Drug experiment: what happens when an entire country legalizes drug use?

From the Boston Globe, January 16, 2011:

In the end, there was no way to ignore the problem, and no way for politicians to spin it, either. Young people across Portugal were injecting themselves with heroin. HIV and Hepatitis C infection rates were soaring. And Casal Ventoso, a neighborhood in Lisbon, had become a dark symbol of this small nation’s immense drug problem. Junkies openly injected themselves in the street, dirty syringes piled up in the gutters, alleyways reeked of garbage and human waste, and no one seemed to care.

“Welcome to Lisbon’s drugs supermarket,” a police officer said to a visitor in 2001, surveying the daily depravity with a shrug. But João Goulão, Portugal’s drug czar, admits now that the police officer was probably understating it. “Casal Ventoso,” Goulão said recently, “was the biggest supermarket of drugs in Europe.”

Faced with both a public health crisis and a public relations disaster, Portugal’s elected officials took a bold step. They decided to decriminalize the possession of all illicit drugs — from marijuana to heroin — but continue to impose criminal sanctions on distribution and trafficking. The goal: easing the burden on the nation’s criminal justice system and improving the people’s overall health by treating addiction as an illness, not a crime.

As the sweeping reforms went into effect nine years ago, some in Portugal prepared themselves for the worst. They worried that the country would become a junkie nirvana, that many neighborhoods would soon resemble Casal Ventoso, and that tourists would come to Portugal for one reason only: to get high. “We promise sun, beaches, and any drug you like,” complained one fearful politician at the time.

But nearly a decade later, there’s evidence that Portugal’s great drug experiment not only didn’t blow up in its face; it may have actually worked. More addicts are in treatment. Drug use among youths has declined in recent years. Life in Casal Ventoso, Lisbon’s troubled neighborhood, has improved. And new research, published in the British Journal of Criminology, documents just how much things have changed in Portugal. Coauthors Caitlin Elizabeth Hughes and Alex Stevens report a 63 percent increase in the number of Portuguese drug users in treatment and, shortly after the reforms took hold, a 499 percent increase in the amount of drugs seized — indications, the authors argue, that police officers, freed up from focusing on small-time possession, have been able to target big-time traffickers while drug addicts, no longer in danger of going to prison, have been able to get the help they need.

“Often, there are lot of fears, misconceptions, and mythology around decriminalization and what might be the consequences,” Hughes said. “This reform has shown that it is possible to decriminalize illicit drugs...without necessarily increasingly drug-related harm, without increasing the burden on the criminal justice system, and without increasing drug use.”

Not everyone agrees with this analysis. The rate of people reporting drug use in Portugal is, in fact, increasing — and some say alarmingly so. Others argue that it’s hard to draw lessons from Portugal’s experiment because the nation increased access to treatment at the same time it decriminalized drugs. Many believe that Portugal’s new focus on treatment — and prevention — may have had as much, if not more, to do with its success than its policy of decriminalization.

Still, the Portuguese findings come at a critical time in the global drug policy debate. Many nations, including Denmark and Switzerland, have pursued harm-reduction strategies in recent years, focused on helping drug addicts, not punishing them. Some nations, including Mexico, have recently decriminalized possession of small amounts of drugs. And many others, including the United States, continue to debate some version of that idea.

A recent Gallup poll found that 46 percent of Americans favored legalizing pot — the highest percentage since 1970, when Gallup first asked the question. In 2008, Massachusetts voters overwhelmingly opted to decriminalize the possession of small amounts of marijuana. And last fall, California voters narrowly rejected an even more radical measure that would have allowed municipalities to approve commercial cultivation of pot and even tax the drug, like liquor. Those pushing for drug policy reform argue that Portugal’s changes prove that decriminalizing drugs won’t lead to a national calamity, but to a society where the criminal justice system can focus on real criminals and drug addicts can get counseling, not a prison cell. And those pushing back point out the holes in the new research, and the difficulty of replicating one nation’s experience in another, especially when the two nations are Portugal and the United States.

In this sense, one drug policy expert noted, the Portuguese experiment has become a sort of Rorschach test — in the dark blobs on the page, people can see whatever they want to see. But Tom McLellan, the former deputy director of the Office of National Drug Control Policy under President Obama, said he’s happy for the conversation. While not in favor of decriminalization, McLellan believes that the American debate over drug reform has become too polarized, with one side calling for incarceration and the other for legalization. “And I just don’t buy it,” McLellan said. The answer is likely somewhere in the middle, he believes, and perhaps that’s where we can learn something from Portugal, a country that at least tried something new.

“I like that approach to drug policy,” McLellan said. “Policy is really a product. And like a product, policy can be made better with experimentation and honest evaluation, rather than stupid polemic polarization of ideology.”

The modern debate over the decriminalization of drugs in the United States can be traced to the spring of 1972. That March, a commission appointed by President Nixon to review America’s drug policy and led by former Pennsylvania governor Richard P. Shafer made a shocking recommendation: Marijuana should be decriminalized. Simple possession, Shafer’s commission recommended, should no longer be an offense and the “casual distribution” of small amounts of pot for no, or little, remuneration should be decriminalized as well.

