ANNUAL REPORT ON THE DRUG SITUATION. Portugal Commissioned by the European Monitoring Centre on Drugs and Drug Addiction

Transcription

1 ANNUAL REPORT ON THE DRUG SITUATION Portugal Commissioned by the European Monitoring Centre on Drugs and Drug Addiction Lisbon, October 2003

2 Table of Contents TABLE OF CONTENTS SUMMARY... 4 PART I - NATIONAL STRATEGIES: INSTITUTIONAL AND LEGAL FRAMEWORK DEVELOPMENTS IN DRUG POLICY AND RESPONSES Political framework in the drug field Legal framework Laws implementation Developments in public attitudes and debates Budget and funding arrangements... 9 PART II - EPIDEMIOLOGICAL SITUATION PREVALENCE, PATTERNS AND DEVELOPMENTS IN DRUG USE Main developments and emerging trends Drug use in the population Problem drug use HEALTH CONSEQUENCES Drug treatment demand Drug-related mortality Drug-related infectious diseases Other drug-related morbidity SOCIAL AND LEGAL CORRELATES AND CONSEQUENCES Social problems Drug offences and drug-related crime DRUG MARKETS Availability and supply Seizures Price, purity TRENDS PER DRUG DISCUSSION Consistency between indicators Methodological limitations and data quality PART III - DEMAND REDUCTION INTERVENTIONS STRATEGIES IN DEMAND REDUCTION AT NATIONAL LEVEL Major strategies and activities Approaches and New Developments PREVENTION School programmes Youth programmes outside school Family and childhood Other programmes REDUCTION OF DRUG RELATED HARM Description of interventions Standards and evaluation TREATMENT Drug-free treatment and health care at national level Substitution and maintenance programmes After-care and re-integration INTERVENTIONS IN THE CRIMINAL JUSTICE SYSTEM...61 IDT 2

3 Table of Contents Assistance to drug users in prisons Alternatives to prison for drug dependent offenders Evaluation and training QUALITY ASSURANCE...63 PART IV - SELECTED ISSUES EVALUATION OF DRUGS NATIONAL STRATEGIES Existence of evaluation Methodology of evaluation CANNABIS PROBLEMS IN CONTEXT: UNDERSTANDING INCREASED TREATMENT DEMAND Demand for treatmentfor cannabis use Prevalence of problematic cannabis use and patterns of problems Specific interventions for problematic cannabis use CO-MORBIDITY Main diagnoses, prevalence Impact of co-morbidity on services and staff Service-provision Examples of best practices and recommendations for future policy REFERENCES...76 Bibliography Data Bases/Software/Internet addresses ANNEXES...79 Drug monitoring systems and sources of information List of Tables used in the text List of Graphs used in the text List of Maps used in the text List of Abbreviations used in the text IDT 3

4 Summary Summary Concerning the institutional and legal frameworks, the most important developments was the reformulation of the coordination structure of fight against drug and drug addiction, the creation of the Institute for Drug and Drug and Drug Addiction (IDT), result of the merge between former Portuguese Institute on Drug and Drug Addiction (IPDT) and Drug Addiction Prevention and Treatment Service (SPTT). Legal diplomas mainly focus in this area of institutional reorganisation. As for situation and responses, data presented in this report allow to conclude that: Concerning drug use: Regional data from national surveys were not available at the time this report was drafted but preliminary results confirm the geographical dissemination and changes in use patterns already reported in 2001; Cannabis continues to be the most used drug and its visibility in several indicators continues to increase, alone or in combination with other substances. Although heroin remains as the main drug involved in health and legal drug related consequences, cannabis continues to gain relative weight and was, for the first time, the drug involved in more seizures than heroin; The tendency towards an increase in polydrug use reported in the 2001 National Report was not confirmed in 2002 indicators; Qualitative research among problematic drug users confirm that heroin is the main substance associated to this population although different profiles of drug use management emerge from a close follow-up of several individual cases; Responses to drug use continue to include several types of prevention interventions with special emphasis on community/municipal prevention. Concerning drug related health consequences: Indicators available continue to suggest effective responses at treatment level (decrease in waiting lists, increase in the number of follow up episodes and in the number of clients involved in substitution programmes) and at harm reduction level (decrease in drug related deaths, levelling off of infectious diseases. Heroin is still the main substance associated to health consequences and specifically in the sub-population of drug users that seek access to different treatment structures; The availability of substitution programmes continues to increase and the scope of the enlargement of the methadone substitution programmes network for, alternative services, other than CATs, are gaining importance as the preferred place to take methadone. In 2002 clients, were mainly from the male gender and from the age group 25-39, confirming the ageing trend of this population, already perceptible in previous years; The decreasing trend in the percentage of drug users in the total number of notifications of AIDS cases continues to be registered. Concerning HIV infection in the treatment setting data from the last 3 years show a level off, with a tendency to decrease, in HIV positive cases percentages. Concerning hepatitis, the percentage of infected cases in the treatment setting was higher that those registered in 2001, although lower than those registered in 2000; IDT 4

5 Summary The stabilisation of the global rates of positive HIV tests may be related, amongst other factors, to the implementation of harm reduction measures, which may be leading to a decrease in intravenous drug use (also visible in data concerning administration route in first treatment demands), or to intravenous drug use in better sanitary conditions, as indicated by the number of exchanged syringes in the National Programme Say no to a second hand syringe ; In 2002, following the trend verified in recent years, a decrease was registered on drug-related mortality (-44% in relation to 2001). The considerable decrease in the number of cases involving both licit and illicit substances, most likely contributed to the decrease verified in drug related deaths. These data may also be reflecting implemented prevention and harm reduction programmes. 58% of the positive cases with information on the presumed etiology were considered possible acute drug related deaths, an inferior percentage to the one reported in previous years. Opiates continued to be the most referred substance although its relative importance amongst all the detected substances continues to decrease; The national outreach network continues to be implemented, targeting especially problematic drug users. Concerning drug related legal consequences: In 2002, concerning the administrative sanctions for drug use, the Commissions for the Dissuasion of Drug Use instated processes most of which were referred by the Public Security Police (PSP). On the 31 st March 2003, 52% had been suspended, 22% were pending and 26% had been filed. From the rulings made, 91% suspended the process temporarily, 3% found the presumed offender innocent and 6% were punitive rulings (this percentage duplicated in comparison to 2001). In 2002, concerning criminal offences against the Drug Law, the number of presumed traffickers increased (+14%) in comparison to 2001, but the number of presumed trafficker-users decreased (-6%). Despite the fact that presumed trafficker-users are still the majority in the total group of presumed offenders, they have been loosing their relative importance, in the last three years, in comparison to presumed traffickers. Amongst the presumed offenders who possessed only one drug, for the second time since 2001, hashish (33%) was reported more often than heroin (17%), which until 2000 had always been the substance more often reported to be held by presumed offenders at the time of their identification. It is also important to emphasise the percentage duplication, in 2002 of cases related to cocaine in relation to previous years, which may be related to the absence of drug users in the criminal circuit after the decriminalisation of drug use in Court data indicates that, in the past three years no significant changes were reported in terms of the number of convictions for traffic and for traffic-use. The majority of these individuals possessed only one drug, mainly heroin, followed by hashish, as in Polydrugs were found mainly in traffic processes. Of the convicted individuals 92% were convicted for traffic, 1% for use and 7% for traffic-use, which reflects the new legal framework. The percentage of individuals in prison for Drug Law offences, in 2002, decreased in comparison to 2001 and Nevertheless, the absolute number was higher for almost all Drug Law related crimes. Individuals were mainly imprisoned for traffic offences (92%) but the number of imprisoned individuals for criminal association and precursor crimes has been increasing. IDT 5

6 Summary Responses in the criminal justice system continue to be developed to ensure treatment availability to drug users in prison, specific training for prison staff and the prevention of infectious diseases. Markets Following the trend, which has been verified since 2000, the number of heroin, cocaine and hashish seizures decreased. The number of ecstasy seizures continues to increase and the same is verified for liamba. For the first time since 1990, the number of hashish seizures surpassed that of heroin, the substance that always registered the highest number of seizures in Portugal. Despite the decrease verified in the total number of seizures, considerable quantities of drugs have been seized since 2000, a situation which is related to the higher weight of law enforcement interventions in traffic repression/control, as shown by the increase in seizures involving significant quantities of drugs. The seized quantities of liamba and ecstasy registered the highest values of the decade and the seized quantities of cocaine registered the third highest value of the decade. Concerning countries of origin of the seized drugs, heroin and ecstasy came mainly from The Netherlands, cocaine from Brazil, hashish from Spain and liamba from Angola. The most part of the seized quantities were destined to the national market and cocaine was, once again, the substance with a higher percentage of quantities destined to the external market. Regarding the prices of drugs at street level, a general decrease was verified for all substances, with a special impact in the case of hashish and cocaine, this last ranking below heroin for the first time at this level. Key issues The Portuguese National Strategy and respective Action Plan call for their internal and external evaluation until the end of Instruments and procedures were designed and internal midterm, as well as external sectorial, evaluation was started in 2002 in cooperation with all national relevant actors. However, due to political and institutional constraints, this process was halted and is expected to resume in the beginning of Cannabis is the most used illicit substance in Portugal and has been gaining visibility in market and drug-use consequences indicators as well as in school surveys. Although not traditionally associated to problematic drug use, its availability and use prevalence as well as the associated co-morbidity and the fact that no specific responses are available at this level raise concern both among professionals and decision makers who have chosen intervention in this area as one of the priorities for Although few national data is available in this area, treatment professionals agree that psychiatric co-morbidity has a high prevalence among problematic drug users in the public treatment network and a considerable impact on services and staff. Formal and informal cooperation between drug treatment units and mental health units, as well as the implementation of low threshold methadone substitution programmes, are indicated as examples of good practice in an area where more research and intervention are undoubtedly needed. IDT 6

