Strategies and experiences of integration
between therapeutic approach and harm reduction.
Luis Patrício. MD Psychiatrist. Lisbon. Portugal
Firenze 13 Dez 2023
Greetings to Italian colleagues, Greetings to
SOCIETÀ ITALIANA TOSSICODIPENDENZE, in the person of its president friend Dr
Augusto Consoli and his team who invited me to come to your Residenziale
Training Event.
Once more I return to beautiful Italy, now with
white hair.
The first time, in 1993, I visited Prof Máximo
Barra in Villa Maraini in Rome.
Other times I returned for the T3E Network, for
the European Federation ERIT (elected chair in Bolonha), for Europad and to
meet with fellow friends in Reggio Emilia, Bologna, Florence, Poppi, Livorno,
Milan, Turino, Pisa.
I feel very honored by this invitation from
SOCIETÀ ITALIANA TOSSICODIPENDENZE
Thank you, President, and friend Dr Augusto
Consoli
It is with joy that I share with you a summary
of many years of the story I have lived.
I wish to share our opinion, clarify concepts,
as professionals who speak to citizens, politicians and decision makers.
In the context of social and health
interventions.
In risk reduction, that is, reduction of
dangers.
In harm reduction, that is, reduction of
sequelae and therapeutic approaches.
Therapeutic objectives. and naturally …
Recovery
The topic of drugs, risky behavior and
addictions is subject to a lot of mistakes and even a lot of fraud.
In Portugal I have a motto: If it's drugs, if
it's about drugs, be suspicious.
Check everything and confirm to know if what
you see is really true, if what you hear is really true, if what you read is
really true.
And distrust me too. Confirm before deciding to
accept or reject. You will be less deceived
Due to sensitivity and fragility, it is
necessary to demand, create conditions for: Competence Responsibility Quality
Motivation
Level of competence and responsibility of those
who work in these different areas
Quality of preparation to intervene in
environments of social exclusion
Motivation of professionals, national
politicians and local politicians
Motivation of consumers with risky behaviors
and sick and dependent consumers
At the end of the 70s and during the 80s, the
consumption of injected and smoked street heroin increased significantly, a
veritable epidemic among young people and adults in large cities.
From the mid-80s onwards, cocaine consumption
gradually increased.
In 1985, there was a clear increase in the
number of abusive consumers of illegal and legal substances throughout the
country.
In some main cities, ghettos of excluded people
were created, which expanded in particular in Lisbon, Porto and Algarve.
The lack of answers to treatment is evident.
In 86 we took the initiative to create the
first therapeutic community made by health professionals and where, naturally,
there were patients medicated with psychotropic drugs.
The need to respond differently to the growing
prevalence and incidence of consumption of psychoactive substances such as
cannabis, alcohol and other legal and illegal sedatives, particularly injected
and smoked heroin, and speed ball, has become evident. Polydrug use was the
solution for many consumers, particularly for heroin addicts in acute
deprivation.
In 1987 a huge change came
The Government creates the VIDA Project, an
Interministerial Plan to combat Drugs
The Ministry of Health takes over the treatment
of drug addicts.
Creates the Centro das Taipas in Lisbon, a
technically autonomous service linked to the regional health administration.
It was located in the city center in a
neighborhood where there was a lot of prostitution activity.
Centro das Taipas – Integrated project for free
treatment. Respected anonymity• External consultations at headquarters without
a waiting list from 9am to 9pm from Monday to Friday, with multiple services:
individual consultation with a psychiatrist and/or psychologist. General
Medicine and Infectious Diseases Consultation. Group therapy. Family Therapy,•
Emergency care every day, 24 hours a day with a permanent doctor, nurse and
3-bed night center• Day center with occupational and pre-professional workshops.
Teams with Psychologists, Occupational Therapists, Physiotherapists,
Psychosocial Technicians. Workshops: IT, Carpentry, Electricity, Painting,
Pottery, Physiotherapy/Psychomotricity• Dishabituation inpatient unit with 13
beds• Coordination with therapeutic communities• Creation of 8 External
Consultation Delegations on the outskirts of Lisbon in connection with Local
Health CentersHuge demand and acceptance. Total in the first 12 months: 1,2781
patients + 13,010 follow-up appointments
• 1999 - Total 48 places of consultations. Significant
geographical coverage.
