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Heroin addiction patterns of treatment-seeking patients, 1992-2013: Comparison between pre-and post-drug policy reform in Portugal

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Background. The abuse of illicit drugs is a significant public health concern. In Portugal, a new drug policy was put into practice with the intent of preventing drug-related problems. Aim. This study was designed to evaluate the patterns of heroin addiction and drug treatment involvement in the periods of pre-and post-drug policy reform. Methods. A comparative study evaluated heroin treatment-seeking clients (N=627; 82.3% males and 17.7% females) at their first visit in one of the two periods 1992-1999 and 2002-2013. Data on drug treatment admissions were also analysed for comparison (N=2,323 cases entering treatment). Results. Comparison between the 1992-1999 and 2002-2013 periods showed that: treatment demand declined by 37%, whereas treatment engagement increased by 94%; drug users have aged, become better educated and reported more cocaine use. In general, men were more likely than women to receive treatment (82.3% to 17.7%), but the number of women accessing treatment increased (from 13.0% to 20.9%). Drug injection has decreased and heroin users are choosing to smoke heroin rather than injecting it. HIV infection decreased, too (28.0% to 19.6%). The prevalence of hepatitis C infection, alcohol use and abuse and a criminal history remain stable. Conclusions. Drug scene has changed in Portugal. The drug-use profile of heroin-addicted patients changed after the new policy on drugs was implemented. Heroin indicators are generally stable or trending downwards. Our clinical findings are discussed in view of the recent drug policy reform. Assessing trends in drug use among heroin-using patients can reinforce prevention efforts.
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Regular article
Heroin Addict Relat Clin Probl 20xx; xx(x): xx-xx
5
Corresponding author: Samuel Pombo; Psicologia Médica, Serviço de Psiquiatria e Saúde Mental do Hospital de Santa Maria –
Piso 2 - Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal. Tel: 21 780 5143;
E-mail: samuelpombo@gmail.com.
Heroin addiction patterns of treatment-seeking patients, 1992-2013: comparison
between pre- and post-drug policy reform in Portugal
Samuel Pombo, and Nuno Félix da Costa
Psychiatric Service of Santa Maria Hospital; Medical Psychology of Medical School of Lisbon University, Portugal, EU
Summary
Background. The abuse of illicit drugs is a signicant public health concern. In Portugal, a new drug policy was put into
practice with the intent of preventing drug-related problems. Aim. This study was designed to evaluate the patterns of
heroin addiction and drug treatment involvement in the periods of pre- and post-drug policy reform. Methods. A com-
parative study evaluated heroin treatment-seeking clients (N=627; 82.3% males and 17.7% females) at their rst visit in
one of the two periods 1992-1999 and 2002-2013. Data on drug treatment admissions were also analysed for comparison
(N=2,323 cases entering treatment). Results. Comparison between the 1992-1999 and 2002-2013 periods showed that:
treatment demand declined by 37%, whereas treatment engagement increased by 94%; drug users have aged, become bet-
ter educated and reported more cocaine use. In general, men were more likely than women to receive treatment (82.3%
to 17.7%), but the number of women accessing treatment increased (from 13.0% to 20.9%). Drug injection has decreased
and heroin users are choosing to smoke heroin rather than injecting it. HIV infection decreased, too (28.0% to 19.6%).
The prevalence of hepatitis C infection, alcohol use and abuse and a criminal history remain stable. Conclusions. Drug
scene has changed in Portugal. The drug-use prole of heroin-addicted patients changed after the new policy on drugs was
implemented. Heroin indicators are generally stable or trending downwards. Our clinical ndings are discussed in view of
the recent drug policy reform. Assessing trends in drug use among heroin-using patients can reinforce prevention efforts.
