Despite enthusiastic international reactions to Portugal`s success, local harm reduction advocates have been frustrated by what they saw as stagnation and inaction since decriminalization came into effect. They criticize the state`s delay in setting up supervised injection sites and drug consumption centres; for failing to make the overdose drug naloxone more readily available; for the non-implementation of needle exchange programmes in prisons. Where are the brave minds and leadership that led the country to decriminalize drugs in the first place? The opioid crisis quickly stabilized, and in the years that followed, there was a dramatic decline in rates of problematic drug use, HIV and hepatitis infection, overdose deaths, drug-related crime, and incarceration rates. HIV infection rose from a record high in 2000 of 104.2 new cases per million to 4.2 cases per million in 2015. The data behind these changes have been studied and cited as evidence by harm reduction movements around the world. However, it is misleading to attribute these positive results solely to a change in the law. Portugal still has a long way to go, and some people continue to use drugs in appalling conditions. But, says Fonseca, “what America and other countries can learn from Portugal is to treat people with more dignity.” Portugal has shown that governments can give addicts the tools they need to get their lives back on track without spending large sums of money. But to do so, he must stop treating them like criminals. After the socio-cultural change and diversification of drug use patterns in Portugal, which were later observed in Portugal but are somehow identical to the main European trends, drug use defies its label of something that takes place on the margins of society. In addition to focusing on normalizing the use of certain illicit drugs and recreational use [59], research has focused on patterns of use defined as functional [60], independent [61], religious [62], healthy [63], socially integrated [64] and non-problematic [57, 65]. These data are gaining momentum to argue for the need to consolidate the ongoing paradigm shift, including by strengthening health concepts broad enough to take into account well-being and not just pathology, which is obviously a bad concept when it comes to strengthening and respecting the dignity of people who use drugs.
As noted earlier, such pathologization serves to undermine the capacity and self-determination of drug users [37]. A key feature of Portugal`s new drug policy, in addition to decriminalization, was the expansion of treatment services. Between 2000 and 2009, the number of outpatient treatment units increased from 50 to 79.37 However, the number of people treated for medicines decreased steadily between 2009 and 2018, possibly due to significant cuts in social and health budgets due to the impact of the global financial crisis.38 Following the integration of the country`s Independent Institute of Drugs and Drug Addiction into the National Health Service (which itself made budget cuts in 2012) of 10%), health spending continued to decline in 2015, from about 9.9% in 2009 to less than 9% of GDP.39 A decline in absolute treatment may also be linked to a decline in problem drug use, as discussed above. The latest available data show that 1.3 million syringes are distributed each year. This is a significant drop since 2003, when the number stood at 2.6 million, but remains one of the highest in the EU.45 Portugal also has around 2,137 needle and syringe exchange programmes, about three times more than Spain – although it accounts for a quarter of the population.46 Yet some supporters have been “frustrated by what they see as stagnation and inaction since decriminalisation came into effect”. particularly with regard to overdose prevention centres, the provision of naloxone, and needle and syringe programmes in prisons.47 Portugal finally opened its first mobile overdose prevention centres in Lisbon and Porto in 2019.48 Other harm reduction efforts have been welcomed – including in terms of providing safer smoke kits – but it is clear that additional investments are needed.49 In 2001, Portugal decriminalized personal possession of all drugs as part of a broader policy shift towards a health-centred approach.