Decriminalization: A Love Story

By SUSANA FERREIRA

Peter WiebenWhen the drugs came, they hit all at once. It was the eighties, one in ten residents slipped into the deep of heroin addiction—bankers, university students, carpenters, socialites, miners—and Portugal fell into a panic.

The way Álvaro Pereira tells the story, it all began in the south. The eighties were prosperous in Olhão, a Portuguese fishing town thirty-one miles west of the Spanish border. Coastal waters filled nets from the Gulf of Cádiz to Morocco, local and international tourism was growing, and currency flowed with relative ease throughout the southern Algarve region. Portugal had emerged from a seventies full of massive changes: the death of long-ruling President António Salazar, the fall of his repressive government, the end of brutal colonial wars, and the bumpy return of thousands of soldiers and colonial settlers. Sunny Olhão, brimming with potential in this new, freer era, was a prime place for a young doctor to set up shop, and Álvaro Pereira moved south with his wife to do just that.

I met Pereira three decades later. He was sprightly and charming, with a trim athletic build, thick wavy white hair that bounced when he walked, a gravelly drawl, and a seemingly bottomless reserve of warmth. He addressed colleagues as “sweetie,” “darling,” “my beloved,” treating every doctor, nurse, patient, and passerby as though they were the highlight of his day. It had long been his way.

A general practitioner can get to know his community of patients fairly intimately in a small town. When he first arrived in Olhão, it didn’t take long for Pereira to steep in the details of people’s lives, their families, and their insides. He’d bump into patients at the café, shopping for fresh catch at the market, and on Sunday afternoon strolls along the boardwalk overlooking the Ria Formosa lagoon. His wife, an educator, came to know generations as students or parents at the local schools. When heroin began washing up on Olhão’s shores, tearing their lives and families and insides apart, Pereira was who they turned to.

“People were injecting themselves in the middle of the street, in public squares, in gardens,” Pereira told me. “At that time, not a day passed where there wasn’t a robbery at a local business, or a mugging.” Seemingly overnight, his quiet slice of the Algarve coast became one of the drug-use capitals of Europe. Local headlines terrified with news reports of overdose deaths, of rising crime. The rate of HIV infection in Portugal ballooned to the highest in the European Union. If the national average meant one in every one hundred Portuguese was battling a problematic heroin addiction at that time, the number was higher in the south. He described how desperate patients and families began beating down his door, terrified, bewildered, begging for help. “I got involved,” he said softly, “only because I was ignorant.”

To be fair, back then nearly everyone in the country was ignorant. First, in a literal sense: the authoritarian rule of Salazar, whose forty-year regime died a few years after he did in 1974, had suppressed education, thinning out institutions and lowering the minimum legally required schooling level to the second grade in a strategy to keep the population docile. Second, as it related to drugs: Portugal had missed out on the free-loving, experimental sixties, locked down under Salazar’s paternal thumb. Coca-Cola was banned under his regime, and owning a cigarette lighter required a license. When marijuana, then heroin, and then other substances began flooding in, the country was utterly unprepared.

Pereira tackled this growing wave of addiction the only way he knew how: intimately, and one patient at a time. The twenty-something student who still lived with her parents might have her family involved in her recovery; the forty-something man, estranged from his wife and living on the street, faced different risks and needed other support. Pereira experimented and reflected, calling on other institutions and individuals in the broader community to lend a hand, tailoring his approach to each person’s unique circumstances.

In 2001, nearly two decades into Pereira’s accidental specialization in addiction, Portugal became the first country to completely decriminalize the consumption of all illicit substances. Rather than being arrested, those caught with a personal supply might be given a warning, assessed a small fine, or sent to have a chat with a local dissuasion commission—a doctor, a lawyer, and a social worker—about treatment, harm reduction, and support services available to them. A bold stance was taken, an opioid crisis stabilized, and the ensuing years saw dramatic drops in problematic drug use, HIV and hepatitis infection rates, overdose deaths, drug-related crime, and incarceration rates. HIV infection rates, for example, plummeted from an all-time high in 2000 of 104.2 new cases per million to 4.2 cases per million in 2015. The data from what is now a decade and a half of largely positive results have been studied and held up as example, and have given weight to harm-reduction movements around the globe. It’s misleading, however, to credit these positive results entirely to a change in law.

Portugal’s remarkable recovery, and the fact that it has held steady through several changes in government—including conservative leaders who would have rather ushered in a return of the War on Drugs—could not have happened without an enormous cultural shift and collective change of heart around how the country viewed drugs, addiction, and itself. In many ways, the law was merely a reflection of transformations that were already happening in clinics, in pharmacies, and around kitchen tables across the country. Decriminalization as an official policy allowed for the pooled support and interconnection of a broad range of health, psychological, employment, housing, social, and cultural services that were already grasping to work together to serve their communities, like in Olhão. The language people used began to shift, too. Those who were referred to sneeringly as “drogados”—“junkies”—became known more broadly, more sympathetically, and more accurately as “people who use drugs” or “people with addiction disorders.” This, too, was crucial.

Portugal’s story also serves as a warning bell.