Key Words: Heroin addiction; substance use disorders; drug abuse pattern; Portugal; drug policy
1. Introduction
During the last few decades, the phenomenon of
drug addiction has changed globally [13, 15, 21]. In
Portugal, the use of drugs began in the 1970s, in the
context of the Portuguese democratic revolution, in-
creased insidiously in the 1980s and reached its peak
as a social and public health problem in the 1990s,
largely due to the problematic use of heroin [18]. At
the end of the 1990s, the number of heroin users was
estimated to be between 50,000 and 100,000 – almost
1% of the population [12]. The rise in intravenous
heroin use started to concern the public health author-
ities, particularly because of the continuous increase
of infection-related diseases such as HIV, AIDS, tu-
berculosis and hepatitis C [16]. For example, in 1999
Portugal had the highest rates of drug-related AIDS in
the European Union (EU) [13, 15, 21]. In reaction to a
rapidly rising drug problem, a new legal drug frame-
work was implemented in the country [31, 32, 47]. In
2001, Portugal became the rst European country to
ofcially abolish all criminal penalties for the person-
al possession of drugs [18, 47]. These changes, how-
ever, did not happen peacefully in Portuguese society,
since a substantial part of the Portuguese population
– namely, social conservatives – alleged that decrimi-
nalizing drug possession would send “the wrong
message”, open the country to drug tourism and ag-
gravate the nation’s drug problem [23]. Apparently,
this seems not to be the case. A previous analysis of
the effects of the Portuguese policy through a review
of all the available Portuguese evaluative documents
concluded that decriminalization of illicit drug use
and possession of those drugs do not appear to lead
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Heroin Addiction and Related Clinical Problems xx(x): xx-xx
automatically to an increase in drug-related problems
and that there are no signs of a mass expansion of the
drug market in Portugal [18].
Even though a causal effect between strategic ef-
forts and social and health outcomes cannot be rmly
established [30], there are some statistical indicators
that suggest a promising correlation. For instance, the
levels of illicit drug use in Portugal remain below the
EU average [17], illegal drug use among teens has
declined [4, 31], rates of new HIV infections caused
by the sharing of dirty needles has dropped [31] and
the number of people seeking treatment for drug ad-
diction has more than doubled [30, 47].
Based on data concerning drug-related trends in
Portugal both pre- and post-decriminalization, Glenn
Greenwald [23] published a comprehensive case re-
port recognizing “the success of drug decriminaliza-
tion in Portugal”, so causing a major impact on the
media and increasing public debate. More than ten
years later, these changes continue to attract support
and criticism. For instance, some authors are scepti-
cal about the changes in heroin use and deaths in a
small country like Portugal, suggesting that, due to
the cyclical nature of drug epidemics, drug use and
related problems might naturally decline no matter
which policies are in place [11, 24, 45, 49]. Although
several reports have demonstrated that heroin-related
problems are declining, the true effects of Portuguese
decriminalization can only be understood by compar-
ing post-decriminalization usage and trends in Por-
tugal with other European countries, as well as with
non-European countries (such as the United States,
Canada, and Australia) that continue to criminal-
ize drugs even for personal usage [23]. For instance,
over the last decade, European countries have made
changes to their penalties for the possession of drugs.
Three broad types of penalty changes can be iden-
tied: those changing the legal status of the offence
(criminal or non-criminal); those changing categories
of drugs, when the category determines the penalty;
and those changing the size of the maximum penalty
applicable. Most of the countries that have altered
their penalties for possession have used a combina-
tion of these types of change, complicating the task
of writing a concise analysis. Motives for change
vary between countries. For example, laws have been
changed to access addicts (Portugal), to simplify
punishment (Belgium, Finland, United Kingdom in
2004), to harmonize misdemeanour penalties (Esto-
nia, Slovenia) and to indicate levels of harm (Bul-
garia, Czech Republic, France, Italy, Luxembourg,
Romania, United Kingdom in 2009) [19]. However,
by and large, usage rates for each category of drugs
continue to be lower in the European than in non-Eu-
ropean countries, which have a far more criminalized
approach to drug usage [8].
In sum, until the present, the interpretation of
evidence on the Portuguese decriminalization of illicit
drugs has continued to be a subject under discussion
[26, 32]. In this regard, conducting a before-and-after
empirical study taking into account the considerable
changes that were made in this country could pro-
vide accurate information on heroin addiction trends
in Portugal. Besides the epidemiological reports of
drug use in the Portuguese general population [4], we
can examine trends and the impact of the Portuguese
policy regarding an important sub-population such
as problematic heroin users. Moreover, heroin trends
need to be monitored actively and continuously, as
past experience has shown that drug problems often
come in epidemic waves, with new generations be-
ing exposed to risk, especially when they have limited
knowledge and experience of the serious problems
that the use of heroin can cause [5, 20]. In response,
and in order to comprehend the clinical prole of
drug users obtained after many years of heroin ad-
diction treatment, we examined the patterns of drug
addiction and drug treatment involvement among in-
dividuals who applied for treatment in our addiction
unit between 1992 and 2013. It was hypothesized that
heroin-addicted patients that were admitted in the pe-
riod prior to drug policy reform would present a more
severe addiction history, when compared with those
who were admitted in the subsequent period.