7 National Strategies Part I National Strategies: Institutional and Legal Frameworks IDT 7

8 National Strategies 1. Developments in Drug Policy and Responses 1.1. Political framework in the drug field The most significant change in terms of political framework in 2002/2003 was the adjustment of the national political coordination of the fight against drugs and drug addiction. With the publication of the Decree-Law n. º 1/2003 of the 6th of January 2003, the coordination structure of fight against drug and drug addiction was reformulated, now encompassing the following levels: The Interministerial Council which is presided by the Prime Minister and includes the Ministers of Finances, National Defence, Foreign Affairs, Home Affairs, Justice, Education, Science and Universities, Health, Welfare, Environment, the Assistant Minister to the Prime Minister and the National Drugs Coordinator. This council ensures Interministerial coordination for the definition and implementation of the national policy on the fight against drugs. The Minister of Health who is the government member responsible for the coordination of the fight against drugs and promotes the government coordination in all matters that are not in the specific mandate of the Interministerial Council. The National Drugs Coordinator who is also the president of the Management Board of the IDT and is responsible for ensuring an effective coordination among the several public administration departments with a mandate on the area. The National Council for the Fight Against Drugs is the consultation body of the Prime Minister and the Government on the national policy for this area. It is consulted on the main strategies for this area as well as on any other issues requested by the Prime Minister or the Minister of Health. This council is the instrument of the civil society on the national policy for this area. During the first meetings of these bodies, both the Prime Minister and the National Coordinator stated emphasis on prevention, and specifically on early prevention Legal framework Decree-Law n. º 269-A/2002, of the 29 th of November 2002 sets up the Institute for Drug and Drug Addiction (Instituto da Droga e da Toxicodependência - IDT), resulting from the merger between the Service for the Prevention and Treatment of Drug Abuse (Serviço de Prevenção e Tratamento da Toxicodependência SPTT) and the Portuguese Institute for Drug and Drug Addiction (Instituto Português da Droga e da Toxicodependência IPDT). Decree-Law n. º 1/2003, of the 6 th of January 2003 reorganises the national coordination structures in the area of the fight against drugs and drug abuse, which exist since. The mission for the Portuguese participation in the Pompidou Group is placed under the National Coordinator. Law n. º 3/2003, of the 15 th of January Transposes to national law Directive 2001/8/CE, of the 8th of February, which substitutes annex I of the Directive 92/109/CEE, concerning the production and market of substances used in the illicit production of narcotics and psychotropics. IDT 8

9 National Strategies Law n. º 47/2003, of the 22 nd of August 2003 Adds PMMA and cannabis seeds to the schedules annexed to the Drug Law Laws implementation Regional Regulation Decree n. º 9/2002/M, of the 25 th of June Sets up the Regional Service for the Prevention of Drug Abuse in Madeira following the approval, in 2001, by the Regional Governmental, of the National Plan for the Fight of Drugs and Drug Abuse. Regulation n. º 484/2003, of the 15 th of April Defines the internal organisation of the central, regional and local services of the IDT Developments in public attitudes and debates Main public debate and media attention in this area concerned, in 2002, mainly three issues: the increase in hashish use among students as reported in the IDT National School Survey (cf National Report), the perceived danger of new substances in the recreational settings (especially concerning GHB) and the new orientations concerning substitution programmes in particular and harm reduction interventions in general. The merger between the IPDT and the SPTT also raised particular concerns regarding treatment units. A new Prevention Law, oriented towards local interventions and central control and evaluation, was presented in the National Parliament by the Socialist Party but was not yet approved Budget and funding arrangements Budget and funding arrangements were kept identical to previous years, however, several reorganisations in several agencies and departments hindered the process of data collection. Concerning the 2002 budget, the information sources which sent data sent more precise and disaggregated data but it was not possible to collect data from sources which had sent data concerning previous years. Thus, the following table presents a total budget of ,48, an amount which is below the total in previous years and which is surely underestimated as data from the Secretary of State of Youth and Sports, the Ministry of Foreign Affairs, the PSP and the GNR, the Institute for Welfare and Social Security, the Institute for Social Reinsertion, the General- Direction of Prisons and the Ministry of Education, were not available. IDT 9

10 National Strategies Ministry of National Defense Ministry of Health (includes the IDT) Ministry of Finance Ministry of Welfare and Employment Ministry of Science and Universities Totals Table 1- Budget and Funding Arrangements Prevention Treatment Rehabilitation Training Harm Reduction , , , , , , , , , , ,00 Research , ,00 Supply Control 1 International Cooperation , , , , , , , , , , , , ,00 1 Includes only Customs (Ministry of Finance) IDT 10

11 Epidemiological Situation Part II Epidemiological Situation IDT 11

12 Epidemiological Situation 2. Prevalence, Patterns and Developments in Drug Use 2.1. Main developments and emerging trends In 2002, the trends reported in 2001 were again verified. The results of the surveys made at national level in 2001, as well as the indicators related with the drug related health and legal consequences in 2002, point to an increase and regional spread of drug use in Portugal, as well as changes concerning drug use patterns. In effect, despite heroin being the predominant drug at the level of problematic drug use, cannabis is the most used drug in the Portuguese population and is becoming increasingly more visible in the circuits of drug use related health and legal consequences. On the other hand, the increase in the percentages of polydrug use registered since 2000 at the level of several indicators was not again verified in 2002, as indicated by drug related deaths and data concerning administrative sanctions for drug use. In this last context, there was a growing visibility of more recent substances combination, especially ecstasy with cannabis Drug use in the population No new data available. Regional/local prevalence data as well as data on profiles and settings concerning both the general population and the school setting are under analysis and will be presented in early Problem drug use In 2002, the main studies financed by the IDT on problem drug use were not qualitative (as was the case in 2001) but qualitative in order to better understand all dimensions of the phenomena. [Vasconcelos2003] focus on the follow-up of six heroin users in the city of Lisbon and describes their relationship with the substance itself, with other drug users and with the surrounding urban setting. He proposes that problematic heroin users are highly skilled in terms of social interactions, and highly organised around the substance they depend on. Dimensions such as loyalty, trust, intimacy and limits are explored to propose a different reading of problematic drug use. [Fernandes2003] uses the snowball methodology and proposes a classification of two different groups of problematic drug users according to their social status and access to resources and analysis their different management skills concerning the use of several substances (cannabis, heroin, cocaine and base cocaine, acids, ecstasy, pills, cocktails and other drugs for the up group and cannabis, heroin, cocaine and base cocaine and other substances for the down group ), what they look for, perceptions and perceived problems, administration routes and experiences. Again heroin is found to be the most intrusive, problematic substance and the most difficult one to manage by users (see also chapter 15 on cannabis related problems). IDT 12

13 Epidemiological Situation 3. Health Consequences 3.1. Drug treatment demand 2 Outpatient first treatment demand data concerning 53% clients of the outpatient public network indicate that heroin remains the main substance used (67%) in the last 30 days prior to the first treatment episode, followed by cannabis (36%) and cocaine (32%). 9% and 5% of the clients, reported alcohol and benzodiazepines, respectively; amphetamine and ecstasy use was referred by 3% and 2% of the clients. In relation to previous years the use of cannabis, amphetamines and cocaine (despite the percentage of cocaine being similar to 2000) is reported more often, and the use of heroin, alcohol and benzodiazepines is less reported. Data concerning the administration route for 28% of those clients also show a lower value of injecting drug use in the last 30 days, in comparison to 2001 (32%), 2000 (36%) and 1999 (45%). In 2002, similarly to previous years, outpatient first treatment 3 clients were mainly of the male gender (84%). The Algarve Region registered the lower percentage of clients of the male gender (78%) and the North Region the higher percentage (88%). Once again the predominant ages were between (51%). 19% were under 25 (15% in the age group 20-24) and 30% over 34 (18% in the age group 35-39). In 2002, the ageing trend of this population, already visible in previous years, was again confirmed: in 2001, near 28% were over 34 (26% in 2000 and 22% in 1999). The Regions of North and Lisbon and the Tagus Valley registered an older population, the Centro and Alentejo Regions registered a younger population. The Algarve Region was, once again, situated in the middle concerning this variable. Regarding detoxification units of the public network, data concerning inpatients in 2002 also reported heroin as the main substance leading to inpatient treatment demand (80%), followed by cocaine (8%) and methadone (8%). The most referred administration route was smoking/inhaling (58%), injecting (39%) and ingestion (3%). In comparison to 2001, injecting behaviour was less referred (44% in 2001), and smoking/inhaling was more referred (54% in 2001). This population was mainly from the male gender (85%) and the main age group was (54%). The ageing of this population was noticed in comparison to Concerning the labour situation (1 757 individuals), near 62% were unemployed, 33% had a stable job, 2% were studying or involved in professional training and 2% were inactive. At admission, most of these clients (75%) reported, as their main therapeutic project, the use of an opiate antagonist; 7% reported abstinence of antagonists and agonists, other 7% reported they wanted to be admitted at a therapeutic community and 4% reported, as their main objective, to stop problematic drug use. Data from inpatient certified detoxification units point towards 86% of male clients, mainly aged (29%). Around 91% of these clients left after programmed medical releases. In 2002, as far as therapeutic communities are concerned, data concerning 72 public and private units and clients, indicate that the majority are of the male gender (84%), aged (29%) and (27%). The majority of them (52%) were admitted for the first time in a therapeutic community. Near 18% were admitted after medical release from a detoxification unit and 17% did not have any kind of treatment before admittance. 27% were admitted by their own initiative, their CAT therapist referred 26% of them and 26% requested admission due to family pressure. On the 31/12/2002, 70% of the clients admitted had left: 40% had completed treatment, 32% went into halfway houses. Around 39% left before having completed one month of treatment. On the same date, 70% of those who left after having completed treatment were abstinent of the drug(s) for 2 Complete text, tables and graphs on this indicator are available in print [ODT2003] and at 3 Percentages calculated on the number of cases for which information exists on the considered variables. IDT 13

14 Epidemiological Situation which they had sought treatment. The same is true for the 21 who left without having completed treatment 4. Data concerning 43 clients of the Day Centres of public network in the Northern Region (Cedofeita and Oriental) also indicate heroin as the main drug (98%). These clients have been using heroin for more than 3 years and 23% of them for more than 15 years. They were mainly from the male gender (91%), aged (35%), single (67%) and with 6 years of compulsory school (58%). Information concerning 490 clients from accredited Day Centres, also indicates heroin as the main drug (90%). 85% of the clients were of the male gender, aged (28%), single (67%) and with 6 years of compulsory school (42%). Around 26% left with programmed medical released, after being in the programme between 3 months and 1 year. Near 29% left without programmed medical released, after being in the programme for less than 3 months. As for the 870 clients in high threshold methadone substitution programmes who took their medication in pharmacies 5, between the 27th of July 1998 to the 31st of December 2002, data indicate that they are mainly from the male gender (74%), aged (29%) and (27%). At admission, 58% reported having a regular job, 5% a temporary job, 34% were unemployed and 2% were following professional training. On the 31/12/2002, around 47% were participating in the programme, 31% had been transferred to other treatment units, 7% had left with programmed medical released, 4% had been suspended, 3% had left the programme and 2% had been admitted to therapeutic communities. Concerning those involved in the programme on the 31/12/2002, 43% were involved for more than 2 years, 26% between 1 and 2 years and 31% for less than 1 year Drug-related mortality 6 According to 2002 data from the Special Register (the National Institute of Forensic Medicine - INML), 156 drug related deaths, cases with positive toxicological tests were reported. Once more a decrease was registered in relation to previous years (-44%), a trend which is verified since 2000 (14% decrease between 1999 and 2000, 12% decrease between 2000 and 2001). The number of requested tests has been increasing in previous years in the Lisbon, Porto and Coimbra delegations, but there has been a decrease in the number of positive tests since 1998 in all the delegations of the INML. In 2002, the percentage registered for all delegations was 13%, 22% in 2001, 25% in 2000, 35% in 1999 and 37% in Near 58% of the cases with positive toxicological tests and information on the presumed etiology of death were suspected acute drug related deaths. This percentage was inferior to the ones registered in previous years (73% in 2001 and 72% in 2000). 48%, 40% and 12% of the 156 registered drugs related deaths in 2002, occurred respectively in the forensic regions of Lisbon, Porto and Coimbra. 4 For 51% of clients that left without having completed treatment in 2002 the situation is unknown. The situation in 2002 of 1999 inpatients in public and certified therapeutic communities: 53% of those who completed treatment in 1999 were abstinent in 2002 of the drug(s) which had lead to admittance (the situation is unknown for 31% of the cases); 19% of those who left without a programmed medical release were abstinent, in 2002, of the drug(s) which had lead to admittance (the situation is unknown for 65% of the cases). 5 A protocol, signed in June 1998, between the SPTT (now IDT), the Order of Pharmacists and the National Association of Pharmacies. 6 Complete text, tables and graphs on this indicator are available in print [ODT2003] and at IDT 14

