By Helen Redmond
Wednesday, April 11, 2012
“I really don’t care if people use drugs. I don’t want them to suffer from it.”
- João Goulão, president of the Institute on Drugs and Drug Addiction
Portugal is a rogue state. The small country of ten million people on the Mediterranean decriminalized all drug use in 2001. Even the scary hard drugs like heroin and crack cocaine. It was a seminal moment in the international war on drugs that went largely unnoticed in the media but not among the world’s drug warriors. Members of the International Narcotics Control Board (INCB), the organization that enforces drug prohibition via the UN Single Convention on Narcotic Drugs, flew to Lisbon. The Vienna-based group has a long track record of bullying and threatening countries that attempt nonpunitive approaches to drug policy. But the Portuguese wouldn’t back down and set into motion the Carnation Revolution Part 2. The first revolution in 1972 opened the country up to democracy and drug experimentation in a way that wasn’t possible until the forty year fascist dictatorship of António de Oliveira Salazar had been overthrown and the borders flung open. The Portuguese had missed “Reefer Madness,” “chasing the dragon,” and the psychedelic sixties. There was a lot of catching up to do.
Sitting in a dingy, windowless waiting room in Lisbon waiting to interview Nuno Capaz - a Portuguese sociologist with a PhD and vice president of the Comissão para a Dissuasão da Toxicodependência, the Commission for the Dissuasion of Drug Addiction (CDT), and I’d later learn, a big fan of the band Jane’s Addiction - I spied a poster on the wall. It declared, “Ante tratar que punir.” Translation: Better to treat than to punish. It is the deceptively simple ideology that drives Portuguese drug policy: Drug treatment is preferable to punishment and prison. Like most countries, Portugal locked people up for drug consumption. It didn’t work.
During lunch, Capaz, a whip-smart, funny, sarcastic man in his early 40s unleashed a tirade against the US drug war. He’s studied the effects of American drug prohibition and rattles off statistics: Half a million imprisoned for drug offenses, 50,000 marijuana arrests in New York City every year, and one trillion dollars spent over forty years on the war on drugs.
Capaz has the ability to distill the dimensions of the drug war down to its dregs. The American criminal justice system: “You Americans,” he shook his head, “In Portugal, we’re not handing out criminal records.” On American politicians: “Good drug policy is bad politics. Politicians want to get elected.” On Drug Czar Gil Kerlikowske’s visit to Portugal: “He listened, but he’s not going to change anything.” Mexico and the drug war: “Americans get high. Mexicans get shot.”
It is this raw honesty and willingness to confront failure that led drug policy experts in Portugal to decriminalize drugs. In 1999, a commission composed of nine experts in drug policy, medicine, addiction, and law was convened. The group met to take stock of the drug problem, examine drug laws, and create a new approach. No policy recommendations were off the table.
I met Dr. João Goulão, the president of the Instituto da Droga e da Toxicodependência, Institute on Drugs and Drug Addiction (IDT) in his office in Lisbon. He is short with jet black hair and wears business casual blue pants and a light blue, button down shirt. He was one of the nine members of the historic commission that decriminalized drugs. Goulão is a flexible drug policy expert and physician. I showed up at the IDT on the wrong day for the interview and he rearranged his schedule to meet despite having a packed day. How many busy presidents of prestigious national institutes would do that for a freelance journalist from Chicago?
Goulão is the living memory of before and after drug decriminalization. He tells me that in the 70s and early 80s there was little drug treatment available. What was on offer consisted of private, for-profit clinics that couldn’t meet the demand and the exorbitant fees charged excluded thousands. In 1986, the Portuguese government made a huge public investment in drug treatment and opened Centro das Taipas in Lisbon and additional centers across the country. A few years later, all drug treatment centers became integrated into one system organized and funded by the government.
During the 1990s, Goulão noted with alarm that problematic drug use was spreading throughout society. He said, “It affected almost every family?the poor, the middle and upper classes. You could find drug abuse everywhere.” The discovery of HIV/AIDS was a historic game changer. The disease forced every country to examine their drug policy because intravenous drug use was a major vector for the virus. Goulão estimates that there were over 100,000 injection drug users in Portugal and open air drug scenes were established in major cities. “In Lisbon, more than 5000 came every day. It was a supermercado of drugs. It was shocking,” he said.
