Overview:
This is the third story in a three-part series on drug policy in Portugal and Canada. Canadian Affairs reporter Alexandra Keeler was in Portugal throughout December to conduct this reporting.
One of the most contentious aspects of Canada’s drug policies in recent years is harm reduction, services that aim to keep people alive and healthy while using drugs.
Portugal, which decriminalized all drugs 25 years ago, also offers harm reduction services. Like Canada, these programs are easy to access and peer-driven.
But Portugal’s experience also offers some lessons for Canada: that harm reduction works best when part of a coordinated, national system that links street-level care to treatment, housing and social supports; and that harm reduction must be adequately funded to be effective.
“Before [Portugal’s drug] policy got implemented, they created a decriminalization regime, planned for all of the subsequent problems … made provisions to get people services and help,” said Miguel Moniz, an anthropologist at the University of Lisbon, who studies Portugal’s drug policy and its implementation in North America.
“Portugal has also funded and expanded some of their programs… [like] safe injection sites, mobile methadone wellness vans — it’s another gateway towards health services.”
A coordinated system
Like most high-income countries, Canada and Portugal have a problem with high-risk drug use. Canada’s rates, however, are far worse.
In Canada, an estimated three to eight per cent of adults used illicit drugs in 2023, according to Health Canada’s most recent Canadian Substance Use Survey, which uses self-reported data. About one per cent engaged in high-risk use, such as daily use or injection.
By contrast, Portugal’s rate of high-risk illicit drug use is about half the Canadian level. Around 0.5 to 0.7 per cent of the population uses drugs such as opioids, heroin and cocaine.
Portugal also loses far fewer people to drugs than Canada.
In 2023, Portugal, a country of nearly 11 million people, lost 80 individuals to overdoses. Canada, which has a population about four times the size, loses 75 times this number — more than 6,000 individuals a year.
Portugal’s drug policies help explain these differences. As Canadian Affairs previously reported, drug decriminalization in Portugal has been accompanied by the nationwide implementation of comprehensive drug dissuasion, harm reduction, treatment and drug monitoring services.
The country’s harm reduction services are visible at centres like GAT IN Mouraria in Lisbon, the country’s capital.
GAT not only oversees safe drug consumption. It also offers everything from general medicine and psychiatric care to social support and hot meals.
But Dr. Lia Trombetta, a general doctor at GAT, says one of the centre’s most interesting features is their reliance on peer workers.
Drawn from the community, these employees are responsible for building long-term relationships with drug users. They teach safer drug use practices and, in some cases, help them take their first steps toward managing their own health.
“[These workers] have had some parallel [experiences] with these people,” said Trombetta, noting many come from the same drug‑using community.
“They are [closer] to the [drug] community than … a doctor or a nurse.”
They also act as “ambassadors,” said Carla Mascarenhas, a nurse at GAT. “It’s easier for some people to talk to them … or for them to find [people who use drugs] on the street and say, ‘You come to the centre, because there … you can talk freely, and you can say the substances that you use, and we also try to help.’”
Peer workers may also guide individuals to treatment options, such as buprenorphine, a medication that curbs opioid cravings and withdrawal.
Dr. Manuel Cardoso, deputy director-general of Portugal’s Service for Intervention in Addictive Behaviours and Dependencies (ICAD), says the country’s harm reduction centres serve a relatively small group of people who continue to use drugs problematically while keeping pathways open to treatment and reintegration.
“We have … lots of harm reduction responses,” he said.
“What we try to pass on to the professionals working in [harm reduction] is that they are more than just helping these people to … use less problematically. [Rather, we’re] giving them the possibility to change, to move, to get out of this situation, give them other possibilities.”
Users who are identified by the country’s Dissuasion Commissions as high risk can be referred to state-funded residential or outpatient treatment programs.
These programs follow a structured, full-abstinence approach and can last for a year or more. For individuals who face waits accessing treatment, the government offers short-term care or methadone treatment. The government covers all treatment costs for low-income patients.