The Portuguese opioid addiction epidemic was contained, not made to disappear. The consequences of the eighties and nineties weigh heavily today, as the oldest generation of chronic users and ex-users grapple with complications that include hepatitis C, cirrhosis, and liver cancer. The long-term costs of problematic drug use are a burden on a public healthcare service that is still struggling to recover from a recession filled with cutbacks. Many Portuguese harm-reduction advocates have been frustrated by what they see as stagnation and inaction; they criticize the state for dragging its feet on establishing supervised injection sites and drug consumption rooms, for not making the anti-overdose medication naloxone more readily available, for not implementing needle exchange programs in prisons, and for not demonstrating the same bold leadership that led the country to decriminalize drugs in the first place.

In the U.S., nearly one in every hundred Americans struggles with problematic opioid use—a number that’s creeping very close to the rate of addiction in Portugal when the crisis was at its height. Overdoses are now the leading cause of accidental death, and the leading cause of death period for Americans under fifty, with prescription drugs and the synthetic opioid Fentanyl to blame for much of the horrific jump. More than a quarter of global overdose deaths happen in the United States, according to the most recent UN World Drug Report, with an overwhelming fifty-nine thousand overdoses recorded just last year. Families and communities are being ravaged, as they were during a wave of heroin and then crack addiction in African-American communities in the 1960s and 1980s respectively—epidemics that were largely demonized, criminalized, and untreated. While President Donald Trump’s administration has largely favored using the tough language and unforgiving measures of the failed War on Drugs, his stance softened slightly following an alarm-filled report by a special commission he appointed early in 2017. In a letter addressed to the president, dated July 31, the commission painted a stark picture: “With approximately 142 Americans dying every day,” the letter said, “America is enduring a death toll equal to September 11th every three weeks.” The commission recommended Trump declare a state of emergency. A week and a half later, he did, though it’s unclear what this will mean.

 

In the early days of Portugal’s panic, when Pereira’s beloved Olhão community began falling apart before him, the state’s first instinct—and it is nearly always the first instinct—was to attack. Drugs were called evil, drug users called demons, and proximity to either was criminally and spiritually punishable. The Portuguese government launched a series of national anti-drug campaigns that were less “Just Say No” and more “Drugs Are Satan.”

Pereira wasn’t the only one grasping for more scientific solutions. Treatment approaches and experiments sprang up throughout the country as doctors, psychiatrists, and pharmacists worked independently to address the flood of drug dependency disorders piling at their doors, sometimes risking ostracism or arrest in order to do what they hypothesized was best for their patients.

In the far north, psychiatrist Eduíno Lopes pioneered a methadone program at Porto’s Centro da Boavista in 1977. Better known by his nicknames—“Dr. Hero-in,” “The Methadone Man”—he was the first to experiment with substitution therapy in continental Europe, flying in methadone powder from Boston under the auspices of the Justice Ministry, not the Health Ministry. His efforts earned him vicious public backlash and the insults of his peers, who considered methadone therapy nothing more than state-sponsored drug addiction.

In Lisbon, Odette Ferreira (no relation to the author), then a sixty-something pharmacist and pioneering HIV-2 researcher, took on death threats from drug dealers and legal threats from politicians when she started an unsanctioned needle exchange program to address the growing AIDS crisis. The petite scientist—who today, in her nineties, still carries enough swagger to pull off long fake eyelashes and red leather for a midday meeting—started giving away clean syringes in the middle of Europe’s biggest open-air drug market, in the Casal Ventoso neighborhood of Lisbon. Along with clean needles, she brought in washing machines; collected and distributed donated clothing, soap, razors, condoms; and gave out fruit and sandwiches. When dealers confronted her with hostility, she snapped back: “Don’t mess with me. You do your job, and I’ll do mine.” She then strong-armed the Portuguese association of pharmacists to run the country’s, and the world’s, first national needle exchange program.

A flurry of pricy private clinics and free faith-based facilities opened throughout the country in those early years, promising detoxes and miracle cures, but the first public drug treatment center under the Ministry of Health—the Centro das Taipas, in Lisbon—didn’t open until 1987.

Strapped for resources in Olhão, Pereira was relieved when Taipas opened. He sent a few people for inpatient treatment there, hoping that time away from their dealers and triggers would help their recovery. Initially, the focus there was on abstinence. The psychiatrists who ran Taipas at the time surmised that drug addiction was evidence of a disturbance in one’s personality. “First you take away the drug, and then, with psychotherapy, you plug up the crack,” said Pereira. There was no scientific evidence to show that this would work, he said, and it didn’t.

Pereira sent other patients to Lopes’ methadone program in Porto, and found that some of them responded well to the treatment. There were two problems with this: Porto was on the opposite end of the country, and the Ministry of Health hadn’t yet approved methadone for use. To get around that—and to avoid the wrath of the psychiatrists at Taipas—Pereira sometimes asked a nurse to sneak methadone south in the trunk of his car.

