Pointers from Portugal on Addiction and the Drug War
nytimes.com
nytimes.com
- The main public opinion driver for both the needle exchange programs and the decriminalization was a _massive_ Heroin epidemic which lead to an HIV, Hepatitis B/C, AND Tubercolosis epidemic, the last one of those is particularly airborne contagious. I often see the lumping of 'heavy' drugs but (although decriminalized) Cocaine consumption in Portugal was marginal at the time (mostly because the majority of the population couldn't afford it). The main precipitator was Heroin consumption.
- These programs served as a 'trojan horse' anchor point to bring these, often homeless/missing, people back into the healthcare system. For added controversy for the americans out there, healthcare is universally free in Portugal.
- There was a clear rupture point both in crime rates and the prison system capacity due to the heroin epidemic. Police forces could no longer be bothered with the 'noise' of the numerous small possessions of 'non-heavy' drugs like haxixe or marijuana. Offloading that to mental health practioners was also logistically useful for law enforcement.
- It took a considerable amount of additional healthcare funding for these programs to be implemented. This would _not_ have been possible for an economy like Portugal without supplementary funds from the European Union economic development programs.
- I am very suspicious of the counter-argument insinuation that the program initially _caused_ an increase in crime rates and consumption, because the start of the program also matched the start of a fairly large economic downturn. The main idea of the program was that people could go and ask for help, without the fear of being put in jail. If you have a desperate person, willing to do desperate things, not pushing them against a corner is usually a good policy for crime rates.
I grew up in one of the "drug towns" of the late 80's/early 90's in Portugal. It was bad, really bad. There wasn't any extended family without a drug problem. That generation, bornt after the 1974 revolution, now in the mid 40's, was almost erased from there. Some died and those remaining, after a life of petty crime and prison, eventually escaped.
Completely agree with your comment. I would just add another relevant factor to the roll: decriminalization gave even more visibility to the addiction problem and newer generations didn't like what they saw. It wasn't cool to use drugs anymore.
I had a friend begging for help with treatment and the only in patient place at the time for substance abuse in the area had an 8 week waiting list... and you had to pay your way so unless you had a family/friend with extra resources you were on your own.
We wonder why the drug problem still exists in this country where we punish those struggling instead of help them.
I’ve got an older friend who did a lot of drugs back in the day, but got his life mostly figured out until a few years ago when he had to get shoulder surgery. Prescribed Oxy for recovery, even after telling the surgeon about his past addiction struggles. As expected, they become less effective over time, he likes getting high, so he starts taking larger doses. Gets to the end of his prescription and can’t get a refill.
Did he make bad choices here? Definitely. But then the health care system screws up:
“I want to detox and get clean again.”
“Sorry, you’ve never overdosed, so you can’t detox in the hospital. Maybe you can get on a waiting list for a private (out of pocket) facility. Oh, and no refills, you’re an addict”
“Maybe I can be a short-term patient at a mental health facility?”
“Sorry, you’ve never tried committing suicide because of your drug use. Maybe you can get on a wait list at a private facility? Oh, and no refills, you’re an addict!”
So... what does an opioid addict who is in withdrawal and can’t get support from the health care system do? Goes and scores some heroin...
Today he’s mostly clean again. I think he pops a pill here and there but isn’t high all day. But... this could have all been avoided. The health care system had many opportunities to help out here, but didn’t.
Edit: one last note: the private facilities are quite expensive and have massive waiting lists. Even if he had had the cash to go, he would have still been in limbo for weeks-to-months with no access to clean drugs nor support to get clean.
I can believe this. My father used to tell me that drugs like heroin have recurring waves of popularity, because when a dangerous drug becomes popular enough, the Russian roulette aspect becomes so obvious. Everybody knows somebody whose life has been ruined by it. When a drug becomes niche, the few people you know who use it might be handling it okay (or early in their trajectory with the drug) and their experience with it can look cool and attractive. He also said his generation was the last one where basically everybody had seen firsthand what heroin could do to people, but he was optimistic that it had "killed enough famous musicians" that it couldn't come back. That was in the 1990s, so....
Just skimming, I see 21 links to other sources. I haven't clicked through on all of them. It appears to weigh various pros and cons. It seems even handed to me on a quick skim.
Further, the NYT has many sections and voices. This piece is specifically from from The Upshot which has this tagline: "Analysis that explains politics, policy and everyday life, with an emphasis on data and charts."
