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Portugal Drugs - Strategies and experiences of integration between therapeutic approach and harm reduction. Dr Luis Patrício

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

Muito obrigado por ler e responder. A minha estima Luis Patricio

 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.

 

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