20 Years of Data from Portugal: Drug Decriminalization

  

20 Years of Data from Portugal: Drug Decriminalization 

 It has indeed been more than 20 years since Portugal famously decriminalized all illicit drugs. Their reason had been a noble one: HIV infections from shared needles were rampant, and the country's existing policy which focused on criminalization and punishment had failed to make any dent in that. It was reasoned that if drug addiction was treated more like a disease and less like a crime, authorities would be more directly confronting the true underlying causes of the problem. So what's the verdict after 20 years? Some ups, some downs, a lot of praise and a fair share of criticism. Today we're going to have a look at the reasons for Portugal's big move, and whether it has accomplished them — according not to pundits, but to the data.

At the time, Portugal's drug problem was a relatively new and unique one. Since 1926, Portugal had been an isolated dictatorship with little tourism and almost no illegal drug problem. Then, with 1974's bloodless Carnation Revolution, the country was opened, and more significantly, all its soldiers were brought back from fighting colonial revolutions in Africa — and many of them brought back vast amounts of drugs and serious drug addictions. The whole country had a drug epidemic essentially dumped in their lap.

By 1999, only 25 years after the Carnation Revolution, Portugal had Europe's highest incidence of AIDS among intravenous drug users, accounting for nearly half of all AIDS cases in the nation. In addition, their prisons were filling fast, with over 40% of prison sentences handed out for drug-related offenses. They were throwing more and more drug users into jail, but it hadn't helped the AIDS problem. And so they launched their new drug strategy to decriminalize all illicit drugs, the first such program of its size and significance in the world. It's called the PDPM, the Portuguese Drug Policy Model.

It is important to note the difference between decriminalization and legalization. Legalization makes the product legal, and people can manufacture, sell, and use it. This is not what Portugal did. They decriminalized the use of all drugs; meaning there are no longer any criminal penalties for drug users, however those penalties remain for those convicted of manufacturing, importing, and selling drugs. Drug dealers are still subject to the same criminal penalties as before.

If this was a little bit of a misconception for you, well, that's the tip of the iceberg. There's a lot of misinformation about Portugal's decriminalization. If you're caught using, buying, or possessing drugs, the cop is not going to say "Hey, right on, enjoy! Have a good one," you are still in trouble. If you have more than 10 days of personal use worth, you're still going to jail. If you have less than that, your drugs are confiscated and you are issued a summons to appear before an administrative panel called a Commission for the Dissuasion of Drug Addiction. Nothing will go on your criminal record.

That commission consists of an attorney, a psychiatrist, a chemical dependency social worker, and sometimes a judge. They'll consider your history and your situation, and then render their decision. They may choose to let you go with no sanctions at all other than some advice to stop doing drugs, which is usually what happens to first time offenders whose cases are deemed low risk, and this is what the commissions do in the majority of cases. They can fine repeat offenders, but the fines are typically small and tailored to your ability to pay. They can sentence you to community service. They can suspend your professional licenses. They can ban you from going to certain places or associating with certain people. They can terminate any social assistance you may receive. They can confiscate personal property and cancel your firearms license. They can require you to report back to them. About the only thing they can't do is send you to prison. Getting caught using drugs in Portugal is no laughing matter; it is not a place where you can freely roll around doing drugs with no concern. They've simply restructured the punishments from those that are proven to prolong drug problems to ones that are intended to reduce them.

The primary architect of the PDPM was João Castel-Branco Goulão, a physician and currently the Director-General of the Service for Intervention on Addictive Behaviors and Dependencies. In designing the program, Goulão's central idea was that drug abusers are not criminals, they are ill, and should be treated as such. Goulão's commission recognized three principles around which the program was designed. The first was to not differentiate between soft drugs and hard drugs. It doesn't matter what the drug is; what matters is whether the user has a healthy or an unhealthy relationship with it. Second was to recognize that an unhealthy relationship with drugs is often a symptom of an underlying cause, which could be any stressful chronic challenge a person can face in life. Third was to note that an all-out war on drugs, to get all drugs off the street, is impossible and quixotic, and thus a losing strategy that would not be a part of the solution.

So, all that background brings us to the moment of truth, which is to turn to the data and answer our big question: Has it worked?

