By ROB WATERS

For the past 50 years, Italy, Portugal, and the United States have taken radically different approaches to drug enforcement and to the epidemics of drug use and addiction that have afflicted each country. One, the U.S., has emphasized punishment. It leads the world in incarcerating people—and at burying them after drug overdoses. Another, Portugal, has decriminalized drugs and created a model for effective drug treatment. Italy, meanwhile, has veered wildly between these two poles, never settling on a clear approach.

This is the story of how Portugal has dealt with its drug problems and largely succeeded, while the U.S. and Italy, despite pockets of success—like the San Patrignano rehabilitation community in northern Italy described in another article in this issue—have mostly failed.

“AN EXPLOSION OF EXPERIMENTATION”

For all three countries, the modern epidemic of hardcore drugs began with a dramatic rise in the use of heroin. In the U.S., heroin use surged during the Vietnam War, as American soldiers experimented with Southeast Asian heroin and many became addicted. When they came home, drug syndicates saw a market and filled it, putting large quantities of heroin onto the streets of U.S. cities.

At its peak, in the late 1990s, about 1 percent of Portugese people were using heroin and one person a day was dying of an overdose—in a country of just 10 million.

Heroin came to Italy in the mid-1970s and its use grew rapidly, striking all social classes. By the late 1980s, Milan alone had an estimated 100,000 heroin users, according to a 1989 article in the New York Times, which noted that in 1988, 809 Italians died of overdoses.

At its peak in the late 1990s, Portugal had one of the highest rates of heroin addiction and fatal overdoses in the world. About one percent of Portugese people were using heroin and one person a day was dying of an overdose—in a country of just 10 million. Then Portugal changed course and took a radical step, eliminating criminal penalties for drug use and possession and making a commitment to provide treatment to all who want it. Today, Portugal has arguably the world’s most enlightened set of drug policies.

As in the U.S., Portugal’s heroin experience began with war. Throughout the 1960s and early 1970s, Portugal deployed hundreds of thousands of soldiers to suppress uprisings in the country’s African colonies. Like the Americans’ experience in Vietnam, these soldiers were exposed to marijuana and other drugs. Then, in 1974, a military coup struck Portugal, followed by a peaceful popular uprising (the “Carnation Revolution”). Almost overnight, decades of rule by a right-wing dictatorship were brought to an end.

A young doctor named João Goulão was then working in the Algarve area of southern Portugal. He had a front-row seat to what happened next.

“Suddenly almost a million soldiers and settlers came back to the mainland, bringing literally tons of cannabis, and there was an explosion of experimentation,” Goulão, who now runs the country’s drug agency, told me in a recent interview. Portugal at the time was going through an extraordinary upheaval, creating a new government and new laws. Young people and returning soldiers savored their new freedom by experimenting with drugs as marijuana, heroin, cocaine and LSD flooded in. “We were completely naïve about drugs,” says Goulão, “and completely unprepared to deal with it.”

FROM BAD TO WORSE

In a flash, Portugal went from having one of the lowest rates of drug use among European countries to having perhaps the highest. The biggest problem was heroin.

Instead of 100,000 heroin users and 360 overdose deaths a year, as it had in the 1990s, Portugal now has about 50,000 users and most are in treatment.

“Heroin spread very fast and among all social groups,” says Goulão. “It was not something that happened only among marginalized people and minorities, or in ghettoes. Suddenly everybody knew someone who had problems with drugs.”

As heroin use grew, so did overdoses. Doctors and public health professionals throughout the country began setting up treatment programs. After his daughter died of an overdose, the Minister of Justice set up treatment centers in three large cities. Private programs popped up as well, but Goulão says most were of poor quality and many ripped off the patients and families who came to them for help.

These efforts amounted to Band-Aids, not a concerted national policy. The number of providers and treatment programs kept growing but heroin use grew even faster. The sharing of needles also spread AIDS, adding to the death toll. With drug possession and sales seen as crimes, the prison population soared. And since drugs circulated widely within prisons, it had little effect on the underlying problem.