And this specific piece is written not by a reporter, but by a expert in the field: Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health.
I appreciate the rest of your comment.
It is great that they paint a positive picture of Portugal as a forward-thinking progressive nation, the point that Portuguese people often take an issue with this and other pieces, in american and british press, is that they fail to explain the motivation behind this policy.
These measures were not a hippie social experiment, they were created out of a desperate lack of alternatives in the face of a de facto public health crisis due to a heroin epidemic.
I cannot put in words that make it justice, you had entire neighbourhoods become drug slums with hundreds of heroin dealers and people inject on the sidewalks in broad daylight. It was crime problem, it was a health problem, it was a whole generation of people lost to this. It's this omission in the 'why' of decriminalization that feels somewhat dishonest.
I'd also add that there is still a Heroin problem, albeit diminished. It is not unusual to see someone walking though the local village, out-of-their head drunk at 9am on a Wednesday. It isn't alcohol though, it's Heroin. But it is also an economically poor area. The weather is amazing and the place is gorgeous, but for someone raised here who doesn't manage to escape it can also be a trap. Many of the older people work in the fields in the morning, the in the late afternoon they meet in the cafes and chat about village life. Coffee is $0.15, a beer is $0.7. There a very few younger people. Those that can leave have left for a city. The ones who remain are that ones who were not able to leave. I spoke with the local President last week and he himself said that the area has become a skills desert.
So yes, I think the route to Heroin addition looks something like this. Get financially stuck in the local area. Get a bad reputation for being lazy. Try to become YouTube/Insta famous. Give up. Turn on those that tried to help. Drink & smoke weed as an escape. When those stop working try Heroin. I know a couple of people in my village that are on this path right now.
There is some crime here. It seems to fall into two categories. First is petty crime where something goes missing that's worth about $100. That's enough to quickly sell for immediate cash (likely for some form of drug). This has happened to me twice, and I don't really mind.
There is more 'organised' crime where a place gets methodically burgled when someone is away. I know people this has happened to.
There is a rapidly growing contingent of foreigners here now, and we're mostly accepted. Economically, I get the impression that most businesses prefer to deal with the foreigners. Even the guy that sells firewood says that 95% of his customers are now foreigners, and that he prefers it that way. There are lots more foreigners arriving too (leaving cities due to covid, basically), very few Portuguese people being added. Most people in my village are over 60. It'll be interesting to see how the demographics play out over the coming years.
Anyway, maybe that is of some interest. The region of Portugal I am in is Castelo Branco. I'm starting an ISP here too: https://gardunha.net
The situation is not perfect, and will never be, but is a LOT better than before! Portugal is a lot safer. The crime that you talk about is probably not drug related and probably not local people. Just read the news. Did you find any place to sell used things? No except for gold.
And if you find someone "drunk" at 9am you bet he is drunk lol "evita a ressaca, mantente bebado" something like "void hangover, stay drunk" every village has a chronic drunk! Maybe now the biggest problem is alcool, not heavy drugs. Why do you think police stop people at 9am and force them to do an alcohol test? They are drinking since 6am!
Regarding your ISP. Your target is people in a rural area? In one of the most less dense population area in Portugal? I will be waiting for the pricing. Good Luck.
People "gouching out on smack" do not look like they are drunk, so I think you're correct.
> most businesses prefer to deal with the foreigners.
Businesses prefer to deal with costumers able to pay more (or quicklier) for the same services/products.
(edited - typo)
20ml is a very small amount of beer. Maybe you meant something else?
There were politicians that publicly spoke about their personal experiences. Others that had family members that were caught up with it.
It was a widespread issue across all classes, not just the poor.
Here's a recent interview about one of the main drivers of this policy (in Portuguese).
It seems like these problems are not directly caused by the drug, but by the fact users cannot buy clean medical grade with a safe method of administration. Portugal model doesn't seem to address that, but only makes consumption slightly more "comfortable" to the users.
This is true, but you're saying something different than what you started off saying.
I agree with you that the government should be supplying heroin to addicts, and if you're decriminalizing drug usage, there's no reason that you shouldn't be doing this. A doctor having the ability to monitor addicts under their care would give us the means to keep them happy and productive, and to make sure they can get off the drug when they're willing to risk the effort.
In general, the main drug-related vector for disease is needle sharing. Most pathogens wouldn't survive long in the actual heroin, and it's not clear how they'd get there in the first place.
In principle only.
In practice: how much have you spent on dentist bills in the past year?