2. Methods
Correlational and comparative methods were
used to assess the study hypothesis. Retrospective
data were collected during the period 1992 to 2013
from the Addiction Unit of the Mental Health and
Psychiatric Service of Santa Maria University Hos-
pital in Lisbon – to our knowledge, the rst clinical
structure to address the problem of drug addiction in
Portugal (created in 1973).
All patients were taken from the therapeutic pro-
gramme centre and inclusion depended on meeting
the criterion of a ‘primary’ diagnosis of heroin de-
pendence. In DSM the “primary” drug is dened as
the drug that causes the patient the most problems at
the start of treatment. This is usually based on the re-
quest made by patients and/or on the diagnosis made
by a therapist (commonly using standard instruments
such as the Diagnostic and Statistical Manual of Men-
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S. Pombo & N. F. da Costa: Heroin addiction patterns of treatment-seeking patients, 1992-2013: comparison between pre- and post-drug policy
reform in Portugal
tal Disorders - DSM) [2, 20].
The standardized outpatient treatment proto-
col, generally based on a contingency management
programme, combines a pharmacological and a
psychosocial intervention. In pharmacological terms,
the addiction unit offers a methadone/buprenorphine
maintenance treatment programme as the treatment
of choice for people who are heroin-dependent. The
main psychological treatment modality is group psy-
chotherapy (weekly; 1 to 2 hours) [42, 44].
In order to evaluate treatment-seeking we as-
sessed the absolute numbers of patients in treatment
from 1992 to 2013. For this purpose, we went through
the hospital database (administrative data) to check
all the cases that were registered as an admission or as
a treatment episode. Treatment demand considers the
number of patients entering treatment in the addiction
unit (“First visits”; N=2,323 cases). The total num-
ber of unit contacts (with the exception of the rst
registration) provides a measure of engagement with
the treatment system (“Other visits”). Demographic
(age and gender) and treatment data (number and year
of admissions) were obtained form medical records
through retrospective chart review.
To examine the changing patterns of heroin ad-
diction, 698 patients were assessed on their use of
drugs, sociodemographic and clinical characteris-
tics, family history and drug-related life-style, with
an abridgement of the European version of the Ad-
diction Severity Index (Europ-ASI). This semi-struc-
tured interview had been used in other reports [42,
44]. Of the 698 patients enrolled, 27 met the criteria
for “primary” cannabis dependence, 29 the criteria
for “primary” cocaine dependence and 15 for schizo-
phrenia and/or other psychotic disorders [2]. All were
removed from the sample. Other exclusion criteria
were patients younger than 18 years of age, state of
alcoholic intoxication (or intoxication with other sub-
stances) during assessment and marked cognitive def-
icit or mental retardation. Using this procedure, we
ended up with a nal sample of 627 patients.
All the subjects included in the study partici-
pated voluntarily and gave their informed consent.
The study had been approved by the local Ethical
Board of the Medical School of Lisbon University,
and all the procedures described were conducted in
accordance with the Helsinki Declaration of 1975, as
revised in 1983.
2.1. Data analysis
The normal distribution of the variables was
conrmed using the Kolmogorov-Smirnov test. Thus,
considering normally distributed data, parametric
methods were used to calculate numerical relations
among variables. Comparisons between the two gen-
ders regarding baseline variables (sociodemographic
and drug use data) were performed using chi-square
and student t-tests. The Mann-Whitney U test was
used to test group differences regarding the educa-
tional level, since the number of years of schooling
completed did not present a normal distribution.
To investigate the study hypothesis, the data
were split into two subgroups. Heroin-dependent sub-
jects were divided into subgroups through allocation
to one of two periods on the basis of the year 2000
cut-off (the year of implementation of Portugal’s drug
political reform). Thus, patients admitted in the period
1992-1999 were designated as subgroup 1 (N=207),
while those who were admitted in the period 2002-
2013 were assigned to subgroup 2 (N=354). In an ef-
fort to best dichotomize the groups, patients admitted
in 2000 and 2001 were excluded from the analysis
(N=66).