Pereira’s close work treating addiction eventually caught the attention of the Ministry of Health. “They heard there was a crazy man in the Algarve who was working on his own,” he said, curling the corners of his mouth into a slow smile. Pereira relished that great Portuguese tradition of self-deprecation, and performed it with gusto. “They came down to find me at the clinic and proposed that I open a treatment center in the south.” That was all good and well, he told them, but he wouldn’t do it alone. He invited a colleague at a family practice in the next town over to join him—a young local doctor named João Goulão.

 

João Goulão was about twenty years old, sitting in a circle with friends passing around a joint, when he was offered his first hit of heroin. The young medical school student declined—he didn’t know what it was. By the time Goulão finished school, got his license, and began practicing medicine at a health center in the southern city of Faro, problematic heroin addiction had exploded in the Algarve. Tourist dollars and plentiful fishing made scoring dope easy, and the young doctor struggled over how to treat the addicts who began pouring in daily, looking for help. Like Pereira, he ended up specializing in drug addiction treatment by accident.

When the two young colleagues joined forces to open the first public treatment center in the south (though they’ve changed names and acronyms over the years, these centers are still commonly referred to as “Centros de Atendimento a Toxicodependentes,” or CATs), it was against the wishes of residents, and the doctors were still mostly winging treatments as they went along. Pereira and Goulão opened a second southern CAT, and other family doctors opened more in the north and central regions of the country, forming a loose network. It had become apparent that the response to addiction had to be as personal and rooted in communities as the damage it was causing.

After ten years of running the CAT, in 1997 Goulão was called by the state to help design, then lead, a national drug strategy. José Sócrates, then an adjunct minister to António Guterres—Portugal’s prime minister at the time, and today the secretary general of the United Nations—invited Goulão to assemble a team of experts to study potential solutions to Portugal’s drug problem. The resulting recommendations, including the full decriminalization of drug use, were presented in 1999, approved by the Council of Ministers in 2000, and a new national plan of action went into effect in 2001.

Today Goulão is Portugal’s drug czar. He has been the lodestar through eight alternating conservative and progressive prime ministers, through heated standoffs with lawmakers and lobbyists, through shifts in scientific understanding about addiction and in cultural tolerance for drug use, through brutal Eurocrisis austerity cuts, and through a delicate global policy climate that only very recently became slightly less hostile. He is also drug decriminalization’s busiest global ambassador. He travels almost nonstop, invited again and again to present the successes of the national harm-reduction experiment he helped birth to curious, desperate authorities from Norway to Brazil.

Portugal’s policy rests on three pillars: one, that there’s no such thing as a soft or hard drug, only healthy and unhealthy relationships with drugs; two, that an individual’s unhealthy relationship with drugs often points to frayed relationships with loved ones, with the world around them, and with themselves; and three, that the eradication of all drugs is an impossible goal.

“The national policy is to treat each individual differently,” Goulão told me.

“The secret is for us to be present.”

The first official call to change Portugal’s drug laws came from Rui Pereira (no relation to Dr. Álvaro Pereira), a former Constitutional Court judge who undertook an overhaul of Portugal’s penal code in 1996. He found the practice of jailing people for taking drugs to be counterproductive and unethical. “My thought right off the bat was that it wasn’t legitimate for the state to punish users,” Rui Pereira told me in his office at the University of Lisbon’s school of law. At that time, about half of the people in prison were there for drug-related reasons, and the epidemic, he said, was thought to be “an irresolvable problem. A ‘civilizational’ problem.” He recommended that drug use be depenalized—distinct from decriminalization, which still carries the potential of an administrative penalty—and that it be discouraged without further alienating or bringing more harm to users. His report wasn’t immediately adopted—“the time wasn’t ripe,” the judge said—but it did catch the attention of Goulão’s commission.

“These social movements take time,” Goulão told me. “The fact that this happened across the board in a conservative society such as ours had some impact.” If the heroin epidemic had been restricted only to Portugal’s lower classes or racialized minorities, sparing the middle and upper classes, he doubts the conversation around drugs, addiction, and harm reduction would have taken shape in the same way. “There was a point where you could not find a single Portuguese family that wasn’t affected. Every family had their addict, or addicts. This was transversal in a way that the society felt, ‘we have to do something.’”

 

My parents first left Portugal for Angola in the early seventies. Salazar was still president, my big brother still a wriggling baby, and it would be another decade and an additional transcontinental move to Canada before I came along. Our parents brought us back for summertime visits every five years or so, adamant that my brother and I connect with our vast extended families, and that we touch the mountainous rock and soil of the northern villages that held our roots. Their once-vivid hope that we immigrants would return home grew fainter as the years passed.

Relatives whispered at first, and then spoke openly about break-ins, muggings, how so-and-so’s son is using, and Did you hear about your poor cousin? She’s gone and married a drogado. The word, heavy with that classic Catholic cocktail of judgment and pity, weighed on both sides of the family. I can’t recall when I first heard about drogados in the villages, but heroin must have arrived in the rural north around the time flush toilets arrived at my grandparents’ house, because I remember when both were still new.

Before the drugs, the hills were filled with the rumble of trucks carrying hefty blocks of granite from any one of the quarries scattered throughout the region. The quarries had long since closed, though. The jobs left with them. Most working-aged men followed, scattering from their families in search of work in Spain, France, Abu Dhabi, Angola. Some of those who stayed turned to heroin.

