THE COBBLED LANEWAYS of Lisbon are thronged day and night with tourists enjoying the bars, restaurants and historic sites of the seaside city.
But take a walk 40 minutes from the centre, past the picturesque tiled houses and steep cobbled hillsides, and you arrive at a different vista to that experienced by tourists.
Here, next to a busy motorway and under low-flying jetliners bringing in holiday makers, there stands a sprawling, multi-storeyed flat complex in the district of Casal Ventoso.
On Rua da Quinta do Loureiro, in a building in the style of a medical centre, The Journal met psychologist Roberta Reis and the team of nurses, psychologists and social workers who run the city’s Drug Consumption Room (DCR).
In Ireland, this type of facility has become known as a “supervised injection centre” – and the subject of much debate.
The need for such a facility in Dublin has been fiercely advocated by those working with people in addiction, although the location originally chosen was opposed as unsuitable by many locally. Planning for one centre has now been granted but the service is not yet in place.
Debate is heating up about the future of Irish drug policy, with the Citizens’ Assembly on the subject due to resume its deliberations next month. The assembly’s chair, former HSE chief executive, has said a “step change” in policy is needed.
But what could that change look like in practice?
Views differ, but Portugal has often been cited, including at the assembly, as an example of a different and more radical approach to drugs. We wanted to find out what the country’s health-centred approach means in reality, starting at the DCR.
Reis, the DCR’s co-ordinator, works for the non governmental agency (NGO) Ares do Pinhal which is state-funded to provide the service.
Outside the facility on the street, a small group of people are sitting on the rough ground consuming drugs. A car is parked nearby which appears to be a makeshift home. Tents and makeshift camps are scattered across the steep slope rising away from the complex.
“This area that we are in here, it was the biggest drug supermarket in Europe, in the ’80s and ’90s,” Reis said, as she gave us a tour of the facility.
Reis, and all the other officials The Journal spoke to about Portugal’s drug policy mention the heroin epidemic of the 1990s that precipitated the country’s move away from a punitive criminal justice approach – treating addicts as criminals – to a more health-based, holistic policy.
In 2001, the Government moved away from police, arrests and court and essentially decriminalised consumption of all drugs for personal use. If a person is caught by police in possession of drugs they are entered into a diversion programme.
Personal use is not measured by the cost of the drugs discovered by police but instead is limited to the equivalent of a 10-day supply. Anything above that is dealt with as an offence equivalent to Ireland’s Section 15 of the Misuse of Drugs Act – sale and supply.
The Portuguese authorities have not stopped targeting organised crime. Law enforcement officials The Journal met in Lisbon confirmed that they are still seizing tonnes of drugs annually.
Personal consumption of drugs remains technically against the law but instead of appearances in court and a potential prison sentence, the police refer people they find to a “dissuasion commission”.
Officials have said that the police paperwork for the referral is purposefully less complex than that for a court case.
A “dissuasion commission” is akin to a clinical assessment. It involves a psychologist, a social worker and a lawyer. It evaluates a drug user’s risk and offers them counselling and other supports.
For those at the highest risk, authorities can impose sanctions including fines and recommend treatment. The decision to attend is voluntary.
Portugal’s legal system has a so-called administrative sanction system, separate from its criminal mechanism, and the drugs policy falls into the former.
According to legal officials in Lisbon familiar with Irish law, the closest comparison here to these administrative offences would be our road traffic penalty point offences.
Reis is keen to stress that much has changed since the crisis of the 1990s. This consumption centre has been open for just over two years and was positioned in this location because of its proximity to an area where addicts congregate.
The DCR is not the only service under Portugal’s health-centred drugs policy. There are methadone vans touring the city and meeting addicts where they are based. However, experts determined that the mobile clinics weren’t enough.
The DCR operates first in the morning and then for several hours in the evening. There is an injection room and a smoking room, and showers for those who are homeless. There are also clothes and food provided from donations from local people.
Those who attend get access to a doctor and can avail of medical tests for diseases including HIV and Hepatitis.
Reis said many of the service users come from work in the evenings.
“They come here and they can function normally,” she said.
“We asked our service users why they come here and they tell us for dignity.
“They don’t want to consume on the streets and they can’t at home because they have children or a partner – no one judges here,” she said.
