How Europe’s heroin capital solved its overdose crisis

What Canada can learn from Portugal about opioid addiction, rehab and recovery

In a Lisbon gymnasium, people whose bodies have been ravaged by drugs are trying to put their lives back together.

They've formed two lines and laugh as they take turns throwing a ball to their partners.

Drug addicts who've forgotten how to have fun are being given a lesson in how to play again.

"They're surprised at the feeling of feeling good, at being capable of this," says physiotherapist Leonor Madereira, who supervises this work at the Taipas rehabilitation clinic.

Taipas is one of 40 such publicly funded facilities across Portugal treating more than 4,000 addicts free of charge.

Elsewhere in the building, several patients taking an art therapy class are making ceramics, sculptures and paintings.

The clinic's walls are lined with their creations. Some depict damaged, angry souls struggling to escape their bodies.

Recovering addict Fernando Rias, right, thinks jail is no place for those who want to get clean. (Chris Corday\/CBC)

Recovering addict Fernando Rias, right, thinks jail is no place for those who want to get clean. (Chris Corday/CBC)

"This keeps me clean," said Fernando Rias, a 46-year-old recovering heroin addict who paints as part of a small group.

"They treat us like sick people, not criminals," he said.

"Criminal people are not accepted in society. Here, we are accepted."

Overdose recovery

Portugal was once Europe's worst country for drug misery and deaths. Now, it’s a public-health success story with a system that's been copied by its European neighbours.

In 1999, use of heroin, cocaine and other hard drugs was rampant. Approximately 100,000 Portuguese, or one per cent of the population, reported an addiction to hard drugs.

Heroin addiction was an epidemic in Portugal 20 years ago. (Getty Images)

Heroin addiction was an epidemic in Portugal 20 years ago. (Getty Images)

Hundreds died every year, says Dr. Joao Goulao, the public health physician who has received much of the credit for helping turn the situation around.

“It was devastating our people," Goulao said.

It was very similar to the situation in Vancouver now, where city morgues are regularly filled to capacity from opioid overdoses and a mobile hospital emergency ward was set up to relieve the burden on overworked first responders in the city's drug-ravaged Downtown Eastside.

Memorials to those who died from fentanyl overdoses are painted around Vancouver's Downtown Eastside. (Canadian Press)

Memorials to those who died from fentanyl overdoses are painted around Vancouver's Downtown Eastside. (Canadian Press)

In Lisbon, the culprit was heroin. Today, across Canada, it’s the even more powerful opioid fentanyl and, increasingly, carfentanil — packing up to 100 times the punch of fentanyl.

The drugs are believed to have caused an unprecedented number of fatal overdoses across Canada last year, including 922 deaths in B.C.

Goulao’s revolutionary recommendation for Portugal was to remove the criminal penalties for all drug use — in other words, decriminalization. It would be combined with an intense focus on harm reduction, treatment and rehabilitation.

A decade later, the number of addicts was halved and overdose deaths had dropped to just 30 a year for the entire country. The number has remained steady ever since.

Europe’s drug-monitoring agency says Portugal’s mortality rate from drugs is now more than four times lower than the European average.

Goulao says 90 per cent of public money spent fighting drugs in Portugal is channeled toward those health-care goals — just 10 per cent is spent on police enforcement.

In Canada, there's an absence of data on how the spending breaks down, but a 2008 report in the International Journal of Drug Policy suggests nearly the opposite happens, with up to 70 per cent of money spent combating drug use going to enforcement.

Soft judgment

One of Portugal's most important innovations has been its network of "dissuasion commissions."

Anyone caught with a “personal” amount of drugs — up to 10 days’ worth of a substance — can be ordered to appear before a health department official like Nuno Capaz. He's the sociologist who heads up the Lisbon commission.

"When I wake up in the morning, I'm not thinking, ‘How many fines am I going to apply?’ So it’s easy to focus on the health issues and the help we can provide," Capaz said.

There are no gowns or gavels in the commission’s bare-bones office and police and prosecutors aren't involved.

Instead, the commission's function is to identify potential problem drug users early on and either provide them with information about treatment or quickly get them access to the health-care system.

