Ep. 54: Translating Portugal’s Approach to Drugs and Addiction

Welcome to The Undark Podcast, which will deliver — once a month from September to May — a feature-length exploration of a single topic at the intersection of science and society. In this episode, join global health journalist Elana Gordon and podcast host Lydia Chain as they sort through the policies that underlie Portugal’s drug decriminalization approach — which Oregon, the first U.S. state to decriminalize all drugs, used as a model for their new law. But many questions about how success may translate remain unanswered.

Below is the full transcript of the podcast, lightly edited for clarity. You can also subscribe to The Undark Podcast at Apple Podcasts, TuneIn, or Spotify.

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Nélson Silva: So, today we have a tip that someone was sending drugs to Portugal and we arrest the person who goes for the packages, ok?

Elana Gordon: Uh huh.

Nélson Silva: So in here should be …

Elana Gordon This is Nélson Silva. He heads the criminal investigation units in Portugal’s capital, Lisbon. His police codename is furão, or ferret. When we meet, the first thing he wants to do is show me these bags that officers just brought to the station.

Elana Gordon: What am I looking at?

Nélson Silva: This is pillows and inside of the apparent pillow, there is these packages.

Elana Gordon: Vacuum-sealed bags containing what appears to be marijuana. Lots of marijuana. Like, more than 30 pounds. But before he can make this seizure official, Silva has to make sure it’s the real deal. So …

Nélson Silva: My fellow is waiting for us, let’s go to do the analyzing test.

Elana Gordon: We get into an unmarked police car and head to a main lab that tests Lisbon’s confiscated drugs.

Elana Gordon, on tape: So now we’re in a tunnel.

Elana Gordon: It’s about a half hour drive. The car stinks of weed. This part might be surprising to hear from law enforcement, but on the way over, Silva tells me he doesn’t really care about people having drugs, and using them. In Portugal, possession of small amounts of substances is not a crime. Silva says that’s fine with him: It frees him and other officers up to focus on the sellers and the traffickers.

Nélson Silva: Socially, it’s acceptable people have some quantity of drugs. And the cost of arresting everybody for having drugs, it’s very difficult to, to computate in the long term, so it’s not very good to arrest everyone.

[Undark theme music]

Lydia Chain: This is the Undark Podcast. I’m Lydia Chain. Silva operates in a society and system that handles drugs very differently compared to places like the United States, which has a deep history of targeting and arresting people who use drugs — especially people of color.

Twenty years ago, Portugal decriminalized the possession and use of small amounts of all substances — heroin, methamphetamine, cocaine, ecstasy — all of them. Drugs are still illegal — there’s no regulated industry for buying and selling — but the policy means that under a certain limit, there’s no crime, no jail, no criminal record.

Portugal’s decriminalization was a big deal then, but it was part of a much bigger national drug strategy. What the country did — and what happened after — has gotten lots of attention in recent years. Communities around the globe are struggling with a rise in overdoses and deaths. They’re looking for solutions. Last month, Oregon became the first state in the U.S. to decriminalize all drugs when a law passed last year came into effect. That policy is directly modeled off of Portugal’s approach. But understanding how Portugal translates gets messy when you dig into the evidence.

Elana Gordon picks up the story in Lisbon.

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Elana Gordon: Let’s start this story at Casal Ventoso, a Lisbon neighborhood on the edge of a hill next to a highway.

João Goulão: This area is iconic.

Elana Gordon, on tape: So we’re walking on a footpath in between some wildflowers and houses.

João Goulão: There are some syringes and needles, but cannot even compare it to what it was 20 years ago.

Elana Gordon: I met Dr. João Goulão here, last year, just before the pandemic hit. Goulão is a main architect of Portugal’s big drug overhaul that happened two decades ago, and he’s Portugal’s coordinator for addiction, drugs, and alcohol — he’s the drug czar.

João Goulão: I think about this decision of decriminalizing drug use as a bottom-up movement in society. I believe that we had the conditions to develop this comprehensive and compassionate approach.

Elana Gordon: This area, Casal Ventoso, became a symbol of the crisis and that movement for change. It’s mostly empty nowadays. Back in the 80s and 90s, it was home to what was considered the largest open air drug market and encampment in Europe.

João Goulão: Here it was very common to meet some dead bodies in the morning.

Elana Gordon: The country averaged one overdose death a day. Thousands of people came here to buy, sell, and use, mainly heroin.

João Goulão: So we could see here honest families that were led to this activity. I remember seeing here an old lady selling heroin by the window of the house, but at the same time the client was so thin, so weak, that she gave him a cup of soup. “You need to eat something, take it.” So, there was a lot of compassion.

