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How Portugal eased its opioid epidemic, while U.S. drug deaths skyrocketed

Dr. João Goulão, director-general of the General Directorate for Intervention on Addictive Behaviours and Dependencies General Directorate, is widely credited with shifting Portugal's addiction response toward a focus on health care and treatment. Overdose deaths have plummeted.
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Dr. João Goulão, director-general of the General Directorate for Intervention on Addictive Behaviours and Dependencies General Directorate, is widely credited with shifting Portugal's addiction response toward a focus on health care and treatment. Overdose deaths have plummeted.

Talk to people addicted to street drugs in Lisbon, Portugal's capital, and you hear confusion and dismay over the carnage of overdose deaths taking place an ocean away in the U.S.

Ana Batista, a soft-spoken woman in her 50s who's been addicted to heroin for years, said she hasn't lost a single friend or family member to a fatal overdose.

"No, no, no," she said, speaking at a safe drug consumption clinic, where she had come to inject under the supervision of nurses and counselors.

Liliana Santos, 41, a woman with a sad weathered face who had come to the clinic to smoke heroin, voiced similar bafflement.

Had she lost friends or family? "No." Had she overdosed herself? She shook her head: "No, no."

The contrast is striking. In the U.S., drug deaths are shatteringly common, killing roughly 112,000 people a year. In Portugal, weeks sometimes go by in the entire country without a single fatal overdose.

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Ana Batista, who asked that her face not be photographed, comes to a drug consumption clinic in Lisbon almost every day where she can use heroin under medical supervision. "It's different, very different," Batista said, adding that she feels safer and less alone.
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Ana Batista, who asked that her face not be photographed, comes to a drug consumption clinic in Lisbon almost every day where she can use heroin under medical supervision. "It's different, very different," Batista said, adding that she feels safer and less alone.

Portugal has roughly the same population as the state of New Jersey. But while New Jersey alone sees nearly3,000 fatal drug overdoses a year, Portugal averages around 80.

"The statistics really speak for themselves," said Miguel Moniz, an anthropologist at the Institute of Social Sciences, University of Lisbon, who studies addiction policy in the U.S. and Portugal.

An opioid crisis and a pivot toward healing

What's different in Portugal? In the late 1990s, the country faced an explosion of heroin use. The drug was causing roughly 350 overdose deaths a year and sparked a wave of HIV/AIDS and other diseases linked to dirty needles.

Portugal offers people in addiction an integrated network of services, including vans where residents can use street drugs under medical supervision.
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Portugal offers people in addiction an integrated network of services, including vans where residents can use street drugs under medical supervision.

Portugal's leaders responded by pivoting away from the U.S. drug war model, which prioritized narcotics seizures, arrests and lengthy prison sentences for drug offenders.

Instead, Portugal focused scarce public dollars on health care, drug treatment, job training and housing. The system, integrated into the country's taxpayer-funded national health care system, is free and relatively easy to navigate.

"Someone who has problematic drug use isn't someone who is a criminal or someone who has a moral failing," Moniz said, describing Portugal's official view of addiction.

"They're someone who has a health problem, a physical or a mental health problem," he said. "That's a tremendous societal shift."

Many U.S. drug policy experts who've studied the Portugal model say it's clear parts of it worked far better than the tough-on-crime philosophy embraced by U.S.

"I think they showed that when you make [addiction treatment] services extremely available to people who are struggling with problems of drugs, you get a lot of good outcomes," said Dr. Keith Humphreys, an addiction expert at Stanford University.

"The police is always our friend"

There's one other big difference. Beginning in 2001, Portugal's national addiction strategy decriminalized personal drug use and reinvented the role of police.

Municipal Police in Porto, Portugal regularly patrol areas used by drug consumers.  Police in Portugal don't arrest people who use drugs.  Instead they have a strong track record referring people in addiction to counseling and treatment.
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The Washington Post via Getty Images
Municipal Police in Porto, Portugal regularly patrol areas used by drug consumers. Police in Portugal don't arrest people who use drugs. Instead they have a strong track record referring people in addiction to counseling and treatment.

Cops still work aggressively to break up major drug gangs and arrest people committing drug-related crimes like theft. They also disrupt open-air drug markets like the ones that have emerged in some U.S. cities.

But when street cops in Portugal encounter people using small, personal-use amounts of drugs, there's no arrest. Instead, police schedule meetings for drug users with teams of counselors.

While these sessions aren't compulsory, police are trained in strategies designed to encourage people to attend.

"In the beginning, most policemen were very, very skeptical about this policy," said Artur Vaz, who leads Portugal's national police unit focused on drug trafficking.

In the U.S., this role for law enforcement, serving as a bridge to social service programs, has faced a backlash and is often seen as ineffectual.

In Oregon, for example, where small amounts of drugs were decriminalized in 2020, police regularly hand out information cards referring people to a drug counseling hotline. Court data shows drug users rarely call.

In Portugal, by contrast, government data shows roughly 90% of people referred to drug counseling sessions by police do turn up, at least for an initial session.

"Most [Portuguese] police have come to believe this is a balanced approach," Vaz said. "People who consume drugs should be treated by the health system, not the criminal system."

As a consequence, people living with addiction face far less stigma, rarely serve jail or prison time, and don't live with criminal records.

Ronnie Duchandre, who is addicted to alcohol and hashish, and also smokes crack, says police in Portugal are "our friends" and serve as part of the social safety network that helps drug users recover.
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Ronnie Duchandre, who is addicted to alcohol and hashish, and also smokes crack, says police in Portugal are "our friends" and serve as part of the social safety network that helps drug users recover.