In the comparative analysis between the 1992-
1999 and 2002-2013 periods, all categorical vari-
ables were re-investigated using a logistic regression,
where age, gender and school level were forced into
the equation. All categorical variables were dummy
coded (for example, females received code 0 and
males code 1). Logistic regression was interpreted in
terms of odds ratios (OR). For comparisons involving
clinical continuous variables, a General Linear Model
(GLM) was conducted, incorporating age, gender and
school level, which were used as covariates.
Data were analysed using the Statistical Package
for Social Sciences (SPSS-Version 20.0). Statistical
signicance was dened at p<0.05.
3. Results
3.1. Treatment demand and engagement
(Administrative records)
Considering the absolute number of patients
entering treatment (N=2,323), 76.7% were males
(N=1788) and 23.3% females (N=535). The average
age was 35.1 (SD=5.0). In general, looking at treat-
ment demand, there was a peak of rst time attend-
ance in 1997-1998 (N=220), followed by a falling
trend in subsequent years. Treatment results also led
to a slight increase in the number of patients entering
treatment between 2007 and 2008. This in its turn was
reected in a trend of increasing treatment episodes,
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Heroin Addiction and Related Clinical Problems xx(x): xx-xx
i.e., more patients in treatment, with a peak attend-
ance in 2008. Comparison between the periods 1992-
1999 and 2002-2013 prompts the observation that
there was a decrease of 37% (percentage difference)
in the absolute number of patients entering treatment
and an increase of 94% in the total amount of unit
contacts after the rst registration (other visits). For a
more detailed overview, please see gure 1.
3.2. Sociodemographic and family-related
characteristics (clinical sample)
The clinical sample was matched by the abso-
lute number of patients entering treatment with re-
spect to age (F=90.8; p=0.39) and gender (χ2=0.50;
p=0.47). The sample comprised 627 heroin-depend-
ent patients, with a mean of 7.8 years of education.
Age varied between 18 and 58 years, with a mean
value of 33.9 years. The majority were males (82.3%
vs. 17.7% females), single (58.5%) and unemployed
(56.8%). Regarding family substance use, 25.8% of
the patients reported alcohol-related problems in the
father of the family, and 23.0% drug related-problems
in siblings. All these data are summarized in table 1.
Considering gender differences, females were
younger than males (F=0.7; p=0.01). There were no
signicant differences between men and women re-
garding school attendance (F=3.4; p=0.09), marital
status (χ2=7.1; p=0.08), occupational status (χ2=3.6;
p=0.73) and family-related characteristics (p=0.15-
0.29).
3.3. Drug-related characteristics of the clinical
sample
Concerning the ‘primary’ drug of abuse (heroin),
patients reported more than one decade of consump-
tion, with users preferring to smoke heroin (65.4%)
rather than injecting it (34.7%). Almost all patients
had used tobacco (98.1%), alcohol (98.1%), cannabis
(92.2%) and cocaine (87.9%) at some point during
their lifetime.
Examining age of onset, we can see that pa-
tients started to use tobacco, alcohol and cannabis at
a mean age of 14-15 years and cocaine and heroin
afterwards, at a mean age of 20-21 years. Around one
Figure 1. Absolute numbers of clients in treatment from 1992 to 2013
The results presented in this graph are reported in standard scores to allow comparisons. “First visits” dene the number of clients entering
treatment in the addiction unit (treatment demand). “Other visits” refers to the total amount of unit contacts after the rst registration (treat-
ment engagement). Methadone was introduced in our unit in 1995. 2000 was the year of implementation of Portugal’s drug policy reform.
Metadon
P
olitical reform
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S. Pombo & N. F. da Costa: Heroin addiction patterns of treatment-seeking patients, 1992-2013: comparison between pre- and post-drug policy
reform in Portugal
quarter of the sample presented a positive history of
HIV (23.9%) and hepatitis C infection (33.0%), a his-
tory of lifetime problematic alcohol use (26.3%) and
reported having shared needles (33.8%). A previous
history of delinquency and criminal behaviour were
present in 34.9% and 38% of these cases, respectively.
