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.