Controversy in Canada
In Canada, harm reduction centres have been controversial. This is in part because they are often expected to manage the most visible consequences of drug use without offering the coordinated treatment, housing and social supports that surround similar services in Portugal.
As a result, many Canadian critics of harm reduction say the centres contribute to public disorder and fail to get people off drugs. They point to inconsistent administrative oversight of the centres, gaps in security, and strained relations with surrounding communities. The fatal 2023 shooting of a young mother near Toronto’s keepSIX safe consumption site underscored these challenges.
In response, federal and provincial governments have started to scale back funding for harm reduction or closed sites altogether.
Last year, Ontario’s Ford government shuttered 10 overdose prevention sites, replacing some with Homelessness and Addiction Recovery Treatment (HART) Hubs. These hubs provide primary care, housing support and social services, but not supervised consumption or needle exchanges.
Critics of the closures say the shift reflects a recurring tension in Canada’s drug policy: gaps in the system are often “fixed” by replacing harm reduction, rather than integrating it into a broader continuum of care.
Bill Sinclair, CEO of Neighbourhood Group Community Services, a Toronto-based social agency whose services include harm reduction, and Laila Bellony, a harm reduction manager in Toronto, told Canadian Affairs in January 2025 that HART Hubs should complement, not replace, supervised consumption sites, since they serve different populations along the continuum of drug use.
“I don’t think it’s an either-or,” said Sinclair. “I think it’s an ‘and’ situation.”
Federal consultation feedback confirms harm reduction is often constrained by fragmented funding and weaker links to treatment and housing systems.
Moniz, from the University of Lisbon, notes that Canada has partially adopted the language and approaches of Portugal’s drug policy. But politics often obstruct the shift to a public health oriented framework.
“[Canadian politicians] are less worried about solving the public health crisis and more concerned with the political crisis,” he said, noting politicians will undermine evidence-based policies for fear of a public backlash.
Social pressures
While Portugal has in many ways become the global gold standard for drug policy, it too faces challenges. Many are of its own making.
Mascarenhas says, anecdotally, the population of people using drugs problematically is rising. “The number keeps growing very quickly,” she said. “The [number of] people living in the streets is increasing.”
Cardoso, of ICAD, says funding constraints have made it harder for high-risk users to access treatment over the past decade. “These days, we have lots of difficulties,” he said.
“We have lots of people waiting … [to] enter into the treatment process.”
Shrinking referral networks and long waitlists mean Dissuasion Commissions increasingly struggle to offer concrete alternatives to problematic drug use.
“They [offer] psychological support and try to say to the persons … how to use drugs more safely,” said Trombetta. “But there’s a big problem of access, especially for mental health.”
Upstream funding gaps are now visible in harm reduction centres as well.
GAT’s outdoor supervised inhalation area was closed after demand outpaced what the centre could safely manage. With insufficient funding, the service was eliminated rather than run unsafely, says Giada Milandri, a harm reduction worker at GAT.
The centre still distributes safe drug consumption kits, which contain citric acid, alcohol, sterile water, cups, needles and condoms. But Milandri says budget cuts have forced the centre to stop providing pipes for smoking crack.
Without access to clean pipes, users are at greater risk of burns, infections and transmitting diseases.
“They’re kind of dismantling [public health care] slowly,” said Mascarenhas, the GAT nurse.
Such changes affect individuals like the young woman Canadian Affairs met at GAT, who described her use of crack as a fleeting escape.
“I had a very nice life before,” the woman said. “I speak four languages, university, all of it. But when I used to snort coke, you know, with my friends, we [would] go out to techno parties, snort coke, ketamine, pills, MDMA — whatever, it’s fine. It’s all good.
“When you speak about changing the coke for the stone, it’s like a different world.”
The woman said the grip of addiction comes from the tiny relief it offers.
“No one goes to buy a stone of crack with a smile on their face,” she said. “It’s an emptiness inside. It’s a hole. You just go and buy it to have a little sensation of peace for just microseconds. And then it’s back to the chaos.”