'The best cases are the ones that don't show up again.'

-Nuno Capaz, dissuasion commission of Lisbon

In the case of a 25-year-old man named Bruno, his penalty for possessing a small amount of hashish was a meeting with Capaz and another health worker followed by the offer of some information about addiction services.

"If it were not for the commission, we would be obliged to go to the court and court expenses are far more expensive," the young man told CBC News.

Capaz says measuring the success of such meetings isn’t easy.

"The best cases are the ones that don't show up again," he said.

Outreach allies

Canada has developed harm-reduction policies, such as needle exchanges and safe injection sites, based largely on local advocacy.

Portugal, on the other hand, set up a central agency to co-ordinate its response nationwide.

The result in Canada is a patchwork. Cities such as Vancouver have had outreach programs for drug users for years whereas other places offer little in the way of services.

Ines Costa, Catarina Branco and Marta Correia work with the Lisbon harm-reduction non-profit group Crescer. (Chris Corday\/CBC)

Ines Costa, Catarina Branco and Marta Correia work with the Lisbon harm-reduction non-profit group Crescer. (Chris Corday/CBC)

In Portugal, every health district in the country has outreach teams that visit addicts every day and get to know their stories and needs.

Our CBC News crew met up with Ines Costa, Catarina Branco and Marta Correia as they visited a derelict former industrial area of east Lisbon to hand-deliver supplies, such as clean needles and pipes.

"I think our work makes a big difference," said Correia, a recent graduate from a university psychology program.

"Many of them wouldn't go to treatment if it wasn't for us."

Hard drug use is mainly limited to derelict parts of Lisbon, but there used to be open drug use on city streets, much like in Vancouver's Downtown Eastside. (Chris Corday/CBC)

The European Monitoring Centre for Drugs and Drug Addiction estimates Portugal had between 27,000 and 34,000 high-risk opioid users in 2012 and roughly half of them were involved in some type of treatment program. That suggests a far higher take-up rate than in Canada.

A 2012 report from the Canadian Community Health Survey found only a fraction of Canadians with substance abuse problems were accessing publicly funded treatment programs.

The women regularly meet Pedro during their daily visits to east Lisbon. (Chris Corday\/CBC)

The women regularly meet Pedro during their daily visits to east Lisbon. (Chris Corday/CBC)

Among those waiting for supplies from the outreach workers in Lisbon was a man named Pedro, who asked that we not use his last name.

"Their job is very important and they are very brave," he said of the young outreach workers, who risk being pricked by dozens of discarded needles as they make their rounds in neighbourhoods of homeless people.

He told us he's familiar with Canada's opioid problem from the news.

"I know there are lots of drugs in the alleys," he said of Vancouver.

Hard drugs are still widely available in Portugal although officials say drug use has sharply declined since decriminalization. (Chris Corday/CBC)

While Lisbon still has places users frequent to buy and use drugs, the open drug market that once characterized parts of the city is gone. And the worst neighbourhoods that had the highest death rates no longer see many drug fatalities.

Vancouver, meanwhile, has struggled to reduce overdose deaths for more than 20 years.

Don MacPherson of the Canadian Drug Policy Coalition and one of Canada’s best-known harm-reduction advocates, says even before the fentanyl epidemic, the number of overdose deaths rarely dipped below 300 a year.

“That line [overdose deaths] is supposed to be going down and down, not plateauing,” he said. “We couldn’t get that line to go down and now it’s way back up again.”

Mobile methadone

Methadone is one of the most important tools in the battle against opioid addiction in Portugal.

A heroin substitute that’s also widely used in Canada, it satisfies the craving without producing the high.

In Lisbon, it’s delivered to thousands of users in the places where they live and work via one of two mobile vans.

Each van serves hundreds of addicts a day, driving through the city’s narrow cobblestone streets and parking at five different locations.

Within minutes of pulling up at the Lumiar stop in central Lisbon, a line of 20 people formed, each waiting for a cup with a five milligram daily dose.

Those in the line included office staff, cooks, cleaners and restaurant workers, including Manuel, a 40-something father of two who came on his lunch break.

The mobile van program means "I can have a job, I can have health, I can have life," he said.

