Portugal shows the world how to deal with drugs

Previously unpublished , June 24 2009

Up and down the United Kingdom, on every working day of the year, harrassed magistrates shuffle the cards which the government has dealt them and hand out community punishments and anti-social behaviour orders and even jail sentences to the endless procession of drug users who stumble before them. It doesn’t work.

The UK still hits the high spots on European league tables for the use of illicit drugs and for the illness and crime which are linked to the blackmarket. And after more than a decade of Labour promises about treatment, UK drug users still drop out of under-funded and badly managed programmes like autumn leaves on a windy day. (See Sidebar, copy below)

On the second floor of a Ministry of Health building near the centre of Lisbon, a psychologist, a sociologist and a legal adviser sit as a specialist drug-control commission. They now deal with the drug users who once came before the courts. They don’t deal in punishments but in treatments, because the Portuguese have broken away from the global campaign of prohibition by decriminalising all drugs. And it works.

Eight years since the new system came into effect, on July 1st 2001, the Portuguese now have fewer people using drugs and far fewer drug-users suffering death and disease and inflicting crime and disorder on their communities. An influential report for the generally conservative US Cato Institute this year concluded: “The data show that, judged by virtually every metric, the Portuguese decriminalization framework has been a resounding success. Within this success lie self-evident lessons that should guide drug policy debates around the world.”

Portugal’s starting point was grim, symbolised by the notorious open-air supermarket at Casal Ventoso, in the western suburbs of Lisbon, where up to 6,000 users a day surged through the narrow cobbled streets while dealers paid 500 euros a day to rent a humbled terraced house from which to serve them. Opinion polls regularly revealed drugs as the public’s greatest source of anxiety. The rates of consumption, illness, death and crime rose steadily through the 1990s.

A commission of experts in 1997 urged the government to try a new approach, based partly on a humanitarian perception that it was simply wrong to punish people who were addicted and partly on a tactical belief that an open offer of help of all conceivable kinds would bring in users who were otherwise beyond reach. The Portuguese Socialist Party had to run serious political risks to take this new route.

From abroad, any possibility of legalising drugs was blocked by the aggressive opposition of the International Narcotics Control Board, which aims to enforce the US-inspired global policy of drugs prohibition. The Portuguese finessed this by leaving the law untouched, continuing to punish dealers but moving users out of the criminal courts so that their offence was treated as an administrative problem, like a parking ticket.

Within Portugal, there was opposition from every side. Vitalino Canas, who was the drugs minister from 1999 to 2002, recalls the leader of the the right-wing Popular Party predicting an invasion of foreign junkies while the news media, the police, the centrist Social Democrats and even his own Socialist colleagues were divided: “Everybody was divided because this was then a very new thing. We had no experience. We had no other references. Even the people who supported the reform had some doubts. This was a reform that was not well received by the people.”

Now, at the drug-control commission in central Lisbon, a poster advertises the policy: “Antes Tratar que Punir”. Preferring treatment to punishment, the commission is informal. Dr Vasco Gomes, the psychiatrist who chairs its hearings, looks like a student – young and bearded in an open-necked shirt and jeans. On an average day, he and his two colleagues will see five drug users, sent by police who have no power now to arrest users but instead issue notices referring them to the commission. There are no lawyers, no guards, no compulsion, just help. And, for heroin addicts, the core of this help is the free supply of the heroin substitute methadone.

Most addicts will be on a ‘low threshold’ programme which provides the methadone without any precondition. They are given as much as they need for as long as they want in order to reduce their involvement with blackmarket heroin, thus reducing the health risk to the user and the crime threat to the community. For those who are too chaotic to collect from a clinic, a mobile van will deliver the methadone to them. About a quarter volunteer to move on to the ‘high threshold’ programme in which they will attempt to stop all use of blackmarket heroin. In both programmes, the methadone will be part of a tailored package, which is likely to involve psychotherapy as well as practical help with employment or education or housing – all of which was previously unavailable to users who saw the old system as a threat.

Dr Antonio Costa, a psychiatrist who directs of one of the high-threshold programmes in Lisbon, has seen a significant change during his 22 years working with drug users: “When I began, my normal client was a 25-year-old who had been injecting for five years. Now, the mean age would be 35. Young people, in their early 20s, are very rare now.” In the same way, he says, he used to have patients who had been burgling and shoplifting to fund their habits but now he and two colleagues find no law-breaking among their clients.