As Goulão talked, his BlackBerry intermittently vibrated. He told me a former patient had sent him a text message. He’d given this woman his personal cell phone number ten years ago. I was amazed.
It was 1997 and rates of HIV/AIDS were increasing in Portugal. José Sócrates, the former Prime Minister asked Goulão, “What are we going to do?” The two men took a road trip to study drug policy. They visited Britain, Holland, Spain, and Switzerland. They read volumes of drug policy publications and researched the impact of drug laws. Sócrates put together the commission of nine and within a year it recommended a revolutionary solution to the drug problem. For Goulão, the new drug policy had to end the fear that drug users had of approaching the treatment system and the professionals who could help them. The doctor had far too many conversations with drug users trying to assure them they’d be no calls to the police or punishment, but they often replied, “No, you can’t assure me of that.” Goulão knew they were right. He never believed in punishing people for having a drug dependency and said, “I really don’t care if people use drugs. I don’t want them to suffer from it.” Goulão gets one of the major reasons people use drugs: for the pleasure. He explained, “The pleasure is something we have to take into account. We always talk about the suffering, the destruction and we forget about the pleasure. I think it’s very important to talk about this.”
In 1961, Portugal signed the UN Single Convention on Narcotic Drugs. It forbids legalization of drugs for personal consumption. The commission discussed going outside the convention but were told “No” after consultation with the Portuguese Ministry of Foreign Affairs. Defying the UN convention, it was implied, could bring international sanctions. The goal then was to stay within the confines of the convention, but according to Goulão, “To go as far as possible.” Still, he remembers, the INCB was “angry” with the commission. The most controversial recommendation was the decriminalization of all drug use. The nine architects of the new drug policy were doubling down on the drug war in defiance of the INCB not knowing if the gamble would pay off.
The government accepted the recommendations of the commission and in 2001, implemented the law named 30/2000. The foundation of the new drug policy was a fundamental paradigm shift from punishment and prison, to humanism and pragmatism. The humanistic principle in the law states: “Recognition of the human dignity of the people involved in the drug phenomenon and consequently an understanding of the complexity and the relevance of the individual, his/her family and background, as well as drug addiction as an illness and the consequent assumption of responsibility by the State in upholding drug addicts constitutional right to health and the avoidance of social exclusion.” In the twenty-first century, the idea that drug users have human rights is still novel. In most countries drug use is against the law, drug users are criminals who are castigated and killed with near impunity. Chronic drug users are forced to the margins of society and live in a dangerous underground where death from overdose is a daily risk. In Russia, it’s estimated that in 2009, 30,000 people died of heroin overdose. The criminal designation allows all manner of violence to be used against illicit drug users both the casual and the addicted and for the evisceration of civil rights. Law 30/2000 ended this discriminatory, criminal distinction. It forced Portuguese society to confront stigma and view drug users as human beings, some who enjoy psychoactive substances recreationally, and others that are addicted and are in need of drug treatment. The new drug policy plucked drug use out of the purview of the criminal and plopped it down into the purview of public health.
The principle of pragmatism allowed the Portuguese to dispense with dead end drug war slogans like “Zero tolerance” and “Just say no,” eschew public campaigns to reduce drug use that relied on scare tactics, and launch scientifically proven, nonabstinence-based treatment for drug addiction. Pragmatism in drug policy recognizes basic truths: People will always use drugs, menacing drug war hype doesn’t deter drug use, and expecting drug users to abstain from all drugs is a set up for failure.
Law 30/2000 was a tough-on-crime politician’s nightmare. Conservative Portuguese lawmakers, hooked on punishing and incarcerating drug users for political credibility unleashed doomsday, drug war hyperbole and fear-based lies. They argued drug use and addiction rates would skyrocket and Portugal would become a popular drug destination?Europe’s new “Club Meth.” It didn’t occur to the scaremongers that Portugal was already a drug destination. Millions of tourists visit Portugal for the alcohol. Tourism to the country relies heavily on the promotion and the promise of drinking fine wines like porto and vinho verde and tours to the wine producing region of the Douro River Valley. The world renowned city of Oporto is a magnet for thousands of tourists who stay in wine lodges and drink port that is high in alcohol content. Fortunately, the drug warrior politician’s dire admonitions of doom were discredited and defeated. Instead of getting tougher on drug crimes, the Portuguese got real on drugs.