I remember when, decades later, the heaviness began to lift. On a walk with my grandmother a few years before she passed, high in the eucalyptus- and pine-fringed footpaths in the hills above her mountain home, she said what a relief it was to be able to walk without fear of being mugged. This was where the drogados used to come to smoke their drugs, she said, their used foils discarded throughout. The only smoke in the air now was from nearby forest fires, a lamentably regular summertime phenomenon. She casually mentioned how someone, one of many extended relatives I couldn’t recall ever meeting, had started methadone treatment a few towns over. It’s nice, she said sweetly, that drug-dependent people are getting help now.

 

When Pereira first opened the CAT in Olhão, he faced loud opposition from residents; they worried that with more drogados would come more crime. But in fact, the inverse happened. Months later, one neighbor came to Pereira for forgiveness. She hadn’t realized it at the time, but there had been three drug dealers on her street; when their local clientele stopped buying, they packed up shop and left.

The CAT building itself is drab, brown, two stories, with offices upstairs and an open waiting area, bathrooms, storage, and clinic areas down below. The front doors open every morning at 8:30, seven days a week, 365 days a year. Patients wander in throughout the day for appointments, to chat, to kill time, to wash up in the toilets, or to pick up their weekly supply of methadone doses, biweekly if they live farther away. They tried to close the CAT for Christmas Day once, but patients asked that it stay open. For many of them, estranged from loved ones and far adrift from any version of home, this is the closest thing they’ve got to community and normalcy.

“It’s not just about administering methadone,” Pereira told me. “You have to maintain a relationship.”

He brought me to a back room where rows of little canisters with liquid methadone doses were lined up, each labeled with a patient’s name and information. They all had the same amount of banana-flavored liquid, but a nurse explained that some doses were simply more diluted than others, depending on the individual’s needs—it kept patients from comparing their prescriptions. The Olhão CAT regularly served about four hundred patients, but that number can double during the summer months when seasonal workers and tourists come to town. Anyone receiving methadone treatment elsewhere in the country or even outside of Portugal could easily have their prescription sent over to the CAT, making the Algarve an ideal harm-reduction holiday destination. Sending patients to other countries, however, could often be trickier. They had a hard time sending methadone patients to France sometimes, the nurse said. Italy? Depended on the region. Spain was easy.

Pereira turned away from the methadone bottles to face me. “We’re going to have lunch now,” he announced, “and I want you to know that I’m going to drink wine.” He asked me, did I think alcohol was a hard or a soft drug? The question gave me pause. Wine was soaked into Portugal’s very identity, and an oft-quoted Salazar-ism equated it with patriotic duty: “Beber vinho é dar de comer a um milhão de portugueses,” or “Drinking wine provides food for one million Portuguese.” Alcoholism was also the country’s most alarming, destructive dependency, far ahead of heroin or any other substance. “That depends,” I responded, and he nodded.

“The wine that I drink is no different from the wine that alcoholics drink. The problem isn’t with the wine,” Pereira said. He repeated this several times, and phrased it in many different ways in the two days we spent walking and talking in Olhão: the problem wasn’t the drug; it was how the drug was used.

“I often say that the knife that slices the neck of the husband’s mistress is the same knife that peels potatoes to feed the child,” he continued. “The problem isn’t with the knife; the problem is in the hand that uses it. So, let’s not demonize substances. Let’s understand that there are little demons inside of people.”

 

My visit to Olhão in 2015 came years after that quiet mountain walk with my grandmother. It was my first visit back to Portugal since her passing earlier that year, and one of the few I’d made alone as an adult. Like many children raised in diaspora, visits “back home” can feel complicated. My first solo trip, in 2009, was also the first time I reported on drug decriminalization. Following a summer internship at the Wall Street Journal’s Southern Europe bureau, I filed a freelance story for the paper on how the quiet Portuguese drug experiment was faring. My article was measured in its praise, noting that it was still too early to fully understand what factors led to the epidemic’s stabilization. I quoted the 1999 government report presented by Adjunct Minister Sócrates, where he referenced the complexity of human dramas and implored that “drugs are not a problem for other people, for other families, for other people’s children.” The intimacy of his words stuck with me.

Back in Portugal once more, I wanted to have a closer look at what he meant.  I spent weeks crisscrossing the country, visiting community-based programs that nurtured personal connections as a form of harm reduction, accompanying psychologists who spent day after day seeking out vulnerable users who would much prefer to stay hidden from the outside world. I drank coffee with users and activists from families that redefined the meaning of love and loyalty in order to stay together, and sat and listened in small towns that were still in the process of shedding shame and healing the wounds from several long, hard decades. These conversations flipped what I thought I knew about addiction on its head.