Nixon was livid. Even before the report was published, the president vowed not to loosen penalties for pot possession. “I think it was a conservative recommendation if you really think about drug policy,” said Richard Bonnie, the commission’s associate director at the time and now a professor of law and public policy at the University of Virginia. “We really needed to learn how to prevent and discourage the use of drugs, especially in adolescent years. But you should use tools appropriate to the purpose, and criminal sanctions carried a lot of costs that really weren’t appropriate.”

In the wake of the report, about a dozen states, including Oregon, California, Ohio, Maine, and Texas, didn’t decriminalize the possession of all illicit drugs, like Portugal has done, but they did significantly reduce the penalties for marijuana possession. By the late 1970s, however, marijuana use was on the rise, especially among youngsters. Public health experts began ringing alarm bells; one described marijuana as a “major and serious public health hazard.” And with the Reagan revolution gaining steam, America’s brief flirtation with drug decriminalization came to a halt.

Now, in the Portuguese data, Bonnie believes he can see what might have been had the United States continued on the path of decriminalization. Portugal, like many US states in the 1970s, didn’t legalize drugs. Instead, it opted to decriminalize possession. Those caught with drugs would no longer be sent to jail, but to Commissions for the Dissuasion of Drug Addiction, or CDTs, panels made up of lawyers, social workers, and medical professionals whose job was imposing fines, warnings, or treatment on individuals instead of criminal penalties. Meanwhile, Portuguese police have continued to pursue high-level drug traffickers, who, when caught, face prison time — a system that has not only worked, Goulão said, but has resonated in a nation where, a decade ago, nearly 1 percent of the population was hooked on heroin or some other drug.

“It touched every family,” Goulão said. “It was difficult to find a family that didn’t have problems with drug addiction. And the people they knew who were drugs addicts — they knew they weren’t criminals. They needed help, rather than to go to jail.”

Now in Portugal, Goulão said, many addicts get that help — or at least have easier access to it, which seems to be having some effect. The number of problematic drug users in the country has declined — from about 100,000 in the mid-1990s to 60,000 today, Goulão said. The proportion of drug-related offenders in the nation’s prison system has dropped from 44 percent in 1999 to 21 percent two years ago, and the number of prisoners reporting prior heroin use has also declined — from 44 to 30 percent, suggesting, in general, a criminal population less hooked on drugs.

But the numbers aren’t all positive. According to the latest report by the European Monitoring Center for Drugs and Drug Addiction, the number of Portuguese aged 15 to 64 who have ever tried illegal drugs has climbed from 7.8 percent in 2001 to 12 percent in 2007. The percentage of people who have tried cannabis, cocaine, heroin, amphetamines, ecstasy, and LSD all increased in that time frame. Cannabis use, according to the drug report, has gone up from 7.6 to 11.7 percent. Heroin use jumped from 0.7 to 1.1 percent, and cocaine use nearly doubled — from 0.9 to 1.9 percent. In other words, said Keith Humphreys, a professor of psychiatry at Stanford University, the changes in Portugal have had a somewhat expected outcome: More people are trying drugs.

“What it says to me is that when you decriminalize, use goes up — potentially dramatically,” said Humphreys. “You can see a doubling of cocaine use, a doubling of heroin use. And because drug use carries some risk — no one disputes that — it becomes inevitable that as use goes up, more people will get hurt.”

In fact, drug-related deaths in Portugal — after falling between 1999 and 2002 — jumped considerably between 2005 and 2008. But the drug-related death data is misleading, most likely due to a “shift in measurement practices,” and an increase in the number of toxicological autopsies performed, according to Hughes’s and Stevens’s research. And Hughes also takes issue with Humphreys’s argument that drug use, in general, is increasing at a dramatic clip.

What’s most relevant, she said, is not the percentage of people reporting using drugs at some point over some course of their lifetime, but the percentage of people reporting using drugs in the past year. “That’s going to be affecting the government and communities now,” she said. And here, the increase of Portuguese reporting illicit drug use is much smaller — up from 3.4 percent in 2001 to 3.7 in 2007.

Still, there are doubts that decriminalization was the key factor in solving some of Portugal’s troubling drug use problems. Between 1998 and 2008, the number of users in treatment in Portugal jumped from over 23,000 to over 38,000 — an advance that could have potentially happened, critics say, without decriminalization. “We know Portugal decriminalized drugs,” said John Carnevale, former director of planning, budget, and research at the Office of National Drug Control Policy under presidents Reagan, Bush, and Clinton. “But we don’t know the effects of that decriminalization.”

Even Goulão himself cautions against decriminalizing drugs without offering what he called “the whole package”: expanded treatment services, increased prevention measures, and a nationalized effort to attack drug addiction, and its consequences, as a public health problem, not a criminal justice issue. “There’s no choice,” he said, “in becoming an addict.”

Even with all the questions, Goulão is in demand. In recent weeks, he has been asked to speak about Portugal’s drug experiment in Great Britain and Australia, and other trips are sure to come. Everyone, it seems, wants to hear from the drug czar who, for the most part, isn’t interested in punishing those who use drugs.