It’s free in practice.
It's not by accident that Portugal has oral health on par with the poorest Eastern European countries.
> But Portugal’s experience is often misunderstood. Although it decriminalized the use of all illicit drugs in small amounts in 2001, including heroin and cocaine, that’s different from making them legal. And it did not decriminalize drug trafficking, which would typically involve larger quantities.
> Portugal’s law removed incarceration, but people caught possessing or using illicit drugs may be penalized by regional panels made up of social workers, medical professionals and drug experts. The panels can refer people to drug treatment programs, hand out fines or impose community service.
> A lot of the benefits over the years from Portugal’s policy shift have come not from decriminalization per se, but in the expansion of substance-use disorder treatment. Such a move might bring the most tangible benefit to the United States.
The war on drugs is a make-work jobs program for people who can't build anything useful. Relative to skill, these are well-paying stable jobs.
[1] https://upload.wikimedia.org/wikipedia/commons/thumb/4/48/U....
Buprenorphine has saved my life and I wish everyone could have access to it and that it would be provided for free. Pay for it from grabbing back cash from the Sackler's.
I'm surprised in the article the phrase 'less than half' which sounds like it's on the higher end towards 50.
I would have guessed much lower. I can't find a great source but this has some numbers [1]. Says only 36% of rehabs have access to at least one replacement therapy.
And that's people who can access rehab...
To be able to prescribe Suboxone - from what my Dr. has told me - MDs have to have a specific DEA certificate. And they limit the number of patients one single Dr. can treat at a few hundred.
In my state there aren't many prescribers - not nearly enough for the number of addicts. And I live in a liberal state.
It's easier for Drs to dole out opiates than prescribe buprenorphine.
We can also learn from Portugal in more community and healthcare intervention.
The big problem here to get there is that DAs, sheriffs, mayors are elected and there are 50 states. We will need to shift public opinion everywhere to make meaningful progress outside of big cities. Plus with Barr's Justice Department catholic radicalization who knows what happens if they get another 4 years.
It's gross that in America those who are poor, BIPOC, are far more likely to have their lives ruined by unequal drug prosecutions.
If we ever start treating addiction not prosecuting it, I hope we'll do better than marijuana and clear old records/convictions for small drug possession.
https://nam.edu/improving-access-to-evidence-based-medical-t...
That example would probably be called a vicious cycle, rather than a virtuous one. ;)
And it is virtuous from the perspective of those entities profiting from the above cycle...
Definitely can from methadone especially mixed with a benzo
for sure people sell it but they're going to use with or without it.
studies have shown that those who don't get long time sober and do replacement therapy on and off nonetheless have longer periods of abstinence and lower death time frames (not sure how to phrase that they dont die as much/soon)
in a lot of ways it would be safer. clean, known dose, less theft to pay for drugs, less violence no cartels
buprenorphine + naloxone is nothing like methadone
suboxone has few to none of the externalities of methadone
just in general with drugs and treatment we would be so much better off if those who force their personal values upon others had some sympathy and compassion
Eg Americans today smoke a lot less tobacco and drink less coffee too. Education works!
Government propaganda, a good deal of it channelled through TV and Hollywood have so thuroughly established unrepentant drug users as villians that many people want it prosecuted on its face for its immorality.
Lawmakers find it difficult to let up on drug crimes because they are quickly painted as weak and enablers of other crimes. It's the same tirh the death penalty. The problems with it are plain for all to see. But lawmakers feel the need to signal the virtue of "justice" or "strength" and enough voters still respond to that signal. Even in the supposedly lefty stare of Washington where I reside, progress on criminal justice issues has been glacially slow.
The “solution” of locking someone up and then walking away is easier than it is to help someone, work through relapses and end up with a healthy individual after X years. The latter is obviously better, and cheaper, but it costs patience and empathy. Things that are in short supply these days.
Really? Curious about this, because everyone around me (including me) drinks a metric crap ton of caffeine, either in tea, coffee, or energy drinks.
Coffee consumption has dropped more than 50 percent in 70 years https://www.outsidethebeltway.com/u-s-coffee-consumption-had...
Why??
A nice upside to remoting.
Still quite a lot of coffee, but it tastes much better.
Also, in recent years total coffee consumption started to increase again, driven by hip coffee shops.
It's hard to win against billions in marketing.
https://www.ers.usda.gov/amber-waves/2007/june/coffee-consum...
https://qz.com/quartzy/1287862/american-coffee-consumption-i...
