ORGANIZATION OF AMERICAN STATES

INTER-AMERICAN DRUG ABUSE CONTROL COMMISSION

GENERAL SECRETARIAT OF THE ORGANIZATION OF AMERICAN STATES, WASHINGTON, D.C. 20006

NEW DIRECTIONS FOR THE INTEGRATION OF DRUG TREATMENT STRATEGIES IN COMMUNITY INTERVENTIONS

THE CASE OF COIMBRA, PORTUGAL

João Goulão, MD

President of the IDT (Portuguese National Institute for Drugs & Drug Addiction)

National Coordinator for Drug Policies

FIRST INTERFIRST INTER--REGIONAL FORUM OF EUREGIONAL FORUM OF EU--LAC CITIES:LAC CITIES:PUBLIC POLICIES IN DRUG TREATMENTPUBLIC POLICIES IN DRUG TREATMENTApril 2 April 2 –– 5, 20085, 2008Santo Domingo, Dominican RepublicSanto Domingo, Dominican Republic

OEA/Ser.L/XIV.4CICAD/EULAC/doc71pp/082 April 2008Original: English

EUEU--LACLACFirst Interregional City ForumFirst Interregional City Forum

New Directions for the Integration of Drug New Directions for the Integration of Drug Treatment Strategies in Community Interventions Treatment Strategies in Community Interventions

–– The Case of Coimbra, PortugalThe Case of Coimbra, Portugal

João Goulão, MDJoão Goulão, MDPresident of the IDT President of the IDT

(Portuguese National Institute for Drugs & Drug Addiction)(Portuguese National Institute for Drugs & Drug Addiction)National Coordinator for Drug PoliciesNational Coordinator for Drug Policies

Santo Domingo Santo Domingo –– April 2April 2--5, 20085, 2008

IDT, IPIDT, IPInstitute for Drugs and Drug AddictionInstitute for Drugs and Drug Addiction

IDT IDT –– Institute for Drugs & Drug AddictionInstitute for Drugs & Drug Addiction

•• MissionMission

•• Illicit Drugs & AlcoholIllicit Drugs & Alcohol

•• Areas of intervention / responsibilityAreas of intervention / responsibility

•• TreatmentTreatment•• PreventionPrevention•• Risk and Harm Reduction Risk and Harm Reduction •• RehabilitationRehabilitation•• Demand reduction (dissuation)Demand reduction (dissuation)•• Investigation & Epidemiological surveillanceInvestigation & Epidemiological surveillance•• TrainingTraining•• International representationInternational representation

PIF PIF –– Focus Intervention ProgramsFocus Intervention Programs (c. 20 projects funded by IDT (c. 20 projects funded by IDT –– 2 years)2 years)

•• Intervention in leisure spaces / youth music festivals Intervention in leisure spaces / youth music festivals ……•• Dysfunctional familiesDysfunctional families•• Young people with risk behaviorsYoung people with risk behaviors

PORI PORI –– Operational Program for Integrated ResponsesOperational Program for Integrated Responses

•• IDT funded programs developed for detected priority territoriesIDT funded programs developed for detected priority territories (92)(92)•• RAR methodology (more properly RARERAR methodology (more properly RARE……))•• Integrated responsesIntegrated responses

•• both at technical and institutional levelsboth at technical and institutional levels•• fully evaluated at all levels of implementationfully evaluated at all levels of implementation

Main IDT national community intervention programsMain IDT national community intervention programsIDT IDT –– Institute for Drugs & Drug AddictionInstitute for Drugs & Drug Addiction

•• Interventions Interventions centered on the citizencentered on the citizen

•• TerritoryTerritory driven & designed programsdriven & designed programs

•• IntegrationIntegration of institutional effortsof institutional efforts

•• IntegralityIntegrality & & continuitycontinuity of responsesof responses

General Strategic PrinciplesGeneral Strategic Principles

IDT IDT –– Institute for Drugs & Drug AddictionInstitute for Drugs & Drug Addiction

•• Treatment consultation teams all over the countryTreatment consultation teams all over the country