15 Epidemiological Situation In , 87% of these episodes occurred in individuals of the male gender, aged (76%). Similarly to what occurred between 2000 and 2001, this year a higher relative weight of the age group and a decrease in the percentage of individuals under 25 were registered. These percentage variations were higher between 2000/2001 than between 2001/2002. Similarly to 2001, the female group was, in general, younger than the male group. In 2002, opiates 8 were detected in 69% of the cases. This percentage has been decreasing in previous years (81%, 88% and 95%, in 2001, 2000 and 1999). Opiates were detected isolated in 30% of the cases, associated to other substances in 39% of the cases, mainly cocaine and/or alcohol (35%). In 2002, a percentage decrease of opiate cases was verified in relation to previous years, particularly important for opiates associated to other substances. Cocaine was detected in 44% of the episodes (a higher value in comparison to previous years), usually associated to other substances (31%), mainly opiates and/or alcohol (29%). Around 13% of these episodes involved cannabis and, contrarily to what happened in previous years, in most cases it was detected isolated (8%). Methadone was detected in 4% of the cases, isolated (1%) and in association to other substances (3%). Only in one case was the presence of MDMA detected in association with opiates. There are no confirmed registered cases of amphetamines. In 23% cases, alcohol was involved in association with other drugs and, in 2% of the cases; medication was associated to other drugs. Both situations registered lower percentages in comparison to 2001 (41% and 8%). Opiates are, in all age groups 9, the main substance involved in drug related deaths, except in the age group where cocaine cases were predominant. In those groups, cocaine appears as the second most involved drug, except in younger age groups, where the number of cases involving cannabis was superior (<20 years old) or equal (20-24) to the cases involving cocaine. An analysis within each age group shows higher percentages of opiates in younger (<20 years old) and older individuals (>44 years old), higher percentages of cocaine cases in the age groups and and higher percentages of cannabis cases in the age groups and Contrarily to last year, cases involving only one substance were predominant in almost age groups, a situation that is probably related to the decrease of drug related deaths. The age group and those aged over 44 were most affected by drug related deaths involving more than one illicit drug. Beyond this analysis, which shows some of the differences in problematic use patterns in different age groups, it is important to stress that, similarly to recent years, the age group is still the most affected age group by drug related deaths and the one where more cases occurred involving any type of drug analysed in this report. On the other hand, the analysis of the substances involved in the male and female group, cannabis and cocaine had a higher weight in male individuals as well as higher percentages of association with other substances. Contrarily, a higher weight was verified, in the female group, of methadone and the only case of MDMA registered in Although data from the National Office of Statistics (GMR) confirms this decreasing trend, data is still not comparable with the above presented data for reasons involving coding procedures and information flows which have been regularly reported to the EMCDDA. 7 Percentages calculated on the cases for which information exists on the considered variables. 8 Includes heroin, morphine and codeine. 9 Percentages calculated within each age group. IDT 15

16 Epidemiological Situation 3.3. Drug-related infectious diseases 10 According to notification data from the CVEDT, on the 31/03/2003, cases of HIV infection had been notified (9 911 AIDS cases, with related complex and asymptomatic carriers). Until the 31/03/2003, notifications of HIV cases diagnosed in 2002 were received at the CVEDT: 652 AIDS cases, 101 related complex cases and 505 asymptomatic carriers cases. Notifications of drug use related cases diagnosed in 2002, represented, until 31/03/2003, respectively 46%, 27% and 29% of the total notifications of AIDS, AIDS related complex and asymptomatic carriers cases. These figures confirm the decreasing trend of the percentage of drug users: respectively 51%, 46% and 53% of the total accumulated AIDS, AIDS related complex and asymptomatic carriers cases until 31/03/2003. The decreasing trend of the percentage of drug users in the total number of diagnosed cases of AIDS is again verified: on the 31/03/2003, those percentages were 62%, 59%, 57%, 54% and 46% of the diagnosed cases in, respectively, 1998, 1999, 2000, 2001 and Notified drug related AIDS cases are mainly of the mail gender (85%), a percentage that has been increasing. Most of them were aged (91%), mainly (60%). The male gender is also predominant in the other AIDS cases not drug use related (82%), but those individuals are older: 48% are aged 20-39, with a predominance of ages over 39. Drug users with AIDS related complex and asymptomatic carriers are mainly of the male gender and aged The districts of Lisbon, Porto and Setúbal remain the districts with the higher percentages of the total notified AIDS cases (respectively 44%, 22% and 15%), as well as of the drug related AIDS cases (42%, 31% and 14% respectively). The relativisation of these notifications to the resident population in each district also shows these districts as the ones with higher rates of drug users with AIDS per inhabitant. Faro ranked fourth, despite registering only 3% of the total number of notification cases of AIDS and 2% of drug use related AIDS. The CVEDT received, until the 31/03/2003, notifications of AIDS related deaths, 51% of which were drug related. The drug related and non-drug related AIDS cases showed identical percentage of deaths (55%), the mortality by gender being also similarly in both groups. Once more it was verified that the districts, which presented higher percentages of the total drug, related AIDS cases notified (Lisbon, Porto and Setúbal) were the ones that registered a higher number of deaths. Nevertheless, inland districts (such as Castelo Branco, Guarda e Portalegre) registered the higher percentages of mortality of AIDS cases related to drug use. Also concerning this topic, it is of the utmost importance to consider data concerning HIV testing in the drug users sub-populations which demand treatment in the public treatment network and the certified units. Differences in the coverage of these data exist according to the geographical area and the types of services Complete text, tables and graphs on this indicator are available in print [ODT2003] and at 11 In 2002, 27% of the clients in outpatient first treatment episodes, 78% of the clients of detoxification units (100% of the clients in public DUs and 54% of the clients in certified DUs) and 94% of the clients in Therapeutic Communities (100% of the clients of public TCs and 94% of the clients in certified TCs). IDT 16

17 Epidemiological Situation 2002 outpatient first treatment demand data concerning HIV tests indicate 11% of HIV positive individuals amongst those individuals who presented the results of their tests. This percentage is lower than the one registered in 2001 (14%), in 2000 (14%) and in 1999 (18%). 33% of these HIV positive individuals were following antiretroviral therapy, a lower percentage than the one registered in 2001 (44%) but higher than in 2000 (22%). 13% clients from inpatient and private detoxification units tested positive for HIV, a percentage lower than in 2001 (17%) and in 2000 (14%). 38% of these individuals were in antiretroviral therapy, a percentage higher than the one registered in 2001 (28%). Concerning public and private therapeutic communities, 16% of the tested clients were HIV positive and 69% of those were in antiretroviral therapy. The percentage of positive tests was slightly inferior to the one verified in the last 3 years (18% in 2001, 17% in 2000 and 18% in 1999) and the percentage of clients in antiretroviral therapy was inferior to the one registered in 2001 (76%), similar to 2000 (69%) and superior to 1999 (55%). Analysing separately public and private units, the percentages of HIV positive cases in different drug users subpopulations that requested treatment in different units, ranged in 2002 from 11% to 21% (in 2001 between 10% and 18% and in 2000 between 8% and 17%), and the percentage of clients who tested positive for HIV and were in antiretroviral therapy, ranged from 31% to 69% (in 2001 between 27% and 83% and in 2000 between 22% and 80%). These data confirms the trend already verified in previous years concerning the levelling off and tendency to decrease of the positive HIV rates between drug users subpopulations that seek access to treatment 12. The implementation of harm reduction measures aiming at reducing intravenous drug use visible in administration route data from the TDI - or at promoting safer conditions for intravenous drug use visible, amongst other data, in the number of exchanged syringes in the National Syringe Exchange Programme Say no to a second hand syringe may be instrumental in this trend. Concerning Hepatitis and Tuberculosis, data available refers to the tests made in drug users subpopulations that demand treatment in the public and certified treatment structures. The coverage of these cases 13, as for HIV, is different depending on the region, type of unit and tested disease. In 2002, data on Hepatitis B and C show that 8% of the tested clients in their first outpatient treatment episode were positive for Hepatitis B (AgHBS+) and 64% for Hepatitis C (HCV+). In 2001, these percentages were respectively 5% and 45%, and in 2000, 10% and 49%. In detoxification units the global 14 percentage for public and certified units were 10% for Hepatitis B 12 Considering results per type of service but not differentiating between public and accredited units. 13 In 2002, results for Hepat itis B were presented by 29% of the clients in outpatient first treatment episodes, 73% of the clients of detoxification units (100% of the clients in public DUs and 43% of the clients in certified DUs) and 95% of the clients in Therapeutic Communities (100% of the clients of public TCs and 95% of the clients in certified TCs). Results for Hepatitis C were presented by 29% of the clients in outpatient first treatment episodes, 80% of the clients of detoxification units (100% of the clients in public DUs and 58% of the clients in certified DUs) and 95% of the clients in Therapeutic Communities (100% of the clients of public TCs and 95% of the clients in certified TCs). Concerning Tuberculosis, test results were presented by 15% of the clients in outpatient first treatment episodes, 65% of the clients of detoxification units (79% of the clients in public DUs and 49% of the clients in certified DUs) and 97% of the clients in Therapeutic Communities (100% of the clients of public TCs and 97% of the clients in certified TCs). A problem that came up with TB tests in one public Detoxification Unit lead to the impossibility of considering the 310 tested cases in that unit. This underestimates the real coverage in these units but allows for a more reliable context of the available positive results. The coverage percentages for TB tests are usually inferior to the other tested diseases due to issues pertaining to the clinical diagnosis and to the places were tests are made (at the Centres for Pulmonary Diagnosis), which implies the displacement of the clients to those Centres. 14 Considering results per type of service but not differentiating between public and accredited units. IDT 17

