Dissuasion — the Portuguese Approach

Traveling with a group of legislators last week, I had the opportunity to sit down for an extended discussion with the Vice President of the Commission for the Dissuasion of Drug Addiction of Lisbon — Nuno Capaz.

In 2001, Portugal reviewed and completely revised its approach to combatting drug addiction, shifting away from a punitive approach to a public health approach. It appears that they have reduced some of the harms of drug use without increasing drug use.

They consolidated all of their efforts to help people with addiction under a single public-health-oriented umbrella agency and now rely heavily on treatment, often medically assisted treatment, for people with opioid addiction.

They have not legalized drugs. Convictions for drug sales still result in imprisonment.

But possession of drugs for personal use is no longer a crime. It is still illegal and can result in fines and other penalties, but those fines are not imposed by the courts. Instead, when a person is found in possession of an illegal drug, they are sent to the Dissuasion Commission.

The very name of the agency, “Dissuasion Commission”, says a lot about how Portugal has chosen to view drug addiction.  The central goal of their policy is to reduce drug use, but they want to dissuade users — to help users change behavior instead of punishing them.  The DC focuses its attention on the chronic users who have substance use disorders. It seeks to get them into treatment voluntarily.

If a person simply refuses to work with the DC, the DC does have the ability to increase pressure. They can levy fines and if the fines are unpaid can then take the property of the user — for example, their cell phone or their stereo or their game box. Usually the threat of taking away toys is enough to engage the user.

They frequently offer methadone and suboxone as treatments. These are both drugs that, when properly prescribed, are not intoxicating but allow people to function without experiencing the cravings that result in relapse. Their view is that these drug treatments, while not entirely ending abuse of other drugs, have big benefits in behavior change. These treatments are also much cheaper than residential treatment. And, indeed, medically assisted treatment is much more consistent with the emphasis on voluntary treatment — users will take these drugs much more readily than they will enter residential programs.

In the United States, we spend a lot of money locking up drug users — sometimes in prison for the crime of use or more commonly in some form of compelled residential treatment. Many U.S. leaders are not comfortable with the idea of giving people drugs to get off drugs. When users seem to be unable to control their drug cravings, many leaders feel better about physically restraining the users than about giving them drug treatments to reduce their cravings.

Mr. Capaz ridiculed these punitive, moralistic thought patterns. We do not, he pointed out, lock up overweight people who cannot control their food intake. We do not lock up people who insist on smoking their way to lung cancer. Instead, we offer them drugs that work to help them control their behavior.

I came away from the conversation with deeper conviction that we need to make medically assisted treatment more available in Massachusetts. Decriminalization is a step that we should not be afraid to further consider.  I believe it would make it easier to reach users and give them help — the threat of incarceration pushes them into the shadows.

Published by Will Brownsberger

Will Brownsberger is State Senator from the Second Suffolk and Middlesex District.

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38 Comments

  1. I have long been championing Portugal as a model for addressing substance abuse. Thank you for the thoughtful consideration.

  2. It should have been done many years ago in the U.S. The war on drugs has always been lost and will never be won. There is just to much money in it. The benefits in decriminalization in the crime rate, domestic abuse and enhancing the stability of third world countries like Mexico would be world changing. The savings to the domestic economy in law and border enforcement could easily fund treatment.

  3. So the police in Portugal still prosecute drug dealers and still bust down doors to get at illegal drugs.

    Drug users are still arrested but go to a re-education camp instead of to a court.

    Portugal, the star of Europe. Maybe we should all move there.

  4. I had read about this interesting program in Portugal, so it’s great to get your feedback based on first-hand exposure to it. I agree with your conclusions, and if we can just divorce morality from the debate, we might be able to move to a more constructive, effective solution here too the way we eventually did with gay marriage.

  5. I don’t have an issue with this – But I think we can also build on current state hospital sites – drug rehab communities where they are not prisons but they can not leave the grounds freely either. Just something in the middle – a drug treatment center that is not a prison. For Example the Fernald School in Waltham is a perfect place for such a rehab or assistance center. Medfield state hospital – We have many areas that can be reutilized and should also stay in the hands of the state instead of being given off to the private interests

  6. Let’s not allow Boston to become San Francisco. The idea on its face has some merit, but it’s a fallacy to compare food addiction to drug addiction. Obesity affects the individual almost exclusively. Drug addiction often results in behaviors that negatively impact others in addition to the individual. I see this behavior on what has become a daily basis where I live in the Fenway.

    1. With respect, obesity does affect all of us, too. Indirectly, through tax dollars paid to Medicaid and Medicare, is one of the ways. I agree that we need to make careful policy choices, but the main difference between food addiction and opioid addiction is that there are alternatives to pain treatment, but there are not alternatives to food. The difference you stated is not really correct.

  7. This seems to be a reasonable and effective way to deal with addiction crisis. Putting people with addictions in prison is condemning them to a lifetime of addiction.

  8. I favor a year trial program, anything to
    Cease this terrible plight.

    Drug dealers should be convicted, illegal
    immigrant should be deported. Huge effort
    Should be made as a first step to eliminate
    The drugs.

  9. Fascinating angle, Will.
    Thank you for bringing this approach to the table for consideration, Will.
    Deeply appreciated.

  10. I have, for years, advocated for legalizing all drugs thus taking distribution out of the hands of criminals. Prohibition didn’t work in the 1920’s; drug prohibition isn’t working now. Putting people in prison for using in no solution.
    This seems like a sensible middle road approach.
    I hope that Massachusetts can see clear to adopting this approach.