•• Teams & mediators for community intervention inTeams & mediators for community intervention in

•• Prevention; harm reduction, rehabilitationPrevention; harm reduction, rehabilitation……

•• National intervention programs (financed whenever necessary)National intervention programs (financed whenever necessary)

•• Specialized treatment units Specialized treatment units -- alcohol (3), detox. Units (5), therapeuticalcohol (3), detox. Units (5), therapeuticcommunities (3 units + 1200 conventioned beds)communities (3 units + 1200 conventioned beds)

•• National network for demand reduction / dissuasion National network for demand reduction / dissuasion (18 teams / portuguese law enforcement)(18 teams / portuguese law enforcement)

Drug Intervention Network in PortugalDrug Intervention Network in PortugalIDTIDT

Other National Health Service (NHS) facilitiesOther National Health Service (NHS) facilities

TheThe City of CoimbraCity of Coimbra

•• More than 1.000 years oldMore than 1.000 years old•• Roman city of Roman city of AeminiumAeminium•• One of the worldOne of the world’’s oldest universities (700 y. +)s oldest universities (700 y. +)•• 165.000 to 185.000 inhabitants 165.000 to 185.000 inhabitants •• 35.000 university students; 10% from 40 countries35.000 university students; 10% from 40 countries•• Activity mainly connected with services, Activity mainly connected with services,

teaching & health care teaching & health care •• Cluster in biotech, pharma. & software industriesCluster in biotech, pharma. & software industries

CoimbraCoimbra

– Santa Clara da Califórnia EUA – Halle Alemanha – Poitiers França – Salamanca Espanha – Santos Brasil – Aix-En-Provence França – Cambridge EUA – Yaroslavl Rússia – Fès Marrocos – Santiago de Compostela Espanha – Mindelo Cabo Verde – Curitiba Brasil – S. Paulo Brasil – Beira Moçambique – Taipa China (Macau) – Pádua Itália

– Díli Timor Leste – Damão India – Esch-sur-Alzette Luxemburgo

– Saragoça Espanha

Coimbra : International City Coimbra : International City Partnerships Partnerships –– Twin CitiesTwin Cities

Coimbra : City ProgramsCoimbra : City Programs

•• UrbanUrban Rehabilitation Projects Rehabilitation Projects -- old quarters & city social housing developmentsold quarters & city social housing developments

•• ““Nomads ParkNomads Park”” -- gypsies temporary housing facilitiesgypsies temporary housing facilities

•• Project Project ““Planalto SeguroPlanalto Seguro”” -- urban rehabilitation, security & citizenship promotionurban rehabilitation, security & citizenship promotion

•• CLAS CLAS -- CoimbraCoimbra’’s Council of Social Partnerss Council of Social Partners (122 State Deps & NGOs)(122 State Deps & NGOs)

•• Strong civil society Strong civil society ……•• RIAC RIAC –– CoimbraCoimbra’’s Network for Addictionss Network for Addictions (leader : IDT; c. 20 partners)(leader : IDT; c. 20 partners)•• ……