18 Epidemiological Situation and 59% for Hepatitis C. In public and certified therapeutic communities 10% were positive for Hepatitis B and 51% for Hepatitis C. Hepatitis B percentages were higher than those reported in 2001 (respectively 7% and 9% in detoxification units and in therapeutic communities) and lower than those reported in 2000 (respectively 25% and 14% in detoxification units and in therapeutic communities). Concerning hepatitis C, percentages were similar to 2001 (respectively 58% and 51% in detoxification units and in therapeutic communities) and lower than in 2000 (69% and 49%). A separate analysis of public and private units, increases the range of these percentages, in 2002 between 2% and 28% in the case of Hepatitis B (in 2001 between 3% and 13% and in 2000 between 4% and 53%), and, in the case of Hepatitis C between 39% and 64% (in 2001 between 44% and 71% and in 2000 between 43% and 79%. Concerning Tuberculosis, 4% of the new outpatient clients who presented results for their tests were positive and all were following treatment. These percentage was superior to the one registered in the last two years (2%). In detoxification units the global percentage of positive cases was 1% for Tuberculosis. Identical percentage was found among clients of public and private therapeutic communities. In detoxification units the percentage was lower than the one registered in 2001 (13%) and similar to 2000 (1%). In therapeutic communities the percentage was once more similar to 2001 and 2000 (1%). Lastly it is necessary to insist on the need for taking into account the specific context for the positive values of each disease, namely due to the differences in coverage and in the preferential criteria for client admission in the different types of units which, in some cases are related to the precarious health conditions of the patients Other drug-related morbidity Please see chapter 16. IDT 18

19 Epidemiological Situation 4. Social and Legal Correlates and Consequences 4.1. Social problems Main drug related social problems reported continue to be low educational status, unstable labour situation and legal consequences. Specifically on unemployment, the highest national rate for the general population in 2002 was 6.2% (the highest national rate since 1998), a much lower figure than the lowest figure reported for unemployed individuals with drug problems (28% of the individuals involved in administrative sanction processes were unemployed) Drug offences and drug-related crime 15 In 2002, data from the Criminal Police identified presumed offenders 16, presumedtraffickers and as presumed trafficker-users. Despite the presumed trafficker-users group being predominant in relation to the presumed traffickers groups, a situation that is verified since 1998, presumed trafficker-users have been loosing relative importance in the last 3 years in comparison to presumed traffickers. In comparison to 2001, an increase was verified in the number of presumed traffickers (+14%) and the number of presumed trafficker-users suffered a small decrease (-6%). Similarly to 2001, the districts, which reported a higher number of presumed offenders, were the most populated ones: Lisbon (39%) and Porto (18%). Setúbal (8%), Faro (6%), Braga (5%) and Aveiro (4%) also registered an important number of presumed offenders. The rates of presumed offenders per inhabitants shows that, besides Lisbon, Faro, Porto and Setúbal, already mentioned in previous years data, the Autonomous Regions of Madeira and the Azores, also appear in the group of regions with higher rates of presumed offenders per inhabitants. Concerning the substances identified in the moment of the intervention of the law enforcement agencies, 62% of these individuals possessed only one drug, a value lower slightly than the one verified in Among these cases, and for the second consecutive year, hashish (33%) predominated in comparison to heroin (17%), the main substance involved in these situations until % of the cases concerned cocaine only, a percentage which doubled in comparison to This is also related to the current composition of this group (the absence of users had, until July 2001 an important weight and very small percentages of situations which involved cocaine only). As in previous years, in the situations where more than one drug was involved (38%), the main combination was heroin and cocaine (13% of the presumed offenders and 35% of those who possessed more than one drug). 5% of the presumed offenders (14% of the presumed offenders with polydrugs) possessed heroin, cocaine and cannabis, 4% of the presumed offenders (10% of the presumed offenders with polydrugs) possessed heroin and cannabis, and 3% of the presumed offenders (9% of the presumed offenders with polydrugs) possessed ecstasy and cannabis. On other hand, the growing importance, of less vulgar combinations in this circuit since 2000, point towards a diversification of these type of substances in the national market. In short, since 1996, a decrease in the relative weight of the cases, which are related to heroin, only is verified. This is due to the increase of both the relative weight of situations involving polydrugs and of situations involving cannabis only. This trend, as well as the increase in the percentage of cases related to liamba and to ecstasy, has been verified during the last 3 years but in 2002, the percentage of 15 Complete text, tables and graphs on this indicator are available in print [ODT2003] and at 16 The percentage data presented are calculated on the cases for which information exists on the considered variables. IDT 19

20 Epidemiological Situation cocaine related cases doubled, probably is related with the decriminalisation of drug use and consequent is probably more related with the decriminalisation of drug use and consequent lack of users in this circuits. 85% of the presumed offenders were of the male gender, the lowest percentage verified since 1995, which may be related to the increase of the relative weight of traffickers within the total of presumed offenders, as this was always the group, which reported a lowest percentage of the male gender. 73% were aged between 20 and 39, mainly (26%) and (21%). Curiously, these presumed offenders are younger than in 2001, contrarily to what had been verified in the last two years (a slight ageing had been reported related to the higher relative weight of the traffickers group which had always reported older individuals than the other groups). Concerning nationality, 85% were Portuguese, a percentage that is also decreasing since 2000, also related to the increase in the relative weight of the traffickers among these presumed offenders. Among those who are not Portuguese nationals, most of them come from the Portuguese speaking countries (10%), mainly from Cape Verde, a situation already verified in previous years. Concerning the administrative sanctions for drug use 17, in 2002, the Commissions for the Dissuasion of Drug Use instated processes in mainland Portugal, most of which in the districts of Porto and Lisbon, followed by Setúbal, Braga and Faro. However, when taken into account the number of residents in each district, Beja, Faro, Portalegre and Castelo Branco presented the higher occurrence rates. Similarly to 2001, most cases (44%) were referred by the Public Security Police (PSP) but, contrary to 2001, Courts referred slightly more cases than the Republican Guard (GNR). On the 31 st of March 2003, 52% of the instated processed in 2002 were suspended, 22% pending and 26% had been filled. Of the rulings made, 91% were suspending rulings, 3% found the presumed offender innocent and 6% were punitive rulings, a twofold increase of punitive rulings in comparison to As in 2001, the provisional suspension of the process in the case of users who were not considered addicted, where the majority in the total percentage of rulings made (64%). On the other hand, the percentage of suspension rulings in the case of drug users who accepted to undergo treatment decreased in comparison to Concerning punitive rulings, the weight of pecuniary sanctions doubled in comparison to 2001 although non-pecuniary sanctions remain the majority, particularly the mandatory periodical presentation to an institution chosen by the CDT. As in 2001, the vast majority of these cases involved only one drug (91%), mainly hashish (57%) and heroin (24%). The weight of processes involving hashish only increased in comparison to those involving only heroin. For processes involving several drugs, the association heroin-cocaine was again predominant, followed by the association heroin-cannabis. The association ecstasycannabis originated more processes than the combination cocaine-cannabis, contrary to what had happened in 2001 in this setting but similar to what had happened in 2001 concerning presumed users before the decriminalisation law was enforced. Although there is a district diversity in terms of use patterns, the cases related to hashish were predominant in almost all Commissions, with the exception of Beja and Leiria, where cases related to heroin only were predominant. 17 Law n. º 30/2000, of 29 th of November, ruled by the Decree-Law n. º 130-A/2001, of 23 rd of April, and, by the Regulat ion n. º 604//2001, of 12 th of June. 18 Percentage data presented are calculated for the cases which have information on the considered variables. 19 Each process corresponds to one occurrence and to one individual IDT 20

21 Epidemiological Situation 5% of the individuals involved in the 2002 instated processes (absolution ruling excluded) relapsed in The highest concentration of such cases was verified in the coast districts. Concerning their socio-demographic profile 20, the situation was similar to the one verified in They were mostly from the male gender, aged with a distribution by age group slightly younger than in They were mainly Portuguese, single and with no children. 38% had frequented grades 7 to 9 and 25% had completed compulsory school 28% were unemployed and, among the 48% who were employed, most were in extraction industries and civil construction, other industries, artisans and non-qualified labour. Individuals who relapsed were older, reported a lower educational status and a higher level of unemployment. Concerning court data 21, in 2002, processes were closed which represents a decrease in comparison to previous years and a reflection of the drug use decriminalisation law 22. These processes involved individuals, 72% of whom were convicted, 16% found innocent and 11% saw their processes filled. The vast majority of these individuals were initially accused of traffic (93%). Of the convicted individuals 23, 92% were convicted for traffic, 7% for traffic-use and 1% for use 24. In the last three years, weren t registered significant oscillations in the number of convictions by traffic and traffic-use. In 2002, the districts of Faro, Lisbon and Bragança registered the higher rates of conviction per resident, followed by Porto and Setúbal. This conviction involved 25 effective prison (49%) and suspended prison (44%), which reflects, among other factors, the fact that the majority of convictions were traffic-related. The majority of these convictions again involved the possession of only one drug (70%), heroin being the main substance reported (41%), followed by hashish (20%) and cocaine (7%). When polydrugs are considered, the association heroin-cocaine was predominant followed by heroincannabis. Although heroin remains the main substance involved, it scaled down since 1998, and mainly since 2000, in benefit of hashish and polydrugs. Data of the last two years also indicate the trend towards a slight percentage increase of cases concerning cocaine only. Such trend is consistent to the one verified in the case of presumed offenders. Similarly to previous years, most of these convicted individuals 26 are of the male gender (87%) and aged (73%). The ageing of this population had already been verified in previous years but, since 2001, a small percentage increase is also reported for the under 20-age group. They are mostly of Portuguese nationality, single and with no children and reported again low educational status. 38% were unemployed at the time of their conviction, changing the last two-year trend for the percentage decrease of this situation. As in previous years, most of the employed individuals worked in extracting industries and civil construction, with a high number of cases reporting nonqualified work in several activity sectors. In comparison to trafficker-users, traffickers reported a lower percentage of situations involving the possession of heroin only but higher percentages of situations involving hashish, cocaine and polydrugs. Traffickers also reported, again, a higher weight of female and of foreign individuals 20 Individuals who relapsed (who originated the instatement of more than one process in any given year) were counted only once. 21 Database at the Statistical Unit/ National Monitoring Centre / IDT. 22 According to methodological criteria of previous years, 2002 data may be updated in decisions, which reach the IDT between 31/03/03 and 31/03/04, will be considered. 23 Percentage data presented are calculated for the cases, which have information on the considered variables. 24 Drug planting (article 40.º of Decree-Law 15/93, of the 22nd of January) continues to be considered a crime. 25 Sanctions may involve more than one crime. 26 Drug use convictions (see footnote 24) concern only 40 individuals and are thus not included in the detailed data analysis. IDT 21