Reis’ team are social workers, nurses and psychologists. They interact in a jovial way with the clients, there is laughter and banter. The atmosphere is friendly.
The service users are a mix of well dressed men and women (mostly men) but also clearly struggling and at risk addicts. Most of the service users are in the former group, however – indistinguishable from other residents of this city.
We take a seat inside the glass-fronted medical staff area with a view of the separate smoking and injection rooms. The smoking room is a table with chairs, tiled walls and a loud fan in the roof to extract the fumes.
All the staff are trained in dealing with an overdose when it happens. There is a supply of naloxone – which can temporarily reverse the effects of opioids including heroin – along with specialist resuscitation equipment. Reis said there have been overdoses in the centre but no one has died.
She said the centre has not had an incident in months and usually it happens to relapsing addicts who mistakenly believe they can take the same dose they did before rehab.
Inside the bright, clean injection room there are separated cubicle desks with individual needle disposal boxes. There is a curtained off area for addicts who inject into their groin.
The main drug people are injecting is a cocktail of heroin and cocaine known as a “speedball”. The drug users inject it into their arm veins, their groin or their necks.
As they consume the drug, most are silent and quiet. When the task is done, they clean the desk, thank the staff and leave. Many are taking multiple injections and the only obvious physical discomfort is for one of the more high risk addicts who stands up having been injected in his neck by a friend and clutches his contorted hands and arms behind his head, his face twitching.
“It is sometimes difficult for us to watch, but this is the way they will be ok,” Reis said.
The manager is keen to emphasise that she and her team have a very good relationship with local police – on the rare occasion they need their help they come rapidly and deal with people in a direct but empathetic manner.
“It is super important to say that they have a job to do too,” she added.
Reis said the pandemic had a profound impact on addicts and undermined gains made by the health-based system, not least because outreach services were affected. Similar issues were experienced in the 2008 economic crisis.
The work of the NGO is funded 20% by the Lisbon local authority and 80% by the Government agency managing the policy, SICAD.
She believes there is a need for increased funding and that there needs to be many more injection centres across Lisbon. She added that her group is working with the resources they have.
“There is always a need for more. When we opened there were 300 people who signed up immediately but within days there were 2,000 people. That is the reality of the need.
“We have the same sized team that was made for 300 users not the number we have, so this is a trouble for the funding,” she added.
There are 300 service users on average daily, Reis said, with 150 to 160 “acts of consumption” – heroin and crack cocaine or a combination of heroin and cocaine are the drugs most used.
Reis believes it is critical to extend the service across the country and she believes that Ireland, in its decision making, should look at the possibility of having centres in every urban area.
“One Drug Consumption Room (DCR) is not enough – there need to be DCRs across the city,” she added.
It’s clear from speaking to Reis and her staff that they have immense pride and a sense of purpose and pragmatism in their work.
Reis stresses that the drugs issue is only one part of a broader societal issue. Expensive rents are forcing more Portuguese people into homelessness which in turn, Reis believes, creates the circumstances where addictive behaviours flourish.
“I think the [drug] policy is working, I think it is effective but we need to improve it.
“People are working but not able to pay the rent and they are then pushed onto the streets.
“No one who lives on the streets in Lisbon right now is ‘just a drug user’. They are people that used to have a house.
“But no one survives on the streets with nothing – they turn to alcohol or any other kinds of drugs and then it is normal for people to become disorganised.
“So there needs to be a way to solve these problems because people lose control of these issues and it gets worse.”
Reis said a delegation from Cork City Council had visited the injection centre to examine the Portuguese model.
Her advice for those Irish policy makers and the workers that could be tasked with implementing a health focused approach in Ireland is: “You must bring the service to the users.”
“You must not wait for people to come to you – go to where they are.
“You need to find answers, the DCR is only one answer and it doesn’t work for everyone. You also need specific answers for different people who consume. We have very young people coming here so I ask what is going wrong in the system.
“So you must always look in the panoramic and you cannot rest, keep changing the system, keep making it better.”
Back outside the centre, the addicts we met earlier wish us a pleasant stay in Lisbon. More people are coming down the hill, heading towards the drug consumption centre. Out of sight of much of the rest of this bustling city, the centre’s work for people living with addiction continues.
Tomorrow in The Journal we speak to experts about what lessons Ireland could learn from Portugal’s two decades of a different approach to drugs.
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