7–8 June 2018, Sydney

A conversation with Manuel Cardoso: drug use, health and human rights

Dr Suzie Hudson talks to Manuel Cardoso, Deputy General-Director, General-Directorate for Intervention on Addictive Behaviours and Dependencies (SICAD), Portugal. This snapshot from the conversation provides a background for his keynote at NADA Conference 2018. Register now.

SH: Can you describe the changes that have occurred in Portugal regarding the possession and use of illicit drugs?

MC: In the eyes of the law before 2000, consumption of drugs was a crime–you could go to prison. Then parliament changed this from a criminal offence to an administrative one. So the consumption, acquisition and possession for personal use of banned substances was no longer a crime. It's only an administrative offence. The offender is send to a Dissuasion Commission which evaluates the consumption risk and what to do next. The answer may be treatment, or not.

SH: By taking it away from the criminal system and putting it more centrally in the health system, what had to change then in terms of responding, for those people who perhaps might identify as being concerned about their drug use?

MC: Not so much because before this law, we already determined how many units of treatment we needed: treatment centres, therapeutic communities, and how many places within each.

What is different is the way you look at the issue. What really changed was the way the person who needed treatment faces the treatment programs. Most used to be afraid of entering into these kind of programs, as they feared referral to the criminal justice system.

When consuming drugs was a criminal offence, people who helped consumers in any way, for instance with needle exchanges, were also committing a criminal offence.

People who used drugs were labelled 'criminal' and therefore were stigmatised, so the people who work with them were stigmatised by association. In this way, things have changed a lot.

Also before, we couldn't identify people by their real name because they were afraid that the police would identify them at the centres. Now we can attach the treatment processes to each person–we found more than 20 per cent were duplicate or triplicate. Now we can treat people using their real name, from one centre to another, nationally.

SH: What would you say was the catalyst, or what were some of the things that led to the change in laws?

MC: So many issues related to this.

MC: Firstly, there was the problem itself. Remember when we say one per cent of the population had a problematic drug use, it's a lot of people. We also know that drug use reaches everyone–every family has someone–and they think...my son, my daughter, is not a criminal. This is what the population was feeling.

Then the former president of the Republic said something along these lines: I am concerned with all citizens and their problems. That includes people who use drugs.

Our president promoted many meetings to discuss the issues, and then the government created a Commission composed both by leading public officers and researchers in the field of drugs. The government asked the commission to prepare a report on how to deal with drug use issues with only one request: don't go against United Nations conventions.

So, many things moved at the same time to create an atmosphere for change.

We chose decriminalisation and not the legalisation. The commission proposed decriminalisation and they also proposed prevention and treatment: it's a comprehensive strategy related to demand and supply. The main principles of our strategy were humanism and pragmatism.

SH: Are there then people who continue to disagree with the change, I'm wondering?

MC: No. The conservative parties were more strongly opposed to decriminalisation. However, at the end of 2001, the government changed from socialist party to a conservative one and that conservative government continued the decriminalisation process approved in 2000, and put into place in 2001. So things have been maintained.

SH: You have mentioned the impact of the changes in the laws as including destigmatisation, access to treatment, and the positive impact on workers in the field. What do you feel like have been some of the major challenges for you and the treatment sector?

MC: The first major challenge was to give treatment to all who asked for it. I prepared a report to identify how many people we have in treatment, then how many are waiting for an answer or an appointment. Mid-1998 we had 2,500 people requesting for treatment and not receiving help. In six months, we reduced this to 600, and one year later all people had treatment if they asked for it.

The second challenge was to help people who didn't have the ability to seek treatment. We went to the streets to find those who needed help. I think this was very interesting and challenging, but it's in the process to start building a structure of integrated responses.

Then in 2002, we put all the national co-ordination, treatment issues, harm reduction, prevention, re-integration all in the same Institute, in the Health Ministry. It was challenging to put these people working together in a multi-disciplinary area. We prepared the 'National plan against drug and drug addiction' which was approved by the government.

After that we created a national plan of integrated responses. But first we had to identify what is the important things to do in small territories–you have to invite the people and those responsible for these small areas to identify problems and the way to solve them.

There are many challenges, trying to harmonise the work in each region is one: it's different and it's autonomous. Now they work together and do things in the same way.

Since 2008 we have become responsible for alcohol issues too. More than 1,000 people are working on this. And since 2012, we became responsible for all addictions: gambling, the internet and more. That's why we are called Addictive behaviours and dependencies'.

We have no responsibility for tobacco nowadays–in that field, things are working pretty well.

SH: Pharmaceutical drugs?

MC: This is a challenge. We have lots of people consuming prescribed medicines, a few non prescribed one. And we have others challenges... but to identify people who drink, who drink a lot, we need to identify this as early as possible.

But people don't know that they could be having a risk consumption. We all know that people use–illicit or licit–substances because one of two reasons: in search of pleasure or to relieve pain. The problem arises when the only way to get pleasure is by using substances. People drink because they like it, they feel well, they feel good, and in a wine producer country almost everyone drinks.

SH: Yes, it's very socially acceptable.

MC: For events, or even because you are tired and you need to relax a little. So, it's difficult but the idea is to get the primary healthcare (GPs) to ask three questions and then refer those with a problem to our network.

SH: There's lots of harmony between these experiences you're describing and what the challenges that we face here and the things that we are doing as well. I think when you come to Australia, there's lots that we can learn from you and your experiences.

This interview was edited for brevity.

Registrations for NADA Conference 2018 close Friday 25 May. Register now.

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Australian Government Department of Health

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