3.4. Comparison of pre- vs. post-drug policy reform
Concerning the comparison of the two time in-
tervals, patients who came into treatment in 2002-
2013 were signicantly older and more educated,
when compared with those that were admitted be-
tween 1992 and 1999. For instance, the percentage
of treatment entrants aged 30 or older increased sig-
nicantly in the period 2002-2013 compared with the
period 1992-1999. There were also signicant differ-
ences between groups regarding gender. The propor-
tion of females entering treatment was higher in the
2002-2013 period, when compared with the 1992-
1999 period. All statistical results are presented in ta-
ble 1. Concerning substance use habits, only cocaine
consumption revealed signicant results. Thus, in
patients admitted in the period 2002-2013 (subgroup
2), we observed a higher prevalence rate of cocaine
use as well as an earlier age at onset of cocaine use,
when compared with those who were admitted in
the period 1992-1999 (subgroup 1). The prevalence
rates of repeatedly shared needles and HIV infection
were signicantly lower in subgroup 2, when com-
pared with subgroup 1. Considering now the form of
heroin use, intravenous injection was signicantly
more prevalent in the subgroup of patients admitted
between 1992 and 1999. In contrast, smoking was
signicantly more prevalent in the subgroup of pa-
tients admitted between 2002 and 2013. The average
Table 1 – Socio-demographic and family-related characteristics of 627 heroin addicts attending the treatment unit in
Portugal between 1992-1999 and 2002-2013.
Total sample 1992-1999 2002-2013 Statistics
N=627 N=207 N=354
Age (M±sd) 33.9±7.1 31.2±6.1 35.9 ±7.0 F =6.9 / p=0.00
10-19 [N(%)] 4 (0.7) - 4 (1.2 c2=66.8 / p=0.01
20-29 175 (28.2 94 (53.7) 60 (17.3)
30-39 292 (46.9) 90 (30.9) 165 (47.5)
40-49 144 (23.1) 21 (14.7) 113 (32.6)
50-59 7 (1.1) 2 (0.7) 5 (1.4)
Years of school attendance (M±sd) 7.8±3.4 7.4±2.9 8.2±3.6 Z= -1.9 p=0.01
Gender (%)
Male 82.3 87.0 79.1 2=5.5 / p=0.02
Female 17.7 13.0 20.9
Marital status (%)
Married/marital union 27.0 25.3 26.9 2=9.8 / p=0.06
Single 58.5 66.0 54.9
Separated 14.5 8.8 18.2
Occupational status (%)
Employed 39.9 35.0 42.7 c2=3.5 / p=0.17
Unemployed 56.8 62.0 53.7
Retired 3.4 3.0 3.4
Family substance use (%)
Father
Alcohol 25.8 25.1 26.3 c2=0.3 / p=0.85
Drug 1.8 1.4 2.0
Mother
Alcohol 2.0 1.9 2.0 c2=1.1 / p=0.57
Drug 1.1 0.5 1.3
Siblings
Alcohol 5.2 6.9 4.2 c2=1.8 / p=0.39
Drug 23.0 24.4 22.3
Note: Values are expressed in percentages (%), means and standard deviations(M/SD). Groups were compared using Chi-Square
(c2), Mann-Whitney U (Z) and Student t (F) tests.
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Heroin Addiction and Related Clinical Problems xx(x): xx-xx
number of previous drug treatments was signicantly
higher in subgroup 2, when compared with subgroup
1. All statistical results are presented in table 2.
4. Discussion
The present study has demonstrated that the
“reality” of heroin addiction has changed in Portu-
gal [13, 19, 37]. Considering the two periods classi-
able as pre- and post-drug policy reform, 1992-1999
and 2002-2013, drug users have aged, become better
educated and reported more cocaine use, less HIV
infection and less behaviour associated with shared
needles. In general, our ndings follow the EU ten-
dency: heroin indicators are generally stable or trend-
ing downwards, and the data being collected continue
to indicate a decline in heroin-related treatment entry,
long-term downward trends in drug overdose deaths
and drug-acquired HIV infection [15, 21, 47]. Al-
though trends have varied overall over the last dec-
ade, new recruitment into heroin use now appears to
be on the decline. The overall numbers of new heroin
clients are declining in the EU, moving, for instance,
from a peak of 59,000 in 2007 to 31,000 in 2012 [21].
