How to Win a War on Drugs [Archive.org URL]

Decades ago, the United States and Portugal both struggled with illicit drugs and took decisive action — in diametrically opposite directions. The U.S. cracked down vigorously, spending billions of dollars incarcerating drug users. In contrast, Portugal undertook a monumental experiment: It decriminalized the use of all drugs in 2001, even heroin and cocaine, and unleashed a major public health campaign to tackle addiction. Ever since in Portugal, drug addiction has been treated more as a medical challenge than as a criminal justice issue.

After more than 15 years, it’s clear which approach worked better. The United States drug policy failed spectacularly, with about as many Americans dying last year of overdoses — around 64,000 — as were killed in the Vietnam, Afghanistan and Iraq Wars combined.

In contrast, Portugal may be winning the war on drugs — by ending it. Today, the Health Ministry estimates that only about 25,000 Portuguese use heroin, down from 100,000 when the policy began.

The number of Portuguese dying from overdoses plunged more than 85 percent before rising a bit in the aftermath of the European economic crisis of recent years. Even so, Portugal’s drug mortality rate is the lowest in Western Europe — one-tenth the rate of Britain or Denmark — and about one-fiftieth the latest number for the U.S.

[…]

It’s not a miracle or perfect solution. But if the U.S. could achieve Portugal’s death rate from drugs, we would save one life every 10 minutes. We would save almost as many lives as are now lost to guns and car accidents combined.

[…]

So let’s be clear on what Portugal did and didn’t do. First, it didn’t change laws on drug trafficking: Dealers still go to prison. And it didn’t quite legalize drug use, but rather made the purchase or possession of small quantities (up to a 10-day supply) not a crime but an administrative offense, like a traffic ticket.

Offenders are summoned to a “Dissuasion Commission” hearing — an informal meeting at a conference table with social workers who try to prevent a casual user from becoming addicted.

[…]

The dissuasion board can fine offenders, but that’s rare. Mostly the strategy is to intervene with counseling or other assistance before an offender becomes addicted.

[…]

The public health approach arises from an increasingly common view worldwide that addiction is a chronic disease, perhaps comparable to diabetes, and thus requires medical care rather than punishment. After all, we don’t just tell diabetics, Get over it.

My sense from observing the hearings and talking to users is that the Dissuasion Commission isn’t terribly effective at dissuading. How successful could a 15-minute session be? Then again, criminal sanctions also seem ineffective at discouraging drug use: When scholars look at the impact of crackdowns, they find there’s typically little impact.

In the first year or so of decriminalization in Portugal, there did seem to be the increase in drug use that critics had predicted. But although the Portuguese model is often described simply as decriminalization, perhaps the more important part is a public health initiative to treat addiction and discourage narcotics use. My take is that decriminalization on its own might have led to a modest increase in the use of hard drugs, but that this was swamped by public health efforts that led to an overall decline.

On balance, the evidence is that drug use stabilized or declined since Portugal changed approaches, particularly for heroin. In polls, the proportion of 15- to 24-year-olds who say that they have used illicit drugs in the last month dropped by almost half since decriminalization.

Decriminalization also made it easier to fight infectious diseases and treat overdoses. In the U.S., people are sometimes reluctant to call 911 after a friend overdoses for fear of an arrest; that’s not a risk in Portugal. In 1999, Portugal had the highest rate of drug-related AIDS in the European Union; since then, H.I.V. diagnoses attributed to injections have fallen by more than 90 percent and Portugal is no longer at the high end in Europe.

One crucial mistake that Portugal did not make was to follow the United States in adopting prescription opioid painkillers for routine use. Adalberto Campos Fernandes, the health minister, said that Portuguese doctors resisted overprescribing and that regulators also stood in the way.

Another factor that has benefited Portugal: The economy has grown and there is a robust social fabric and safety net, so fewer people self-medicate with drugs. Anne Case and Angus Deaton of Princeton University have chronicled the rise of “deaths of despair” and argue that opioid use in America in part reflects a long-term decline in well-paying jobs for those with a high school education or less.

[…]

One attraction of the Portuguese approach is that it’s incomparably cheaper to treat people than to jail them. The Health Ministry spends less than $10 per citizen per year on its successful drug policy. Meanwhile, the U.S. has spent some $10,000 per household (more than $1 trillion) over the decades on a failed drug policy that results in more than 1,000 deaths each week.