In the 1990s, Portugal was in the throes of a national crisis, averaging 360 drug overdose deaths a year in a country of 10 million. Today, it has one of Europe’s lowest rates of drug, alcohol and tobacco use and the number of overdose deaths in 2016 was 26. In a weeklong series from Portugal, Vancouver Sun columnist Daphne Bramham looks at the lessons to be learned from the country’s radical approach to addiction treatment.
MONTE REDONDO, Portugal — The moat is long gone and so is the family of the 1st Marquis of Alegrete, who built Quinta das Lapas more than two centuries ago.
Today, the manor’s residents are recovering substance users. They live in dorm-style rooms built behind the main house. But they have full access to the expansive gardens, carpentry shop, art room and, of course, counselling rooms.
Less than an hour outside of Lisbon, it’s in a picturesque village with both old-fashioned and modern windmills towering over the winding streets.
“I felt loved here,” said 63-year-old Jorge Faustino. He’d only recently completed six months here at the Quinta das Lapas community when we spoke and was in the third and final stage of his treatment — re-integration into the community, by working at a restaurant job that the staff had helped him find.
Faustino had been a heroin addict in the 1990s, recovered, and then relapsed after 20 years of abstinence. He’d been walking by the place where he used to use drugs and thought he’d try it just one more time.
“It was a bad idea. It was very hard on me. I had a very violent reaction,” he said.
Faustino left Quinta das Lapas after two months in treatment. But almost immediately, he regretted it and was allowed to return.
Quinta das Lapas is one of Portugal’s 63 therapeutic communities – 60 of which are operated by non-profit organizations and three by government. The goal of the communities is to treat residents’ addictions and provide them with the tools they need to avoid relapsing into drug or alcohol use. This includes building a network of social supports, employment training and skills development. For some, the stay can be as little as a few months. Others may remain in the community for up to three years.
The privately paying patients here, including foreigners like a young Portuguese American who we met during our visit, pay 3,000 euros or about $4,600 a month.
Those referred here by the Commission for the Dissuasion of Drug Addiction or by their family doctors pay less. The government picks up 80 per cent of the tab — 720 euros or about $1,100 — and the residents or their families provide the remaining 20 per cent. But if the families can’t pay or if the clients are on social assistance, their costs are fully covered by government.
When we visited, eight of the 40 beds were empty even though there are 15 people waiting to have their applications processed.
It didn’t used to be like this, said Rui Martins, the centre’s communications director. Before the government passed laws in 2001 aimed at making it easier to get treatment, there were fewer steps and less paperwork. Of course, not everyone had access then because the treatment wasn’t government funded. Now, more people have access to therapeutic recovering communities, but they have to go through the process of either having the treatment recommended by addictions specialists at the regional treatment centres or by the dissuasion commission. Those recommendations take time.
“Before, people might be waiting three weeks,” he said in an interview. “Now the waiting time has increased to up to four months and during that time, a lot of people lose their motivation.”
But the legal changes had positive effects as well, according to Dr. Rosalie Francisco, the community’s technical director.
With decriminalization of drugs for personal use, people are more likely to admit their substance abuse and seek help. If they relapse, she said, they no longer have to worry they might end up in jail.
About 45 minutes west of Lisbon, another therapeutic community called Farol (meaning Lighthouse) is tucked into the mountainside in a tony neighbourhood of Sintra, a popular tourist destination because of its beaches, two castles and a Moorish fortress that towers over the valley.
The long walkway from the parking lot to the former college is shaded with mature trees. Farol is a collection of classrooms converted into dorms and therapy rooms. As we walk to the office, we can hear the shouts of residents playing volleyball. Like most people in recovery, 70 per cent of the residents here are men ages 28 to 35.
The government handed the buildings over to the Associação para o Tratamento das Toxicodependências in 1995 and, since then, close to 2,000 people have been treated here.
Despite the promise of fast pathways to treatment, everyone who winds up here has had to wait. The waiting list for the 27 beds is at least a month.
“It’s not quick to get in,” Farol’s director, Assuncao Cruz, said. “It’s never less than a month or a month and a half on the waiting list. They can go to a treatment centre for support once a week while they wait. But we do lose many patients during those waiting times.”
“Recovery for us is abstinence and giving the client a different kind of life with the internal and external reserves to have a family and a job. That’s the most important thing: To give them the self-esteem that they’ve lost,” said Cruz.
Ze Dias da Cunha, a 62-year-old former heroin addict, has been on the association’s board since it began more than a decade ago. He had to go to London for treatment 33 years ago and when he returned in 1985, Dias started Portugal’s first narcotics anonymous chapter.