Table 2 – Drug-related characteristics of 627 heroin addicts attending the treatment unit in Portugal between 1992-
1999 and 2002-2013
Total sample 1992-99 2002-13 Statistics
N=627 N=207 N=354
Seroprevalence (%)
HIV 23.9 28.0 19.6 OR=1.7 / p=0.01 (CI 95% 1.1 – 2.6)
C hepatitis 33.0 31.4 33.6 OR=1.0 / p=0.66 (CI 95% 0.7 – 1.6)
Substance use habits
Alcohol 98.1 98.3 97.8 OR=1.0 / p=0.7 (CI 95% 0.8 – 1.4)
Problematic alcohol use 26.3 25.5 26.7 OR=1.1 / p=0.8 (CI 95% 0.6 – 1.8)
Tobacco 98.1 98.9 98.2 OR=1.0 / p=0.7 (CI 95% 0.8 – 1.1)
Cigarette number (day) 26.0±11.6 25.9/10.1 25.7±12.4 F =0.1 / p=0.9
Cannabis 92.2 91.5 93.2 OR=0.5 / p=0.9 (CI 95% 0.2 – 1.1)
Cocaine 87.9 80.4 93.4 OR=0.2 / p=0.00 (CI 95% 0.1 – 0.5)
Onset of substance use (age)
Tobacco 13.8±3.4 13.9±3.3 13.8±3.4 F =0.4 / p=0.5
Alcohol 15.1±3.6 15.5±4.1 15.0±3.5 F =0.1 / p=0.9
Cannabis 15.9±3.2 15.6±3.1 15.9±3.4 F =0.9 / p=0.7
Cocaine 21.3±6.2 24.6±9.2 21.2±6.0 F =7.7 / p=0.04
Heroin 20.4±5.5 21.6±6.4 20.5±5.6 F =3.1 / p=0.09
Years of drug consumption 14.5±6.3 13.8±6.6 15.9±6.0 F =0.3 / p=0.6
Years of heroin consumption 11.8±6.1 10.3±5.3 12.8±6.5 F =1.3 / p=0.3
Previous drug treatments 3.6±3.6 3.0±2.8 3.9±3.7 F =5.3 / p=0.03
Drug overdoses 1.9±1.6 2.1±1.7 1.7±1.5 F =0.5 / p=0.4
Mode of abuse (primary drug)
Smoke 65.4 48.3 77.9 OR=3.4 / p=0.00 (CI 95% 2.3 – 5.1)
Intravenous 34.7 51.7 22.1
Ever shared needles 33.8 39.6 28.6 OR=1.7 / p=0.02 (CI 95% 1.1 – 2.7)
Legal history
Delinquency 34.9 38.6 33.1 OR=1.3 / p=0.2 (CI 95% 0.8 – 1.8)
Criminal behaviour 38.0 34.8 39.8 OR=0.8 / p=0.4 (CI 95% 0.6– 1.2)
Nº condemnations 1.5/1.1 1.4/0.9 1.6/1.0 F =0.3 / p=0.6
Note: Values are expressed in percentages (%), means and standard deviations (M/SD). Groups were compared with a linear
regression model adjusted for age, gender and school level. Logistic regression was interpreted in terms of odds ratios (OR).
Legend: Seroprevalence for Hepatitis C Virus and Human Imunodeciency Virus expressed the percentage of patients tested or
conrmed in the medical records; Substance use habits dened the most important psychoactive substances that have been used
during patients´ lifetime (expressed in percentage); Problematic alcohol use categorized lifelong alcohol related problems; Onset
of substance use was dened as the age where a patient was most likely to have started to use a specic psychoactive substance;
Years of drug consumption and years of heroin consumption consider the length of time of all substance use and only of heroin
use, respectively; Previous drug treatments was dened to assess whether the patients had previously been in some kind of "for-
mal" treatment for drug abuse; Mode of abuse (primary drug) considers the behaviour associated with heroin consumption; and
the Legal history refers to the percentage of patients that reported a delinquent behavior or/and criminal activity over the lifetime.
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S. Pombo & N. F. da Costa: Heroin addiction patterns of treatment-seeking patients, 1992-2013: comparison between pre- and post-drug policy
reform in Portugal
gender stereotypes [6, 22, 33].
