City-level drug policies in Portugal: the COVID-19 pandemic as an analyser of harm reduction intervention responsiveness in Porto and Lisbon

Abstract Background The COVID-19 pandemic health crisis and its potential implications for people who use drugs (PWUD) created permissive conditions toward social innovation and experimentation. Still, it also exposed gaps in harm reduction approaches. The local level situations informed the harm reduction responsiveness, so it was not applied uniformly in different regions. This paper intends to contribute to the analysis of harm reduction responsiveness during the COVID-19 outbreak by comparing the adaptations and implementation of harm reduction and municipal services to support street-involved PWUD in two Portuguese cities – Porto and Lisbon. This study aims to shed light on the city-level implementation of drug policies in Portugal. Methods This study is based on a comparative qualitative analysis based on the experiences of PWUD and HR professionals regarding the implementation of harm reduction responses during the COVID-19 pandemic in Porto and Lisbon. The study is based on interviews with street-involved (SI) PWUD (n=22, 12 in Porto and 10 in Lisbon) and online focus groups with harm reduction professionals (N=12, 6 in Porto and 6 in Lisbon). Results Harm reduction teams in Porto and Lisbon implemented contingency plans and proactive adaptations to respond to the pandemic-related emerging needs. However, the study revealed contrasting experiences in the city-level support to harm reduction and responsiveness to the impacts of COVID-19 among SI PWUD in Porto and Lisbon. There were relevant differences in the support they received from the City Council and the city-level responses implemented to support street-involved (SI) PWUD. While the approach in Porto was described as restrictive and zero-tolerance towards drug use, in Lisbon, the responses were harm reduction-focused. The harm reduction-focused approach implemented in Lisbon revealed better results regarding the harm reduction responsiveness to the pandemic health crisis and adherence of SI PWUD to services, mostly because of their inclusive approaches. Conclusion The pandemic constraints and adaptations must be contextualized in an overall process of disinvestment in harm reduction in Portugal. Moreover, beyond the Portuguese drug policy model, city-level drug policies are crucial in the design and implementation of local drug policies.