Ronnie Duchandre, who is addicted to alcohol and hashish and sometimes smokes crack cocaine on the streets of Lisbon, told NPR he views police as helpful.

"The police is always our friend, as long as you speak with them properly," Duchandre said. With support from Portugal's system, he predicted that he would recover from his drug use.

"It's not in one day that we reach the bottom," he said. "We can also go up and it's the same process, slowly up and up."

Dr. João Goulão, Portugal's national drug czar, said street cops have emerged as a vital link between the most vulnerable drug users, like Duchandre, and opportunities for treatment.

"Through the intervention of police, this is a unique opportunity to meet face-to-face with people we otherwise would not see," he said.

Liliana Santos, who lives in Lisbon, Portugal, is addicted to crack cocaine and heroin. It's a hard life but unlike drug users in the U.S., she has free access to healthcare, which means she has a much lower risk of overdose or death compared with people living with addiction in the U.S.
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Liliana Santos, who lives in Lisbon, Portugal, is addicted to crack cocaine and heroin. It's a hard life but unlike drug users in the U.S., she has free access to healthcare, which means she has a much lower risk of overdose or death compared with people living with addiction in the U.S.

Portugal's formula: less stigma, fewer penalties, access to care

Police referrals are only one of many pathways to drug treatment in Portugal.

"Decriminalizing drug use is a good step," Goulão said. "The more you have other kinds of responses available, the better."

Experts here say people who use drugs are constantly nudged toward health care and addiction treatment, including methadone programs and housing.

A person addicted to heroin prepares to inject at a consumption clinic in Lisbon, under the supervision of nurses.  People in Portugal are 45 times less likely to die from an overdose compared with people in the U.S.
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A person addicted to heroin prepares to inject at a consumption clinic in Lisbon, under the supervision of nurses. People in Portugal are 45 times less likely to die from an overdose compared with people in the U.S.

The results are striking. Over the last 20 years, Portugal cut drug deaths by 80% and reducedthe number of HIV/AIDS and hepatitis cases in half.

During that same period, U.S. drug deaths exploded by more than 500%, according to the Centers for Disease Control and Prevention.

Researchers predict unless America somehow changes course, the overdose crisis will kill a total of 2.2 million people in the U.S. by the end of this decade.

Could elements of Portugal's system save lives in the U.S.?

A debate is underway in the U.S. over whether elements of Portugal's system could save lives here.

"If we stopped arrests and did nothing else, that's a positive intervention because of the well-documented harms of incarceration [on people with addiction]," said Morgan Godvin, a former heroin user who now studies drug policy in Portland, Ore.

A growing number of cities and states around the U.S. have begun to de-emphasize drug war-era policies, shifting away from drug arrests and funding more treatment.

California voters approved Proposition 14 a decade ago, reducing drug possession from a felony to a misdemeanor. In 2020, Oregon voters decriminalized personal-use amounts of drugs and provided more funding for health care and counseling.

Advocates of those changes hoped they would quickly reduce drug deaths and serve as a model for the rest of the U.S., but implementation has been rocky, and in many places fatal overdoses have risen.

Critics say drugs were fully or partially decriminalized before other social programs, like the ones in Portugal, were in place and widely available to pick up the slack.

"We still suck at access to voluntary treatment," Godvin acknowledged, speaking of drug policy reforms in Oregon. "We need a vast voluntary system, so that people can engage with treatment when they want it."

A tidal wave of U.S. drug deaths and a backlash against programs designed to help them

Drug policy experts say these relatively new experiments have been crippled by a lack of funding, by strict U.S. drug laws that make some harm reduction measures illegal, and by this country's complicated, costly and often poorly regulated addiction treatment system.

The spread of deadly fentanyl and a national surge in homelessness have also led to a spike in highly visible drug use, sparking a backlash among many voters and politicians who want streets, neighborhoods and parks cleaned up quickly.

There are now efforts underway to recriminalize drugs, and toughen law enforcement's response, in California and Oregon.

Humphreys, at Stanford University, says he still supports dramatically expanding access to addiction care, similar to Portugal's model.

But he doesn't support decriminalization and believes police and criminal courts in the U.S. will need to play a more aggressive role forcing people with severe addiction off the streets and into treatment.

"They don't have relationships, they're isolated, so if there's no law [enforcement] pressure, there's no pressure at all," he said.

Miguel Moniz, the anthropologist at the Institute of Social Sciences, University of Lisbon, disagrees. He says the data shows Portugal's approach, combining decriminalization and health care, is more humane and more successful.

People in Portugal are now 45 times less likely to die from drug overdoses, compared with people in the U.S. — and street crime in cities like Lisbon has dropped.

"There's an impression in the U.S. that if you decriminalize drugs, it's a Wild West where everyone uses drugs," Moniz said. "That hasn't been the case in Portugal."

But as the death toll from the U.S. overdose crisis mounts, Moniz voiced skepticism that American policymakers will have the political will or patience to pivot to a focus on health care and social services.

"There's a different political environment in the U.S," Moniz said. "The way health care is funded is completely different. The role of police in American society is different. So to talk about the Portuguese experience [being adopted in the U.S.] is complicated."

— Tilda Wilson, an NPR Kroc Fellow, contributed field reporting. Inês Pereira Rodrigues provided translations.

Copyright 2024 NPR. To see more, visit https://www.npr.org.

Brian Mann is NPR's first national addiction correspondent. He also covers breaking news in the U.S. and around the world.