Elana Gordon: Goulão says this humanizing view came out of Portugal’s distinct history, and how it got to this point. No other European nation had endured a fascist dictatorship for so long. For much of the 20th century, it approached the world alone.

João Goulão: “Orgulhosamente sós.”

Elana Gordon: “Proudly alone” was the motto of Antonio Salazar, Portugal’s ruler from 1932 to 1968.

João Goulão: Yes, proudly alone.

[Archival tape of a revolutionary song and cheering]

Elana Gordon: When this isolation broke with a non-violent coup that led to a democratic revolution in 1974 …

João Goulão: Drug use in Portugal exploded after our democratic revolution.

Elana Gordon: Drugs started pouring in, through the open ports. Heroin swept into struggling communities.

João Goulão: Everybody, every family had their problems.

Elana Gordon: By the 80s and 90s, Portugal’s drug-related HIV rates soared. They were among the highest, if not the highest in Europe. As a family doctor in the touristy south, Goulão was flooded with people seeking help. He became a leader in addiction and helped set up a network of treatment centers. Then the government tapped him to lead a group of experts — judges, nurses, psychiatrists — to come up with a new strategy for addressing drugs.

João Goulão: You know, the only boundary that the government had put to us when they invited us to build a strategy was, OK, you may propose whatever you want, but you should stick to the United Nations treaties, which imposed a prohibitionist paradigm.

Elana Gordon: He says they took a pragmatic approach, focusing on addiction evidence, not ideology.

João Goulão: Everything was built based on the idea that we were dealing with a health condition, rather than a criminal one and that the key intervention should be on the health and the social side rather than in the law enforcement and police and supply side. And accordingly, we proposed the decriminalization of drug use and possession of use.

Elana Gordon: The legislature approved their plan. In 2001, personal drug use became a civil sanction, like a ticket for driving without a seatbelt. But Portugal’s plan involved a lot more than decriminalization. The country revamped its entire addiction and health care system. That meant expanding services for methadone, counseling, syringe exchanges, and inpatient treatment. This was a big shift.

Elana Gordon: A core of these responses is the kind of initiative located at the very bottom of this hill. Crescer is a nonprofit that has a busy drop-in center for people who use drugs, a housing program, an employment initiative, and outreach teams. One of them lets me join them in their van to see harm reduction outreach in action. We stop in an overgrown field and the team unpacks health information and other supplies from the trunk — needles, condoms, alcohol wipes.

The group walks through a footpath in the tall grass. A man wearing sunglasses, jeans, and a nice blue jacket approaches.

João Sá: My name is João. I am João Sá, I am a lawyer, and I use more than 20 years. Now, in this moment, I use methadone and consume cocaine. And I give my face because I don’t have shame to have a disease. Why? Why? I can’t choose other type of life because I like it.

João Vicente: [Speaking in Portuguese]

Elana Gordon: Nearby, João Vicente picks up discarded needles with a special scoop. He’s a peer with the outreach team. He has lung disease and speaks softly.

João Vicente, translated: I started using when I was 11 years old, and I stopped three years ago, so it’s a long time. I have a longer life as a user, a drug user, than as a normal person.

Elana Gordon: Vicente says he’s not here to deter people from using drugs or pressure anyone into treatment.

João Vicente, translated: Personally I think it works only when someone wants to do something, if they try to force me to do something, it doesn’t work. It depends on the will of the subject.

[Music]

Nuno Capaz: Under a criminal perspective, everything is black and white. You either do it or you don’t.

Elana Gordon: Nuno Capaz helps lead Lisbon’s Commission for the Dissuasion of Drug Addiction. This commission is the other main part of Portugal’s approach, that goes along with decriminalization and boosting services. In Portugal, when police find people with small amounts of drugs, they issue citations, as in fines, and they refer them here.

A dissuasion commission may seem like a daunting name — but in reality, it’s under the ministry of health, there’s one in each region, and it’s made up of a social worker, a medical professional, and a lawyer. The one in central Lisbon is in an easy to miss office. The sign inside is small. Capaz, a sociologist by training, says the process when people get here is really informal.

Nuno Capaz: And that was on purpose. When we decided to start the dissuasion commissions, what we wanted to do is to establish another point of connection to the users. And in order to establish that connection, we need to remove all those formalities that normally are associated with the court and the criminal system, with all that ritualistic approach and all the uniforms and all the rules normally are there precisely for that — to avoid connecting with the person.