In vibrant Lisbon I spent my afternoons at a drop-in center called IN-Mouraria, in a lively neighborhood and longtime enclave of marginalized communities that was rapidly gentrifying. Between 2:00 and 4:00 p.m., the center provided services to undocumented migrants and refugees; from 5:00 to 8:00 p.m., they opened their doors to drug users. A staff of psychologists, doctors, and peer support workers—themselves former drug users—offered clean needles, pre-cut squares of foil, crack kits, sandwiches, coffee, clean clothing, toiletries, rapid HIV testing, and consultations—all free and anonymous. Rosy-cheeked youth stood around waiting for HIV test results while others played cards, complained about police harassment, tried on outfits, traded advice on living situations, watched movies together, and gave one another pep talks. They varied in age, religion, ethnicity, and gender identity, from all over the country, from all over the world. When a slender, older man emerged from the bathroom, unrecognizable after having shaved his beard off, the energetic young man flipping through magazines to my right threw up his arms and cheered. He then turned to the quiet man sitting on my other side, his beard lush and dark hair curling up and out from under a cap that said COSTA RICA, and said: “What about you? Why don’t you go shave off that beard? You can’t give up on yourself, man. That’s when it’s all over.”  The bearded man cracked a smile.

I got to know some of the peer support workers, including Magda, slender with long, dark hair, who sweetly checked in every so often to ask about my reporting, and João, a compact man with blue eyes, who was rigorous in going over the details and nuances of what I was learning.  Both had been longtime drug users, and they understood the language of the people who came in to see them. João wanted to be sure I understood that their role at the drop-in center was not to force anyone to stop using, but to help minimize the risks users were exposed to.

“Our objective is not to steer people to treatment—they have to want it,” he told me. But even when they do want to stop using, he continued, accompanying them to appointments and treatment facilities can feel like a burden to the user—and if the treatment doesn’t go well, there is the risk that person will feel too ashamed to return to the drop-in center, further marginalizing themselves. “Then we lose them, and that’s not what we want to do,” João said. “I want them to come back when they relapse,” João said. Failure was part of the treatment process, he told me. And he would know.

João was an active marijuana legalization activist, was open about being HIV-positive, and after being absent for part of his son’s youth, he was delighted by his newest role as a grandfather. He had stopped doing speedball after several painful, failed treatment attempts, each more destructive than the last. He had long smoked cannabis as a form of therapy—methadone did not work for him, nor did any of the inpatient treatment programs he tried—but the cruel hypocrisy of decriminalization meant that although smoking weed was not a criminal offense, purchasing it was. His last and worst relapse came when he went to buy marijuana from his usual dealer and was told, “I don’t have that right now, but I do have some good cocaine.” João said no thanks, but as he drove away he found himself beelining to an ATM, withdrawing enough cash for cocaine, and going straight back to the dealer. He had already rebuilt his life after his last relapse years prior: after he and his wife temporarily split, he found a new girlfriend, got a new job, and started his own business, at one point presiding over thirty employees. But then financial crisis hit. “Clients weren’t paying, and creditors started knocking at my door,” he told me. “Within six months I had burned through everything I had built up over four or five years.”

 

In the mornings, I went out with street teams to the crusted extremities of Lisbon. I met Raquel and Sareia—light of step, soft of voice, slender limbs swimming in the large neon vests they wear on their shifts—who worked with Crescer na Maior, a harm-reduction NGO. Six days a week they loaded up a large white van with drinking water, wet wipes, gloves, boxes of tinfoil, and piles of state-issued drug kits: green plastic pouches with single-use servings of filtered water, citric acid, a small metal tray for cooking, gauze, filter, and a clean syringe. Portugal didn’t yet have any supervised injection sites—although they are allowed under legislation, several attempts to open one have not been fruitful—so, the street team duo told me, they went out to the open-air sites where they knew people went to buy and use. Both are trained psychologists, but out in the streets they are known simply as the “needle girls.”

“Good afternoon!” Raquel called out cheerily as we walked across a seemingly abandoned lot in an area called Cruz Vermelha. “Street team!”

People materialized from their hiding places like some strange version of whack-a-mole, poking their heads up and out from the narrow gutters where they’d gone to smoke or shoot up. “My needle girls,” one woman cooed to them tenderly. “How are you, my loves?” Most made polite conversation, updating the girls on their health struggles, love lives, immigration woes, housing needs. One woman told them she would be going back to Angola soon to deal with her mother’s estate, that she was looking forward to the change of scenery. Another man updated them on his online girlfriend, how he had managed to get her visa approved for a visit. “Does she know you’re still using?” Sareia asked. The man looked sheepish. “I start methadone tomorrow,” another man said proudly. He was accompanied by his beaming girlfriend, and waved a warm goodbye to the girls as they handed him a square of foil for a swan-song hit.

The last stop was the once-notorious Casal Ventoso, the neighborhood Odette Ferreira had taken on decades before with her renegade needle exchange project, perched high on a lonely hill overlooking dry bush and freeways. Here we met Carlos, tall and trim with few grey hairs, his swollen hands the only sign of long-term intravenous drug use. Raquel passed him a few needle kits, and he tucked those into his canvas shoulder bag next to an extra pair of clean socks he carried at all times. He had learned to take care of his feet in the military, he said. Carlos pointed at mine—I was in sandals, feeling foolish next to Raquel’s and Sareia’s hiking boots—and warned me to be careful, for there were needles everywhere.