“People could spend two or three years in jail and come back worse than when they went there,” says Goulão. “The situation was getting worse every day.”

STEP ONE: DECRIMINALIZATION

In 1998, Portugal Prime Minister António Guterres, (now secretary-general of the United Nations) convened a group of nine experts—judges, psychologists and health professionals including Goulão—to develop a national strategy for addressing the crisis. The group visited other European countries, interviewed professionals and researched different approaches. In the end, they concluded they could do relatively little to address the supply of drugs—but could do a lot to address the demand.

The committee developed a set of concrete proposals focused largely on “prevention, treatment, harm reduction, and the reintegration of people,” Goulão says. “All of it was based in the idea that we were dealing with a health and social condition rather than a criminal one.”

The committee’s most radical proposal was to eliminate criminal penalties for the use and possession of drugs. Government leaders accepted the proposal but it also required the approval of Parliament. So Goulão and his colleagues took their case to the public and spent the next year presenting their plan in dozens of forums and discussions.

Their proposal was opposed by right-wing parties and Goulão remembers their arguments: “Portugal will become a paradise for drug addicts and drug users from all over the world. We will have planes coming to Lisbon every day with people to use drugs. Our children will start using drugs at early ages.”

But support from the public and, surprisingly, from the Catholic Church carried the day—in 2001, Parliament passed the sweeping changes. “Using drugs in Portugal was no longer a crime,” Goulão says.

STEP TWO: MULTIPLE OPTIONS FOR TREATMENT

Today, some 40 programs in Portugal provide detoxification and long-term treatment, with 1600 beds in residential treatment programs known as “therapeutic communities,” Goulão says. Most are run by nonprofit agencies, under contract with the government. They employ a variety of treatment approaches, but all must provide health, nutrition and counseling services, have a multidisciplinary staff, and be approved by Goulão’s agency, the General Directorate for Intervention on Addictive Behaviors and Dependencies.

Many of the programs provide either methadone or buprenorphine, drugs that substitute for heroin or other opioids by satisfying the cravings but eliminating the high—and the risk of overdose. This buys time to allow the patient to benefit from psychological and social support. Other programs use the 12-step approach, which couples abstinence from drugs and alcohol with the support of a spiritual community of peers, or a 12-Steps offshoot, the Minnesota model, which takes the same approach and adds professional counseling and evaluation.

“Having different options allows us to address the patients according to their personality and their characteristics,” Goulão says. “If you wish to get treatment, we have centers all over the country. They work for free, there’s no payment to be made.” Goulão’s agency spends about 65 million Euros a year (nearly $74 million) on these programs, with help from other agencies such as the departments of Justice, Home Affairs, Education, and Social Welfare. “In most of them, we have no waiting lists,” he says. “If you need help, you just ask for it.”

STEP THREE: A MOBILE VAN

Portugal’s approach has not eliminated drug problems, but Goulão says it has made them far more manageable. Instead of 100,000 heroin users and 360 overdose deaths a year, as it had in the 1990s, the country now has about 50,000 users and most are in treatment. In 2016, Goulão says, only 16 people died of an overdose. Needle use is no longer a principal source of HIV infection.

Public perceptions have shifted, too. In the 90s, the Portuguese saw drug addiction as one of the top problems facing the country but today “it ranks 13 or 14 in the concerns of people,” Goulão says. “In 2001 there was open division between left wing and right wing parties. Nowadays everybody agrees that we made a good choice and nobody even tries to go back to more harsh policies.”

In December, Portugal planned to take another radical step by deploying a mobile van that will travel around Lisbon, making stops to allow drug users to inject in a supervised environment. While Vancouver, along with cities in Europe and Australia, have tried this approach for years, Portugal did not. “Injection drug use was dropping so fast,” Goulão says, “we felt it was not a good idea to give that sign to society.” But in recent years, some longtime heroin users who had been in treatment relapsed “and we believe that having a safe injection room may be useful for that population.”