•
Teams with doctors from health
centers, GP and some from Public Health, and young psychiatry interns/junior
doctors
•
Training carried out in regular
activities in the main centers, internships in Portugal and abroad and,
particularly with shoulder-to-shoulder training, and with gradual but clear
rapprochement of psychiatric services (many of which had previously been
hostile), increased responses and care for comorbidities.
INTEGRATED
THERAPEUTIC PROJECT
Pathological addictions and comorbidities
(Since 1987)
Easy access to screening followed by
Consultation: individual or group, without waiting list.
Availability for interventions within the scope
of General Medicine, Psychiatry Psychology Nurse Social Service. Family team
support
Psychopharmacological support.
Psychotherapeutic support.
Sociotherapeutic support. Other medical
specialties: Infectiology Pulmonology Gynecology Obstetrics Dentist
After completion, possibility of attending Day
Center programs – occupational and pre-professional activities.
Socialization/Insertion
Internments/ inpatient:
Short time – Acute withdrawal syndrome +
Comorbidity induction treatment
Larger time - Therapeutic Community +
Reinsertion Apartment
Referral to attend self-help groups. and
Meetings in the Service
Cooperation with harm reduction structures: Street
teams. Shelter center. Contact centers.
Regular meetings with teams: discussion and
follow-up of patients sent from Risk Reduction programs.
Programs: reducing risk behaviors
In1993, a specific risk reduction program
appeared for the first time
Exchanging syringes and kits
STOP SIDA - Pioneer project – Coimbra
National syringe exchange program in
participating pharmacies
And in Lisbon, VAN appears – Syringe exchange
in places of consumption – Lisbon
And we also placed a condom vending machine in
the Lisbon center of Taipas for the first time in a healthcare institution,
followed, naturally, by offering free condoms to users.
But syringes are not offered.
Because there were people who injected
themselves in the bathroom, the doors were cut 30 cm above the floor.
This way you could see and remove someone who
had fallen to the ground
Drug neighborhoods with easy access. Use on the
street Open scene
In Lisbon, Porto and Algarve, there are
well-known supply districts, easy to access and use locally, and consumer
frequency increased immensely from the 70s to the 80s.
Open scene consumption is clear and shocking in
filthy and unhealthy places from the 90s to the 2000s
In Portugal, the best-known and most frequented
neighborhood in Lisbon is the old Casal Ventoso neighborhood.
It is
located 900 meters from the Presidency of the Council of Ministers, 1 km from
the Assembly of the Republic and approximately 3 km from the Ministry of Health
and 4 km from the EMCDDA.
1996 - It became clearly necessary to intervene
in this location, to reduce the risks among the hundreds of daily visits from
consumers and dozens of residents, who did not seek help for treatment.
It was in this neighborhood that the largest
intervention began and which encouraged other interventions to take place in
other places and other cities.
Unfortunately, in this neighborhood, on the
hillside, this practice was never completely eradicated and it also moved to
the valley. And then it took root. And since 2010 it has gradually increased,
currently reaching in this location, in 2023, once again the dimension of
scandal in open scene consumption, in the corners, on the edge of the avenue,
clearly visible to those passing by, under the viaducts and even outside the
subsidized consumption room by the state.
Synchronic perspective
After these years, what has changed in Lisbon
Initially dispersed throughout the city and
surrounding areas of Lisbon, it returned to many of the old offering locations.
Other locations opened
Increase in patients in the PMO Stabilization of heroin use
Heroine
Overdose Reduction
Increased screening for infectious diseases
Reduction of intravenous use Decrease in the incidence of HIV
Increased consumption of smoked heroin
Increased consumption of powder cocaine and
crack
Increased cannabis consumption
Increased alcohol consumption
Emergence of synthetic substances “fertilizers,
bath salts and incense” on the legal free market from 2007 to 2013
Lack of preparation of teams to respond
With the pandemic and after, an increase in
home delivery of substances and online shopping
Younger people using / abusing alcohol and
cannabis
Interventions of the Lisbon Casal Ventoso Plan
The Municipality of Lisbon decides to intervene
in the main consumer neighborhood CASAL VENTOSO, carrying out the housing and
social conversion of this neighborhood by destroying old houses on the hillside
with narrow and inclined streets, drug and consumer houses and relocating
people living in modern buildings in the valley.