He turned to Raquel again, and told her he’d seen her at a bus stop a few days before. Raquel smiled brightly. “Really? Where?” “I don’t want you to take it the wrong way,” he said, “but if I see you on the bus, or on the streets out there, I won’t say hello.” Raquel’s smile dimmed.

“I know you in here. Out there, I don’t. I do this for you. I don’t want people to think badly of you for hanging around drogados.”

 

In the foggy northern city of Porto, I met another man named João, this one tall and nearly toothless, at a noisy café a few blocks from the apartment he shared with his mother. He came here every Tuesday morning to down espresso, fresh pastries, and toasted sandwiches with his fellow peer support workers from CASO, the only association by and for drug users and former users in Portugal. They met to talk out challenges, debate drug policy (which, a decade and a half after the law came into effect, was still confusing for many), and argue with the warm rowdiness characteristic of people in the northern region. When I asked them what they thought of Portugal’s move to treat drug users as sick people in need of help rather than criminals, they scoffed. Sick? We don’t say “sick” up here. We’re not sick.

I was told again and again in the north: thinking of drug addiction simply in terms of health and disease was too reductionist. Some people are able to use drugs for years without any major disruption in their personal or professional relationships. It only became a problem, they told me, when it became a Problem. CASO was supported by APDES, a development NGO with a focus on harm reduction and empowerment, including programs geared toward recreational users. Their award-winning Check!n project had for years set up shop at festivals, concerts, bars, and parties to test that the substance in the baggie or the pill in your hand was what you paid for. If drugs were legalized, not just decriminalized, I was told more than once, these substances would be held to the same rigorous quality and safety standards as food, drink, and medication.

“I love drugs,” tall João told me, his voice so deep I imagined his long body rattling with the rumble. “I never stopped liking drugs.” He enrolled in a state methadone program when he decided to quit heroin some years back, but still allowed himself the occasional bit of cocaine. And he only quit heroin, he said, to save his mother’s life.

“My mother is a saint,” he told me. “She gave me all the money I needed, even if she had to go borrow it.” João’s mother loved her son, but hated what the drugs did to him, so she had to make a choice—and she chose to protect him as best she could. Bills went unpaid, appliances were sold, all in the name of supplying the cash he needed to support his habit. Eventually, João’s mother began selling drugs too, and employed him and some of his friends in her business. She offered them hot lunches, regular pay, and easy access to the heroin and cocaine they were hooked on as part of her employment package, all in the name of shielding her son—and the sons of others, whose own mothers had turned their backs on them—from further harm. To these other mothers she was unforgiving. You’re a bad mother and I’m not, she’d sneer.

Twice, she was arrested and jailed. João was jailed four times, and when his mother fell ill during his last stint in prison six years ago, writhing and worrying from her bed about who would pay off his dealers and protect him if she were to die, that’s when something in him snapped: it was his turn to make a choice.

 

From Porto I took a train and then a car ride into the rural mountains, to the quiet village where my grandmother had raised her children, the air filled once more with the ash of forest fires. My relatives reacted to my cross-country reporting with amusement. You want to learn about drogados? they would say, using the word with gruff, warm familiarity. I can take you to meet some right now.

One of my uncles, more reflective than the others, told me after a late lunch one day about one family in particular, how their history with drugs was an open secret—everyone in the village knew—but he himself had never spoken to them about it directly out of politeness. Small towns are the same everywhere.

Later that same afternoon I found myself seated in a quiet living room, sofas soft blue and plush in the way of furniture that is rarely used, accidentally facilitating a woman and her granddaughter’s first frank conversation about addiction. The scent of chicken stewing in garlic and wine wafted in from the kitchen. The woman asked that I not use anyone’s name, so I’ll call them what they called each other: Grandmother and the Girl.

The Girl’s father grew up nearby, and trouble started somewhere around the time Grandmother’s daughter fell in love with him. “The day that he smoked for the first time—I think that he smoked it, I don’t know how these things work—he felt sick,” Grandmother told me. “He must have been fourteen or fifteen years old.” Was it heroin?, I asked. “Maybe it was that, yes. There’s cocaine and hero—heroin? It’s not the same thing?”

For the two decades that he struggled with addiction, Grandmother stayed quiet when items went missing from the house, when euros went missing from her purse, and when withdrawal drove her son-in-law to make wild and desperate threats. He was in a car accident, high and speeding after he’d stolen and resold goods to buy more drugs, and Grandmother bailed him out of jail. “My mother lent me money many times, and my sisters,” she said, her voice lowered. “It stayed between us. Not even my husband knows about this.”

When the Girl was still young, her parents moved to France. There, far from his friends, far from his dealers, far from the stresses of small-town life and the depressed northern Portuguese economy, they seem to have finally found a new sort of normal. The Girl has gone to visit, and says with some pride that both of her parents have jobs and a home with a beautiful garden. The Girl, still a student, stayed behind in Portugal with her grandmother.

Grandmother turned to the Girl: “There are a lot of people who die when they’re taking drugs? What is that called?”

“Overdose,” the Girl offered.

“Overdose! Yes! Right, right. It’s happened here.”