Elana Gordon: Capaz says fines are usually waived for people coming here for the first time. All their referrals are voluntary. On the morning I stop in, a mother waits with her teenage son, who was caught smoking weed outside school. He definitely does not want to be here. Same goes for 23-year-old Daniel Martins da Costa.

Daniel Martins da Costa: I was pissed because they just stopped us like that. We were doing nothing. And yeah, I was pissed.

Elana Gordon: Da Costa says police searched him and found hash when he was out with friends over the weekend. He says he’s already had to do community service before, for possession of an amount that’s above the personal limit.

He goes in, meets with the dissuasion team for an assessment, and is out within 10 minutes or so. He tells me he was asked …

Daniel Martins da Costa: If I still smoke, are regular, if I intend to stop.

Elana Gordon, on tape: What did you say?

Daniel Martins da Costa: I said no. And they ask me if I want help. I said no too. They said I have to … [switches to Portuguese]

Elana Gordon: Go to a job center. He says he’s actually been meaning to set up an appointment at the job center to apply for work, for some time. So, that part …

Daniel Martins da Costa: No, it’s a good thing.

Elana Gordon: The commission sees just a handful of people each day. They’re not busy. Unlike the start of Portugal’s drug crisis, the majority of people who wind up here are for recreational use of marijuana. Most are younger. Capaz says that’s probably because they’re living at home, and use outside the home, so police are more likely to catch them.

Nuno Capaz: Are people still using drugs in Portugal? Sure. And are people still dying of overdose in Portugal? Sure. But we managed to reduce a lot those figures. And we also managed to increase a lot of the people that are in treatment because we made that more accessible.

[Music]

Nuno Capaz: I would say that by now we are more or less in cruise mode. The policy, it’s fairly well accepted by everybody, the network is more or less established, and it’s a solid network. We don’t see any debate going back to what we had before.

Elana Gordon: The European Monitoring Center for Drugs and Drug Addiction describes Portugal’s drug reform as coherent and consistent. Portugal’s drug policies have endured despite multiple changes in governments. But now, some worry that stability has turned into stagnation — a stagnation that risks peeling back progress.

Magda Ferreira: I’m a peer worker of Gat, the group of activists of treatments. So and I work for the rights of people that use drugs. So it’s a very healing job because you take the label of shame off yourself.

Elana Gordon: That is Magda Ferreira. She’s 48. She started using drugs as a teen when it was a crime. I meet her near an area that’s a historical hot spot for drugs. It’s centuries old, the streets are narrow. It’s also home to lots of immigrants from all over the world. Tourism bleeds in. Police cars race through. Ferreira and others worry that a new generation that didn’t experience Portugal in the 90s may have lost that connection, that compassion, for people who use drugs, and that Portugal is failing its most marginalized — like sex workers and older people. She sees an irony to this.

Magda Ferreira: I don’t understand Portugal. We could be so much more avant garde as we were, you know, and every time I have to remember this, you know, why not? Why not? If other people that come to learn with us are doing it, why can’t we do it all together? It’s so easy, you know, and it helps people. It really helps people.

Elana Gordon, on tape: So what’s missing?

Magda Ferreira: What’s missing — more investment is missing, of course, because harm reduction does a lot with the short money, but we need money like everything.

Elana Gordon: Investment for outreach and other related programs has dropped during recessions. The overall health budget was cut by nearly 10 percent in 2012. Some worry about losing essential outreach services and connections for people. For Ferreira, expanding drug checking services — to see what’s actually in illegal drugs — would also really help people use more safely. The other big lag, she and other activists say, is that the country is long overdue to legalize marijuana for medical and recreational use.

[Music]

Researchers are careful about how they understand Portugal’s success over the last 20 years as a model, more broadly. Alex Stevens is a professor in criminal justice at the University of Kent. He says evidence in the real world gets messy.

Alex Stevens: I’ve been researching the overlap between drugs, crime, and public health for more than 20 years now, including what happened in Portugal after they decriminalized drugs and invested in public health treatment. And it’s difficult, you know, if you want to find out how these policy reforms affect people’s drug use, their health problems, crime in the areas where this stuff is done, it’s extremely difficult to come up with a rigorous research design that lets you do that.

Elana Gordon: Stevens says Portugal didn’t have a control group. The country also didn’t have a lot of data before the change, as a point of comparison. Researchers have noted that drug arrests prior to 2001 had already been low.

