Decriminalization and Harm Reduction in Portugal: An Interview with Dr. João Goulão
João Goulão, M.D., is the Director-General of The General-Directorate for Intervention on Addictive Behaviours and Dependencies (SICAD) in Lisbon, Portugal. SICAD’s main responsibility is to promote the reduction of the use of licit and illicit substances and the decrease of addictions across Portugal. SICAD develops universal prevention strategies across different state institutions (including schools), supports harm reduction mechanisms and collects the latest information and statistical data for submission to the Management Board for the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA).
Dr. Goulao was originally a family doctor and has become a leader of Portugal’s drug policy reform movement. He was part of the expert panel who developed the initial recommendations for the decriminalization of drugs presented in 1998. He graduated from the University of Lisbon’s Faculty of Medicine in 1978, and became a general practitioner in 1983. He joined the Taipas Centre in Lisbon when it was established in 1987 by the Portuguese Ministry of Health for the treatment, recovery and social reintegration of drug addicts. In 1997, he became the national director of the network of drug treatment centers in Portugal. He is currently the Chairman of EMCDDA, also based in Lisbon.
Linnae Ponté (LP): What changes have you seen in national drug use and abuse rates since Portugal decriminalized all drug use in 2001?
Dr. João Goulão (JG): Portugal decriminalized the possession of all drugs for personal use in 2001. This decision was taken in the framework of the first National Strategy (1999), which included a set of policies clearly based on the assumption that drug addiction is mainly a health issue and not a criminal one. Policies and practices that had been developed in the previous years—like the enlargement of a network of treatment units, acceptance of opioid substitution, harm reduction tools such as syringe exchange, and reintegration measures—were systematized and implemented at a political level.
It’s difficult to measure the impact of decriminalization as an independent variable; the evolution of the indicators has to be seen as a result of the development of all those responses. Considering different indicators of changing drug use patterns and demographics, some effects of decriminalization have included:
- Levels of drug use are below the European average;
- Drug use has declined among those aged 15–24, the population most at risk of initiating drug use;
- Lifetime drug use among the general population has increased slightly, in line with trends in nearby countries (however, lifetime use is widely considered to be the least accurate measure of a country’s current drug use situation);
- Rates of past-year and past-month drug use among the general population have decreased;
- Rates of continuation of drug use (i.e., the proportion of the population that has ever used an illicit drug and continues to do so) have decreased;
- Rates of problematic drug use and injecting drug use have decreased;
- HIV infections among injecting drug users have decreased.
Overall, this suggests that removing criminal penalties for personal drug possession did not cause an increase in levels of drug use. This is in line with significant evidence from around the world that shows that the enforcement of criminal drug laws has, at best, a marginal impact in deterring people from using drugs. There is essentially no relationship between the punitiveness of a country’s drug laws and its rates of drug use. Instead, drug use tends to rise and fall in line with broader cultural, social, or economic trends.
LP: Are psychedelics regulated any differently from other drugs in Portugal? How do use and abuse rates compare, both before and after decriminalization, between psychedelics and other classes of drugs such as cannabis, cocaine, opiates, and alcohol?
JG: No, psychedelics are not regulated any differently from other drugs in Portugal. Cannabis remains the most used illicit substance. Heroin was the most problematic at the time of policy changes and the main driver for those changes. Since then, the impact of heroin use has steadily decreased; there’s a decrease in the number of users, namely starters among youth, and an increase in the number of users enrolled in opioid substitution programs. The rates of use of other classes of drugs tend to suggest a decrease in the importance of heroin. Cocaine use has increased slightly proportionally with other drug use rates, as have Ecstasy and LSD.
LP: How does your professional background as a family physician inform your views on drug policy? When you started working as a doctor with addicted populations, did you intend to become involved in drug law reform?
JG: Being a family physician working in the Algarve, a region of Portugal particularly affected by the heroin epidemic in the 1980s, I felt the need to study and prepare myself to respond to the demands of treating the population under my responsibility. I got more and more involved in finding a solution for the problem, and in 1997 I became responsible for the national service (under the Ministry of Health) in charge of preventing and treating drug addiction. When the Government decided to build the first National Strategy, I was included in the drafting working group. It was a very enriching experience, as we each had the opportunity to propose what we felt to be the most coherent approaches.
LP: What lessons could the United States and other countries learn from Portugal’s approach to drug policy? Are there other aspects of Portuguese law and/or culture that might make Portugal’s experience different from other countries?
JG: Two things we can surely say are that decriminalization does not increase drug use, and that decriminalization does not mean legalizing the use of substances. It’s still illegal to use drugs in Portugal—it’s just not considered a crime. It’s possible to deal with drug users outside the criminal system. Furthermore, Portugal has a governmental structure specifically responsible for coordinating policy regarding illicit drugs and alcohol. It oversees the planning, conception, management, monitoring, and evaluation of the different steps of prevention, treatment, rehabilitation, and harm reduction in the field of drugs and alcohol. The agency ensures the improved coordination and monitoring of established policies and strategies, ensuring a comprehensive and integrated model of intervention in this area, implemented in partnership with the civil society organizations.