Decriminalization is not legalization. In Portugal all drug use and possession is still illegal. What changed is drug offences are no longer deemed criminal, but instead administrative. The law states that a person can be in possession of 10 doses of any drug; an amount over that is considered drug trafficking and is subject to prosecution in a court of law. Here’s how it works in practice. If police find drugs on a person they’re confiscated. If the amount doesn’t exceed the legal limit, the police issue an administrative citation. No arrest is made. An administrative citation compels the person to meet with the Commission for the Dissuasion of Drug Addiction (CDT) within 72 hours. The commission is a unique Portuguese creation. It doesn’t exist anywhere else in the world. There are three members of the CDT appointed by the Ministries of Justice and Health. In Lisbon, the CDT is composed of a lawyer, a clinical psychologist, and a sociologist (Capaz). They work with a multidisciplinary “technical team” of social workers and psychologists who meet with the offender and evaluate their drug use. A clear distinction is made between recreational drug use and chronic and persistent addiction. An examination of the social determinants of drug use? unemployment, homelessness, lack of meaningful relationships, trauma, poor education, and mental health problems?are a central component of the assessment. The goal is to offer drug education and social services, not to punish drug use. The CDT meets with the offender in a hearing and based on the assessment and recommendations of the technical team make a ruling. The hearing is not adversarial in nature but rather conducted in a spirit of cooperation. Innovative options to address drug use are individualized to each person’s unique life circumstances. The CDT can recommend community service, regular attendance at a health center, inpatient drug treatment, banning from certain places, restrictions on travel, or a monetary fine (but not for addicts.) The user has the right to reject the recommendations, but according to Capaz and Goulão, the majority accepts. The most common CDT ruling, (68 percent) was for the “provisional suspension” of the offense. An additional 15 percent were provisionally suspended with an agreement to enter drug treatment. Law 30/2000 effectively stopped the war on drug users.
What drugs are the Portuguese receiving administrative citations for? According to data from the IDT, the top three drugs used are cannabis, (76percent), heroin (11 percent), and cocaine (6 percent). These numbers refute one of the main myths promoted by the drug warriors: If drugs were decriminalized, hordes of young people would start using “hard” drugs, become addicted, overdose, and die. Portugal clearly shows that even when there are no criminal sanctions, people aren’t interested in injecting powerful opiates or stimulants into their veins and becoming dependent on them. Marijuana, a drug that has been rigorously studied and found to be non-addictive and safe, continues to be the most widely used substance in Portugal. The IDT study found a decrease in illicit drug use among adolescents. Young people often consume drugs as a way to rebel against authority and to declare independence. With decriminalization, these reasons to use drugs make little sense. In addition, opiate overdose and the rate of transmission of HIV and hepatitis C have decreased.
Stopping the war on drugs has had a libratory effect on drug users in Portugal. No longer deemed delinquent, drug users can ask for help without the fear of arrest and prosecution - this is particularly important for pregnant women. The elimination of the “fear factor” has allowed a decade of Portuguese drug users’ entry into the drug treat system and back into mainstream society. More drug users are alive and HIV negative. The stigma of addiction and the social exclusion of drug users have receded.
The Portuguese understood that an expansion of drug treatment services was vital for the success of the new drug policy. It was easy because Portugal has a national health service. In 1976, two years after the Carnation Revolution, Portugal recognized the right to health care in the Constitution. Health care as a human right was among the most important gains of the revolution. The government-run health system is funded by general tax revenues and everyone, including the undocumented, has access health services. Drug treatment is integrated into the NHS. According to Goulão, there are 40,000 people receiving drug treatment. Ease of access to treatment is critical because if drug users have to wait weeks or months, they continue to use drugs or lose motivation for treatment. In Portugal, drug treatment is a vital part of health care because it prevents the development of other health problems and reduces overdose deaths. Goulão summed up how the system works: “If you are a drug addict you are invited to enter treatment. No waiting list. Everything is easy and smooth. The doctor is waiting for you. Everything goes according to people’s needs.”