I asked the Girl how she and her friends in town viewed drugs, and she shrugged. “I think the people in my generation are more open. I have friends who talk about it, some who experimented but then stopped,” she said. “Here, where we’re very rural, you do one thing and everyone knows, and no one believes that people can change.” Her family may have tried to shield her from her father’s struggles with addiction, disguising car rides to pick up methadone as family field trips, but she knew. All the kids in school knew.

Grandmother had been listening to her intently. She leaned closer to her granddaughter, seeming to forget I was in the room for a moment. “I’m going to ask you a question,” she said: “Do you really believe that your father stopped using?”

“Yes, I believe that. Yes, I’m sure of it.”

“You’re sure?”

“Yes.” The Girl paused, as though searching for the words to reassure her grandmother. “He’s very different.”

Grandmother leaned back, her brow furrowed, eyes still fixed on her granddaughter’s face. “He made a very big change,” she said softly. “I want to believe, but you’re always afraid.”

 

The Portuguese began seriously considering decriminalization in 1998, immediately following the first United Nations General Assembly Special Session on the Global Drug Problem, UNGASS, where the slogan was “A Drug-Free World: We Can Do It.” High-level UNGASS meetings are convened every ten years to set drug policy for all member states, addressing concerning trends in addiction, infection, money laundering, trafficking, and cartel violence. Latin American member states pressed for a radical rethinking of the prohibitionist War on Drugs at the first UNGASS, but every effort to examine public-health-rooted alternate models, such as decriminalization, was blocked. By the next UNGASS in 2008, worldwide drug use and violence related to the drug trade had ballooned. Once again, Latin American member states turned up the pressure. An extraordinary session of UNGASS was held last year in New York, but despite the promising signs of cracks in the Drug War façade and greater pushes for Portugal-style decriminalization, it was largely a disappointment—the outcome document didn’t mention “harm reduction” once.

Despite that letdown, 2016 did see a number of promising developments: Chile and Australia opened their first medical cannabis clubs; four U.S. states introduced medical cannabis, and four others legalized recreational cannabis; Denmark opened the world’s largest drug consumption room, and France opened its first; South Africa proposed legalizing medical cannabis; Canada outlined a plan to legalize recreational cannabis nationally and to open more supervised injection sites; and Ghana announced it would decriminalize all drug use—just like Portugal.

The biggest change in global policy climate in recent years has been the momentum surrounding cannabis legalization. Portugal’s official policy, meanwhile, has barely shifted since it came into force in 2001. Local activists have pressed Goulão to take a stance on regulating cannabis and legalizing its sale. For years, he responded the same way: the time was not yet ripe.

Here’s a second difficulty: legalizing one substance would call into question the entire structure of Portugal’s drug and harm-reduction philosophy. If the drugs aren’t the problem, if the problem is the relationship with drugs, if there’s no such thing as a hard or a soft drug, and if all illicit substances are to be treated with the same even hand, then shouldn’t all drugs be legalized and regulated?

The UN, longtime proponent of prohibition and initially hostile to the Portuguese drug experiment, is now headed by António Guterres—prime minister of Portugal when decriminalization went into effect. The current Portuguese prime minister is António Costa, formerly a very progressive mayor of Lisbon and Guterres’ minister of justice. As is the case in regional and national scenarios, massive international cultural shifts in thinking about drugs and addiction are needed to make way for decriminalization and legalization globally—a Drug-War-Free World. Despite loud calls for change in America over the years, the White House has remained reluctant to address what drug policy reform advocates have termed an “addiction to punishment.” But if conservative, isolationist, Catholic Portugal could transform into a country where drug use is decriminalized, where same-sex marriage and abortion are legal, and where the current agnostic leader of a left-leaning coalition government can put forward motions to debate legalizing euthanasia, sex work, and, yes, the national production and sale of cannabis, a broader shift in attitudes seems possible. Or at least it does not seem like “an irresolvable problem, a ‘civilizational’ problem,” as the as the constitutional judge put it. But, as the harm-reduction adage goes: one has to want the change in order to make it.

 

After our lunch at a restaurant owned by a former CAT employee—perfectly seared local tuna, fresh lemony clams, and, as promised, glasses of crisp vinho verde from the Alentejo region, all of Pereira’s choosing—the doctor took me to visit his baby. His decades of working with addiction disorders had taught him some lessons, and he poured all of his accumulated knowledge into designing a special, radical treatment facility on the outskirts of Olhão: the “Unidade de Desabituação,” or Center for Dishabituation.

Several UDs, as they’re called, have opened in other regions of the country, each of them differing slightly, but this center was developed to Pereira’s specifications to cater to the particular circumstances and needs of the south. He stepped down as director some years ago, but his replacement asked him to stay on to help with day-to-day operations; the few doctors who specialize in addiction treatment in the Algarve region are spread thin. At age sixty-eight, Pereira should be retired by now—and, boy, has he tried to retire—but Portugal is suffering from an overall shortage of health professionals, and there are simply not enough young doctors interested in stepping into this specialization. As his colleagues elsewhere in the country grow closer to their own retirements, there’s a building sense of panic that no one will replace them.

“Those of us from the Algarve always had a bit of a different attitude from our colleagues up north,” Pereira told me. “I don’t treat patients. They treat themselves. My function is to help them to make the changes they need to make.”