In my view, one historical fact that definitively influenced the so-called “Portuguese Experience:” the circumstance that problematic drug use, mainly of heroin, began later in Portugal than in other countries (after our democratic revolution in 1974) but then spread in a transverse pattern to all social classes. In the 1990s, it was almost impossible to find a Portuguese family who didn’t experience drug-related problems. It happened among marginalized people, but also among middle and even upper social classes. I believe this made it easier to find social and political support for decriminalization when you could hear middle-class housewives saying, “My son is not a criminal; he is a good guy in need of help.” Even the Catholic church supported Portugal’s progressive developments.
LP: Boom Festival, which takes place in Portugal every two years and attracted over 40,000 attendees in 2014, may be considered the world’s leading model of on-site psychedelic harm reduction services. When you visited Boom in 2014, what did you think of Boom’s approach to harm reduction, Kosmicare, which combines psychological support services with on-site drug testing?
JG: Since 2010, the Portuguese governmental structure responsible for the coordination policy in the field of illicit drugs and alcohol, now the SICAD—Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências (General-Directorate for Intervention on Addictive Behaviours and Dependencies)—has been involved in the design of Kosmicare. This has been accomplished through a partnership between Good Mood Productions (which organizes Boom Festival) and the Faculty of Education and Psychology at the Catholic University of Portugal. It has been a very interesting project in which, for the first time, a university research center, an event producer, and a governmental structure are working together on a harm reduction model. This includes integrating research into Kosmicare in order to transform of the project into an evidence-based intervention model.
Kosmicare relies on Harm Reduction and Risk Minimization (HRRM) principles, crisis intervention models, and Stanislav Grof’s psychedelic psychotherapy approach for crisis intervention in situations related to the unsupervised use of psychedelics. Kosmicare’s main purpose is to offer care and support to people undergoing crises related to psychoactive drug use, particularly psychedelics, allowing their experience to unfold in a safe environment and be adequately integrated. The intervention intends to reduce the risk for mental disorders related to drug use, and to enhance possible benefits that emerge from the experience. The other part of Kosmicare’s purpose has been to produce knowledge about the relationship between substance use and mental health in order to reduce risks related to the use of psychoactive substances, and to have a positive impact of drug users’ views of themselves, their relationship to substance use, and to life in general. Boom Festival, characterized by its strong values of humanism, sustainability, and equality, is famous for the effort and investment it puts into care of attendees. Within this ambit, Kosmicare is understood as a strategy for dealing with multiple levels of risk associated with psychoactive drug use.
It was a very interesting experience for me to go to BOOM and see, in the field, the work done by Kosmicare. At the Kosmicare tent, staff provide a range of services including not only basic paramedical and medical emergency services, but also harm reduction services such as information and outreach, chill-out spaces, clean/safe drug use devices, drug testing, and a care space especially designed for people undergoing difficult psychedelic and emotional experiences. The project therefore attempts to reduce harm related to drug use, as well as preventing abuse and drug dependency. The results of Kosmicare research shows that the Kosmicare service intervention works to attend to and resolve crises resulting from drug use. Crises that Kosmicare is unable to resolve tend to be cases in which visitors are suspected to have pre-existing psychopathological diagnoses. This is very good news, confirming the need for harm reduction services in these recreational settings.
LP: Current laws such as the RAVE Act in the United States criminalize harm reduction efforts, threatening event organizers who provide those services with property seizure and arrest for acknowledging drug use. In your view, why is it important to encourage rather than condemn harm reduction services at events, and what kinds of services are most effective?
JG: In Portugal, we came to the conclusion that the criminal system was not best suited to deal with this situation—that incarcerating drug users or organizers who provide those services was not the best option. The best option is referring problematic users to treatment while creating a system to prevent and dissuade consumption, working alongside civil society organizations prepared to do so. The Portuguese approach stands on the assumption that, even when users keep using drugs, we are still trying to provide them with conditions for a longer life and a better quality of life. In our model, we don’t give up on people. That’s why we provide support for basic life needs and keep in touch with even the most disorganized groups, always available to fulfill their requests.
LP: Based on your experience working with international regulatory bodies such as the European Union and United Nations, do you foresee a global shift in drug policy away from a prohibitionist model and towards a public health model?
JG: I believe we are already watching that shift; in general terms, this new approach is common in the European Union context, but still within a prohibitionist paradigm. I think that our main task in the international context should be to produce further evidence that the humanistic approach is far more efficient than policies based on prosecution, which are sometimes in complete disregard of human rights. I believe we must show this clearly to the countries that still have very strict policies, such as those that apply the death penalty to drug-related offenders.
I would also like to take this opportunity to say that, sometimes, I feel that there’s a lack of intellectual seriousness in discussions about the regulation of substance use, especially regarding cannabis. I think that discussions about its medical use (an issue for the medical community, medicines agencies, etc.) should be held separately from discussions about recreational use. Both discussions are needed, but mixing both issues creates a lot of confusion among citizens and politicians.
LP: How do you believe that the science of drug addictions and drug effects (such psychopharmacology, neurotoxicity research, and neuroscience) can inform policy change?
JG: Intervention in the field of drugs (and other areas) can no longer be determined by moral standards. We need more evidence-based studies to inform the design of policies because it is the only way to effectively improve the quality of people’s lives and to promote healthier societies.