The airplanes fly so low over Centro das Taipas you could almost touch the underside of the jets. The roar of the engines forces the air to vibrate. The drug treatment center under a flight path is located in Parque de Saúde de Lisboa (Health Park of Lisbon.) It’s ground zero for over a dozen public health institutions. The contrast of light and shadow that strike mauve pink and chalk white buildings are awarding winning Getty Images. The landscaping is a mix of exotic plants, flowers, trees, and bright, green grass. Despite the sound of the occasional 747, it feels healing to be inside the walls of the park.
Dr. Miguel Vasconcellos is the chief psychiatrist at Taipas. He wore a crisp, light blue, Ralph Lauren Polo dress shirt, dark blue pants and black shoes. The man has seen it all. He remembers the days of abstinence only drug treatment, zero methadone maintenance, and the liberal prescription of prison for the drug addicted. But the streets were still crammed with drug users, he tells me. Vasconcellos believes that it’s because of harm reduction that the lives of drug users have improved dramatically. The principles of harm reduction are the bedrock of the Portuguese drug treatment system: Meeting people “where they’re at,” offering choices, and not coercing people into treatment. Vasconcellos said, “I don’t want people to use. We don’t encourage people to take drugs but we accept that people will use drugs.” He added, “I’m not trying to convince drug users to stop. I’m concerned about social exclusion.”
Taipas offers a range of drug treatment services, both inpatient and outpatient: drug detoxification; pharmacological therapies including methadone and psychotropic medication; physiotherapy; and individual and group therapy. Vasconcellos uses a mix of cognitive behavioral and psychodynamic therapy to work with patients. He never mentions the disease model of addiction, the 12 Steps, or mandatory AA or NA meetings. I asked about this. Vasconcellos smiled, shook his head, and replied, “Treatment is not a religious quest. In Portugal we believe in the separation of church and state…People have the power to cure themselves…Drug addiction is a health issue.” But he’s quick to add that all religious beliefs are respected? they’re just not the foundation of treatment.
Vasconcellos took me on a tour of the inpatient detoxification unit. The spaces were large and open with different configurations of windows facing in all directions to let in the maximum amount of natural light and air. The walls were covered with art made by patients and the quality was astonishing. One piece was eight tea cups cut in half and glued into mosaic tile. In the spacious day room awash in squares of sunlight, I watched staff interact with patients. There was an atmosphere of cooperation, caring, and freedom of movement (although a few areas were locked.) Vasconcellos led me into a room that contained exam tables with thick, black padding and stainless steel, medical equipment. He explained that staff applies heat packs to patients who are detoxing to ease muscle cramps. Then he showed me a machine that’s used for scar reduction. Long-term intravenous drug users often have thick layers of needle scars on their forearms that are disfiguring and stigmatizing. Vasconcellos said dermabrasion “Is an invitation to talk.” I wanted to cry. I don’t believe there are any drug treatment programs in the United States that treats drug injectors with as much dignity and respect as Taipas. And I know there are none that offers needle scar reduction.
The next stop was a small gym. Red rubber fitness balls and blue exercise mats covered the floor. Physiotherapy is an important part of treatment. Vasconcellos explained, “Heroin anesthetizes the user. With fisioterapia, patients begin feeling their body again.”
We exit the detoxification unit, walked down a winding staircase, the circular walls covered in yet more amazing art, and headed to the office of António Costa, the director of Taipas. His office was old world Europe beautiful; high ceilings, natural light, and white walls decorated with interesting art. When Vasconcellos told Acosta I’m from the United States, he smiled warmly but then a sad look crossed his face. Acosta, too, knew about “tough love” American drug treatment. He said, “I understand. I’m sorry.”
I take a taxi from Taipas to meet workers from the mobile methadone team. The office is nestled on a narrow street full of apartment buildings. The taxi stopped at the address and a thin man with bright green eyes rushed over and asked, “Are you Dr. Helen?” I replied, “I’m Helen, but I’m not a doctor.” Bruno Vaz ushers me inside the small building and introduces me to Elsa Silva. She was tanned and wore a colorful flower print shirt and flouncy pants. Both will be my guides into the world of methadone on the move. After a quick tour, we piled into Elsa’s car and sped off to one of the main methadone dispensing areas. During the ride, they took turns explaining how the program works. Bruno stated when the staff called “technicos” meet with someone who wants methadone, “We have to give them a fast answer. That day. If they have to wait weeks, we lose them.” Elsa said, “We don’t punish drug users, we help them.” Like Goulão, their number one concern is the health of drug users, not convincing them to stop. Bruno and Elsa tell me that at the three methadone sites in Lisbon they have contact with over 1300 drug users every day. This face to face contact is a critical opportunity to talk, earn trust, and offer a continuum of services to drug users who in the past, hustled to buy illegal drugs in an unsafe subterranean world that was cut off from mainstream society.
