Luis is a 44-year-old, thin, small-framed man wearing jeans and a plaid blue shirt. Standing outside one of Lisbon’s low-threshold mobile units (a.k.a. methadone van), Luis is affable, approachable and happy to tell stories. Particularly about his good fortune in not succumbing to heroin addiction.
Imagine if we lived in a time and place where a disease was killing 1% of the population. Without discrimination–young and old, rich and poor. All were susceptible to the ravages of this illness. In the United States today, that would translate to 3.25 million people dying annually. 360,000 people in Canada. A whopping 13 million individuals in India.And yet this was exactly the public health crisis faced by the people of Portugal in the 1980s and ‘90s.
In honor of International Overdose Awareness Day, I’d like to share my experience visiting with drug policy leaders in Portugal earlier this summer. Dr. Joao Goulao, a tall and stately gentleman who was a family medicine doctor during the peak of the heroin epidemic, reflected on this dark time. “So many of my patients and their family members were addicted.” He went on to say that 100,000 people nationwide were hooked on heroin. Staggering rates of HIV, as well.
In my work as an addiction medicine doctor in New York City, I became familiar with Portugal’s then radical yet effective response to the “war on drugs”–a war which the Global Commission on Drug Policy declared a “colossal failure.” Through generous facilitation by the late Dr. Robert Newman–a pioneer in addiction medicine whose remarkable life was eloquently captured in the NY Times obituary–and collaborators at the Drug Policy Alliance, I was connected to several key architects of Portugal’s drug policy reform movement. I packed my bags for Lisbon. What I learned was simultaneously sensible and transformative.
In “How to Win a War on Drugs,” published in the NY Times September 2017, Nicholas Kristof describes the impact of Portugal’s decriminalization. Heroin is still illegal, just like it is in the U.S. and Canada. However, unlike in North America, a person possessing and using heroin in Portugal will not be arrested and incarcerated. Individuals possessing a 10-day supply or less of an illicit drug–a threshold set by the government–are referred to the Dissuasion Commission. “Setting a threshold reduces discretionary power from the police officer,” points out Dr. Goulao, now the General Director of the Service for Intervention on Addictive Behaviours and Dependencies (SICAD). Dealers and traffickers still face legal and criminal consequences.
“It’s been downgraded from criminalization to an administrative offense,” explained Nuno Capaz, PhD, and head of the Dissuasion Commission, which assesses the drug user and recommends a course of action. The Commission consists of ten people: four technical experts (psychologists, social workers) who perform a comprehensive evaluation and assessment; three administrators; and three board members.
Recreational users may receive an administrative charge (e.g. fine or community service). Individuals assessed as having a substance use disorder (i.e. addiction) are referred to treatment. “Nobody goes to jail,” emphasizes Capaz.
Ever since Portugal decriminalized all drugs in 2001, the data has been astounding. Drug-related HIV infections have decreased by 95%. Overdose fatalities dropped from 80 in 2001 to only 16 in 2012. By alarming contrast, 72,000 people died in the U.S. from drug-related causes in 2017.
My visit with Portugal’s drug policy experts taught me important lessons but also reinforced key concepts that need to be implemented in the United States.
- “Change the mindset.” Goulao recognized early in the drug reform battle that society’s perception about drugs and people who use them needed to change. Everyday Portuguese people were dying, and they demanded change. People in positions of power needed education: policymakers, judges, prosecutors, doctors, etc. Not unlike this country. We all have gaps in our knowledge. I’m no different: I knew very little about addiction (and absolutely nothing about harm reduction) after medical training. My “mindset” changed when I learned that addiction is a chronic medical disease of the brain, and that most people with addiction–once connected to the appropriate treatment and care–GET BETTER.
Lipi Roy - Lifesaving medications need to be widely available. Methadone is highly effective at reducing cravings for opioids like heroin (and was persistently advocated by addiction leader, Dr. Newman). In Lisbon, methadone is distributed in vans (it can also be given as take-home doses, described later). Psychologist Hugo Faria coordinates one of two Low Threshold Mobile Units which not only administer lifesaving methadone, but also provide a wide range of services: blood testing (TB, HIV, syphilis, etc.), syringe exchange, condoms, other medications (e.g. antibiotics) and education. Luis, who last used heroin 8 years ago, says “the van changed my life. I would be dead without it.”
- Multi-disciplinary, public health approach. Goulao and Capaz point out that decriminalization is only a part of the Portugal drug reform model. “The best part of Portugal’s program is the ease of referral to treatment AND the ability to tailor treatment to each individual,” explained Pedro Catita, clinical psychologist, Centre of Taipas (detoxification unit). Most patients received no prior health care. Now, according to Catita, people have access to a primary care doctor, infectious disease specialist, psychologist and social worker. Established patients can receive take-home doses of methadone, packaged in varying doses. They are also connected to a work program and other social services.
- Harm reduction strategies need to be widely adopted. Reducing the negative consequences associated with drug use (e.g. infections, liver failure, sex work, incarceration) creates safer and healthier communities. We need to move away from abstinence-only (“Just Say No!”) campaigns as they have failed. Harm reduction principles remind us to meet people where they’re at. Examples include syringe exchange programs, naloxone (“Narcan”), condoms, care coordination (e.g. assisting with legal aid, clothing, jobs) and health services.
Lipi Roy - Reduce the stigma towards drugs and people who use drugs. As Nuno Capaz reminded me, “the vast majority of people who use drugs are recreational users who will never develop addiction.” Yet, he points out, we are creating drug policies based on only 10% of users who develop substance use disorders (SUD). Of the 23 million Americans with SUD, only 10% access treatment. Stigma remains a MAJOR barrier to care. We can start by using less-stigmatizing language (e.g. replace “drug abuser” and “addict” with “person with addiction or substance use issues.”) [To learn more, you can watch my brief videos on reducing stigma.]
- Policymakers need to listen to technical experts. This was the leading piece of advice by Nuno Capaz. In crafting Portugal’s current drug policy, then Prime Minister Antonio Guterres invited experts on addiction and drug policy; this specialized group then visited countries that decriminalized drugs (Spain, Italy, the U.K.); they closely evaluated the Portugal’s drug overdose problem; then created a report that focused on prevention, harm reduction, dissuasion, treatment and decriminalization.
Today, the “Portuguese Experiment” is widely considered the “Portuguese Model.” While overall health has drastically improved, Dr. Goulao acknowledges challenges currently faced by his homeland, including an increase in new psychoactive substances and an aging population who have complex, chronic medical and psychosocial issues (e.g. dementia, heart failure and cocaine dependence). He believes countries like the U.S. and Canada could learn from Portugal and perhaps tailor their approaches.
We could start by loosening the regulatory hurdles that sick people are forced to overcome just to take methadone, sometimes driving hours, only to wait outside with other people who are actively using (thus acting as a trigger). Can you imagine if we made chemotherapy this difficult to access for people with leukemia? We also need to incorporate all forms of harm reduction including safe consumption sites (now opened in multiple Canadian cities). In addition, the criminal justice system shouldn’t be wasting millions of taxpayers’ dollars arresting and incarcerating low-level drug users. Because of decriminalization, law enforcement in Portugal can now focus their attention on bulk drug trafficking.
Let’s remember that addiction–to drugs, gambling, smart phones, sugar–impacts EVERYBODY.
Policymakers need to increase funding for education, prevention, treatment and recovery. Together, I am confident that a person with addiction in Brooklyn or Birmingham will achieve long-term recovery like Luis.
