enlightened to the stigma, discrimination and, frankly, outright hate that people who use drugs face every day. I got direct messages calling me a junkie and suggesting I die for saying that I benefit from the opioid painkillers I take as prescribed to deal with a degenerative spine disease. I also began to notice the way drug users are described in mainstream media—as zombies, junkies, dirty, less than human. 

And yet, not all drug use is problematic and the causes of problematic use itself are the same as the causes of a host of social ills. Although the likelihood of any one person falling into addiction is determined by many factors, the prevalence of addiction in a population increases steadily as social determinants of health worsen. 

In writing about drugs I find, as Burke-Shyne suggests, a microcosm of issues I’ve written about for 20 years: housing and homelessness, inequities, racism, sexism, colonialism, and hateful, human rights-suspending policies and attitudes towards people who experience trauma and poverty.

I also encounter resistance movements led by marginalized people themselves. This is where the hope comes from. 

The greatest harm

Over the past century, perhaps the greatest non-intrinsic harm of opioid drugs has been prohibition. Not only has it resulted in the development of a massive and racialized industry of incarceration, prohibition has also incentivized producers to increase the strength of illicit drugs like heroin, giving the user no certainty about the dose they are taking. 

That’s why, in the midst of the North American fentanyl crisis, Portugal’s 2001 decision to decriminalize doesn’t actually seem so radical anymore. Calls for decriminalization in Canada are getting louder and louder. Mexico has promised to decriminalize as well, although it’s not clear what that’s likely to mean in practice. 

Harm reduction rally in Toronto, Canada. Credit: Carlyn Zwarenstein

Marijuana has been decriminalized for medical and even recreational use in many parts of the United States, and Uruguay and Canada have legalized it entirely. Support for decriminalization of psychedelics is growing in the U.S., with Denver recently decriminalizing psilocybin mushrooms and Oakland having recently voted to decriminalize natural hallucinogens ranging from magic mushrooms to ayahuasca and peyote. 

And evidence for why this is a good thing doesn’t only come from Portugal. New research suggests that the overdose crisis in British Columbia, a province hit especially hard in Canada, would have been far worse without harm reduction initiatives like supervised consumption sites, a small number of opioid substitution programs, and public access to naloxone—a lifesaving medication that can almost immediately reverse a fatal opioid overdose. An estimated 3,000 fatal overdoses were prevented over a two year period in B.C. 

Conversely, when a prescription heroin program that existed decades ago in the U.K., providing a safe supply of pharmaceutical-grade heroin to already-dependent patients, was cancelled, 41 of the 450 participants were dead within two years. And in Portugal, where the austerity policies imposed between 2010 and 2014 resulted in cutbacks harm reduction, injection drug use increased to the point that the country is opening its first supervised consumption sites, an emergency measure once thought unnecessary. 

Unconditional love

Fundamentally, harm reduction is a philosophy of both pragmatism and love. It recognizes the complexity of why drug use exists. It’s sobering to realize, for example, that while pleasure is one important reason that people use drugs, opioids may also be a tool for coping with trauma for people who don’t have access to expensive therapists. Stimulants like methamphetamines may be used to stay awake when living in shelters or on the street in order to prevent theft, assault or rape. 

Graffiti in Porto, Portugal: “It’s urgent to think of love.” Credit: Carlyn Zwarenstein

Harm reduction honors that by decreeing that all people, including those who use drugs, have basic human rights. “People who use drugs deserve the best,” says Franky, a Toronto overdose prevention site worker who I interview for a different story I write upon returning home. I see this sentiment in the respectful, thoughtful work of MEWA in Mombasa and Metzineres in Barcelona. 

I hear this kind of language in Porto from everyone, from drug users to physicians, policy makers and police and when I speak to anyone from anywhere in the world working directly with people who use drugs. 

But perhaps no one puts it quite as eloquently as Dr. Baptista Leite, the Portuguese MP: “Harm reduction and love share a common denominator. For it to truly work, it needs to be unconditional.”

This story is part of a collection called Transcending Judgement: Stories about taking care of everyone, no matter their life circumstances. Read more here. Also in this series, author Carlyn Zwarenstein takes readers on an interactive multimedia tour of harm reduction around the world. Check it out

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