This reconversion plan disorganized the drug
supply sales system, which was in the open and consumption was also in the
open, in dirty places.
There was an increase in consumers who, coming
from abroad, lived there in shacks and tents and holes.
Many of these street consumers agreed to join
the structures created for this purpose: a contact center, and agreed to be
referred to the shelter and then for treatment in consultation and
hospitalization in a therapeutic community.
In this location, supply and consumption
decreased.
Many sellers have spread out geographically and
reorganized. They moved to neighborhoods or towns on the outskirts of the city,
which means that consumers from the outskirts stopped coming to the center of
Lisbon, being then and now supplied in those locations, which locally
contaminated these communities.
2000 - Decriminalization law
Very significant action to break the stigma of
criminal consumption and consumerism.
It meant and still means that the possession of
illegal substances in quantities defined by law as for personal use is not
punished as a crime, subject to imprisonment. It is illegal and is seized by
the police.
It is an administrative offence. The possessor
has no right to possession, he is identified and sent for evaluation by a drug
addiction deterrence committee where it is decided whether, for example, he
will pay a fine, or do work in the community or be sent for treatment.
The possessor must present himself to the
District Dissuasion Commission, which can mean a long geographical journey,
which is more difficult for those who are poor or excluded. It will be missing.
AND…
When the quantity found is greater than that defined by law, the possessor is
considered a trafficker and possession is treated as a crime, he will be
brought before a judge and subject to imprisonment.
2000 - Decriminalization law
Breaks the stigma
of consumption and criminal
use.
There are those who wrongly attribute the
mobilization of dependents for consultations to this decriminalization law.
That is not true. Consultations were already
well attended before decriminalization.
And there were even those who reported that
before, patients did not go to consultations for fear that psychologists or
doctors would report them to the police.
I absolutely disagree.
Note: in the last 3 years prior to the
decriminalization law, there was no reference to people being imprisoned for
possession of a substance for consumption.
Consumption was criminalized, but people were
not arrested or imprisoned nor were alternative measures applied to prison,
whether community work or other measures.
So, the previous law was not complied with.
The law that ordered arrest was not enforced
even in alternatives to prison.
In fact, the decriminalization law arises in
this situation, but naturally it was and is welcomed particularly to end or
help end the stigma.
Risk Reduction Law 2001 Harm Reduction Law 2001
Diachronic perspective 2001 – 2023 Answers
Since the beginning of 2000, in the Ministry of
Health services, treatment responses have been expanded, but with the
mobilization of professionals from other treatment structures, which reduced
the response and quality “here”, to increase the response “ there".
At the end of the decade, a clear asymmetry in
the quality of knowledge and treatment (under-treatment) began to emerge. I
heard from professionals, I work for statistics and not for patients, a growing
opinion.
The cleavage grows: said by authorities and
lived by those who work.In 2009, in the USA, the Cato report chose Portugal as
a success, citing untruths in contrast to those who live and work here.
From 2007 to 2013, a network offering
synthetics in stores developed in Portugal: sales of incense, fertilized bath
salts, in reality substances for abusive consumption
In 2010, the EMCDDA in Lisbon drew attention to
the damage caused by the consumption of these substances in countries where
they were illegal, ex the United Kingdom and the Netherlands and the
Netherlands.From 2010 to 2013 in Portugal, the network of sales establishments
increased across the continent and on the islands of the autonomous regions,
the consequences were disastrous.
Today it still exists despite the stores having
been illegalized.
Officially, Portugal continues on the path to
success. And warnings from those who work start to be denied or ignored. The
abuse of alcohol, crack, cocaine, cannabis and synthetics is evident. Street
consumption is undeniable, visible if you want to go and see. The offer also
continues on the street. The quality... be suspicious
Synchronic perspective
After these years, what has changed in Lisbon
Initially dispersed throughout the city and
surrounding areas of Lisbon, it returned to many of the old offering locations.
Other locations opened
Increase in patients in the PMO Stabilization of heroin use
Heroine
Overdose Reduction
Increased screening for infectious diseases
Reduction of intravenous use Decrease in the incidence of HIV
Increased consumption of smoked heroin
Increased consumption of powder cocaine and
crack
Increased cannabis consumption
Increased alcohol consumption
Emergence of synthetic substances “fertilizers,
bath salts and incense” on the legal free market from 2007 to 2013
Lack of preparation of teams to respond
With the pandemic and after, an increase in
home delivery of substances and online shopping
Younger people using / abusing alcohol and
cannabis.