22 Epidemiological Situation than trafficker-users and an age structure with more weight of both older and younger individuals. They also present higher percentages of married individuals and of individuals with children under care. Contrary to 2001, educational status in this group was higher than in the group of traffickerusers but, unlike data from 2001, the percentage of unemployed individuals was lower. In terms of predominant professional groups their situation is very similar to the one reported by traffickerusers. Similarly to previous years this group reported higher percentages of effective prison and aggravated sentences Social and economic costs of drug consumption No data available IDT 22

23 Epidemiological Situation 5. Drug Markets Availability and supply In 2002, the trend of effectiveness of interventions in this area, visible since 2000, was consolidated with a decrease in the total number of seizures, but an increase in the number of significant seizures and the quantity seized of some drugs. For the first time since 1990, the number of hashish seizures surpassed that of heroin. The indicators suggest a decrease on the circulation of heroin in the national market, and in other hand a higher circulation of other drugs, with special relevance to cannabis, liamba and ecstasy. Some changes were verified in the main traffic routes, especially in the case of cocaine, and a general decrease was verified in the prices and a general increase in purity of drugs at street level Seizures Contrarily of what had been happening since 1990, in 2002, cannabis, and not heroin, was the substance involved in more seizures 28, followed by heroin and cocaine. Since 2000 heroin seizures have been decreasing and in 2002 not only heroin but also the number of cocaine and cannabis seizures (respectively 45%, 12% and 14%). In 2002 the number of liamba seizures increased (+50%). The number of ecstasy seizures continued to increase (+16%), despite being inferior to the increase between 2000 and 2001 (+102%). The visible trends expressed in the number of seizures are not always equal to the quantity of drug seized, this is the case of cannabis in In comparison to 2001, in 2002 decreases of the seized quantity of heroin (-70%) and cocaine (-44%) were registered, on the other hand, the quantity of cannabis (+78%), liamba (+54%) and ecstasy (+76%) increased. It should also be considered that, in 2001, the number of cocaine, liamba and ecstasy seizures was the highest in the last decade. In 2002, the seized quantities of liamba and ecstasy represented the highest values of the last decade, and cocaine occupied the third place in the decade ranking. Concerning other drugs and/or drug availability in the national market, in 2000 special attention should be given to seizures of LSD stamps, hallucinogenic mushrooms, cannabis pollen and powder ecstasy, not only for the quantity seized, but specially for the fact that the first record of seizures concerning these substances are recent (the first reference of LSD stamps was in 2000 and in the other cases the first seizures were reported in 2001). In 2002, a first reference to ecstasy crystals was recorded. Seizures involving more significant quantities 29, correspond, in 2002, to 8% of the total number of heroin, 20% of cocaine, 4% of cannabis, 7% of liamba and 30% of ecstasy seizures. In the past three years, these seizures involving significant quantities have been increasing its relative weight in the total number of seizures, which reflects new legal diplomas but also, probably, the reinforcement supply control interventions in the and/or higher availability of drugs. Regarding main origins countries of the seized drugs in Portugal, The Netherlands and Spain are the main origin of the heroin seized in 2002 (respectively 33% and 10%), both being traditional 27 Complete text, tables and graphs on this indicator are available in print [ODT2003] and at 28 A seizure involving more than one drug is included in the number of seizures for each of the involved substances. 29 For heroin and cocaine quantities above 100g are considered and for cannabis quantities above 1000g are considered, according to the criteria used by the UN. For ecstasy, according to the criterion used by the National Criminal Police, seizures above 50 pills were considered significant. Accordingly, for the purpose of data analysis, only the seizures expressed in that unit were considered. IDT 23

24 Epidemiological Situation countries referred in these routes in previous years. Contrarily of what occurred in the past two years, no heroin seizures were registered coming from Turkey, but the origin of 56% of seized heroin remains unknown. In the case of cocaine, only 4% was from unknown origin, and Brazil (54%) and Ecuador (33%) are the main countries of origin for this drug. Despite having been referred during the last decade, in 2002, less cocaine came from Ecuador but much more came from Brazil than in previous years. Similarly to previous years, Spain (12%) and Morocco (1%) were the main origin for the seized hashish but, in 2002, in inverted ranking positions which can also be caused by the high percentage (86%) of hashish of unknown origin. Concerning liamba seized in Portugal in 2002, again Angola (93%) appeared as the main origin, and 6% was of unknown origin. In the case of the seized ecstasy, again The Netherlands (70%) appeared as main origin, followed by Belgium (4%) and Spain (1%). 25% were of unknown origin. In 2002, most of the seized drugs were destined to the national market. The totality of the seized quantities of liamba and ecstasy, with information concerning its route, had Portugal as destination. Cocaine remains the substance with a higher percentage destined to the foreign market. At regional level, the district of Lisbon registered the highest quantity of seized heroin (47%), followed by the districts of Porto (21%), Braga (8%) and Aveiro (4%). Concerning cocaine, the district of Porto (79%), followed by Lisbon (14%), Faro (3%), Azores (3%) and Setúbal (1%), were the regions with more quantities seized. Similarly to previous years, Faro was the district with the highest quantity of seized hashish (82%), followed by Lisbon (6%), Setúbal (5%) and Porto (4%). Lisbon, similarly to previous years, was the district with the highest quantities of seized liamba (96%), followed by Porto (2%) and Bragança (1%). The districts with higher quantities of seized ecstasy were the districts of Faro (39%), Leiria (23%), Lisbon (19%) and Porto (10%). In 2002, the districts of Aveiro, Lisbon and Coimbra, presented the highest quantities of hallucinogenic mushrooms seized, Faro and Setúbal the highest quantities of LSD stamps, and in Lisbon powder ecstasy. The cannabis pollen was seized exclusively in the district of Porto Price, purity Data on average prices of seized drugs at street level point towards a general decrease in the price of drugs, particularly for cannabis and cocaine (see Standard Table 16). In 2002, for the first time since , the average price of cocaine at street level presented a lower value than heroin. Despite this, decrease in the prices may be due to changes in the data collection selection of this indicator in comparison to previous years 31 but may be also related with a higher circulation of these substances in the market, particularly the case of cannabis and cocaine the substances that registered the higher prices decrease since data on other indicators reveal an increase in the use of cannabis and cocaine and the seizures made by the law forces in this context indicates cannabis as the substance involved in more seizures in 2002 (for the first time since 1990). Concerning purity, data from the Forensic Laboratory of the Criminal Police (see Standard Table 14) show relevant increases in the purity of all substances except for heroin. Except for cannabis, all samples are street level samples (seizures weighting less than 1 gramme). 30 First time data on this indicator became available. 31 Information concerning drug use ceased to be available in the Criminal Information System when the new drug use legal framework (Law 30/2000, of the 29th of November) was implemented. Thus, in 2002, drugs average prices at street level are collected only through presumed traffickers and presumed trafficker-users. IDT 24

25 Epidemiological Situation 6. Trends per Drug Cannabis Data from the 2001 national surveys referred last year 32, show that hashish is the preferred illicit drug used both in the general population between 15 and 64 years of age and in the 7 th to 9 th grade pupils, and presents much higher prevalence s than other illicit drugs. The trend verified in previous years concerning the growing visibility of cannabis (and namely hashish) in several indicators was confirmed in Concerning drug use-related health consequences, namely treatment demand and drug-related deaths, the use of cannabis emerges with higher visibility than in previous years. In effect, 2002 data concerning first treatment demand clients in the public treatment network, show that cannabis was the second most referred substance (36%) regarding illicit drug use in the last 30 days prior to the treatment episode, for the first time with a higher percentage than cocaine (in 2000, cocaine was referred in this context by 33% of the respondents and cannabis by 29% and in 2001 both were referred by 29% of the respondents). Concerning drug-related deaths 33, cannabis was present in 13% of the occurrences. Besides the increase in the relative importance of cannabis products in the framework of these occurrences (5% in 1999, 6% in 2000, 11% in 2001 and 13% in 2002), in 2002 and contrary to previous years, in the majority of cases, cannabis was not associated to other drugs (8%). Concerning drug use related legal consequences, cannabis continues to emerge with growing importance and as main drug. In the framework of administrative sanctions for drug use, 52% of the processes instated in 2001 were related to cannabis (47% for hashish only and 5% for liamba only). In 2002, 60% of the processes instated were cannabis-related (57% for hashish only and 3% for liamba only). In effect, the growing visibility of this type of drugs in these circuits had already been shown in the former legal framework with data from presumed offenders for drug use (cannabis, not associated to other drugs, represented 45% of the reports in 2001, 37% in 2000 and 33% in 1999), court data for convictions for drug use (cannabis, not associated to other drugs, represented 35% of convictions for drug use in 2001, 34% in 2000 and 22% in 1999). On the other hand, if associations to other drugs are considered, cannabis gains even more visibility, not only due to its traditional association to heroin and cocaine but also due to the appearance, in the last few years, of a frequent association to more recent substances, namely ecstasy. Such situation had also been shown in the former legal framework (data from presumed offenders for drug use and court data on convictions for drug use) and the trend remains in the current legal framework as data from the administrative sanctions show (the association of cannabis and ecstasy gained more relative importance in 2002 than in 2001, involving in 2002 a higher percentage of processes than the traditional association of cocaine and cannabis). In 2002, the regional distribution of these processes showed the predominance of cannabis related cases in almost every district (except for Beja and Leiria), with higher relevance in percentage terms in the districts of Viana do Castelo, Portalegre, Faro, Lisbon, Setúbal, Santarém and Porto (percentages higher than 60% of the total number of instated processes in each district), and in absolute terms in the districts of Lisbon, Porto, Setúbal, Faro and Braga. 32 See, amongst others, Relatório Anual 2001, A Situação do País em Matéria de Drogas e Toxicodependências, Vol.I Informação Estatística, Lisbon, IPDT, 2002, which also includes complete bibliographic references. 33 Cases with positive toxicological tests, at the National Forensic Institute (INML). IDT 25