The car pulled up under a highway overpass and there were two, white, unmarked vans parked under the bridge. Bruno explained that one vehicle dispenses methadone and the other functions as an exam room for Dr. Carlos Gomes. The genial Guinean primary care doctor provided physicals, cleared drug users to start methadone, and prescribed a range of other medications. A group of people were chatting in front of a concrete embankment wall spray painted with graffiti art. My guides introduced me to the technicos as a journalist from the United States. They welcomed me and were excited that I was writing an article about Portuguese drug policy. They’re immensely proud of the work they do and they want other countries to know how successful mobile methadone is.
Bruno and I climbed into the methadone van. A nurse dressed in a white T-shirt and black cargo pants sits behind a tiny counter with a laptop. She had instant access to everyone’s electronic medical record. A young woman stepped into the van and approached the teller like, plexiglass window and gave her name and an identifying number. The nurse did a quick visual assessment to make sure the woman was alert then typed the number in to the computer to find the dosage of methadone. A plastic, amber bottle full of methadone sat near the window. A beige cylinder that calculated dosage was screwed on to the top of the bottle. In a practiced flash, the nurse turned the blue ring on the neck of the cylinder to the correct number and then pushed down on the pump to dispense the liquid into a small plastic cup. She handed the medicine to the woman who swallowed it and chased it with a few sips of water. From the time the woman approached the window to the moment she walked away, I estimated a minute elapsed. Methadone made easy. Methadone in a minute. That never happens in the United States.
No part of Portuguese drug policy points out more dramatically the cruelty and flagrant disregard of science in US drug policy and drug treatment than how methadone is regulated and dispensed. Treatment for addiction is widely perceived by drug users as another form of prison and punishment. Strict adherence to and acceptance of the disease model and the 12-Steps is demanded, abstinence is the gold standard, nonmedical detoxification is common, poorly trained staff use confrontation and shame, and relapse is cause for treatment termination.
Over forty years of studies have shown that methadone is the most successful treatment for heroin addiction. But in the United States, methadone is more tightly controlled and monitored than all other prescription medications, many that have more dangerous side effect profiles and overdose potential than methadone. Unlike any other medication, the actual prescribing practices of methadone are dictated and enforced at the federal level by the Center for Substance Abuse Treatment (CSAT), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Drug Enforcement Administration (DEA). The DEA issues a license to every methadone clinic. Methadone is only available in specially designated clinics and can only be prescribed by doctors who work there. It is the only medication in the pharmacopoeia that all doctors cannot prescribe and that cannot be picked up at a neighborhood Walgreens or Wal-Mart pharmacy.
There is a shortage of methadone programs in the United States and wait times can top three months for publicly funded treatment slots. Nationally, it’s estimated there are 800,000 to one million people addicted to heroin. According to the American Association for the Treatment of Opioid Dependence, there are 1,200 methadone clinics that serve 270,000 people.
Drug warriors in the United States have deliberately designed one of the most restrictive and humiliating methadone distribution systems in the world. Surveillance and suspicion of patients is the norm. Armed security guards, often off-duty police officers, patrol clinics and nurses who dispense methadone are separated from patients by bulletproof glass. After the patient ingests the liquid methadone, they must open their mouth and raise their tongue for inspection. This degrading oral exam is to catch patients who try to “divert” methadone by not swallowing it and giving it to someone else - presumably another opiate user trying to stave off withdrawal. Methadone diversion, which is greatly exaggerated, exists because methadone is excessively controlled and unavailable to thousands who can’t comply with inflexible clinic rules. If all opiate users had easy and free access to methadone, as they do in Portugal, no diversion would exist.
