We Are Not… -Peter S Kibbe, MD FHM

One often hears or participates in a political discussion about a problem we suffer in the United States which appears to have been improved or solved in another nation.  One side proposes that we adopt what country X has done to solve our problem.  The other side often counters with what is really not an argument but a non sequitur stating, “We are not country X.”  While true that we are not country X, the fact that we are not is an invalid argument within debate.  Embodied in that statement however, is the notion that:  a) we are unique and special, b) we are incapable or politically incompetent to confront the issue, or c) the problem is highly damaging to most of us but is producing great sums of money for a few individuals, and well… “We are not country X.”

I point this out as preface to a discussion of the success of the relatively poor country of Portugal in addressing its opiate abuse epidemic.  Their results in dealing with their own epidemic of opiate-related deaths has been only superficially exposed and virtually ignored by our corporate media. Yet from Portugal’s example we might learn striking and relatively simple lessons to put a halt to our opiate-related epidemic of death, and curb the associated medical pathology and social pathology.

During the 1990’s Portugal saw a rapid increase of opiate addiction and opiate-related deaths, mostly from intravenous heroin use, along with a striking increase in HIV and hepatitis transmission related to the same.  Their death rate climbed to twice the rate for European countries in general.  I have read estimates that one percent of their population suffered from addiction, perhaps more. From accounts, their problems with opiate addiction were almost a prelude or foreshadowing of what we are experiencing today in the United States.

In 2001 Portugal responded to their epidemic by decriminalizing the possession of relatively small amounts of illegal drugs. It has been reported that they consider possession of approximately ten days’ worth of drugs for a person to be a non-criminal offense, but they did not legalize the possession.  Possession of the small amounts of certain drugs remained an administrative offense and manufacturing or selling illegal drugs and trafficking remained criminal offenses.

The majority of addicts were thus removed from the criminal system of courts and prison sentences and therefore the society at large was spared these costs.  Persons found to have small amounts of illegal drugs were referred to administrative committees for evaluation.  These committees consisted of a representative of social services, a person from the legal system and a physician.  The committee retained punitive measures it could bring to bear against these persons, but these did not include prison sentences.  The committee is tasked with assessing the person and suggesting a treatment modality.  If the person does not comply, he/she could suffer various penalties such as forfeiture of licenses related to work.

At the same time Portugal established a free system of treatment centers, some public and some private, that promoted harm reduction, some social services and conversion to medical replacement therapy. They included inpatient services but the bulk of their treatment facilities were for outpatients.

Their success in reducing drug-related death rates over a few years was stunning.  Portugal joined the three lowest death rate countries in Europe.  Rates of HIV and hepatitis transmission also declined dramatically.  The rates of opiate and other drug addictions do not appear to have changed, but this part of the epidemiology is difficult to assess due to the fact that their policy changes made it much easier to count the number of addicts out there once many of them were offered free treatment.

I am not able to comment on the financial costs of this change of policy in Portugal.  There was a savings, no doubt, from not having to support the cost of the courts and incarceration which we continue to sustain in this country.  There was a cost to establish medical facilities for treatment.  Were we to emulate Portugal I suspect we might actually see a net savings, given that within our prison-industrial complex we are currently spending tens of thousands of dollars a year to incarcerate addicts. It would be difficult to quantify the dollars saved by decreasing the social costs of our addiction epidemic—the costs of social services for the foster care of children with addicted parents, the medical costs of the complications of intravenous drug abuse, the EMS costs of dealing with overdoses and so forth.  Political push-back would, no doubt, be strong from the for-profit prison corporations in the United States and assuredly from other entities that directly or indirectly profit from the status quo.

What the Portuguese did was to take the problem out of the system of criminal justice and to treat it as a medical and social problem. There are many reports of entities such as local criminal courts attempting basically the same thing in the United States but clearly we need to change on a national level. For years now our “war on drugs” has failed and criminalization of addiction has failed.  Both have cost us phenomenal amounts in terms of social disruption and pathology, to say nothing of the fortunes sunk in failing policies and policing.  The profits related to these policies have gone to pharmaceutical giants, the private prison-industrial corporations and to cartels of traffickers in illegal substances.

 

Portugal, a much less wealthy nation than our own, has created solutions which we, with much more in the way of fortune and resources, should emulate.  The morgues here are bulging.  Death rates continue to rise.  “We are not Portugal” is an insufficient statement regarding our inertial present posture.