26 Epidemiological Situation ecstasy Amphetamines, ecstasy, LSD, other/new Data from the 2001 national surveys both in the general population between 15 and 64 years of age and in the 7 th to 9 th grade pupils, already reported ecstasy use prevalence s similar to heroin and cocaine prevalence s, or even higher in some situations, namely in recent drug use patterns. Among the prison population, ecstasy use still emerges with lower relevance than more traditional substances. Ecstasy use still plays a relatively secondary role concerning the drug use-related health consequences, in comparison to heroin, cannabis and cocaine. Concerning drug treatment demand only 2% of the clients in first treatment episodes in 2002, in the public treatment network, referred ecstasy use in the last 30 days prior to the treatment episode. Regarding drug related deaths in 2002; ecstasy had almost no expression with only one case detected with the presence of MDMA, in association with opiates. MDMA appeared for the first time in four cases in em 2001, all associated to alcohol. Concerning drug use related legal consequences, ecstasy still appears with residual values, gaining more visibility when associated to other drugs, namely cannabis. In 2002, similarly to what happened in 2001, only 1% of the drug use administrative sanction processes involved ecstasy only. This percentage is slightly more expressive when ecstasy is associated to other drugs, particularly cannabis, and an association, which contributed to the instatement of more processes than the association with cocaine, contrarily to what happened in 2001 both in the area of the administrative sanctions and in the reports concerning presumed offenders for drug use. The weight of this substance in the administrative sanctions processes is very similar to what was occurring under the former legal framework in law enforcement reports concerning presumed offenders for drug use and court data on convictions for drug use (ecstasy becomes visible in these areas mostly in 2001, although always with percentages bellow 2%, and more weight when associated to other drugs, mostly cannabis, then isolated. Heroin / opiates Data from the 2001 national surveys placed heroin well bellow cannabis concerning use prevalence. Heroin lifetime prevalence is also inferior to cocaine and identical to ecstasy in the Portuguese population aged 15-64, and inferior to cocaine and ecstasy in the 7 th to 9 th grade pupils. Nevertheless, it remains the main drug involved in problematic drug use in Portugal and the second most used illicit drug in the national prison population. In 2002, the trend remains, for several indicators, on the decrease of the importance of heroin in comparison to other substances, namely hashish. Nevertheless, it remains the main drug involved in data from drug use-related health consequences, concerning treatment demand, drug related deaths and intravenous drug use (and, consequently the transmission of infectious diseases). Similarly to former years, heroin use is the most referred one among the drug users sub-populations in the outpatient public treatment network concerning 30 days prior to the first treatment episode (67% in 2002, 78% in 2001, 75% in 2000); in public detoxification units concerning the substance which lead to admission (80% in 2002 and 87% in 2001); in Day Centres concerning the main drug. On the other hand, concerning other opiate use, in 2002, around half of the total number of active clients in the public treatment network, were involved in opiate substitution programmes. This percentage has been increasing in recent years (40% in 2001, 36% in 2000 and 22% in 1999). Of the clients involved in opiate substitution programmes on the 31st of December 2002, 84% were in methadone programmes IDT 26

27 Epidemiological Situation and 16% in buprenorphine programmes. 8% (11% in 2001) of the clients in public detoxification units referred methadone use as the motive for admission, which makes it the second more referred substance at the same level of cocaine. Concerning drug related deaths, opiates were again the main substance involved 34 (69%), isolated (30%) or in association with other substances (39%), mainly cocaine and/or alcohol (35%). Nevertheless, the presence of opiates has been decreasing in relation to the other substances detected in drug related deaths (69% in 2002, 81% in 2001, 88% in 2000), and it should be referred that the percentage decrease verified in 2002 was particularly important at the level of opiates associated with other substances. Methadone related deaths represented 4% of the verified occurrences in 2002, mainly associated with other drugs (3%). In 2001 they represented 5% and in % of drug related deaths. Concerning drug use related legal consequences, the decreasing trend continues regarding its relative importance against other drugs, namely hashish, as it emerges as the second most referred substance in drug use administrative sanction processes. In 2002, 24% of the instated processes involved only heroin, a lower percentage than the one verified in 2001 (33%). The decreased visibility of heroin in these areas was already visible in the former legal framework as showed by reports of presumed offenders for drug use (heroin isolated from other substances was present in 28% of the reports in 2001, 32% in 2000 and 39% in 1999), and by court data concerning convictions for drug use (heroin, isolated from other substances, lead to 43% of convictions for drug use in 2001, 44% in 2000 and 56% in 1999). In 2002, the regional distribution of administrative sanctions for drug use showed the predominance of heroin cases only in the districts of Beja and Leiria. Nevertheless, in other districts the presence of this substance was relevant both in percentage terms, as in Vila Real, Aveiro, Bragança and Castelo Branco (percentages between 38% and 40% of the total number of processes instated in each districts), and in absolute terms, as in Lisbon, Braga, Aveiro and Porto. Cocaine / crack Data from the 2001 national surveys both in the general population between 15 and 64 years of age, in 7 th to 9 th grade pupils, and in the prison population showed cocaine use prevalence s identical and in some situations superior to heroin use prevalence s. Concerning problematic drug use, this substance was often reported associated to heroin. In 2002, cocaine gained more visibility in drug use related health consequence indicators, namely in drug related deaths. In the context of treatment demand, data from clients in first treatment episodes in the public treatment network show that 32% of them reported cocaine use in the last 30 days prior to the treatment episode (27% in 2001 and 33% in 2000). 8% of the clients admitted to inpatient public detoxification units referred cocaine use as the motive for admission (20% in 2001), which made it, together with methadone, the second most referred substance. Regarding drug related deaths, in 2002, 44% of the occurrences involved cocaine, isolated (13%) or associated to other substances (31%), namely opiates and/or alcohol (29%). It remains the second most frequently detected substance in this context and, the increase of it relative importance in 2002 (38% in 1999, 34% in 2000, 34% in 2001 and 44% in 2002), was mainly due to cases, which involved cocaine without association to other substances. Concerning drug use legal consequences, cocaine still present s low visibility especially when considered isolated, as shown by drug use administrative sanction data. The percentage of processes involving the possession of cocaine only (6%) was slightly superior to the one verified in 34 Includes heroin, morphine and codeine. IDT 27

28 Epidemiological Situation 2001 (5%). It continues to rank third in this type of processes, although much less important than cannabis and heroin. This secondary role of cocaine in this area was also verified in the former legal framework when considered isolated from other substances, both in data from reports of presumed offenders for drug use (cocaine, not associated to other drugs, was responsible for 2% of the reports concerning presumed drug users in 2001, 3% in 2000 and 5% in 1999), and in court data concerning convictions for drug use (cocaine, not associated to other drugs, lead to 7% of the convictions for use in 2001, 4% in 2000 and 4% in 1999). Considering this low visibility it is no surprise that in administrative sanctions processes, no district reported predominantly cocaine only related processes. Nevertheless, some districts presented higher percentages of cocaine related processes, such as Portalegre, Beja and Braga (percentages between 8% and 10% of the total number of processes instated in each district), and, in absolute figures, Lisbon, Porto, Braga and Beja. Multiple use Concerning polydrug use, the increases verified since 2000 in some indicators were not verified in 2002, as shown by data concerning drug use health and legal consequences. In effect, the percentage of situations involving more than one substance in 2002 concerning drug related deaths, decreased in comparison to 2001 and 2000 (57% in 2000, 68% in 2001 and 47% in 2002). This was due mainly to the decrease in the number of situations involving both licit and illicit substances and may reflect harm reduction interventions implemented in this area. On the other hand, concerning drug use administrative sanctions, the percentage of cases concerning polydrugs verified in 2001 and 2002 was stable (9%). The increasing trend of the visibility of some combinations of more recent substances was also consolidated in detriment of other combinations usually with more visibility: in 2002, the association of ecstasy and cannabis lead to the instatement of more processes than the association of cocaine and cannabis, contrary to what had happened in 2001 and similarly to what had happened in reports concerning presumed offenders for drug use also in In 2002, the districts which reported higher percentages of polydrug use related instated processes were Beja and Santarém, followed by Viana do Castelo, Porto, Coimbra, Lisbon and Setúbal, and in absolute terms Lisbon and Porto. Also concerning law enforcement reports on presumed offenders and court data on convictions for traffic and traffic-use, polydrug related occurrences did not registered relevant percentage changes in comparison to Nevertheless, and concerning traffickers, an increasing trend concerning polydrugs continues to be visible. Concerning presumed offenders, there was also a higher visibility of associations of more recent substances (namely ecstasy with cannabis), in comparison to other associations traditionally more visible in these circuits. IDT 28

29 Epidemiological Situation 7. Discussion 7.1. Consistency between indicators The majority of the indicators point towards consistent results at the level of the characterisation of the Portuguese situation in 2002 as well as at the level of the main trends and are coherent with the previous year data. The emergency of a more diversified drug use, expressed, amongst other indicators, in a higher visibility of cannabis, cocaine and ecstasy use, as well as, with less visibility, amphetamine and hallucinogenic use and new associations of drugs with a significant variety of substances involved, is visible namely in: Epidemiological 2001 survey data (general population, school setting and prison setting); Market indicators (seizures, quantities and prices); Legal consequences indicators, namely the substances possessed by presumed offenders for drug use; Health consequences indicators, namely the substances detected in drug related deaths. The fact that heroin is still the main drug involved in problematic drug use is visible in: 2001 Prevalence estimate data and use patterns of problematic use in Portugal; Health consequences indicators, namely treatment demand and drug related deaths. The increase and geographical dissemination of drug use in Portugal is visible in: Epidemiological 2001 school survey data which indicate an increase in drug use for students in grades 7 to 9, as well as a geographic dispersion of drug use; Legal consequences indicators, which indicate a higher circulation of users in these circuits. Intravenous drug use is still frequent, at least in some sub-populations of users, as pointed out by some indicators, namely: 2001 Prevalence estimate data and use patterns of problematic use in Portugal; Data on the use of drugs in prison Treatment demand indicators. Nevertheless, some indicators suggest possible changes in risk behaviours associated to drug use, namely: The decrease of the percentage of drug users with AIDS in the total of AIDS diagnosed cases in the past years; The levelling off of the percentage of positive cases in several infectious diseases among sub-populations of drug users in treatment; The decrease of drug related deaths. IDT 29

30 Epidemiological Situation 7.2. Methodological limitations and data quality Although significant progress has been made on the harmonisation of indicators in general and on the EMCDDA s key indicators in particular, some methodological limitations remain concerning treatment demand, drug related deaths and infectious diseases. As a result from the delay in the implementation of the National Treatment Information System at national level, treatment and infectious diseases data still has limitations at the level of data breakdown per type of substance, administration route and age group. General analysis on the situation and trend is possible and given in the respective chapter but the filling in of the TDI and other Standard Tables is still very limited to national aggregated data. Other sources of information, specifically for infectious diseases are under consideration and/or development but were not possible to use for the reporting period. On drug related deaths, a national agreement on the concept of drug related deaths and rearrangement of data collection procedures and information flows was finalised in Implementation was due to occur in 2002 but the new political framework and budget restriction rules have been impairing the process. Cases reported are thus still including all drug related deaths (acute and indirect). With the implementation, on the 1 st of July 2001, of the new legal framework on the decriminalisation of drug use, data in this area started to be collected in a central register kept by the IDT and kept apart from the Criminal Police s central register. The necessary procedures to ensure harmonisation of collected data within this new circuit were ensured to allow data comparability. In general, a strong consistency was verified concerning drug users data between both registers. Differences, however, were verified at the level of users age groups, which are probably related to the spirit of the new Law (to reach younger individuals in a prevention perspective), and some geographical differences in the distribution of drug use processes, related to different definitions of the concept place (in the Criminal Police s register place is the place were the infraction occurred and in the IDT s register place is the place of residence of the individual). These different definitions respond to specific needs of the criminal circuit, in the first case, and of the CDTs circuit, in the second case. Since these differences have been identified and their impact assessed for the analysis of 2001 data (the period of time where possible methodological limitations would have a higher impact due to the changes in the middle of the year), the other eventual methodological limitations that persists concern the concept of traffickeruser, which, from now on will be recorded in the Criminal Police register as trafficker and in the IPDT register as user, thus giving the perception of individual double counting and the collection of information on street level drugs price, which may be more difficult to assess. Despite the above referred limitation, data quality and consistency has been improving over the years due to a major effort of the National Information System on Drugs and Drug Addiction and all its national partners in developing standardised protocols for data collection. IDT 30