Heroin addiction is occurring in the context of
broader polysubstance use [14, 42]. These kinds of
drugs are generally used at different levels, ranging
from episodic (e.g., weekend users) to abuse [29]. In
the present study, the tendency for there to be an in-
crease in cocaine use is similar to that observed in
the EU [15]. There are many rationales for integrating
different drugs of consumption. When taken together,
drugs can have cumulative or complementary effects,
increasing the overall psychoactive experience. In a
similar way, offsetting the negative effects of a drug
can be another reason to take an additional substance
[14, 34]. Alcohol use contributes signicantly to the
global burden of addiction diseases [38, 41, 43]. In
the present study, about one quarter of the subjects
reported a problematic alcohol use. Indeed, heroin us-
ers often drink alcohol excessively [1, 3], with studies
showing that approximately 20–50% of methadone-
maintained therapy patients have alcohol-related
problems [10, 25]. Moreover, problematic alcohol
use did not change over the periods of comparison
– encompassing over two decades (25.5-26.7%), so
conrming the stable course of alcohol consumption
and drinking problems throughout life [27].
Intravenous drug use is an important risk factor
for infections [16]. The route of drug administration,
however, has clearly changed during the past few
decades. Drug injection has decreased and nowadays
heroin users are choosing to smoke heroin rather than
injecting it [40]. To the same extent, gures for the
prevalence of habitually shared needles and HIV in-
fection have also decreased in the last decade of re-
corded patient admissions. We may consider a vari-
ety of different explanations for the study ndings;
these should include variations in educational level,
price, purity and form of the heroin, accessibility to
treatment, concerns about health, social stigmatiza-
tion and self-image, information and “public” con-
frontation with heroin addiction, fear of HIV/AIDS
[9, 48]. The introduction of methadone maintenance
programmes is probably the most important single
feature [12]. Indeed, Portugal progressively started
to implement a humanitarian and pragmatic perspec-
tive to help people refrain from drug consumption
and related addictions. The main harm reduction fea-
tures established by the National Plan Against Drugs
and Drug Addictions included syringe and needle
exchange, (low-threshold) opiate stabilization pro-
grammes, contact units in critical zones of intensive
drug use and a global network of integrated responses
with public and private partners. It was a clear state-
A recent report suggests uctuations in rst treatment
demand for heroin use in EU in the last decade. A
trend analysis was performed for two time periods ac-
cording to data availability: a 6-year period (2005-11)
with data from 24 European countries and an 11-year
period (2001–11) focusing on 15 European countries.
Available data show a decrease in rst treatment de-
mand for heroin use in the EU between 2001 and 2011
[20]. Considering the number of patients admitted in
this study between 1992 and 2013, our data indicate
an overall decrease in the number of people who have
entered treatment for the rst time for heroin-relat-
ed problems. A possible hypothesis for these results
could be a fall in the number of new heroin addicts in
this country [47]. Additionally, we might also suggest
that heroin-addicted patients do not need to seek clin-
ical assistance as much because they stay in treatment
longer (showing better compliance). Overall, the data
indicate a rupture in the cycle of attending rehab and
then relapsing, a pattern of behavior described as the
‘revolving door syndrome’.
Comparison between the two periods showed
that patients are getting older, transitioning from the
early thirties to the early forties [28, 29, 36]. This
result might lead us to suppose that individuals who
were admitted to the unit recently may have started to
use heroin later in life, and thus seek for treatment at a
later age. This was not the case, however, since there
was no difference in the parameter “age at onset of
heroin use” between the periods 1992-1999 and 2002-
2013. Thus, rather than reecting the recent involve-
ment with heroin in the older age group (new cases),
this result means that patients initiate treatment at a
greater age, perhaps due to the fact that they live and
stay in treatment longer. Hughes and Stevens [31, 32]
concluded that the greater age of heroin patients, to-
gether with the data on the decline in the prevalence
of problematic drug use, suggest an encouraging fall-
ing trend in the number of young people who are be-
coming dependent on illicit drugs such as heroin.
Men are more likely to be treated for an addic-
tion problem than women [29, 39, 46]. However, con-
sistently with the literature, our ndings indicate that
the number of women accessing treatment has risen
[7, 48]. The percentage of women enrolled in treat-
ment rose signicantly from 13.0% in the mid-1990s
to 20.9% in the last decade. We may consider differ-
ent explanations for the greater number of women
entering treatment. This could be partly explained by
the gradual convergence of women’s and men’s drug
use patterns in the past few decades [35], or by chang-
es in social and cultural circumstances that construct
- 12 -
Heroin Addiction and Related Clinical Problems xx(x): xx-xx
viewing personal drug usage as a health problem rath-
er than a criminal one (so allowing homogenization)
[8, 21, 23].