ACAPO - Ass. de Cegos e Amblíopes de Portugal Centro de Bem Estar Social de Brasfemes Junta d Freg. de Almedina ACIC Centro de Bem Estar Social Sagrada Família Junta de Freg. de Almalaguês ACM - Ass. Cristã da Mocidade Centro de Solidariedade Social "O Pátio" Junta de Freg. de Antuzede ADAV - Ass. de Defesa e Apoio da Vida Centro de Solidariedade Social de Adémia Junta de Freg. de Assafarge ADFP - Fórum Ocupacional Centro Distrital de Segurança Social de Coimbra Junta de Freg. de Brasfemes ADIS Centro Operário Católico da Conchada Junta de Freg. de Castelo Viegas Administração Regional de Saúde do Centro Centro Paroq. de Bem Estar de Almalaguês Junta de Freg. de Ceira Amigos do Cidadão Doente Centro Paroq. de Solid. Social da Freg. de Ribeira de Frades Junta de Freg. de Cernache ANAI Centro Paroq. de Solidariedade Social de S. Martinho do Bispo Junta de Freg. de Eiras APELO - Apoio à Pessoa em Luto Centro Social da Marmeleira Junta de Freg. de Lamarosa APELO - Ass. de Apoio à Pessoa em Luto Centro Social e Recreativo da Cidreira Junta de Freg. de Ribeira de Frades APPACDM Centro Social Nossa Senhora da Conceição Junta de Freg. de S. Bartolomeu APPDA - Coimbra Centro Social Nossa SenhoraD’Alegria Junta de Freg. de S. João do Campo Ass. Cultural e Recreativa de Casal S. João Centro Social Paroq. de S. João do Campo Junta de Freg de S. Martinho de Árvore Ass. das Cozinhas Económicas Rainha Santa Isabel Centro Social S. João Junta de Freg de S. Martinho do Bispo Ass. de Moradores do bairro da Rosa Centro Social Torres do Mondego Junta de Freg. de S. Paulo de Frades Ass. de pais e Encarreg. de Educação da EB1 de Pereiros Centro Social, Cultural e Recreativo de Quimbres Junta de Freg. de S. Silvestre Ass. dos Diabéticos da Zona Centro Centro Social, Cultural e Recreativo do Botão Junta de Freg. de Santa Clara Ass. Integrar Centro Sócio-Cultural Nossa Senhora de Lurdes Junta de Freg. de Sé Nova Ass. para o Planeamento da Família Centro sócio-Cultural Polivalente de S. Martinho Junta de Freg. de Souselas Ass. Port. de Estudos e Intervenção em Psicologia Positiva Comissão de Protecção de Crianças e Jovens de Coimbra Junta de Freg. de Sta. Cruz Ass. Port. de Familiares Amigos e Pessoas com Epilepsia Comunidade Juvenil S. Francisco de Assis Junta de Freg. de Sto. António dos Olivais Ass. Portuguesa de Solidariedade e Desenvolvimento Conferência de S. Paulo Junta de Freg. de Torre de Vilela Ass. Reage CONSENSUS Junta de Freg. de Torres do Mondego Ass. Social recreativa Cultural Cigana de Coimbra Direcção Regional de Educação do Centro Junta de Freg. de Trouxemil Ass. Social, Cultural e Recreativa de S. Paulo de Frades Fábrica da Igreja Paroq. de S. João do Campo Junta de Freg. de Vil de Matos Ass. Sócio Cultural de Recreio e Desportiva dos Pereiros Federação Regional das Associações de Pais do Centro LAHUC - Liga dos Amigos dos HUC ATENEU de Coimbra Fundação AMI - Porta Amiga de Coimbra Liga dos Amigos do C Saúde N de Matos Banco Alimentar Contra a Fome Fundação Beatriz Santos Liga Portuguesa Contra a Epilepsia Câmara Municipal de Coimbra Fundação Bissaya Barreto NRCentro - APPC Cáritas Diocesana de Coimbra Fundação Portug. "A Comunidade Contra a Sida" Obra de Promoção Social do Distrito de C Casa da Infância Dr. Elysio de Moura G.N.R. Obra Social de Torre de Vilela Casa de Repouso de Coimbra Ginásio Clube de Antuzede Policia de Segurança Pública Casa do Pai - Centro de Apoio Social Grupo Sócio Cultural e Desportivo de S. Martinho de Árvore Rede Europeia Anti-Pobreza / Portugal CEARTE Hospital Sobral Cid Santa Casa da Misericórdia de Botão CEIFAC - Centro Integrado de Apoio Familiar de Coimbra Humana Global – Ass. for Prom of H Rights, Culture and Develop Santa Casa da Misericórdia de Coimbra CELIUM - IPSS I.D.T., I.P. – CRI de Coimbra Saúde em Português Centro Comunitário de Desenvolvimento e Solidar. Social IAC - Instituto de Apoio à Criança SOL - Eiras Centro de Apoio Social de Souselas INATEL Sub Região de Saúde de Coimbra Centro de Apoio Social Pais e Amigos da Escola EB 10 Instituto de Reinserção Social - Direcção Regional do Centro Ven Ordem 3ª - Casa Abrigo Pe Américo Centro de Assistência Paroq. Santa Cruz IEFP - Delegação Regional do Centro