“There are two issues with treatment in Portugal that I would change,” he said in an interview. “The state has beds and pays a certain fee per month for treatment. The problem is that for 12-step treatment, the program is very condensed. People only get supported for three months, while some other therapeutic communities that don’t use 12-step are funded for a year.”
The second issue is that Dias believes the government ought to be spending money researching what kinds of treatment are the most effective.
For those who end up at beautiful therapeutic communities like Farol and Quinta das Lapas, it is a bit like winning the lottery, which is fitting since they are the most acutely addicted in need of the most intensive and tender care.
The reality is that most substance users — whether in Portugal, Canada or any other country — end up being treated as out-patients, with some studies suggesting that the results are at least as good as those for in-patients.
In Lisbon, being an outpatient means going to the rather grim Pavilion 21B at the city’s former psychiatric hospital. Built during the Second World War, the pink-stuccoed building has peeling, white-painted trim. Inside what’s now called the Taipas Centre, people wait for appointments in a dimly lit rotunda with too few chairs. They brighten with the arrival of the irrepressible Miguel Vasconcelos, a psychiatrist and the centre’s director.
Ninety-five per cent of the patients are here because they called the well-publicized phone number for addictions help, and some may well be referred for in-patient treatment. Only five per cent are sent here by the Commission for the Dissuasion of Drug Addiction.
There is no waiting list. During their first appointment, patients are asked to talk about their situation, then informed about the services the centre has to offer and the rules of treatment.
Some require immediate treatment and there are six detox beds. There used to be 15, but when the financial crisis hit in 2008, nurses and other staff were transferred to other institutions because of budget cut. The same thing happened at Lisbon’s other institution that deals with alcoholics. Its detox beds were cut to 16 from 30.
It means that 90 per cent of people who are voluntarily going into withdrawal will do so at home.
Within a week of the first visit, Vasconcelos and his team of psychiatrists, psychologists, social workers, nurses and physiotherapists come up with a treatment plan. It’s presented to the patient at a team meeting and it might include methadone therapy, intensive counselling, even laughing yoga, dancing or art classes.
Those classes are given on the somewhat cheerier second floor of the building, where artwork brightens the walls. But there are still many reminders that this is an institution, not least of which the windows in bathroom doors that allow staff to check to see if patients are taking drugs or, worse, have overdosed.
“Treatment is a tailored program,” he said. “Sometimes part of the healing is to reintegrate to jobs and to school, so it can’t be done as an in-patient. … But I am not God. I don’t foresee what will happen to my patients. I can only give them my best advice.”
And his best advice is always aimed at motivating patients to eventually get entirely off drugs.
“The treatment program here is directed toward abstinence and maintaining the rules in the process of healing,” he said. “But I will try to ensure prevention of HIV.”
Among the rules to which patients must agree when they commit to the plan is that they cannot be on drugs when they come to appointments.
The only exception is methadone — an opioid replacement. But it’s considered a short-term therapy needed to get the patient to the next stage of recovery, which is abstinence.
Of course, some don’t agree to the plan set out for them, preferring to continue using methadone or illicit drugs, said Vasconcelos.
“I don’t believe in forced treatment,” he said. “It’s unthinkable to tell a patient what to do. Nothing is mandatory unless the patient puts himself at risk or puts someone else at risk.”
Those who refuse treatment are told how to get free methadone from a mobile clinic and that free needles, hash pipes and condoms are available from local organizations whose mandate is harm reduction, not treatment.
“Harm reduction is an attitude based on the idea that I should accept whatever someone else does,” Vasconcelos said.
That’s something the psychiatrist firmly rejects.
Even before the new law decriminalizing drugs for personal use, he said that medical professionals here agreed that drug users weren’t criminals. Now, with the national guidelines, that’s enshrined in law.
Still, despite all the laws, rules and regulations and even though this is a small country, Vasconcelos said there are regional differences in the types of treatment and the ways it’s delivered.
“Every region thinks it’s best. So, we have the risk of disaggregating the national plan.”
If regional differences and disagreements threaten a national addictions treatment system in Portugal — a country with a tenth of the land mass of British Columbia, albeit double the population — it’s certainly worth considering the challenges if Canada were to embark on a national plan.
But it doesn’t mean that Canada shouldn’t have a national addictions strategy. We’re used to different interpretations of the Canada Health Act across 10 provinces and three territories that stretch over a land mass that is 100 times larger than Portugal with more than triple the population.
Far from viewing regional differences as an assault on a national plan, it could mean that Canadians’ needs are better met by programs and services tailored to their diverse needs.
Day 6: Treatment centres abound; so do waiting lists.
Day 7: Applying the Portuguese model to B.C.