Tenho opinião que ajuda
a melhor entender a realidade
Estamos a elaborar uma reflexão para apresentar a 16 de
Dezembro 2023 em Itália no Congresso Nacional da Sociatà Italiana Tossicodipendenze.
O tema será Estratégias e experiências de integração entre abordagem
terapêutica e redução de riscos
Palavras-chave: Comportamentos de risco de sequelas
bio-psico-sócio-familiar-jurídico-laboral. Ex: risco aditivo, infeccioso,
letal. Substâncias psicoactivas (legais e ilegais). Comportamentos de risco
aditivo. Adições a substâncias psicoactivas. Adições sem substância psicoactiva.
Tratamento. Comorbidades. Patologia Dual. Conhecimentos. Supervisão. Avaliação.
A recolha alargada de opiniões de colegas e profissionais
do terreno, permite melhor aprofundar a reflexão sobre a realidade. Porque por algumas
vezes já estivemos em proximidade na intervenção directa ou no estudo perante
doentes com patologia aditiva, tomo a liberdade de lhe propor a sua colaboração
que, sendo aceite, será naturalmente referida no trabalho final. Assim, muito
agradecemos as suas respostas às questões referentes à área geográfica onde
trabalha.
1 - Em sua opinião, qual é o nível
de motivação dos profissionais que, na sua área, trabalham para o
tratamento de doentes com patologias aditivas? Nível de motivação (assinale com X)
1.__Ausente
2.__Insuficiente 3.__Suficiente
4.__Bom
5.__Elevado
2 - Em sua opinião, qual é o nível
de competência / formação dos profissionais que, na sua área, trabalham para
o tratamento de doentes com patologias aditivas?
Nível de competência / formação (assinale com X)
1.__Ausente 2.__Insuficiente 3.__Suficiente 4.__Bom
5.__Muito
Bom
3 – Conhece, na sua área, equipas
de tratamento onde exista supervisão profissional ou avaliação? 1.__Sim
2.__Não
4 - Em sua opinião, qual é o nível
de motivação dos profissionais que, na sua área, trabalham em actividades
para redução de riscos? Nível de motivação (assinale com X)
1.__Ausente 2.__Insuficiente 3.__Suficiente 4.__Bom
5.__Elevado
5 - Em sua opinião, qual é o nível
de competência / formação dos profissionais que, na sua área, trabalham em actividades
para redução de riscos?
Nível de competência / formação (assinale com X)
1.__Ausente 2.__Insuficiente 3.__Suficiente 4.__Bom
5.__Muito
Bom
6 - Sabe se, na sua área, há supervisão
ou avaliação em alguma equipa de redução de riscos?
1.__Sim 2.__Não
7 - Sabe se, na sua área, há quem
se ocupe de consumidores com comportamentos de risco e doentes sem ter formação
nem competência? 1.__Sim 2.__Não
8 - Sabe se, na sua área há quem
esteja colocado em funções dirigentes sem ter formação/competência? 1.__Sim
2.__Não
9 - Sabe se, na sua área, há profissionais
que ficam calados perante carências, para não serem prejudicados na sua
situação laboral? 1.__Sim 2.__Não
Sff, assinale X na sua profissão: Assistente
Social__ Educador__ Enfermeiro__ Médico
de Família__ Professor__ Psicólogo__ Psiquiatra__ Técnico
Psicossocial__ Outra profissão__
Observações e comentários:
Muito obrigado
Aos colegas e amigos que ajudaram, respondendo ao
questionário
Tenho opinião que ajuda a melhor entender a
realidade
Muito obrigado aos profissionias que aceitaram
estar identificados
Alexandra Garcia, Alda Espanha, Anabela Tavares,
Carolina Pardelinha, Fátima Pinto, Fátima Porto, Fernanda Dias, Fernanda Horta,
Fernando Pinto, Francisco Abreu, João Batalheiro, João da Graça, João Saraiva,
Jose Antonio, Leonor Santos, Livramento Melo, Lucas Manarte, Maria Joao
Ferreira, Marta Roque, Nuno de Oliveira, Paula Pinto, Raquel Lima, Rui Ribeiro,
Sofia Antunes, Soledade Lourenço, Vitor Hugo.