City of Coimbra : Partners in the Social Council (122+ State OrgCity of Coimbra : Partners in the Social Council (122+ State Orgs & NGOs)s & NGOs)

Drug Intervention & Other Health FacilitiesDrug Intervention & Other Health Facilities (1)(1)•• IDT, IP (NHS authonomous administration)IDT, IP (NHS authonomous administration)

•• CRI CRI –– District of Coimbra District of Coimbra Center for Integrated ResponsesCenter for Integrated Responses on drugson drugs

•• 1 Treatment Team (20 technicians 1 Treatment Team (20 technicians –– Psych., Psycol, S. Serv. TechnPsych., Psycol, S. Serv. Techn…….).)•• 1 Community programs intervention team (6 technicians)1 Community programs intervention team (6 technicians)

•• 4 IDT Specialized Units4 IDT Specialized Units•• 1 Therapeutic Community (5 techn.; 12 beds 1 Therapeutic Community (5 techn.; 12 beds –– long term treatment)long term treatment)•• 1 Illicit drugs detoxication unit (12 beds)1 Illicit drugs detoxication unit (12 beds)•• 1 Alcohol Unit 1 Alcohol Unit –– Consult., infirmary, day care, etc. Consult., infirmary, day care, etc. –– 40 techn., 30 beds)40 techn., 30 beds)•• 1 Demand Reduction Team (CDT 1 Demand Reduction Team (CDT –– 3 techn. +)3 techn. +)

•• IDT Regional Administration ServicesIDT Regional Administration Services•• Other IDT financed responsesOther IDT financed responses

•• 1 Harm Reduction Team + 1 Shelter Center (15 beds) + 1 HR Cabin1 Harm Reduction Team + 1 Shelter Center (15 beds) + 1 HR Cabinet et

30.000 consultations / year30.000 consultations / year

Drug Intervention & Other Health FacilitiesDrug Intervention & Other Health Facilities (2)(2)•• NHS NHS –– National Health ServiceNational Health Service

•• 2 Central General Hospitals (beds: University Hosp. 2 Central General Hospitals (beds: University Hosp. -- 1.300 + CHC 1.300 + CHC -- 600)600)(1 Psychiatry & Mental Health Service with 40 psychiatrists)(1 Psychiatry & Mental Health Service with 40 psychiatrists)

•• 6 Primary health care Health Centers6 Primary health care Health Centers•• 1 Psychiatric Hospital (60 Psychiatrists, c. 400 beds)1 Psychiatric Hospital (60 Psychiatrists, c. 400 beds)•• 1 Paediatric Hospital (c. 200 beds)1 Paediatric Hospital (c. 200 beds)•• 1 Oncology specialized hospital (c. 300 beds)1 Oncology specialized hospital (c. 300 beds)

•• Private Practicioners & Clinics (22/1.000 medical doctors) Private Practicioners & Clinics (22/1.000 medical doctors) •• 1 NGO administered protected rehintegration appartment1 NGO administered protected rehintegration appartment•• 1 NGO administered socio1 NGO administered socio--occupational forumoccupational forum•• 1 NGO administered therapeutic community (IDT funded beds)1 NGO administered therapeutic community (IDT funded beds)•• ......