31 Demand Reduction Interventions Part III Demand Reduction Interventions IDT 31

32 Demand Reduction Interventions 8. Strategies in Demand Reduction at National Level Major strategies and activities Major strategies in the area of demand reduction continue to be developed under the guidelines of the National Action Plan Horizonte 2004 (see National Reports from previous years) and, specifically, the political guidelines set by the new government in 2002 (see last year National Report). Concerning specific activities at prevention level, the diagnostic on prevention activities prior to the implementation of Horizonte 2004 raised concerns on negative aspects concerning low focalisation (predominantly unspecific interventions and few adequate prevention materials), low intentionality (low training level of the professionals working in the area), low pro-activity and evaluation (low level of research and lack of evaluation procedures), low continuity (frequent ad hoc interventions) and low coordination and participation (lack of coordination concerning the implemented activities). The National Strategy called for a stronger coordination effort particularly between the Administration (central and local) and the civil society, which lead to the Prevention Network still under implementation, mainly through Municipal Prevention Plans (see last year National Report). The major effort concerning prevention in the school setting concerned the enlargement of the Health Promotion Schools. In the area of harm reduction, after the adoption of the Harm Reduction Legal Framework (Decree- Law N. º 183/2001, of 21 of June) the effort has focused in the adaptation of the already existent structures to the new legal configuration. Under the new IDT a specific Harm Reduction Unit, in the Treatment Department, was set up to plan, follow-up and evaluate all interventions in this area. The national syringe exchange programme enlarged its network through protocols with NGOs. At the level of treatment, fewer users are requesting treatment (see Part I) but more are following it up and half of the active clients in the public treatment network are not involved in some type of substitution programme. The number of prisons that offer treatment through the cooperation with the public treatment network centres was also enlarged. Social rehabilitation focused mainly in the development of the programme Vida-Emprego and the finalisation of the National Rehabilitation Framework, which ended in 2002 (see last year National Report) Approaches and New Developments New developments in the field of prevention concern mainly the effort to monitor and harmonise data from programmes under implementation in Municipal Prevention Plans and PQPII (National framework for prevention). These two programmes, complement each other in terms of the proximity approach and the target settings/populations, recognising that local specificities exist as well as resources and solutions. The IDT plays a regulation and national coordination role while municipalities and local NGOs have a direct intervention in the field. 35 Complete text, tables and graphs on this area are available in print [IDT2003] and at IDT 32

33 Demand Reduction Interventions The recent area of drug use dissuasion, through the work of the CDTs under the new legal framework concerning drug use, has focused in harmonising procedures in all districts to ensure coherence of the interventions at national level and on reinforcing partnerships at community level. It is also important to refer that, during 2002, one Contact Point (mobile structure) was available to reach Lisbon areas which had not previously been covered and carried out the first experience of proximity intervention to synthetic drugs users with information provision, counselling, condom distribution and alcohol tests, as well as pill testing for identification of MDMA. IDT 33

34 Demand Reduction Interventions 9. Prevention 36 Following the emphasis on prevention, the objectives of the National Action Plan Horizonte 2004 and the widening of the scope of the National Prevention Network (cf National Report), initiatives were developed in a range of approached which included health education and promotion and the early stages of the minimisation of risk factors associated to drug abuse, in projects were implemented throughout the country both through 100 projects integrated in 51 Municipal Prevention Plans (in green in Map 1) and 118 in the Second Prevention Framework (in blue in Map 1). Map 1 - Prevention Projects within the National Prevention Network 2002 Source: Prevention Department/IDT As far as the 51 Municipal Prevention Programmes are concerned (36 in 2001), Map 2, allows to verify the current status concerning the implemented projects which increased from 59 in 2001 to 100 in Complete text, tables and graphs on this area are available in print [IDT2003] and at IDT 34

35 Demand Reduction Interventions Map 2 Municipal Programmes for the Prevention of Drug Abuse 2002 Source: Prevention Department/IDT This strategy represented an important effort in the IDT orientation towards technical support in the different steps of the project methodology: conceptualisation, design, implementation and evaluation both to the local services of the IDT and to the municipalities and non-governmental organisations. It also implied a global investment of ,30 in 2002 distributed in the following way: Table 2 Global Investment Plan in Prevention Programmes 2002 PROGRAM AMOUNT Municipal Plans ,28 Framework for Prevention I/II ,02 Total Amount ,30 Source: Prevention Department/IDT 37 Data presented in chapters 9.1, 9.2 and 9.4; refer to projects being developed in the framework of PQPII. Data from projects integrated in the Municipal Plans is presented in chapter 9.5, as the information system implemented in 2002 did not allow for the collection of the same indicators and IDT 35

36 Demand Reduction Interventions 9.1. School programmes The Ministry of Education remains the responsible agent at central level concerning prevention in the school setting and the promotion of prevention-related contents in the school curricula. In 2002, the CCPES continued to invest in training for the school setting actors, supporting interventions at school level, creating, adapting and promoting the dissemination of specific instruments and enlarging the network of Health Promoting Schools (255 local health centres and 1957 schools in 2001, 265 local health centres and 3407 schools in Concerning this network, the annual priority intervention areas defined, by the schools themselves, for 2002 placed addictive behaviours in third place (18,3%) after safety and hygiene (24,5%) and sex education (23,5%). As far as intervention in the school setting in the framework of PQPII are concerned, the intention was to involve all the educational community towards promoting healthy lifestyles, improving the quality of interpersonal relationships and minimising the risk factors linked to the use/abuse of licit and illicit substances. The interventions are directed to all levels of schooling, since pre-school to university. Graph 1 Interventions in the school setting PQP II, 2002 Instruments/materials development 1 Self-help groups 2 Training 6 Cultural/Educational activities 4 Skills aquisition 7 Ad-hoc leisure/pedagogic activities Sportive activities 5 5 Counselling/Follow up Source: Prevention Department/IDT In a total of 32 implemented activities, the main type of activities were related to the acquisition of individual and social skills, followed by training activities, leisure/pedagogic activities and sports education activities. results as in PQP II. The harmonisation effort will be reflected in 2003 data only. As PQP II projects only begun in October 2002, data in this report refer only to the period October-December IDT 36

37 Demand Reduction Interventions Graph 2 Target Population by Age Group to 5 6 to 9 10 to to to to to 40 over 40 Source: Prevention Department/IDT This set of activities targeted individuals, as reported in Graph 2, where we may verify that the main target groups are between the ages of 6 to 9 and 10 to 12 (over 68,7% of the total involved population). Also significant is the involvement 10% of individuals over 40 which corresponds to a strategic target population school professionals (teachers and/or other school staff) Youth programmes outside school Youth programmes outside school include projects targeting young school dropouts and/or young students with school problems; Specific groups with a common identity and/or problem are included in projects inserted in the prevention programme for youth delinquency (cf 2002 National Report). Concerning the area of school dropout/problems, these projects aim to develop preventive measures on the basis of social integration promotion, vocational orientation, school and preprofessional training. They may be implemented both in the school context and outside school. IDT 37

38 Demand Reduction Interventions Graph 3 Activities developed in situation of school drop out PQP II 2002 Cultural-Educational activities 5 Attendance/Guidance Skills aquisition Ad-hoc leisure/pedagogic activities Counselling/Follow up Source: Prevention Department/IDT 13 activities were implemented in this area, most of them focusing in cultural and educative activities and counselling and follow-up activities. Graph 4 Target population by Age Group to 9 10 to to to to to 40 over 40 Source: Prevention Department/IDT IDT 38

39 Demand Reduction Interventions Activities targeting school dropouts/problems involved 116 individuals. 75% of this population is under 15 (still in mandatory schooling age), which may be explained by groups of young people who live off the streets. Concerning early intervention in specific groups, projects aim to help develop individual and social skills and to make available training in healthy life styles, namely through information/awareness to specific risk situations. 33 activities were implemented, most of which were centred in cultural and educational activities, followed by activities for skills acquisition. In this set of activities, 348 individuals were involved, 65,2% of who were aged 15 or younger, although 23,3% of this population was aged over 19. As for the programmes for the prevention of youth delinquency, their main objectives are also the promotion of healthy life styles and the development of individual and social skills. Graph 5 Activities developed in the framework of Programmes for the prevention of youth delinquency PQP II, 2002 Peer group implementation 1 Cultural and educational activities 7 Conselling/Follow-up 1 Ad hoc leisure and pedagogic activities 4 Sports activities Source: Prevention Department/IDT In this area, the financed projects mainly focus on educational-cultural activities, followed by leisure and pedagogic activities and sportive activities. The different activities involved a total of 161 individuals, mainly in the phase of adolescence. Graph 6 Target Population, to 9 10 to to to to to 40 over 40 Source: Prevention Department/IDT IDT 39

40 Demand Reduction Interventions 9.3. Family and childhood The development of projects in the area of family has as objective increasing and promoting parental skills and to provide updated and useful information in the area of drug abuse. In 2002, a total of 31 activities were implemented and/or developed, with special emphasis on counselling activities which corresponded to 51,6% of all the activities developed. Graph 7 Target population per age group, to 5 6 to 9 10 to to to to to 40 over 40 Source: Prevention Department/IDT Those 31 activities involved a total of 464 individuals, with a strong presence of individuals aged 26 or over 58,4% -, showing relevant interest for this area Other programmes Prevention in recreational setting Prevention initiatives in this area aim at promoting healthy lifestyles through strategic interventions in recreational, leisure and sports settings normally used as leisure time settings. Prevention in recreational night settings is not included in this chapter (please see chapter 10 and Standard Table 21). 58 activities were implemented in this area, with special emphasis on educational and cultural activities 50% of the total. Graph 8 Target population to 5 6 to 9 10 to to to to to 40 over 40 Source: Prevention Department/IDT IDT 40