Alex Stevens: The data we wish we had is infinite. Talking about crime and imprisonment, we don’t have great data from Portugal about levels of crime. We don’t, for example, have a very reliable self-reported household survey of victimization like we do in the States or in the U.K. So it’s very difficult to tell what happened to crime. Apart from that, if you talk to police officers and municipal staff and to doctors, they will tell you that they observed a reduction in the types of crime that were associated with drug use.

Elana Gordon: What is clear is that HIV rates went down as they’d hoped, as did the social and health costs from drug use, according to one study. Drug-related deaths dropped right after decriminalization. The numbers have increased some years, but are still lower than 2001, and the mortality rates are much lower than the European average. The number of people in treatment increased. But Portugal’s approach involved dozens of different measures, beyond decriminalization, some of which started a few years before 2001. Stevens says it’s hard to parse out how much any one part of the country’s drug policy drove improvements in public health, and then how much other factors may have played a role.

Alex Stevens: There was also other things going on, like an increased investment in social housing, clearance of the slums, where the drug problems were concentrated. Portugal for the first time introduced a guaranteed minimum income. So a whole range of other types of policies that you would expect to see reducing problematic drug use, as well as this combination of decriminalization and public health measures, which was the sort of more centrally-recognized element of Portuguese drug policy.

Elana Gordon: Stevens says one thing has become clearer in research over the years — drug decriminalization didn’t cause the harms that some opponents feared. There wasn’t an overall growth in drug use. And what fluctuations did occur, mirrored what was happening in other nearby countries.

In 2018, a high-profile United Nations board backed decriminalization as part of a broader public health driven approach to drugs. Lots of other countries have loosened their criminal approach to drug use over the years. With deaths on the rise in Europe, places like Norway have reviewed assessments of what Portugal did, as they move forward with their own decriminalization proposals. Debates are heating up in Scotland. Across the Atlantic, Vancouver’s city council voted to back decriminalization a few months ago. And then, there’s Oregon.

Advertisement 1: I’m a nurse who treats patients with addictions — we know a jail term isn’t good drug treatment, it ruins lives …

Elana Gordon: Last fall, ads in support of a proposal to decriminalize all drugs, started rolling out in the state. The clips featured people talking about how the addiction and criminal justice systems failed them.

Advertisement 2: This has followed me for over two and a half decades, it’s kept me from getting housing, apartments …

Elana Gordon: An independent statewide assessment from Oregon’s Criminal Justice Commission estimated that Measure 110 would reduce arrests for drug offences by 90 percent, and it would dramatically reduce the racial and ethnic disparities in drug arrests. Theshia Naidoo is a lawyer with the national advocacy group, the Drug Policy Alliance, and helped craft the measure.

Theshia Naidoo: We’ve had this punitive approach for decades now. And we haven’t seen any improvement in key indicators. You know, we’re seeing high rates of overdose. We’re seeing prison overcrowding, jail overcrowding, saddling people with lengthy records that follow them, in some cases for the rest of their lives. And all of these obstacles that criminalization poses to successful reintegration, housing, employment, educational opportunities, family obligations. So the current system has proven to be completely ineffective and a failure.

Elana Gordon: Opponents expressed real concerns about removing the role of courts in deterring use and directing people to treatment. A majority of the state’s district attorneys were against the measure. But on Nov. 4, voters in Oregon approved it, making Oregon the first U.S. state to remove criminal penalties for possessing small amounts of drugs. But, like Portugal’s approach, it’s more than that.

Theshia Naidoo: It will increase access to health and harm reduction services, including the full spectrum of services that might be needed, including housing and drug treatment and recovery services. And, of course, harm reduction is a key component of the type of services that will also be available.

Elana Gordon: The new policy means that anyone found with small amounts of drugs will instead get a citation — as in, a hundred dollar fine. Or …

Theshia Naidoo: You can avoid the citation by being connected to a health screening — where your various needs are assessed and then you could be provided with linkages and connections to the various services.

Elana Gordon: Those assessments would happen at one of several addiction and recovery centers in the state. On paper, this is very similar to Portugal’s approach. Naidoo says that was intentional. She directly pulled from Portugal’s playbook.

Theshia Naidoo: I mean, it’s not possible to replicate exactly the Portugal model in the United States. But what we can do is learn from what are the key components of Portugal’s success and how can we replicate those components.

[Music]

Beau Kilmer: I think we have to be careful about taking the results from Portugal and just assuming that those results apply here in the United States.

Elana Gordon: Beau Kilmer directs the drug policy research center at the RAND Corporation, a policy think tank. He is eager to study the impacts of what Oregon is doing — how people experience it, how it might affect behaviors, its impact on crime, on law enforcement, on access to and actual use of services. But first he wants to know what the policy means in practice, as in, how Measure 110 is actually enacted at the state and local levels.