Elvira Ferreira, a Lisbon methadone van client, explains how the outreach program has helped her live without heroin. 

For some patients, methadone treatment can make the cravings stop after several months. But for others, it can take much longer, even many years.

Hugo Faria, a psychologist who manages the program, said some addicts have been making visits every day for more than a decade.

"This was started to help those people who are marginal," Faria said.

"Without these kind of programs, these people wouldn't go anywhere to be treated.”

More than rehab

For all the success stories, budget cuts are threatening the future of Portugal's addiction treatment system.

Europe's financial crisis in 2009 took a heavy toll on the country. As unemployment went up, so did alcoholism and addiction, says Dr. Joao Goulao.

As part of the austerity measures that followed, the government eliminated the central agency responsible for co-ordinating the country's drug treatment program.

The Dianova plant nursery in Torres Vedras, north of Lisbon, employs a number of recovering drug addicts. (Chris Corday\/CBC)

The Dianova plant nursery in Torres Vedras, north of Lisbon, employs a number of recovering drug addicts. (Chris Corday/CBC)

Among the other causalities was a program that placed recovering addicts in job training.

About an hour outside Lisbon, rehab provider Dianova used to employ up to 14 addicts and former users in its flower greenhouses.

When the government grants were cut, the number of workers shrunk to just five.

Dianova manager Rui Martins says finding jobs and housing for recovering addicts is fundamental to their future. (Chris Corday\/CBC)

Dianova manager Rui Martins says finding jobs and housing for recovering addicts is fundamental to their future. (Chris Corday/CBC)

Manager Rui Martins worries Portugal risks giving up the gains it has made.

"We know that only treating people is not enough … The de-motivation that comes after treatment from not having those opportunities might lead them again to start using," Martins said.

Fentanyl-free

In Canada, harm reduction policies have been implemented against a backdrop of legal uncertainty. Some police forces — including Vancouver’s — rarely arrest addicts for possessing drugs but it’s ad hoc.

Any decision to universally decriminalize or legalize drugs — such as what’s happening now with marijuana — rests with the federal government.

Over the years, it has either turned a blind eye or, in the case of the Harper government, openly fought efforts to create safe zones for injection drug users.
More than a decade after the opening of Insite, Vancouver’s first safe injection site, it remains one of only two in Canada, although several others are poised to open elsewhere in cities such as Montreal, Kelowna, B.C., and Edmonton.

A prescription heroin program supplies roughly 100 addicts in Vancouver, but difficulties in obtaining the drug — along with the high cost — make it a questionable longer-term solution for addiction.

Vancouver is also home to the Crosstown Clinic, the only program in North America to offer medical-grade heroin to chronic drug users. (Rafferty Baker\/CBC)

Vancouver is also home to the Crosstown Clinic, the only program in North America to offer medical-grade heroin to chronic drug users. (Rafferty Baker/CBC)

Don MacPherson, the Canadian harm-reduction advocate, says Portugal's lesson for the world is that broadly removing criminal sanctions from drug use can be the catalyst to change public attitudes about drug use and users.

“The Portuguese were clear they needed a health response.”

Drug addiction is treated like any other disease within Portugal's universal health-care system. (Chris Corday/CBC)

A crucial unknown about the Portuguese model is how it would handle a crisis such as fentanyl.

The drug has ravaged other European countries such as Estonia and to a lesser extent Germany, but Portuguese police say it has yet to turn up there in a significant way.

MacPherson argues Portugal’s long-standing treatment practices and harm-reduction policies would allow the country to mitigate the damage should fentanyl start appearing on the street.

“The innovations in drug policy have grown out of disasters,” MacPherson said. Fentanyl is a new disaster, he says, so the response is going to be different everywhere.

"I think ... [Portugal] would be in a very good position to deal with fentanyl," he said, "because they have a very coherent response."

Taipas physiotherapist Leonor Madereira, middle, says the best part of her job is telling recovering addicts that anyone can feel good about themselves. (Chris Corday\/CBC)

Taipas physiotherapist Leonor Madereira, middle, says the best part of her job is telling recovering addicts that anyone can feel good about themselves. (Chris Corday/CBC)