And thank goodness, he deadpanned as we pulled into the center’s parking lot, there is only one change to make: “you need to change almost everything.” He cackled at his own joke and stepped out of his car.

The glass doors at the entrance slid open to a facility that was bright and clean without feeling overwhelmingly institutional. Doctors’ and administrators’ offices were up a sweeping staircase, just ahead. Women at the front desk nodded their hellos, Pereira obliged with his “Good afternoon, my darlings,” and we began our tour.

The Olhão center was built for just under three million euros, publicly funded, and opened to its first patients nine years ago. This facility, like the others, is connected to a web of local, regional, and national addiction, health, and social reinsertion public services. It can house up to fourteen people at once: treatments are free, available on the reference of a doctor or therapist, and normally last between eight and fourteen days. When people first arrive, they put all of their personal belongings—photos, cell phones, everything—into storage, retrievable on departure.

“We believe in the old maxim: ‘No news is good news,’” explained Pereira. “We don’t do this to punish them, but to protect them.” Memories can be triggering, and sometimes families, friends, and toxic relationships can be enabling.

To the left, there were intake rooms, a padded isolation room, clunky security cameras propped up in every corner. Patients received their own suites—simple, comfortable, private. To the right, there was a “color” room, with a pottery wheel, recycled plastic bottles, paints, egg cartons, and loads of glitter and other craft supplies. In another room, colored pencils and easels for drawing. A kiln, and next to it a collection of excellent handmade ashtrays. Many patients remained heavy cigarette smokers; tobacco addiction, like alcoholism, has a troublingly large and socially accepted presence throughout Europe.

The schedule here was more or less the same every day: wake up, have breakfast, take meds. Then exercise or physiotherapy, followed by a group psychotherapy session. Lunch. After lunch, most patients gathered to smoke in a courtyard overlooking the basketball court and a small soccer pitch. Then they made art all afternoon, broke for lanche (a late-afternoon Portuguese snack), and, if there was more medication to take, a second round of meds. Patients were always occupied, always using their hands or their bodies or their senses, always filling their time with something. After so much destructive behavior—messing with their bodies, their relationships, their lives and communities—learning that they could create good and beautiful things was sometimes transformational.

“We’d often hear this expression come from the mouths of our patients: ‘me and my body,’” Pereira said. “As though there was a dissociation between the ‘me’ and ‘my flesh.’” To help bring the body back, there was a small gym, exercise classes, physiotherapists, a jacuzzi—an alternative source of pleasure to drugs.

“Our patient is challenged to construct a future,” Pereira continued. “Now that they have time, finally they have time, they have too much of it, and they have the freedom to choose.” He believed that each of them—human, imperfect—was capable of finding their own way given the right support. “You know those lines on a running track?” he asked me. “Our love is like those lines.”

I came back to visit the Center for Dishabituation the following day, and after clearing it with them first, Pereira said I could meet some of the patients. There was one man, a former patient who fell into using heroin again after twelve years, the bumpiness of a long financial crisis sending him back into a spiral. Another was a very poor, frail-looking farmer whose wife brought him in on the back of a donkey; she was desperate for him to get help with his alcoholism. Another patient, a young man, a longtime cannabis user, was there for the first time and didn’t feel much like talking.

“Now,” Pereira said, “you’re going to meet a woman who is interned here for the fourteenth time.” I thought I’d misheard. Fourteen? “Yes, fourteen.” She’d used a cocktail of alcohol, heroin, and cocaine for decades, her way of coping with a series of personal traumas, but her upper-class Lisbon family was opposed to her taking methadone or any other substitution therapy as part of her treatment. When I asked her why she wouldn’t consider it, she—blonde highlights fresh, nails immaculate, lipstick slightly faded after lunch—explained, “Oh, no, I don’t want to get addicted to another drug.”

While relapsing is often part of the path toward wellness, giving her the exact same treatment after thirteen failures was an error in Pereira’s eyes. “Isn’t it time to come to terms that this woman is going to need close monitoring for the rest of her life?” Pereira was exasperated.  This, too, was part of the process.

He was firm, but never punished or judged his patients for their relapses or failures. Patients were free to leave the center at any time, and they were welcome to return if they needed, even if it was more than a dozen times. He offered no magic wand, no ready-to-wear, one-size-fits-all solution—only this daily negotiation for balance, a mark that shifted constantly: getting up, having breakfast, making art, taking meds, doing exercise, going to work, going to school, going into the world, going forward. Being alive, he said to me more than once, can sometimes be very complicated.

“My darling,” he told me, “it’s like I always say: I may be a doctor, but nobody’s perfect.”


Research and travel for this piece were made possible by the Matthew Power Literary Reporting Award
.

 


[Purchase Issue 14 here.]

 


Susana Ferreira is an award-winning freelance writer and radio producer. She has filed breaking news and features from throughout the world for major dailies, newswires, magazines, television news networks, and radio, including for
TIME, Reuters, The Wall Street Journal, BuzzFeed, PRI, CBC, and France 24. She’s a Portuguese-Canadian dual citizen and speaks five languages. 

Illustration by Peter Wieben.

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