Pubdate: Sun, 24 Sep 2017
Source: New York Times (NY)
Copyright: 2017 The New York Times Company
Author: Nicholas Kristof


Portugal treats addiction as a disease, not a crime.

LISBON - On a broken-down set of steps, a 37-year-old fisherman named
Mario mixed heroin and cocaine and carefully prepared a hypodermic
needle. "It's hard to find a vein," he said, but he finally found one in 
his forearm and injected himself with the brown liquid. Blood trickled
from his arm and pooled on the step, but he was oblivious.

"Are you O.K.?" Rita Lopes, a psychologist working for an outreach
program called Crescer, asked him. "You're not taking too much?" Lopes
monitors Portuguese heroin users like Mario, gently encourages them to
try to quit and gives them clean hypodermics to prevent the spread of AIDS.

Decades ago, the United States and Portugal both struggled with illicit
drugs and took decisive action - in diametrically opposite directions.
The U.S. cracked down vigorously, spending billions of dollars
incarcerating drug users. In contrast, Portugal undertook a monumental
experiment: It decriminalized the use of all drugs in 2001, even heroin
and cocaine, and unleashed a major public health campaign to tackle
addiction. Ever since in Portugal, drug addiction has been treated more
as a medical challenge than as a criminal justice issue.

After more than 15 years, it's clear which approach worked better. The
United States drug policy failed spectacularly, with about as many
Americans dying last year of overdoses - around 64,000 - as were killed
in the Vietnam, Afghanistan and Iraq Wars combined.

In contrast, Portugal may be winning the war on drugs - by ending it.
Today, the Health Ministry estimates that only about 25,000 Portuguese
use heroin, down from 100,000 when the policy began.
Continue reading the main story

The number of Portuguese dying from overdoses plunged more than 85
percent before rising a bit in the aftermath of the European economic
crisis of recent years. Even so, Portugal's drug mortality rate is the
lowest in Western Europe - one-tenth the rate of Britain or Denmark -
and about one-fiftieth the latest number for the U.S.

I came to Portugal to talk with drug dealers, users and public health
experts because this nation has become a model for a drug policy that is 
not only compassionate but also effective.

It's not a miracle or perfect solution. But if the U.S. could achieve
Portugal's death rate from drugs, we would save one life every 10
minutes. We would save almost as many lives as are now lost to guns and
car accidents combined.

This issue is personal to me, because my hometown in rural Oregon has
been devastated by methamphetamines and, more recently, by opioids.
Classmates have died or had their lives destroyed; my seventh-grade
crush is now homeless because of her addictions.

Many people are also coming to Portugal to explore what a smarter,
health-driven approach might look like. Delegations from around the
world are flying to Lisbon to study what is now referred to as the
"Portuguese model."

"This is the best thing to happen to this country," Mario Oliveira, 53,
a former typesetter who became hooked on heroin 30 years ago, told me as 
he sipped from a paper cup of methadone supplied by a mobile van. The
vans, a crucial link in Portugal's public health efforts, cruise
Lisbon's streets every day of the year and supply users with free
methadone, an opioid substitute, to stabilize their lives and enable
them to hold jobs.

Methadone and other drug treatment programs also exist in the U.S., but
are often expensive or difficult to access. The result is that only 10
percent of Americans struggling with addiction get treatment; in
Portugal, treatment is standard.

"If I couldn't come here, I don't know if I'd still be alive," Oliveira
told me. He said that he used to steal to support his habit but is now
getting his life under control. Two weeks ago, he began reducing his
dose of methadone, and he hopes to wean himself off opioids completely.

Yet Portugal's approach is no magic wand.

"I'm homeless and jobless and addicted again," Miguel Fonseca, a
39-year-old electrical mechanic, said as he held a lighter under a sheet 
of tin foil to turn a pinch of heroin powder into fumes that he smoked
to get high. He spends about $100 a day on his habit, and in the past
sometimes has turned to theft to support it.

Public health workers like Lopes may never be able to get Mario to give
up drugs, but she can help keep him alive. Seeing Mario, his blood
spattered on the steps from his constant injections, tottering off to
get more drugs, it was clear that the Portuguese model isn't as
effective as we might hope - but it occurred to me that in America,
Mario might well be dead.

Portugal switched to its health focus under the leadership of a
socialist prime minister named Antonio Guterres - and if the name sounds 
familiar, it's because he's now the United Nations secretary general. 
The new approach was a gamble. "We were facing a devastating situation, 
so we had nothing to lose," recalled Joao Castel-Branco Goulao, a public 
health expert and the architect of the policy ("our national hero," as 
one Portuguese cabinet minister told me).

So let's be clear on what Portugal did and didn't do. First, it didn't
change laws on drug trafficking: Dealers still go to prison. And it
didn't quite legalize drug use, but rather made the purchase or
possession of small quantities (up to a 10-day supply) not a crime but
an administrative offense, like a traffic ticket.

Offenders are summoned to a "Dissuasion Commission" hearing - an
informal meeting at a conference table with social workers who try to
prevent a casual user from becoming addicted.

Less than 100 feet away, Mario, the fisherman I began this story with,
was injecting himself with heroin and cocaine, and showing little
interest in Lopes's health outreach. He assured her that he wasn't
overdosing, and he scoffed at the idea of methadone as an alternative to 

Mario told me that he had started with heroin at age 14 (another man I
met had started at age 11), and used it during the two years he worked
as a fisherman in Massachusetts. "Portuguese heroin isn't as high
quality as American heroin," he complained. He then reached for a pipe
and began to smoke cocaine.