For the first three months of treatment, patients have to report to the clinic six days a week. No exceptions! Dosing is strictly regulated, patients are constantly and randomly drug tested, clinic hours are limited, and positive urine tests can result in a decrease in dose or program expulsion. Pressure is put on patients to detoxify from methadone within a year, but for many long-term users of opiates methadone is for life. In for-profit methadone clinics, patients can be detoxified for not paying: It’s dubbed an “administrative detox” and it’s legal. The real cost of a dose of methadone is less than 50 cents, but weekly fees vary from $45 to $100. The ethical concerns of forcing patients into abrupt withdrawal or being tapered down for nonpayment are trumped by the drive for profit.
In order to get take home doses of methadone, 8 conditions must be met:
1. You must show through random drug testing a minimum of 8 instances per year of drug free urine toxicology screens
2. You must keep clinic appointments
3. You must show “appropriate” behavior
4. You must not engage in criminal activity
5. You must have a stable home and stable non drug-related relationships
6. You must promise to store the methadone safely
7. A doctor must agree that the risks of diversion are outweighed by the benefits of taking methadone at home
8. You must meet the minimum time in treatment
Imagine for a minute other vital medications people are prescribed: Humulin for diabetes, Metoprolol for hypertension, or Novoseven for hemophilia. Now envision that medication is only available in special clinics that strictly control access and failure to comply with the 8 conditions, inability to pay, and elevated levels of blood sugar, blood pressure or “too many” bleeding episodes can result in punishment and denial of medication. Hard to imagine, right?
Peter Vanderkloot, a long-term methadone patient authored a powerful insider’s account of the U.S. methadone system titled Methadone: Medicine, Harm Reduction, or Social Control? He wrote, “It would be difficult to design a more stressful and traumatic system if one tried. First, patients are doled out only the smallest possible supply of a substance that they need like food or oxygen. Then they are placed under constant scrutiny by a hostile and distrustful staff and regularly threatened with loss of access to their medicine.”
The stigma of being on methadone - a safe, legal medication - is ubiquitous and incredibly, matches the stigma of using heroin. Methadone users are shamed, told they’re still not “clean,” are substituting one addiction for another, and need to lower their dose or stop as soon as possible. These judgmental attitudes are found among drug counselors, health care providers, and even drug users. The war on drugs fuels the American obsession with abstinence-only, “one size fits all” drug treatment and the demonization of methadone. The central involvement of the DEA in regulating access to methadone has created a dispensing dystopia that replicates prison and parole in perpetuity. “The reality is the system through which methadone is provided is a uniquely oppressive bureaucracy that greatly reduces the benefits of the medication and generates harm where none existed before. Methadone itself is a tool of harm reduction; the system that controls methadone is a system of harm production,” Vanderkloot concluded in his article.
In 2011, the Global Commission on Drug Policy released a scathing report on the war on drugs asserting in unequivocal terms, “The global war on drugs has failed, with devastating consequences for individuals and societies around the world.” The group formulated a comprehensive drug war exit strategy based on the principles of harm reduction. Among the recommendations: end the criminalization and stigmatization of drug users; experiment with models of drug regulation; expand health and drug treatment services; provide easy access to opioid substitution therapy; respect the human rights of people who use drugs.
Portugal’s gamble on a new drug policy in 2001 paid off in spades. They implemented the recommendations of the Global Commission on Drug Policy a decade ago. Now the world has to catch up with Portugal.
Dr. Goulão’s BlackBerry was vibrating almost continuously as the interview came to an end. I commented that he must be very popular. He smiled and said it was another text message from the same patient. And then he told me the story of the woman who was desperately trying to reach him. Ten years ago he treated her for an opiate addiction. She was stable on methadone. The woman’s father was terminally ill, the mother had cancer, and they were both hospitalized. She told Goulão, “I’m lost. I’m trying not to go there.” He drove to the woman’s house and she was astonished to see him at the door. Goulão said, “Let’s go to the hospital to see your parents.” While they were visiting, the woman’s mother died. He comforted her and used his power to arrange for the father to stay in the hospital a few extra days. Privately, the father had confided in Goulão that when he died his daughter would be alone. He drove the woman home. They sat in his car outside her house for two hours while she talked and cried. Goulão finished the story saying, “I like this patient very much.”