5. Conclusions
In sum, the abuse of heroin is a problem that has
been growing in Portugal since the 1980s. The clini-
cal prole of heroin addicts changed in passing from
the period of pre- to the period of post-drug policy re-
form in Portugal. By now, heroin indicators are con-
stant or trending downwards.
Future research is needed to monitor the pattern
of change or stability of heroin indicators over the
next decade.
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Acknowledgements
None
Role of the funding source
Authors state that this study was nanced with inter-
nal funds. No sponsor played a role in study design; in the
collection, analysis and interpretation of data; in the writ-
ing of the report; and in the decision to submit the paper
for publication.
Contributors
The authors were involved in the review of the lit-
erature, critically reviewed the manuscript and had full
editorial control, and nal responsibility for the decision to
submit the paper for publication.
Conict of interest
Authors declared no conict of interest.
Ethics
Authors conrm that the submitted study was con-
ducted according to the WMA Declaration of Helsinki -
Ethical Principles for Medical Research Involving Human
Subjects. The study had been approved by the local Ethical
Board of the Medical School of Lisbon University.
Note
It is the policy of this Journal to provide a free re-
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Received March 14, 2016 - Accepted July 28, 2016
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... The Portuguese legal system underwent a change in 2001, by allowing problematic drug users to be evaluated by a commission, and be sent to treatment instead of being jailed and legally sanctioned [31]. This political decision which has joined the increase of Harm Reduction Programs and the exponential previous increase in Treatment Programs and facilities, (since late 80ties to 2000) including Opiate Maintenance Programs (High and Low Threshold Programs) was an answer to the 2000 opiate-related health emergency [28]. ...
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On political grounds, the liberalization and decriminalization of treatment instruments, as long as they are used for medical purposes, have become a priority in improving treatment standards. Scientifically based interventions should never be hampered by restrictive regulations targeting substance classes, let alone specific medical preparations. Pathways to recovery should also be made easier by lessening the restrictions on work and travel that are generally applied to substance users or offenders against laws on drugs. In other words, the figure of the patient should be allowed to prevail in legal contexts over that of the offender, as long as treatment can guarantee a positive outcome. For non-responders, alternative sanctions or ‘decriminalization’ may be considered too, although the need to prevent social harmfulness may justify restrictive measures. Decriminalization should stop being a substance-related matter, and become a diagnosis-related one. Categories of mentally ill patients (addiction being one main issue) should be decriminalized in so far as their offence can be considered a result of their addictive behaviour. Intoxication-related behaviour may, therefore, be decriminalized when it springs from addiction, and generically sanctioned when it is independent of addiction or other brain disorders. In terms of social security, decriminalization should be distinguished from depenalization. The person in question should not be charged with legal responsibility, as long as he/she is addicted or mentally ill, but restrictions may be applied when there is no other way of preventing social harm. The definition of categories of abuse, addiction and mental illness is a medical matter. One consequence is that the most reasonable way to allow ‘pathologic’ offenders to be given treatment is to check whether each offender belongs to a decriminalized category. The physician should become the central figure in assessing and handling social risk related to psychiatric disorders, because he/she is able to give medical criteria and knowledge priority over laws targeting generic substance use, trading in substances or substance-related crime.
... 5) Injections: BPN is quite often injected (methadone mixture seldom), but it will wean by itself during rehabilitation. A report from Portugal comparing two OST groups with interval of some years, showed a more than 50% reduction to 22% of injection with the opioid on attending OST [15]. 6) BDZ treatment: This is better handled by GP than by SU. ...
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The Beckley Foundation Drug Policy Programme (BFDPP, www.internationaldrugpolicy.net) is a non-governmental initiative dedicated to providing a rigorous independent review of the effectiveness of national and international drug policies. The aim of this programme of research and analysis is to assemble and disseminate material that supports the rational consideration of complex drug policy issues, and leads to more effective management of the widespread use of psychoactive substances in the future. The Beckley Foundation Drug Policy Programme is a member of the International Drug Policy Consortium (IDPC, www. idpc.info), which is a global network of NGOs specialising in issues related to illegal drug use and government responses to the related problems. The Consortium aims to promote objective debate on the effectiveness, direction and content of drug policies at national and international level.
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