"How long have you been using?" Nuno Capaz, a sociologist and member of
the Dissuasion Commission in Lisbon, asked a 26-year-old factory worker
caught with hashish. They chatted, with Capaz trying to figure out if
the young man was in danger of taking up harder drugs. The dissuasion
board can fine offenders, but that's rare. Mostly the strategy is to
intervene with counseling or other assistance before an offender becomes 

"My main concern is the health of the person," Capaz explained
afterward. "Our approach is much closer to that of a medical doctor than 
to a court of law."

The public health approach arises from an increasingly common view
worldwide that addiction is a chronic disease, perhaps comparable to
diabetes, and thus requires medical care rather than punishment. After
all, we don't just tell diabetics, Get over it.

My sense from observing the hearings and talking to users is that the
Dissuasion Commission isn't terribly effective at dissuading. How
successful could a 15-minute session be? Then again, criminal sanctions
also seem ineffective at discouraging drug use: When scholars look at
the impact of crackdowns, they find there's typically little impact.

In the first year or so of decriminalization in Portugal, there did seem 
to be the increase in drug use that critics had predicted. But although
the Portuguese model is often described simply as decriminalization,
perhaps the more important part is a public health initiative to treat
addiction and discourage narcotics use. My take is that
decriminalization on its own might have led to a modest increase in the
use of hard drugs, but that this was swamped by public health efforts
that led to an overall decline.

Portugal introduced targeted messaging to particular groups -
prostitutes, Ukrainians, high school dropouts, and so on. The Health
Ministry dispatched workers into the most drug-infested neighborhoods to 
pass out needles and urge users to try methadone. At big concerts or
similar gatherings, the Health Ministry sometimes authorizes the testing 
of users' drugs to advise them if they are safe, and then the return of
the stash. Decriminalization makes all this easier, because people no
longer fear arrest.

So how effective are the methadone vans and prevention campaigns? I
thought I'd ask some real experts: drug dealers.

"There are fewer customers now," complained one heroin dealer in the
gritty Lumiar neighborhood. Another, Joaquim Farinha, 55, was skeptical
that methadone was costing him much business. "Business is still pretty
good," he said, interrupting the interview to make a sale to a
middle-aged woman.

(Portugal's drug market is relatively nonviolent and relaxed partly
because of another factor: Handguns are tightly controlled.)

On balance, the evidence is that drug use stabilized or declined since
Portugal changed approaches, particularly for heroin. In polls, the
proportion of 15- to 24-year-olds who say that they have used illicit
drugs in the last month dropped by almost half since decriminalization.

Decriminalization also made it easier to fight infectious diseases and
treat overdoses. In the U.S., people are sometimes reluctant to call 911 
after a friend overdoses for fear of an arrest; that's not a risk in
Portugal. In 1999, Portugal had the highest rate of drug-related AIDS in 
the European Union; since then, H.I.V. diagnoses attributed to
injections have fallen by more than 90 percent and Portugal is no longer 
at the high end in Europe.

One crucial mistake that Portugal did not make was to follow the United
States in adopting prescription opioid painkillers for routine use.
Adalberto Campos Fernandes, the health minister, said that Portuguese
doctors resisted overprescribing and that regulators also stood in the way.

Another factor that has benefited Portugal: The economy has grown and
there is a robust social fabric and safety net, so fewer people
self-medicate with drugs. Anne Case and Angus Deaton of Princeton
University have chronicled the rise of "deaths of despair" and argue
that opioid use in America in part reflects a long-term decline in
well-paying jobs for those with a high school education or less.

Portugal initially was scolded around the world for its experiment, as a 
weak link in the war on drugs, but today it's hailed as a model. The
World Health Organization and American Public Health Association have
both praised decriminalization and a public health focus, as has the
Global Commission on Drug Policy.

One attraction of the Portuguese approach is that it's incomparably
cheaper to treat people than to jail them. The Health Ministry spends
less than $10 per citizen per year on its successful drug policy.
Meanwhile, the U.S. has spent some $10,000 per household (more than $1
trillion) over the decades on a failed drug policy that results in more
than 1,000 deaths each week.

I've been apprehensive of decriminalizing hard drugs for fear of
increasing addiction. Portugal changed my mind, and its policy seems
fundamentally humane and lifesaving. Yet let's also be realistic about
what is possible: Portugal's approach works better than America's, but
nothing succeeds as well as we might hope.

The hilly Casal Ventoso neighborhood of Lisbon was ground zero for
heroin in Lisbon 15 years ago, "a wall of death," remembered Paulo
Brito, 55, who has been using heroin since he was 15.

Brito weaned himself off drugs with the help of health workers and
remained "clean" for 10 years - but relapsed a year ago, and I met him
in today's Casal Ventoso. There are fewer overdoses now, but it is still 
littered with hypodermic packages and other detritus of narcotics, as
well as a pall of sadness.

"I've hit rock bottom," Brito told me despairingly. "I'm losing the
person I most love in the world."

His girlfriend, Teresa, is begging him to give up heroin. He wants to
choose her; he fervently wants to quit. But he doesn't know if he can,
and he teared up as he said, "It's like entering a boxing ring and
facing Mike Tyson."

Yet for all his suffering, Brito lives, because he's Portuguese. The
lesson that Portugal offers the world is that while we can't eradicate
heroin, it's possible to save the lives of drug users - if we're willing 
to treat them not as criminals but as sick, suffering human beings who
need helping hands, not handcuffs.
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MAP posted-by: Matt