He recalls the client from the old days who went into prison as a hairdresser with an unsolved heroin problem and who emerged as a highly skilled pickpocket who then funded his drug habit from the wallets of passengers at Lisbon airport. By contrast, he watched a more recent patient use the high-threshold programme to escape his heroin addiction, to get work and a family – and then to relapse and to lose the family, to return once more to the high-threshold programme, from which he regained his career although sadly not his wife and child.

“Highs and lows are frequent in the lives of addicts. People stay in the programme. There is a strong motive – to have a new life, a job and a house and some money. People can always leave if they want to, but it is very rare for somebody to fall out. Some go drug free after two or three years. Some will stay for ten years. We really do want to help them. People may like or not like drug addicts but they feel that they need help.”

Not everything in Portugal is perfect. While addicts have been drawn into treatment, the users of non-addictive drugs like cannabis and ecstasy still visibly buy and sell on street corners in Lisbon. While the notorious open drugs market at Casal Ventoso has been bulldozed, the head of the community centre there, Luis Coelho, says the change is superficial: “This place had a bad image and so they removed it, but there were a lot of bad problems, and they have not been solved. The people and the problems have just been moved to other places.”

Still the success is clear. Contrary to the predictions of its political opponents, the reform has not attracted planeloads of foreign users: 95% of those who come to notice are Portuguese. Nor has decriminalisation provoked a boom in usage. On the contrary, the bottom line figure for Portuguese adults (aged 15 to 64) who have used illicit drugs has fallen from 44.2% in 2001 to 31.2% in 2007. Within that, the figure for young people (aged 15 to 24), who tend to be the highest users, has fallen from 67.1% to 45.3%.

The health benefits are equally striking. Deaths in which heroin is found in the victim’s blood have been halved, falling from 281 in 2000 to 133 in 2006. Where a pathologist has ordered a blood test on a dead person, there has been a dramatic fall in the number revealing traces of any illicit drug of any kind, from 25% of tests in 2000 to only 9% in 2006. Drug-related disease has also improved. While HIV rates have been falling slightly in the population as a whole, the number of Portuguese drug users identified with AIDS has crashed downwards from nearly 1,400 in 2000, the year before the reform, to fewer than 400 in 2006.

The report for the Cato Institute concluded: “While drug addiction, usage and associated pathologies continue to skyrocket in many EU states, those problems – in virtually every relevant category – have been either contained or measurably improved within Portugal since 2001…. By freeing its citizens from the fear of prosecution and imprisonment for drug usage, Portugal has dramatically improved its ability to encourage drug addicts to avail themselves of treatment.”

The head of the Government’s drugs policy department, Dr Joao Goulao, says the policy of decriminalisation is now above political dispute: “We should have no right or left on this subject, just right policy and wrong policy.”

And, with that thought in mind, other countries have sent their specialist officials to inspect the Portuguese initiative. Even George Bush’s hardline drug tsar came and listened. One country has been conspicuous by its indifference: nobody from the UK government has ever asked the Lisbon government how it works.

** SIDEBAR STORY     By contrast with the pragmatism of Portugal, the UK is still bound by the ideology of prohibition. The police remain the primary agency dealing with dealers and users of illegal drugs; courts continue to use punishment as their only tool to change the behaviour of users; treatment remains focussed on abstention, refusing to recognise the value of prescribing methadone and diamorphine for as long as addicts need them.

The UK National Treatment Agency claims that in 2007/8, 202,666 drug users received treatment. However, this figure includes any user who had any contact of any kind, however brief. Only 82,381 of them actually then started ‘a treatment journey’. 17,941 of those dropped out within 12 weeks. 34,201 more of them dropped out, were kicked out, went to prison, moved away or died some time after 12 weeks. Some returned to treatment and finally 35,441 became what the NTA calls ‘successful discharges’.

But these success stories include 17,306 who were still using drugs when they completed their treatment and a further 10,811 who were still using drugs and were simply passed on to other agencies.

Of the 202,666 who started treatment, only 7,324 were finally recorded as drug-free – and that includes an unspecified number of users who were not using addictive drugs in the first place or who were officially registered as drug-free before they began their treatment.