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.

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.


Everyone Was Looking For Answers

My wife and I went to a town hall meeting in Carroll County, Maryland, yesterday. The meeting was about the opiate drug abuse epidemic and what different agencies and people were doing about it. The keynote speaker was an agent with the Drug Enforcement Agency (DEA). He gave the usual statistics on number of deaths and overdoses, and what his agency has been doing to counter them. He also talked about how most of the heroin being used in Virginia, Maryland, Pennsylvania and West Virginia flows from Baltimore on what is called “the heroin highway.” (Of course, he clarified that heroin and other opiates are being illegally imported from Mexico.) We then got to hear from people in the community who run different intervention programs. Included in those presentations was one by the local hospital. It went “dilaudid-free” this year, and they’ve seen the number of “seekers” go down along with an increased positive response about pain control from other patients. In essence, not everyone needs dilaudid — a powerful opiate-based analgesic — for things like sprained ankles or strained backs.

People from the local and state health departments also spoke about their agencies’ efforts to curb the epidemic. Locally, they’re raising awareness about the link between abusing prescription painkillers and getting hooked on heroin. They’re also using recovering addicts to talk to peers about prevention. And, of course, they’re distributing Narcan to friends and family of people abusing opiates and heroin in order to prevent deaths from overdoses. Statewide, new rules are coming online to keep track of what opiates and how many are being prescribed. In that vein, a lot of finger-pointing was done at dentists who give prescriptions for 30 days of OxyContin for tooth extractions or installation of braces. A lot of the attendees — many of them parents whose children were prescribed these opioids for “simple” procedures — said that it seemed to them that prescribers (e.g. dentists) didn’t want to deal with a complaint about pain, so they just prescribe the strongest thing in their arsenal.

Most painful of all were the stories of parents whose children died recently from heroin overdose. One parent, a pharmacist, talked about a “pill mill” not far from our location. He wanted something done about that because his child started off addicted to OxyContin. Another parent said that she still has some heroin from her child at the home, and she wanted the local sheriff to take it and analyze it to see if they could trace it back to the source. (Something that is very difficult, if not impossible, to do.) Other parents gave similar stories of otherwise “normal” children who fell into opioid drug abuse and then moved onto heroin, which is easier to acquire and quite cheap.

I say that these stories were painful not only because of the loss of life, the loss of their children. It was painful because it was obvious that they wanted answers, they wanted someone to pay the price for their loss. But there was no one to blame, at least not in the room. For the parents who wanted the drugs analyzed in order to maybe find a dealer, it’s probably not going to happen. And, even if they do track down the dealer, the chance of the dealer being charged with their son’s death are low. And I can see how that must be incredibly frustrating. Someone, somewhere, made the conscious decision to manufacture and sell poison to their kids. Someone profited from their deaths. Even if the chances of people “in the game” are likely that they’ll get killed or seriously hurt for being in it, someone is getting away with hurting those who overdose and/or die.

However, the answers to the epidemic are almost as varied as the drugs that are being used. You can seal up the border to keep heroin from coming in through Mexico, but you’ll have it come in from Asia via Canada. Or you’ll have designer opiates (like all the Fentanyl variants) being made here in the US. And, of course, you’ll have prescription opiates being handed out like candy by people who don’t want to hear your whining about your broken leg. Or could severely restrict prescriptions, piss-off the pharmaceutical industry, and have people move to heroin as they can’t get their pills. Then you could do both, but the underlying social and mental health issues that drive people to addictions are not addressed and they go to other dangerous/illicit drugs (or some licit ones like alcohol and marihuana in several states).

In a perfect world, you would dismantle drug cartels by taking away the demand for drugs. You’d take away the demand by solving social problems that lead people to want to escape their situations by abusing heroin and other drugs. You’d also have mental health readily available to help people who have something happen in their life that leads them to want to escape. Or, if they’re there already, you’d have recovery services ready to help. You’d also have clean needles to prevent infections and people from dying, or Narcan in every public place (like Automated Electronic Defibrilators are now) and in the hands of every addict and their immediate circles in order to keep them alive.

Of course, there are other things that work which I might be forgetting.

While some at the meeting were being optimistic that maybe the epidemic was subsiding, I’m not as optimistic. Looking at the trends, this thing is happening in waves. As Baltimore and other major cities get “dangerous” during the summer, people turn to other drugs to fill their needs. Then they go back to buying heroin once things calm down in the cooler/colder months. Heroin overdoses seem to wax and wean like that, just like almost everything else in epidemiology. I certainly hope that it is calming down. I hope that more parents aren’t looking for more answers. But I don’t know… I just don’t know.

Governor Larry Hogan of Maryland speaks of addressing heroin epidemic, but will he act?

Maryland Governor Larry Hogan presented his plan to address heroin addiction in Maryland yesterday. Unlike some of his more conservative counterparts, Gov. Hogan clearly stated that heroin addiction — like all addiction — is a disease, and that people with the disease need to be helped:

“”This used to be considered an urban problem, but it’s not anymore,” he said. All over the state, he said, local officials told him heroin had become their No. 1 problem. The governor said he felt a personal connection because a cousin died of an overdose a couple of years ago.

“I know the kind of devastation it can cause for families and communities, but still I was shocked by how widespread this problem had become,” he said.

Hogan said heroin was both a law enforcement problem and a health issue. “This is a disease, and we will not be able to just arrest our way out of that crisis,” he said.”

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