LetLet’’s go for a (virtual) tours go for a (virtual) tour……

Territory 1Territory 1 –– Coimbra Downtown AreaCoimbra Downtown Area•• Heroin traffic & consumption + Buprenorphine TrafficHeroin traffic & consumption + Buprenorphine Traffic•• Petty crimes (pick pocketing, small thefts), damage to urban strPetty crimes (pick pocketing, small thefts), damage to urban structuresuctures

Territory 2Territory 2 –– Suburban Barrios of Suburban Barrios of Rosa & IngoteRosa & Ingote•• Traffic + Consumption (mainly heroin & THC)Traffic + Consumption (mainly heroin & THC)•• Occasional violent incidents, destruction of urban propertyOccasional violent incidents, destruction of urban property

Territory 3Territory 3 –– University Campuses & BeyondUniversity Campuses & Beyond•• Alcohol consumption, Alcohol consumption, ““Club DrugsClub Drugs””•• Student Festivities, Recreational Areas, Music FestivalsStudent Festivities, Recreational Areas, Music Festivals

Coimbra : Diagnosed Priority TerritoriesCoimbra : Diagnosed Priority Territories

Territory 1Territory 1 –– Coimbra Downtown AreaCoimbra Downtown Area

PORIPORI

Coimbra : Diagnosed Priority TerritoriesCoimbra : Diagnosed Priority Territories

Territory 1Territory 1

Territory 2Territory 2 –– Suburban Suburban BarriosBarrios of of Rosa & IngoteRosa & Ingote

PORIPORI

Coimbra : Diagnosed Priority TerritoriesCoimbra : Diagnosed Priority Territories

Territory 2Territory 2

T2T2

Territory 3Territory 3 –– University Campuses & beyondUniversity Campuses & beyond

= = …… all of the city all of the city ……

Coimbra : Diagnosed Priority TerritoriesCoimbra : Diagnosed Priority Territories

““Queima das FitasQueima das Fitas”” graduation feastgraduation feast One hundred years ago ?One hundred years ago ?

And nowadaysAnd nowadays…… Night Serenade Night Serenade –– Fado SongsFado Songs

Parents & Population from all over the country also participateParents & Population from all over the country also participate……

Hundreds of thousands of people in the cityHundreds of thousands of people in the city……Bottles all over the placeBottles all over the place……

Every year our Mayor has several huge headackesEvery year our Mayor has several huge headackes……

Graduated students paradeGraduated students parade……

Green Green -- AgronomyAgronomy

Paradise at the reach of everybodyParadise at the reach of everybody……

Orange Orange -- PsychologyPsychology

Safe Sex ?Safe Sex ?……

Medical care Medical care –– I.V. BEER I.V. BEER

Girls do it to !...Girls do it to !...

Discoverers of Hispaniola ?...Discoverers of Hispaniola ?...

Music festivals ... a week longMusic festivals ... a week long…… always drinkingalways drinking

Yellow : MedicineYellow : Medicine A A ““Wine Barrel TomographyWine Barrel Tomography”” ……

Red : LawyersRed : Lawyers……

The son of one of usThe son of one of us……

1.1. New treatmentNew treatment protocols protocols •• Multiple drugs, alcohol & drug(s)Multiple drugs, alcohol & drug(s)•• Comorbid mental health problemsComorbid mental health problems•• Ultra Rapid Detox ProtocolsUltra Rapid Detox Protocols

2.2. Better Better integrationintegration of services & of programs with partners (PORI + of services & of programs with partners (PORI + ……))•• Harm reduction Harm reduction -- …… -- Classical Classical ““indoorindoor”” treatmenttreatment•• After care services, followAfter care services, follow--up protocols, treatment continuityup protocols, treatment continuity

3.3. Evolution from Evolution from RARRAR to to RARRARE E -- Evaluation at all levels Evaluation at all levels •• CostCost--efficacy / Efficiency / Health gainsefficacy / Efficiency / Health gains

4.4. Formal Formal AccreditationAccreditation of Treatment Facilities, Processes & Protocolsof Treatment Facilities, Processes & Protocols

Conclusion Conclusion -- Strategic ChallengesStrategic Challenges

Thank You forThank You forYour AttentionYour Attention

www.idt.ptwww.idt.pt

joao.goulao@idt.minjoao.goulao@idt.min--saude.ptsaude.pt

Coimbra City (Foto) TourCoimbra City (Foto) Tour

Thank You forThank You forYour AttentionYour Attention

www.idt.ptwww.idt.pt

joao.goulao@idt.minjoao.goulao@idt.min--saude.ptsaude.pt