Are there any scientific facts which would back this?
To me it feels like there have been several other causes to that which were much more relevant. Not allowing people to smoke inside, vaping and smoking getting "out of fashion" were much more successful.
It's just not cool anymore and those who still want to smoke are being confined to disgusting places to do it. Soo...it kinda works against your argument because it was a bad example. The only thing we may take away from it would be that if we'd have made smoking tobacco illegal everywhere, it would have remained cool to do so secretly...maybe.
https://247wallst.com/special-report/2019/06/19/price-of-a-p...
Other things (bans on ads, bans on smoking in venues, health information) do help, but they're a smaller part of the picture.
The decline started decades before vaping and bans on smoking inside. It started when the message changed. In the US "peak smoking" occurred in the 1960s and consumptions has been decreasing ever since [1]
[1] https://www.ncbi.nlm.nih.gov/books/NBK294310/figure/ch2.f1/
National culture plays a huge role in what vices people take on.
Consumption per capita up here in the wonderful Nordics is quite high, with Finland typically leading at 12 kg/person. The corresponding number for the US is around 4.2 kg (9.3 lbs). The Telegraph has a fun list [2] showing the top 20 consumers.
[1] https://www.cbi.eu/market-information/coffee/trade-statistic... [2] https://www.telegraph.co.uk/travel/maps-and-graphics/countri...
The food is soooo sweet, sugar, sugar and sugar everywhere.
Other places like Salzburg are different in so many ways. Viena has always been a political, bureaucracy center.
Cafeterias in Viena are political institutions, you can imagine Freud or Lenin or Stalin, Stefan Sweig, Carl Jung, Hitler, Marx, Goethe, just there, because they went there.
This is history now. But I agree that it was very bad, it was part of Austria's "coffee house culture" to have the stale smoke odour everywhere (furniture, curtains etc.). It was much worse in the 80's and earlier though.
The sugar addiction is mainly due to the influence of bohemian cuisine and popular sweet snacks like "Manner Schnitten".
Practically everyone around me thinks they need caffeine to get through the day. I'm one of the only people I know who are caffeine-free.
Long ago, I thought caffeine gave me headaches, and I refused to drink it. Then I started having trouble staying away during the day and nothing the doctors did mattered. So I turned to caffeine reluctantly, and it helped for a while. Eventually I was drinking so much caffeine each day that I was getting sick from it.
So I cut back, and then I was falling asleep during the day again. (Or at least feeling exhausted and that I needed to sleep and kind of took a waking nap.)
So I cut off the caffeine again and, no big surprise, it's the same as when I was drinking caffeine. Except that I don't get any caffeine-withdrawal headaches when I can't get enough or forget to drink enough.
I know from the past that telling people they don't need caffeine doesn't work, though. They just won't listen. They have to figure it out themselves.
So yeah... If there's an anti-caffeine education here, it's very subtle.
Is this a good thing?
In America, the worse year of the opioid crisis killed ~65k people from my recollection. The "real pandemic" killed that many americans in the past 2 months. Am I misunderstanding something?
Edit: I cannot spell.
https://www.cdc.gov/media/releases/2020/p0318-data-show-chan...
Another interesting tidbit is that the Netherlands did not in fact legalized cannabis. They just decline to prosecute that crime. There's no legal framework to regulate its sale, like for any other consumable good.
This leads to silliness like people in "coffee shops" being allowed to smoke weed, but not tobacco since that is regulated for all indoors venues.
This can be seen in the fact that use is usually a crime. There are no other substances, however nasty they might be, that are a crime to drink/eat/inject. To me this elevates the use of drugs to some sort of sin for, really, arbitrary reasons.
This makes taking a pragmatic and facts-based approach difficult.
It is a country far from perfect, but the people are nice, the cuisine is excellent, the weather is amazing and it is consistently moving in the right direction.
It is said that after the housing bubble burst around 2008 that there was very little “liquid” cash floating around and that dark money from drug trafficking was one of things that helped the US from going completely under.
Add to that all the covert operations to overthrow governments and bribe crooked foreign leaders that require vast sums of money that doesn’t leave a paper trail.
The “war” on drugs is too keep drugs illegal and to sustain the flow of dirty monies.
Also, does anyone remember the name of the doctor that started this whole movement? I think the first name is João, but I can't remember or find it. I might be tripping, pun intended.
He even gave a recent interview about all this.