Made in Portugal: A recipe to fight the opioid crisis
Opioid abuse is one of the biggest challenges currently faced by American society. Twenty-five years ago, Portugal too was amidst a drug epidemic. The Portuguese strategy to fight the drug epidemic had at its core the idea that drug addicts are not criminals, but rather patients who need help. And you know what? It succeeded.
In recent years, the opioid crisis in the United States has been making headlines all over the world. Opioid use in the US started slowly during the ’90s but rose steadily over time, becoming one of the biggest challenges currently faced by American society. In 2018 alone, there were over 70,000 drug overdose deaths in the US. However, the consequences of the opioid crisis are not limited to deaths or even restricted to the healthcare sphere. Opioid abuse impacts many distinct aspects of society, including the criminal justice system, family relations, or the labor market. It is not clear what the best strategy to tackle the current epidemic is, but I believe that there are lessons to learn from the Portuguese experience.
After decades under an authoritarian regime, Portugal suddenly opened to new markets in 1974. Portuguese society was craving new products and experiences. Thus, when drugs like marijuana and heroin started flooding in, the country was largely unprepared. During the ’80s and ’90s, Portugal had one of the highest prevalences of problematic drug use among European countries, particularly heroin. For example, in the late 80’s one in every 100 Portuguese was battling problematic heroin addiction. There were concerns about rising overdose deaths and crime. Users would inject themselves in plain daylight, and used syringes were often left abandoned in public areas. The rate of HIV infection was the highest in the European Union. In 1999, Portugal reached its historical peak in HIV incidence, registering 3332 new cases (out of 10.19 million inhabitants).
At this point in time, new solutions to tackle the drug epidemic in Portugal were being discussed, which culminated with the decriminalization of illicit drug possession and consumption in 2001. Decriminalization applied to both soft and hard drugs. An individual caught with less than a 10-day supply of any drug (exact amounts for each drug were determined by law) would be treated as a user and not a dealer. He would be sent to a local committee consisting of a doctor, lawyer, and social worker to learn about treatment and available medical services. Note that drugs were still illegal and selling drugs remained a criminal offense. However, the purchase, possession, and consumption of illicit drugs were downgraded from criminal to administrative offenses.
Eliminating the threat of criminal penalties eliminates a great deal of stigma and makes it easier for users to seek treatment. Perhaps equally important, it safeguards the ability of drug users to get jobs and participate in society in the future, both of which are significantly hindered for individuals with a criminal record.
Treatment is provided in specialized medical centers. In case individuals do not show interest in treatment, then the aim is to make sure they use drugs in the safest way possible. To enable this, risk and harm-reduction activities are carried out, mostly by non-governmental organizations receiving public funding. These organizations distribute kits containing clean syringes and needles for heroin-injecting users, hygiene agents, and condoms. To get a new kit, users have to hand back used syringes and needles. The opening of supervised drug consumption facilities, where drug users can consume drugs in safer conditions with the assistance of trained staff was also planned, though progress in this area has been very slow. Finally, reintegration teams provide help with finding a job and housing for individuals undergoing treatment, aiming at easing their transition into society.
What were the results of drug decriminalization in Portugal? While slightly more young people try drugs, drug consumption is among the lowest in Europe. There was a decline in HIV infections and drug-related deaths. There was an over 60 % increase in the number of individuals undergoing treatment between 1998 and 2011, with most receiving opioid-substitution therapy. Finally, the percentage of individuals in prison for drug law violations has decreased from 44 % in 1999 to 24 % in 2013, and recidivism rates are low.
Overall, these results suggest that it is possible to win the war on drugs. The Portuguese strategy encompassed the creation of specific structures to ease the transition of users into treatment and later back into society. It had at its core the idea that drug addicts are not criminals, but rather patients who need help. This was a controversial view back in 2001. Perhaps, in some countries, it still is today. But it might be time for a change in paradigm!
Ana Moura is a Ph.D. candidate in Economics at Tilburg University and a member of the Nova SBE Nova Health Economics & Management Knowledge Center. Her research interests span the areas of health economics, applied microeconometrics, and health policy.
