Lessons From Portugal: Drug czar comes to the RI State House

“Drugs are good — drugs are so good that they may become the only source of pleasure in one’s life.” Those may not be words that you would expect from someone in charge of a national drug policy, but Dr. João Goulão knows what he’s talking about. On January 9, a crowd of about 75, including several state legislators, gathered in the State House Library for a program called “How To Solve A Drug Crisis: Lessons from Portugal” to hear the drug czar reflect on the successes of the Portuguese approach to drug use and misuse, and what lessons we might be able to apply to RI’s drug crisis. Hosted by Rep. Scott Slater, the Center for Biomedical Research and Excellence (COBRE) on Opioids & Overdose, and the Substance Use Policy, Education and Recovery (SUPER) PAC, the educational event aimed to broaden attendees’ perspectives in terms of addressing addiction and overdose through a public health lens, rather than a criminal justice one.

In the ’80s and ’90s, 1% of Portugal’s population was addicted to heroin. Since adopting the new policy in 2001, overdose deaths are down 80% (the lowest overdose death rate in Europe) and drug-related social costs have decreased 18%. HIV rates, youth drug use and problematic drug use rates have all declined as well. When the program began, there were 100,000 heroin users in Portugal. Now, there are fewer than 50,000 citizens addicted to any drug at all, and of those, 30,000 are taking advantage of treatment options. In 2017, Portugal lost 38 citizens to overdose out of a population of 10 million. By contrast, Rhode Island lost 314 people in 2018 – under a policy as successful as Portugal’s, we may only have lost 4. 

The results are certainly clear, but what makes Portugal’s drug policy so successful? First, they recognize addiction as a public health issue, not a criminal one. It starts with education — children are taught from a very young age not necessarily that drugs are bad, but about sources of pleasure and how substances can play a role in pleasure-seeking behaviors. Along with evidence-based preventative measures, in 2001 Portugal became the first country to decriminalize the use and possession of all illicit drugs. [It’s important to note that “decriminalizing” and “legalizing” are not the same, and Portugal did not create any type of market industry for selling drugs, similar to how Rhode Island has decriminalized the use and possession of cannabis, without legalizing it for adult use.] In Portugal, when someone is caught with a small amount of drugs (the limit is based on 10 days of personal use), instead of being arrested, they appear before a Ministry of Health panel consisting of a psychologist, a social worker and a lawyer. The panel addresses what the patient’s needs are, if they are struggling with addiction, or what kind of difficulties they may be facing in life that could be causing them to use drugs. If they are struggling with addictive behaviors, they are able to seek help immediately, free of charge. 

This system effectively interrupts the pathway from recreational drug use to serious addiction and overdose. In fact, Portugal has built a comprehensive system of addiction care, funded by the profits of state lotteries, that offers tailor-made treatment and harm reduction services to anyone who would benefit, including those who struggle with addictions to alcohol, gambling and the like — all covered under their universal health care system. This program, known as the Service for Intervention of Addictive Behaviors and Dependencies, includes indefinite treatment despite repeated relapses (“We don’t give up, we are there…we don’t drop people”), as well as harm reduction measures to keep people safe, including safe injection facilities, drug checking sites and safer opioid substitution treatments like methadone and buprenorphine. And although Portuguese prisons aren’t as overcrowded as they used to be, even those that are incarcerated have access to these services. According to Dr. Goulão, the program is “cheap” to maintain, and well worth the investment. Despite some initial resistance from police and politicians, he says, now no one wants to go back to the way things were.

Of course, unlike Portugal, Rhode Island doesn’t have universal health care, and we do have fentanyl, which the Portuguese have not had the misfortune of dealing with yet. Portugal’s drug addiction issues are not as affected by the influence of pharmaceutical companies as ours are here in the US. Despite these differences, Dr. Goulão believes that in Rhode Island, we have all the tools to have a drug policy as successful as Portugal’s. If that is true, then what is stopping us from striving for the same sort of success? Is it Big Pharma, our dysfunctional health care system or just plain ignorance? According to Dr. Goulão, decision-makers need to hear the public voice in order to make a program like this possible in the US; a “bottom-up” approach to policy-making, he says, is critical for success.

Kudos to the organizers of the event, and to Scott Slater for taking the lead toward better drug policies in the RI legislature by recently sponsoring a bill to reclassify drug possession from a felony to a two-year misdemeanor. He, like so many others, understands that treating addiction as a health issue, rather than a criminal issue, will not only allow us to focus police resources on violent crimes and organized drug distribution, but more importantly, it would save many lives. Some may say that we can’t afford to implement a program like Portugal’s, but I would argue that we can’t afford not to.