The most honest answer to this begins with an anticlimactic disclaimer, which is that any such statement like "Drug use has declined by xx%" or "New cases of AIDS are down by xx%" is incomplete and misleading. Implementation of the PDPM was not an overnight panacea for recreational and dependent drug users, it was a complex process fraught with conflicting policies and passionate differences among public attitudes toward it. Keep in mind that Portugal is heavily Roman Catholic, and the belief that there should be zero tolerance for drug use of any kind is predominant. Consequently, ever since the PDPM was put into action, public sentiment has been a mixture of deep moral repugnance toward it, and approval by those with public health in mind.

Much of the complexity arises from the fact that, as Goulão has pointed out, decriminalization alone — doing nothing else — makes the problem worse. It's an improvement only when partnered with the needed treatment resources, which are expensive and required Portugal to invest massively. That investment has had all kinds of challenges thrown at it. First, the United Nations threatened sanctions against Portugal for decriminalization, sanctions that would have struck at the heart of their already-limited ability to pay for it; but they managed to dodge that bullet. Next, the left-wing government that approved the PDPM was voted out and replaced with a right-wing government that only just barely decided to keep it in place. Then the global economic meltdown of 2008 made Portugal insolvent and it had to accept a bailout from the International Monetary Fund, which put it under more pressure from the United Nations to bring back criminal prosecution for all drug offenses. Since then Portugal has had to continue deep cuts in government spending across the board. Through all of this, the PDPM treatment and recovery services survived, though it's been a very rocky road.

Generally, at first the PDPM did work very well in addressing its primary goal: reduction of HIV infections; and that's basically the only reason the incoming government didn't stomp it out of existence in its infancy in 2002. And that trend has continued. The reduction of HIV cases has been its greatest success, and is about the only graph that shows a steady trend, going from 600 per year in 1999 to only about 10 today. Another, which goes without saying, is the percentage of new prison sentences that are for drug related offenses, which is down from Portugal's high of some 40% in 1999 to about on par with the rest of Europe, around 15% today.

But drug deaths? They have not improved. Part of the reason for this is that Portugal has always had low numbers for this, usually less than half of what it is in the rest of Europe. Deaths today are about the same as before the PDPM. Total rate of drug use has also not improved, also because Portugal was always pretty low. It's actually up a bit, again generally in sync with the rest of Europe.

Yet if you do an Internet search to see how Portugal's doing 20 years later, the results are almost universally positive. Much of the reason for this was an extremely influential report published by the Cato Institute in 2009, which was paid for by the Marijuana Policy Project, a US nonprofit that promotes legalization of marijuana. So we should expect the Cato Institute's report on Portugal to be biased in favor of the merits of decriminalization and legalization, and it was. Whether you agree with a position or not, you want it to be based on data, not on bias. In 2010, the Obama administration, faced with pressure to mimic Portugal's policy based on the Cato report, published a white paper listing a number of flaws in Cato's report. Following about a dozen bullet points, it concludes "It is safe to say that claims by drug legalization advocates regarding the impact of Portugal's drug policy exceed the existing scientific basis."

But we should not let the perfect become the enemy of the good. That Cato overstated the PDPM's positive impact doesn't mean the impact hasn't still been positive. It certainly hasn't solved everything, and has had little effect in many areas, but did put an enormous dent in the HIV and AIDS cases among heroin addicts. And in doing so, it has ended up saving Portugal a lot of money. When you take all the costs associated with drug addiction, everything from police and ambulance services, hospital treatment, social services, and so on, it was found in 2015 that social costs associated with drug use dropped 18% by 2010.

The best way to characterize the first 20 years of the PDPM in summary is to note that it has had some major, though somewhat narrow, successes. Importantly, it hasn't failed anywhere; all of its outcomes have been either favorable or neutral at worst. Portugal's policy was implemented in a resource-starved test environment, among a population with a strong element that opposes it. It was done in a country that had a drug problem that was unusual due to Portugal's unique history, and may fare better if implemented in some other countries, and may fare worse in still others. It has suffered from international pushback, but has also inspired plenty of international imitation. The results, as defined by a number of metrics, are not as good as many of us might hope for; in others, they are. But that it's been able to produce results ranging from positive to neutral, with really nothing in the negative, says a lot for it; and that it produced these results under tough conditions says more. It is a model that will work best in countries with a strong interest in public health and data-driven policy, and will likely not work as well in countries that value religion-driven zero-tolerance policies above public health. In that sense, Portugal's drug program is not too far different from many other innovations.