41 Demand Reduction Interventions The 58 activities involved 844 individuals mainly in mandatory school age 74,3%. For issues concerning data harmonisation and compatibility, it was not yet possible to include, in the presented data concerning the Municipal Prevention Plans (MPP) which we will next present according to the following variables: developed activities, target population, implementation settings and technical staff training per region and monthly frequency. The variable developed activities comprises three categories: Awareness/Information activities, which include more ad hoc activities such as: prevention campaigns, workshops/debates and congresses/seminars; Personal and social development activities, which include more systematic activities such as training, skills development, educational and activities and sportive and leisure activities; Counselling, follow-up and referral activities, which comprise low threshold centres, which results were presented in terms of the number of projects the centre promoted. Graph 9 Awareness/Information activities per region MPPs (2002) Norte Centro Lx e V.Tejo Alentejo Algarve Campanhas Workshops/Debates Congressos/Seminários N.º PMP Source: Prevention Department/IDT In terms of the number of awareness/information activities implemented, we verify an identical proportion of prevention campaigns to the number of MPP in each region. In all regions the most reported activities are workshops/debates and less reported ones are congresses/seminars. IDT 41

42 Demand Reduction Interventions Graph 10 Total number of awareness/information activities per month MPP (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Campanhas de Prevenção Workshops/Debates Congressos/Seminários Source: Prevention Department/IDT Throughout the year the frequency of workshops/debates remains constant, followed by prevention campaigns that, exceptionally in the month of August, increases in comparison with other activities, probably because it is a month of holidays and convenient to the implementation of these type of activities. The awareness/information activities are mainly ad hoc activities with no continuity, but, nevertheless may be instrumental to appeal for participation in a project/activity, to raise attentions towards a specific issue or problem or to disseminate projects or Municipal Plans. Graph 11 Development of individual skills per Region MPP (2002) Norte Centro Lisboa V Tejo Alentejo Algarve Training Educative and cultural activities N.º MPP skills development Sports/leisure activities Source: Prevention Department/IDT Concerning the development of individual and social skills, sport and leisure activities are more prevalent as well as educational/cultural activities in comparison to skills acquisition and training, IDT 42

43 Demand Reduction Interventions nevertheless these are also well represented in all regions and in comparison to the number of MPPs. Graph 12 Total hours of implementation per month - MPPs (2002) Janeiro Março Maio Julho Setembro Novembro Formação Treino Competências Act.Educativas/ Culturais Act.Desport/Tempos Livres Source: Prevention Department/IDT Throughout the year, educational/cultural activities, followed by the sports and leisure activities are the types of activities with higher number of hours in opposition to skills acquisition and training activities. This could be a reflection of the idea that development of leisure time activities leisure time is one of the best strategies to prevent risk and/or use situations and behaviours. Those services have being emphasising the necessity of a preventive intention towards the efficiency of activities in pursuing goals in the area of drug use prevention. The setting up of attendance centres has an important structural value for the function of the MPPs. It is a setting which allows for the assessment and referral of cases, counselling and bridge to other types of services and/or programmes. The important number of these type of structures per region, reveals a baseline which may create synergies with the other types of centres already in place and reinforce the local network of interinstitutional cooperation. IDT 43

44 Demand Reduction Interventions Graph 13 Number of attendance centres per Regions MPPs (2002) Norte Centro Lx e V.Tejo Alentejo Algarve Gabinetes N.º PMP Source: Prevention Department/IDT Graph 14 Activities per type and Regions - MPPs (2002) Norte Centro Lisboa V Tejo Alentejo Algarve Campanhas Workshops/Debates Congressos/Seminários Formação Treino Competências Act.Educativas/ Culturais Act.Desport/Tempos Livres Gabinetes N.º PMP Source: Prevention Department/IDT In the general distribution of the type of activities per Regions, it is shown that activities exist that could be promoted and strengthened as they seem to be structuring activities which work in terms of achieving the desired objectives and target audiences. On the other hand, there are areas which IDT 44

45 Demand Reduction Interventions programmes allow for their own replication through strategic target groups, such as training activities and skills acquisition are areas which will deserve specific attention in a near future. Concerning the characterization of the target population involved, it is important to refer that data does not allow for desaggregation at individual level per activity as data was not collected on an individual basis for each project. In 2003, the new methods of data collection will enable for this type of analysis but for 2002 data on the target population was aggregated in final target population and strategic target population. Final target population is defined as the groups of receivers whom activities try to reach in terms of promoting changes in the framework of the project s goals. Strategic target population is defined as the intermediary group(s) which are approached in order to reach the final population, in the context of the same project. Graph 15 Final target-population by number and age group age per month- MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Até 5 anos 6-10 anos anos anos A partir de 21 anos Source: Prevention Department/IDT The most referred target group is the age group 6-10, followed by and The development of projects per month follow closely the school year. IDT 45

46 Demand Reduction Interventions Graph 16 Final target population per category and month - MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Famílias/Pais Técnicos Outros Source: Prevention Department/IDT In comparison to other categories, the category families/ parents was the main target group of these projects, although the category others presents a higher value during the month of September, which may correspond to the many activities developed with several target groups in the beginning of the school year. Graph 17 Strategic target population by professional categories and quarter - MPPs (2002) Janeiro Março Maio Julho Setembro Novembro Téc. Área Social Téc. Educação Téc. Saúde Aux. Acção Educativa Source: Prevention Department/IDT Concerning the strategic target populations, school staff (teachers and auxiliary staff) are the main categories. IDT 46

47 Demand Reduction Interventions Graph 18 Strategic target population by other categories and month - MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Famílias/Pais Grupo de Pares Membros Associação Agentes Segurança Outras Source: Prevention Department/IDT The involvement of parents/families in MPPs projects is higher than the participation level in the other categories. A low involvement of peers show the need to invest in this population to promote proximity work with specific target groups, such as teenagers and/or youngsters. The settings of the projects are presented in two categories: school setting and community environment. IDT 47

48 Demand Reduction Interventions Graph 19 Number of projects in the school setting MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro ATL's Pré-escolar 1º Ciclo 2º Ciclo 3º Ciclo Ensino Secundário Ensino Superior Source: Prevention Department/IDT In the school setting, there is a higher number of promoting entities that develop projects from the 1 st to the 9 th grade (compulsory school) which is consistent with the results on the final target population involved. On the other hand, the university setting is the least chosen context to implement these types of projects. Graph 20 Number of projects in the community setting - MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Ass. Culturais/Recreat. Clubes/Ass. Desportivas Esp. Nocturnos/Lazer Entidade Promotora Outros (Autarquia,...) Source: Prevention Department/IDT IDT 48

49 Demand Reduction Interventions In the community setting there is a higher implementation of projects in spaces of the promoting entities themselves. The category others concerns mainly municipality structures, sports/clubs associations and recreational associations. Nevertheless, there is a reduced number of interventions targeting young people in those settings. In this case, the development of programmes corresponds mainly to school holiday period. The following Graph presents data on the professionals involved implementing MPPs projects. The majority of the elements are psychologists and socio-cultural animators. Following the analysis of data from the first trimester, two new categories which were considered important were introduced - educational professionals and monitors. These data reflect, mainly, the work developed at the level of animation and occupation of the youngsters and, the available psychological support in the different intervention settings as well as staff recruitment and follow-up policies. Graph 21 Composition and training of professionals involved MPPs (2002) Janeiro Fevereiro Abril Maio Junho Julho Agosto Setembro Outubro Novembro Dezembro Téc. S. Social Psicólogos Sociólogos Anim. Sócio-Cult Téc. Educação Monitores Outros Source: Prevention Department/IDT IDT 49

50 Demand Reduction Interventions 10. Reduction of drug related harm 38 The policies of risk and harm reduction are supported by the existing legal framework according to the principle that, no matter how efficient supply and demand reduction interventions are, users will always exist. Thus, in the framework of the National Strategy, risk and harm reduction interventions promote the setting up, implementation and evaluation of several programmes and projects in critical zones of intensive use. These policies aim mainly at: Preventing the propagation risk of infectious diseases, particularly HIV and hepatitis B and C, due to use and other risk behaviours in certain drug users sub-populations. Preventing social exclusion and delinquency. Thus, harm reduction policies promote protective use behaviours among injecting and ingesting drug users who present risk behaviours. This is ensured through the dissemination of basic preventive instruments, namely syringe exchange and condom distribution. Another, more encompassing, harm reduction policy approach is the possibility of motivating drug users to more structured treatment programmes oriented towards abstinence. Concerning recreational drug use, a proximity work is developed to, on the one hand disseminate information and, on the other, minimise associated risks. Two main interventions in this area, which will be described bellow, are the integrated programmes (including supply and demand reduction approaches) in problematic neighbourhoods of Lisbon (Casal Ventoso) and Porto (Contrato Cidade). The strategy, in these cases, implies the setting up of different services which reply to different populations specific needs. Other interventions include the national syringe exchange programme and the implementation of 23 outreach work projects in These aim at reaching out to individuals who are not being reached by more traditional services, particularly problematic heroin and cocaine users, but also young recreational synthetic drug users. The coordination effort of national policies and local practices has been pursued through the cooperation process between the central services at the IDT, the municipalities and the local organisations. The municipalities, for instance, are requested to issue a formal document on the pertinence and convenience of outreach work projects in their area Complete text, tables and graphs on this area are available in print [IDT2003] and at 39 The coordination of national policies with local practices also has a legal framework in the Decree-Law Nº 183/2001. IDT 50

51 Demand Reduction Interventions Map 3 Outreach work projects 2003 Viana do Castelo 1 Braga 1 Porto 4 Vila Real Bragança Aveiro 2 Viseu Guarda Coimbra Castelo Branco Lisboa Leiria 6+1 Santarém 1 Portalegre Évora Setúbal 4 Beja 3 Faro Source: Treatment Department/IDT Description of interventions a) Outreach work in recreational settings One of the above mentioned outreach work projects in 2002 was directed at users of synthetic drugs in recreational settings, such as summer festivals, raves and surrounding settings (see table 21). This project, called Risk and Harm Reduction in users of synthetic and recreational in Summer Festivals, Trance Parties and Rave Parties, focussed its work in the dissemination of information about safer use to minimise associated risks. If requested by users, individuals counselling and follow-up was also available. b) Prevention of infectious diseases The national syringe exchange programme Say no to a second hand syringe (see previous National Reports) 40 aims at preventing HIV transmission in IDU populations. Since it was set up, in October 1993, it has used the national network of pharmacies and has enlarged its partner network through protocols with mobile units, NGOs and other organisations in order to reach a wider population. This programmes was evaluated in 2002 (see last year National Report) From the responsibility of the National Commission of Fight Against AIDS in collaboration with the National Association of Pharmacies. 41 The study concluded that this programme had avoided infections per each IDU from the reference population (1993) and that it was cost -effective. IDT 51