DENIAL, AMERICAN AND ITALIAN STYLE

While Portugal has become the worldwide model for what an innovative and compassionate harm reduction strategy can accomplish, the U.S. and Italy have followed very different paths.

In Italy, a 1990 law made personal consumption of drugs like marijuana, cocaine, LSD and heroin illegal. A 1993 referendum supported by 55 percent of voters decriminalized possession of marijuana—until a hardline 2006 law reversed that, tripling the sentences for possession or use. The number of people incarcerated for drugs exploded, and soon made up 40 percent of Italy’s overcrowded prisons. That law was later struck down, but prisons remain overcrowded.  As of 2016, one-third of Italy’s inmates were incarcerated due to drug offenses.

“Ninety percent or more of all the people who go to AA don’t benefit,” says the former director of the Substance Abuse Treatment Unit at Harvard’s McLean Hospital.

Of all three countries, the U.S. has chosen the most punitive course, and in the process achieved a dubious distinction: It is the world leader in rates of both incarceration and death via overdose. Today, 2.3 million Americans—almost 1 percent of the adult population—are locked up. One in five are imprisoned directly for a drug offense and drugs play a role in many more. While African-Americans represent just 13 percent of the U.S. population, 40 percent of the people in U.S. prisons are black. Meanwhile, the number of people injecting drugs keeps climbing. In 2017, according to the National Centers for Disease Control and Prevention, 70,000 people died of an overdose, twice the number of 10 years ago.

As the opioid epidemic in the U.S. has exploded, a drastic shortage of treatment services means people must often wait months to get help—which for many, doesn’t come in time. According to the National Council for Behavioral Health, more than 90 percent of people with substance use disorders are not receiving treatment. And while some 900,000 doctors can write prescriptions for the opiate painkillers that start many people on their path to addiction, fewer than 32,000 are trained and authorized to prescribe buprenorphine, the opioid substitute that, unlike methadone, can be used at home.

Meanwhile, the federal response in the U.S. has been woefully inadequate. In October, President Trump signed the Opioid Crisis Response Act of 2018, a rare bill that actually passed both houses of Congress. However, while it will reauthorize some existing grant programs and make it easier for Medicare and Medicaid to treat addiction, the bill provides little new money at a time when many experts see the need to spend $100 billion or more over the next five years – roughly the amount the US spends to treat HIV/AIDS. The act “is simply tinkering around the edges,” said Leana Wen, Baltimore’s former health commissioner.

THE REAL ENEMY: FEAR OF CRIMINALIZATION

There’s another problem too, says Lance Dodes, former director of the Substance Abuse Treatment Unit at Harvard’s McLean Hospital, and author of the 2014 book, “The Sober Truth.” The dominant model for alcohol and drug treatment in the US is the 12-step model of Alcoholics Anonymous and Narcotics Anonymous—yet Dodes says it works for only a small fraction of those who make use of the program.

“Ninety percent or more of all the people who go to AA don’t benefit,” he told me in a recent interview. And what’s more, people who go and aren’t helped get blamed. “AA discourages people from leaving. It uses slogans such as ‘It works if you work it.’ In other words if you’re failing at it, it’s your fault. To me, that is a dangerous, harmful thing to say.”

João Goulão recently spent a week in the US, visiting cities to learn about the drug epidemic here. He came away with both impressions and recommendations. He says harm reduction strategies—providing opioid substitutes, needle exchanges and outreach programs to help the most marginalized people—are vital. He also thinks the U.S. should explore the path his country tried by decriminalizing all drugs and offering people treatment. “If you keep it criminalized, people avoid seeking help because they are afraid of being referred for prosecution,” he says.

Goulão noticed something else too: that the U.S. opioid epidemic is now affecting people of all social classes and communities—“medium class, high class, everybody”—as it did in the early days in Portugal.  “And that,” he says, “is the moment to launch a serious debate around these themes.”