  11. What should be done about athletes such as josh Gordon and Arron Hernandez smoking marijuana before football games as early as age 14? Is it their responsibility to overcome drugs when coaches and teammates ignore it? Team sports are supposed to help kids stay away from drugs. Why should government instead of Purdue pharma pay for rehab? Ignoring drug use and addiction is not kind or solving a problem.

  12. Will, Thank you for your (customary) thoughtful and utterly reasonable approach to a difficult subject. I love the idea of removing the social stigma, and attending first to the needs of our addicted “fellow-passengers to the grave”, per Charles.Dickens. It truly sounds as if Portugal is on the right path, which I hope we’ll not be too proud to adopt.

  13. I’m glad to see you pursuing this line of inquiry. I fully support decriminalization of all drug use, or even strictly controlled legalization. I suppose this is mostly a Federal issue, but whatever the Commonwealth can do I support.

  14. Thanks for posting this. A group of my grad students at Brandeis did their group project as a comparison between Portugal and US approach to drug abuse. It was very revealing and did not make the US look good. This was 4 or 5 years ago.

  15. Very interesting approach. What we are doing is certainly not working. I appreciate your thoughtfulness around these issues.

  16. Thank you, Will, for your thoughts and insights. Why don’t we at least try other approaches since the ones we have in the US don’t seem to work?

  17. I applaud this attitude and practice with its emphasis on disease and not punishment. Thank you Will for as usual being the most empathetic person in the room. And I hope it is something that we can achieve in the future.

    However I am very concerned about how we are preceding currently with the great difficulty for addicts to even access Suboxone. Doctors are unable to prescribe it because the extra training is considered onerous and therefore most do not bother doing so. The few places that do provide Suboxone outside of a normal doctor or Hospital setting are a source of concern because some of them are ignoring the rules put in place for prescribing Suboxone. For example, in Arlington there is an office that will give out Suboxone without the required therapy that the state generally links to the prescription.

    Suboxone is a medicine that includes the equivalent of Narcan the drug now famous for opiate overdoses. The addition of naloxone or “Narcan” can be a problem because there are serious interactions with alcohol.

    However, none of these are good enough reasons to require Health Care Providers to go through the separate training program. Subutex, the one without Narcan, is sold on the street for people to get high or too mitigate feelings of withdrawal. This is the usual approach to Addiction in the United States where the treatment is either unavailable, distant or creates a financial burden on the addict.

    Below is a quote from the New York Times regarding the other benefits of Suboxone or Subutex. Amazingly it has been shown to be and antidepressant for certain people who have not responded to the battery of antidepressants we currently have. I am intrigued by this Theory and argument because until we treat the underlying depression that many addicts have we will only be fighting an uphill battle.

    “A medication that modulates the opioid system, buprenorphine, already exists, but is approved for the treatment of opioid addiction. Its actions are incompletely understood, but it is thought to block the opioid receptors that cause depression and only partly activate the receptors that enhance feelings of well-being, thereby blunting the high of drugs like morphine.

    Whether buprenorphine will prove to be an effective and nonaddictive treatment for depression is unclear. Small studies of patients unresponsive to regular antidepressants have been encouraging — including a recent one in which very low-dose buprenorphine given for four weeks reduced suicidal thoughts in dangerously depressed patients. “

  18. I think Portugal proves that decriminalization and drug treatment can provide a more effective, more affordable, and less harmful way to combat drug use. I hope we can bring some of those ideas to MA.

  19. what has happened to personal responsibility and families to take care of ones behavior?

    We are all responsible for the choices we make. No one ( other than children born from drug addicted pregnant women) are born addicts. Poor souls.

    I think government would
    Be better served to educate and put into place opportunities to forstall one from becoming addicted then to coddle folks with additiction.

  20. I agree with changing the approach to drug addiction in this country.

    There is so much the general public doesn’t understand about the effects of opioids.

    I think if we understood it more, we would be more understanding of people who have problems that we don’t share.

    PBS’s Nova has a new movie: “Addiction” that has some very interesting information https://www.pbs.org/wgbh/nova/video/addiction (53 minutes)

    I just don’t know why so many medical treatments in this country seem to cost at least 3 times what it costs in other countries?

  21. If you haven’t seen the Michael Moore film “Where to Invade Next”
    you should. Portugal drugs policy is mentioned.
    In the film Moore visits a number of countries and examines aspects of their social policies that he suggests the United States could adopt.
    Interestingly some of these policies were initially started in the U.S. but then abandoned. Go to Wikipedia “Where to Invade Next” and
    see the Resume.

  22. We had a walking tour of Lisbon and our guide also spoke of this program and its success. I hope we have the will and common sense to adopt these strategies.

  23. I would suggest judges in Massachusetts start looking at drug dealing as a crime and not a way to support families. Lock up the dealers. I also believe that politicians should not have been looking at Marijuana as a revenue generating recreational drug. This sends mixed and confusing messages to our youth. Marijuana could have been limited to a medicinal drug. There is so much hypocrisy when it comes to politicians caring about the drug use of our youth.

    1. Check out the resources links — overall the numbers look good. Most people we talked to feel that the problem is much better controlled.

      I think that there a lot of variables in that situation, but it seems like a win overall.

  24. thank you, Will. This makes a great deal of sense to me.
    Punishment has not acted as a deterrent and hasn’t made a difference in drug use in the US. Please encourage our MA legislature to read aand act on this idea.
    Thank you for the work you do.

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