Learning from Portugal’s Health-Based Approach to Drug and Substance Misuse

This case study will examine how Portugal has tackled drug-related crime through decriminalisation and what we can learn from this in the UK.  

In 2001, Portugal took a radical step by becoming the first country in the world to decriminalise low-level possession and consumption of all illicit drugs. We spoke to Jason Kew, Detective Chief Inspector at Thames Valley Police, about alternative ways of addressing drug-related crime in the UK. He told us that the top 10% of the UK’s heaviest heroin users consume 66% of all illicit heroin [1]. Kew advocates that a similar health-based approach could be replicated to deal with drug-related crime here in the UK.

Problem

The Drug Policy Alliance reported that in the 1990s, Portugal faced ‘one of the highest prevalence rates for overdose deaths and problematic drug use in Europe, with people who inject heroin comprising 60 percent of the HIV-positive population in the country’ [2].  

Two factors contributed to this increase. The first was the end of the colonial war in Africa with people returning from the colonies. The second, the fall of the Salazar dictatorship in 1974, which resulted in a very closed country quickly opening to the world [2].  

Portugal did not have comparably high levels of illicit drug consumption among the general population, but the country had one of the highest prevalence rates for problematic drug use, particularly heroin. The European Monitoring Centre for Drugs survey in 2001 found that 0.7% of the population had used heroin at least once in their lives, the second-highest rate in Europe after England and Wales (measuring at 1%) [3].  

Solution

Almost two decades ago, Portugal adopted a new approach to drug abuse, focusing on shrinking the drugs market, and taking a health-based approach to support addicts. Legislators eliminated all criminal penalties for low-level possession and consumption of drugs; downgrading the possession and consumption of drugs from criminal to administrative offences. The decision was based on the philosophy that it makes more sense to treat drug addicts as patients who need help, rather than criminals, allowing Police to focus on other areas. 

The Drug Policy Alliance states: 

‘A person found in possession of personal-use amounts of any drug in Portugal is no longer arrested, but rather ordered to appear before a local “dissuasion commission” – comprised of one official from the legal arena and two from the health or social service arenas – who determine whether and to what extent the person is addicted to drugs. The commission can refer that person to a voluntary treatment program, pay a fine or impose other administrative sanctions.’ [2] 

The decriminalisation of drug consumption remains part of a holistic approach to reducing the harm caused by drugs to people and societies. It has the primary goal of safeguarding citizens’ health and security. This pragmatic approach places treatment and harm reduction strategies at its core. When a ‘dissuasion commission’ refers someone to treatment, that care is usually provided by the country’s national health service. This treatment acknowledges the individuals’ physical and social situation, decided by a physician or psychologist and is provided through an integrated outpatient model. For those who are not ready or do not want to seek treatment, there are harm reduction strategies.  

The Drug Policy Alliance further states: 

‘Harm reduction is a set of ideas and interventions that seek to reduce the harms associated with both drug use and ineffective drug policies. It is based on acknowledging the dignity and humanity of people who use drugs and bringing them into a community of care in order to minimize negative consequences and promote optimal health and social inclusion. This can include ending the discrimination against drug users, reducing drug overdoses, providing supervised consumption services for people who use drugs, and immunity from arrest for witnesses to an overdose.’ [2] 

Outcomes 

Although studies found an increase in drug experimentation after the law passed, this was a transient effect — most experimentation did not lead to regular drug use. The feared ‘explosion in drug consumption’ did not materialise.  

An International Journal of Drug Policy research paper looked at the relationship between Portugal’s drug decriminalisation and the price of illicit drugs. It found that the retail prices of cocaine and opiates did not decrease following the decriminalization of drugs. It concluded, ‘drug decriminalisation seems to have caused no harm through lower illicit drugs prices, which would lead to higher drug usage and dependence.’ 

Furthermore, in 2010 The British Medical Journal (BMJ) commissioned the report ‘Drug Decriminalisation in Portugal: Learning from a Health and Human-Centered Approach’. The report concluded ‘a sea change in Portuguese drug law has coincided with a marked reduction in harm’ [4]. 

Key outcomes that have been recorded across studies show: 

• Drug use – Transform Drugs, a UK charity working in drug policy reform, concludes that ‘There is essentially no relationship between the punitiveness of a country’s drug laws and its rates of drug use. Instead, drug use tends to rise and fall in line with broader cultural, social or economic trends.’ [5] 

• Health – The rate of new diagnoses of drug related HIV/AIDS cases fell from 1430 in 2000 to 352 in 2008 [4]. 

• Deaths – The number of deaths associated with drug use has decreased, from 131 deaths in 2001 to 20 in 2008. [4] 

• Crime – Incarceration for all drug related offenses decreased by over 40% between 1999 and 2016. [6] 

The British Medical Journal reviewed both arguments, for and against the decriminalisation of illicit drugs, reviewing each argument’s evidence. The paper concluded: ‘Decriminalisation would allow the culture and conversation around UK drug use to change from zero tolerance to harm reduction. Reduced stigma would support earlier help-seeking. The question is not whether decriminalisation would lead to more people using cannabis but whether it would lead to overall worse outcomes in population health. We suggest that the evidence strongly supports our view that it would not.’ [4]  

What can we learn? 

• The importance of focusing on the individual using drugs; taking a holistic approach to their wellbeing and socioeconomic situation.  
• The need to engage doctors and other health professionals in drug policy reform work. 
• Opportunity to reduce racial disparities in access to treatment. As well as, minimising racial bias that compounds the harm and suffering caused by arresting and prosecuting people solely for drug possession. Stopwatch report that ‘Drug policing is a key driver of ethnic disparities throughout the criminal justice system and must be reoriented if ethnic disparities are to be alleviated.’ [7]. 

The Transform Drug Policy Foundation identified five principles that should serve as the foundation for all work on positive drug policy reform. An unwavering commitment to [5]:  

• Upholding the dignity of people who use drugs 
• Reforming the criminal justice system to prevent it from being used as a tool of racism, sexism or xenophobia  
• Creating environments that foster safer drug use;  
• Addressing the root causes of problematic drug use  
• Ensuring that individuals, families and communities that have borne the brunt of the war on drugs are given the opportunity to tell their stories and to seek restitution.  

Sources

[1] gov.uk. 2019. United Kingdom drug situation 2019: Focal Point annual report. [Accessed 23 December 2020] 

[2] Drugpolicy.org. Drug Decriminalization in Portugal Learning from a Health and Human-Centered Approach. [Accessed 23 December 2020] 

[3] European Monitoring Centre for Drugs and Drug Addiction. 2017. Drug trafficking penalties across the European Union: a survey of expert opinion, Technical report. [Accessed 23 December 2020] 

[4] Smyth, B., Cannon, M., Molodynski, A., Curran, H., Eastwood, N. and Winstock, A., 2020. Would decriminalising personal use of cannabis lead to higher rates of mental illness?. BMJ, p.l6975. 

[5] Transformdrugs.org. Drug decriminalisation in Portugal: setting the record straight. [Accessed 23 December 2020] 

[6] Serviço de Intervenção nos Comportamentos Aditivos e nas Dependências (SICAD). 2016. ﷟HYP 

[7] Stopwatch.org. The Colour of Injustice: ‘Race’, drugs and law enforcement in England and Wales.