Portugal, That Bastion of Public Health

We humans are really weird when it comes to assessing risk. Although flying is the safest way to travel (if you divide the number of people-hours in flight by the number of deaths from flying), we have this weird and irrational fear of flying. Although there are more deaths from irresponsible use of firearms than from terrorist acts, we applaud an anthropomorphic sexually transmitted infection who wants “extreme vetting” of Muslims entering the United States. However, when 26 people overdose on drugs in 24 hours in Huntington, West Virginia, no one really bats an eye.

It’s all part of the plan, I guess.

It’s all part of the plan because we, as a society, have come to see people addicted to drugs as less-than-human beings who deserve everything that’s coming to them. Just look at what Mike Pence and his Republican friends did in Indiana. They were perfectly happy to allow an HIV epidemic to go unabated as long as they could because giving people clean syringes to inject drugs is too unpalatable. It enables them to use drugs without facing the consequences, or something like that.

But what if we could stop it?

We can’t, right? People get hooked on drugs and very few get off of them. The image of the drug user/abuser is that of a person who ends up dead in the gutter somewhere. One of the things that I kept being told from the time I was a child was that I would always be tied to drugs like heroin or even marihuana if I ever dared touch them. That worked for me, by the way. My fear of losing control to something like that kept me from trying any kind of psychogenic drug. To this day, I take a local anesthetic instead of anything stronger when getting my teeth worked on.

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My idea of me on drugs.

But that’s not the truth, right? There are plenty of people who, given the right opportunities, can kick the habit of psychotropic drugs (or any other such habits). Take as an example all those soldiers serving in Vietnam who were addicted to heroin. Once they came back from the war, about 95% of them kicked the habit. Why? According to this NPR article, here’s what happened:

“But one big theory about why the rates of heroin relapse were so low on return to the U.S. has to do with the fact that the soldiers, after being treated for their physical addiction in Vietnam, returned to a place radically different from the environment where their addiction took hold of them.

“I think that most people accept that the change in the environment, and the fact that the addiction occurred in this exotic environment, you know, makes it plausible that the addiction rate would be that much lower,” Nixon appointee Jerome Jaffe says.

We think of ourselves as controlling our behavior, willing our actions into being, but it’s not that simple.

It’s as if over time, we leave parts of ourselves all around us, which in turn, come to shape who we are.”

Similar stories of rehabilitation can be found everywhere. People who were addicted to this or that drug got off of it when their environment changed. They moved away from friends who “partied” together with them. They got jobs that were meaningful and they weighed the option of continuing to use the drug versus having a worthwhile life. Or they gained a new support system that brought them the relief from the things that drove them into the use of drugs.

In essence, a “drug addict” is not someone you should just throw away… Throw away to violence between drug gangs, to HIV from dirty needles, to unemployment and social stigma from criminal histories. There are science and evidence-based ways to interrupt drug addiction. It just takes political and social will.

What happened in Huntington, West Virginia, is going to keep on happening until we do what Portugal did. What did Portugal do? From the Washington Post:

“Portugal decriminalized the use of all drugs in 2001. Weed, cocaine, heroin, you name it — Portugal decided to treat possession and use of small quantities of these drugs as a public health issue, not a criminal one. The drugs were still illegal, of course. But now getting caught with them meant a small fine and maybe a referral to a treatment program — not jail time and a criminal record.

The prevalence of past-year and past-month drug use among young adults has fallen since 2001, according to statistics compiled by the Transform Drug Policy Foundation, which advocates on behalf of ending the war on drugs. Overall adult use is down slightly too. And new HIV cases among drug users are way down.

Now, numbers just released from the European Monitoring Centre for Drugs and Drug Addiction paint an even more vivid picture of life under decriminalization: drug overdose deaths in Portugal are the second-lowest in the European Union.

Among Portuguese adults, there are 3 drug overdose deaths for every 1,000,000 citizens. Comparable numbers in other countries range from 10.2 per million in the Netherlands to 44.6 per million in the U.K., all the way up to 126.8 per million in Estonia. The E.U. average is 17.3 per million.

Perhaps more significantly, the report notes that the use of “legal highs” — like so-called “synthetic” marijuana, “bath salts” and the like — is lower in Portugal than in any of the other countries for which reliable data exists. This makes a lot of intuitive sense: why bother with fake weed or dangerous designer drugs when you can get the real stuff? This is arguably a positive development for public health in the sense that many of the designer drugs that people develop to skirt existing drug laws have terrible and often deadly side effects.

Still, it’s very clear that decriminalization hasn’t had the severe consequences that its opponents predicted. As the Transform Drug Policy Institute says in its analysis of Portugal’s drug laws, “The reality is that Portugal’s drug situation has improved significantly in several key areas. Most notably, HIV infections and drug-related deaths have decreased, while the dramatic rise in use feared by some has failed to materialise.””

Some people are horrified at the idea of a safe, secure place where heroin users can go and safely use without the danger of dying from an overdose or a needle-borne infection. But these places exist right over the border in Canada, and they’re having great success at reducing deaths from overdoses and helping people kick the habit. Because it’s not just about giving them help if they overdose or clean needles to avoid infections. It’s also about offering rehabilitation services, mental health services, and opportunities for employment and self-fulfillment… You know? The things that could help someone kick the habit?

More on what Portugal has achieved:

I do have to write that I’ve often said that the United States is not like other countries, and other countries are not like the United States. This principle of mine is why I am very careful about comparing the US to other countries, and vice versa. We are 50 states and territories that are very different between them. Even within the states, there are stark differences between their counties. And even within their counties… You get the idea. But it wouldn’t hurt for someone here in the United States to try and do something better — more based on reality — than the nightmare the war on drugs has been.

 

I'm a doctoral candidate in the Doctor of Public Health program at the Johns Hopkins University Bloomberg School of Public Health. All opinions posted here are my own, of course, and they do not necessarily reflect the opinions of my school, employers, friends, family, etc. Feel free to follow me on Twitter: @EpiRen