• Drug decriminalization and harm reduction in Portugal: a review of the evidence

    Liam Bendicksen is an undergraduate at Brown University studying Public Health and Public Policy. He tweets at @liambendicksen and you can reach him at liam_bendicksen@brown.edu.

    In 2001, the Portuguese government functionally decriminalized drug use and instituted a set of policies aimed at encouraging people with substance use disorders to seek treatment. This unprecedented move and its implications sparked responses from the international press. Most mass-media articles cite this set of policies not just as a success, but as a model for the rest of the world to follow. But what does the evidence say? This post outlines what we know and what is unclear about the effects of Portugal’s drug reforms.

    So what did the reforms tangibly change? According to the legal statute, the drug reforms decriminalized possession up to “the quantity required for an average individual consumption during a period of 10 days” of all psychoactive drugs as well as public and private drug use. Quantities exceeding that threshold are considered evidence of drug trafficking.

    The decriminalization of drug use and possession is distinct from drug legalization, which would sanction the legal sale and distribution of previously-llicit drugs under government supervision. This is not the case in Portugal, where drug trafficking remains a crime. Decriminalization is also distinct from depenalization, in which people who use drugs do not face legally-imposed penalties like fines or community service. This is also not the case in post-reform Portugal. The gist is that Portugal does not incarcerate individuals for using drugs, but people who use drugs still purchase those drugs from illicit markets.

    While popular articles tend to focus on decriminalization, Portugal’s adoption of a harm-reduction approach arguably deserves more attention. This public health-driven strategy primarily entailed the implementation of eighteen regional panels made up of social workers, medical professionals, and drug experts. Instead of arresting people who use drugs, the police refer them to these panels. At that point, panel members refer people who are dependent on drugs to treatment programs. In the case of people who casually use drugs, the panel has the option to assign community service time, fines, or other penalties. In the case of people who use drugs like marijuana that are generally perceived as benign, panels usually follow the recommendations of the statute and choose not to issue any penalty whatsoever.

    The government’s rollout of the panels did not go smoothly and the system still has kinks to iron out. Roughly three-quarters of the cases that the panels processed in 2009 involved cannabis, raising questions about the efficiency of a structure meant to help people who use cocaine or opioids find and access treatment. The lack of an alternative legal framework for people who casually use marijuana means that panels spend an excessive amount of time and resources processing those cases. Aside from that inefficiency, however, the reforms and accompanying social destigmatization of drug use have tangibly increased the availability and provision of drug use treatment. The number of outpatient treatment centers jumped from 53 in 1998 to 79 in 2010, and the number of people receiving treatment for drug addiction increased by about 15,000 in the ten-year span from 1998 to 2008. These programs and facilities seem to have been put to good use, seeing as three-quarters of the population treated in 2008 received medication-assisted treatment for an opioid use disorder, an evidence-based practice and the current standard of care.

    Although decriminalization might seem like a drastic measure from an American perspective, the 2001 reforms in Portugal were not a sea change. Starting in 1998 with the National Strategy for the Fight Against Drugs, the Portuguese government began to accept the growing medical consensus that substance use disorders are psychological conditions, not personal moral failings. The seminal Decriminalization of Drug Use Act essentially codified the prevailing consensus at the time that drug policy should treat people who use drugs, not punish them. Well before the 2001 law, people convicted of drug use were primarily punished with administrative fines. From 1993 to 2000, the total number of people incarcerated for drug consumption alone ranged from 4 to 42. (For scale, the population of Portugal over this period ranged from about 9.9 million to 10.3 million people.)

    Before examining the effects of these reforms, it is important to note that self-reported data on drug use is notoriously unreliable. The Portuguese government did not start surveying national drug use until the reforms took place in 2001. In addition, since the harm reduction policies and decriminalization took effect concurrently, it is impossible to isolate the causal effects of each individual aspect of the reform.

    That said, there are a few reliable results from the reform. For example, there was a substantial and temporary increase in experimental illicit drug use after the law took effect. For the most part, this experimentation did not translate into more regular use in the years following the reforms. The number of people ages 15-24 who reported regular (past 30 days) and recent (past 12 months) drug use declined significantly, while that number rose for people above the age of 24.

    In addition, the burden of drug use-associated diseases and complications declined almost universally, such as notable reductions in opioid-related overdose deaths and the number of new cases of infectious diseases like hepatitis C and HIV that were a growing issue pre-reform. This latter improvement is remarkable because those numbers were recorded by drug treatment facilities, meaning that even as the number of treatment facilities and people receiving treatment increased, the burden of disease decreased. It’s impossible to attribute this reduced burden to any one cause, but the increased availability of treatment and harm reduction programs like needle exchange programs likely helped facilitate this change.

    The policies also reduced prison overcrowding and eased the strain on Portugal’s resource-strapped criminal justice apparatus. However, the number of murders in Portugal increased by 41% in the first five years post-reform, and cocaine seizures increased by 700% over the same period, raising concerns about the policies’ effects on drug trafficking patterns. As Stanford Professor Keith Humphreys put it, “transnational criminal organizations may have taken the new policy as a sign that Portugal would be a safer, lower-enforcement venue in which to operate.”

    It is worth emphasizing that none of these changes can be unambiguously attributed fully to the reforms, as we don’t know what would have happened in their absence.

    In addition, other factors such as broader drug use trends and perceptions of social stigma likely affected self-reported survey responses and other data on drug use-related health outcomes. The claim that decriminalization alone caused these shifts, as many popular accounts imply or state explicitly, is not backed by the empirical evidence. The reality is much murkier and obscured by the lack of reliable, nationally-representative, and longitudinal data on drug use and drug-related health outcomes.

     
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