Beau Kilmer: A lot’s going to depend on how this rolls out in Oregon.

Elana Gordon: And how evenly and consistently it’s funded. Under Oregon’s plan, tax revenue from its legal marijuana industry will be redirected to ramp up services. Some within the addiction community deeply worry that this funding won’t be nearly enough to pull off this overhaul and build up services in the way that Portugal did. Kilmer says an oversight council in Oregon that recently convened, will have a big role.

Beau Kilmer: In measure 110, it does say, look, money is going to be spent on this, on substance use disorders treatment, but it doesn’t say how much. And so that’s why this council is going to be so powerful. You know, how they allocate these resources, they’re going to shape how this gets implemented.

Elana Gordon: Still, Kilmer thinks Oregon could present a natural experiment to better understand the evidence and the impact of drug decriminalization in America. That part took effect in February.

Beau Kilmer: I mean, I think, for example it would be informative to compare what happens in Oregon to, for example, what happens in Washington state.

Elana Gordon: And unlike Portugal, Kilmer says he and others do have historical data on health, crime, and drug trends already, as a baseline. But Kilmer is aware of the traps. Oregon was the first state to decriminalize marijuana in the 1970s. When several states followed, they didn’t have a consistent framework for evaluation. This might seem really granular, but the policies themselves varied, and because they were documented so differently, it was hard for anyone to understand the impact, positive or negative, on people’s lives.

Beau Kilmer: And that helps explain why kind of some of the early results were all over the place.

[Music]

Elana Gordon: João Goulãu, Portugal’s drug czar, thinks his country’s success can be replicated in a place like Oregon, even though the conditions and the contexts are so different. He says the underpinning of Portugal’s approach were the attitudes about people, addiction, and drugs.

João Goulãu: You know, we have lots of visitors coming here. And we have lots of invitations to go abroad and to explain the so-called Portuguese model. You know what is, in my view, the most, uh, important difference in our approach?

Humanism, the humane way that we approach people with drug problems. This is the key.

[Music]

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Lydia Chain: Elana, thanks so much for joining us.

Elana Gordon: Oh, well thank you so much for having me and being interested in this topic.

Lydia Chain: You went to Portugal last year, right before the pandemic hit. How have things changed due to it?

Elana Gordon: Well, across Europe and across the world, what we’re seeing with the pandemic is a big halt or shift in health services and that’s included addiction services and made that more challenging. In Portugal itself, I followed up with Nélson Silva who we heard from in the beginning of the story — the police officer — he was saying that because of the limited movement actually, the availability of drugs has become more scarce, so they’ve become more expensive and they’ve become of lower quality. On the other hand, what we’re seeing in the United States and just in general is this real question and concern about progress being lost on supports for people who use drugs and especially when it comes to problematic drug use, we’re seeing rises in overdoses. People are feeling more isolated and also maybe have more difficulties in getting services like methadone that often involve going in person to a place. So all of this is making the issues of drug use really acute.

Lydia Chain: You open the piece talking about policing, which was also a big motivator for the decriminalization initiative in Oregon. Was there a change in policing or attitudes about policing in Portugal?

Elana Gordon: Well, straight up, not that it was a huge focus to begin with but again, personal possession of drugs was no longer a crime. So if somebody were to be arrested for that, no more. I mean that was the big shift. Also for Nélson, what he told me is, you know, when you do arrest someone for drugs, it’s a lot of paperwork. It’s a lot of resources. So dropping that actually freed up a lot of officers time and ability to go after the big traffickers and focus on the sellers. That’s not to say when I was there I didn’t see a lot of tension between police officers and potentially people who do use drugs. I did observe some random drug checks for example in the street. And people who showed up to the dissuasion commission felt like they didn’t have a good experience of being checked for drugs. And at the same time I also met with a few of the younger officers who felt a little frustrated that they didn’t have this ability to arrest people and pull them over because that felt like they were a little hand tied in how they could improve safety in the streets. And when I asked this back to Silva, he said, you know, give them a few years and they’ll come around and realize this is actually a way more beneficial approach and works out for everyone.

[Undark theme music]

Lydia Chain: Elana Gordon covers global health for The World, from PRX and GBH. Her reporting was part of an International Health Study Fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. Our theme music is produced by the Undark team and additional music in today’s episode comes from Blue Dot Sessions. I’m your host, Lydia Chain. See you next month.