Portugal has continued with drug decriminalisation – McDowell should note this.

Nigel Hawkes, freelance journalist

Drug Misuse
Highs and lows of drug decriminalisation
BMJ 2011; 343 doi: 10.1136/bmj.d6881 (Published 26 October 2011)
Ten years after Portugal became the first European country to
decriminalise all drugs, Nigel Hawkes examines what effect the law has
had

Those who want to see drug laws liberalised have pinned their hopes on
Portugal, a country that has now survived 10 years of drug
decriminalisation without the sky falling in. Americans are especially
drawn to the Portuguese model: the Cato Institute published a report
extolling it in 2009, and it was the subject of a major feature in the
New Yorker earlier this month (17 October).

Seen from a US perspective, Portugal’s experiment does indeed appear
radical. Possession of small amounts of drugs ceased to be a criminal
offence on 1 July 2001, and addiction was redefined as a problem
calling for treatment rather than sanctions. But just how different is
Portuguese law from that of the rest of Europe, and how well has it
worked? João Goulão, chairman of the Portuguese Institute on Drugs and
Drug Addiction, a department of the Ministry of Health, spoke to the
BMJ on a recent visit to London.

He argues that the changes must be seen as a whole. “It’s very
difficult to identify a causal link between decriminalisation by
itself and the positive tendencies we’ve seen,” he said. “It’s a total
package. The biggest effect has been to allow the stigma of drug
addiction to fall, to let people speak clearly and to pursue
professional help without fear.

“You have to remember that we had emerged from 48 years of fascism.
People were reluctant to approach a doctor with a drug problem because
they feared they would be referred to the police. But addiction was
very widespread.

“In the late 1990s, if you asked people in the streets what their main
worry was, they would say the problems arising from drug addiction.
Now it’s down to 13th place in the opinion polls. That’s why the
social acceptance of the new law was so wide—drug addiction had moved
in the 1990s from the margins of society to the mainstream, up the
social scale, there wasn’t a family that hadn’t been touched by it.”

The law that came into force in 2001 did not legalise drugs; that
option was closed off by adherence to the UN convention which obliges
signatories to prohibit drugs of misuse. So drug possession for
personal use is still prohibited, but violations are administrative
and not criminal offences. The amount of drug that users can possess
for their own consumption is limited, at around 10 days’ use for an
average user. All drugs are included. Hearings before specially
established Commissions for Dissuasions of Drug Addiction, comprising
psychologists, judges, and social workers, can impose fines on drug
users but normally waive any sanction in return for an agreement to
seek treatment. Drug trafficking remains a criminal offence.
Has decriminalisation worked?

One of the fears when the law was passed was that Portugal would
become a haven for drug tourists. But that hasn’t happened, Dr Goulão
said. About 95% of those cited under the law have been Portuguese,
with very low numbers from other EU countries.

The clearest change has been a fall in HIV infections among
intravenous drug users, which peaked at around 1600 a year in 1998 and
had fallen to around 200 by 2009, according to data from the National
Coordination for HIV/AIDS Infection. But figures had already begun to
drop by 2001 so this cannot wholly be attributed to the change in the
law. The proportion of those injecting in the 30 days before their
first consultation has fallen from 32% in 2001 to 7% in 2010. But a
sharp fall in heroin use has been matched by increases in use of
cannabis and, to a lesser extent, cocaine.

A second fear expressed in 2001 was that children would start using
drugs, Dr Goulão said, “but 10 years later, there has been a decline
in use of all illegal drugs among 15-19 year olds.” Lifetime use of
any drug among 16 to 18 year olds fell from 28% to 20% between 2001
and 2006, according to the National School Survey. The lifetime
prevalence of drug taking in other age groups has, however, increased.

The numbers of addicts under treatment has risen, while drug seizures
by the police have also increased. Dr Goulão attributes this to the
police having to spend less time pursuing users, which enabled them to
focus instead on those higher up the supply chain—“the sharks, not the
small fish.”

Drug related deaths present a confusing picture. According to the
Portuguese National Institute of Statistics, which counts deaths
wholly caused by drugs, the number of such deaths in Portugal fell
from 76 in 2001 to 20 in 2008. But the National Institute of Legal
Medicine, in contrast, reports a fairly sharp rise in the number of
people in whom postmortem examinations found traces of drugs after
deaths from other causes, such as road crashes—up from 280 in 2001 to
314 in 2007. Dr Goulão attributes this rise to the greater number of
tests now being carried out.

He makes no claims that decriminalisation is responsible for the
changes seen in Portugal. Critics of the law, such as Manuel Pinto
Coelho, a doctor who has treated addicts for many years and is
president of the Association for a Drug Free Portugal, vigorously
contest claims that it has produced any benefits. Dr Coelho says that
medicalisation of the problem has convinced most addicts that they
have to remain dependent on methadone rather than struggling to become
independent. He contests most of the positive statistics, questioning
whether they represent reality. “There is a complete and absurd
campaign of manipulation of Portuguese drug policy facts and figures,
which some authors appear to have fallen for,” he wrote in a rapid
response to a BMJ article a year ago.1
National comparisons

If the aim of the policy is to reduce the use of illicit drugs, then
the most positive claims that Portugal can make is for falls in heroin
use and in all drug use among young people. But English statistics
show similar trends. The proportion of 15 year olds who have ever
taken drugs in England is at a 10 year low, having fallen from 48% in
2001 to 32% in 2010.2 Heroin and crack cocaine use is also falling in
all age groups, suggesting to some (such as Martin Barnes, chief
executive of DrugScope3) that a “generational change” is occurring.

Against this background, Portugal’s record is not especially
impressive. Although heroin use began to fall soon after the 2001 law
came into effect, the use of cannabis and cocaine began to rise, and
this continues into 2011. Overall drug use remains at the low end of
the EU average, however.

While other EU countries have not followed the Portuguese route and
decriminalised drugs, many have laws that mean possession no longer
attracts a custodial sentence. In practice, the differences between
the two policies may be slight, since both set treatment above
sanctions. The US, which has more punitive policies than EU countries,
has the highest use of cocaine and cannabis. But would a more liberal
approach reduce US consumption of illicit drugs? The evidence from
Portugal is far too tenuous to bear such a conclusion.

Dr Goulão believes that the policies adopted in Portugal were specific
to the situation the country found itself in. “Would I recommend this
approach to Mexico?” he said. “Of course not. If a country lacks an
effective health service, it would be ineffective to treat drug
addiction as a health problem.”

His immediate worry is that difficult times brought about by the
recession will roll back the gains that have been made. “More people
may turn to trafficking in drugs,” he said. “And we are finding an
increase in problematic drug use among older people. If at the same
time we pull out the rug by cutting the money spent on services, I
would be very worried.”
Will the recession lead to greater use of illicit drugs?

It is a battle between the economic and the psychological drivers of
behaviour, says Rosalie Liccardo Pacula, co-director of the RAND Drug
Policy Research Centre in Santa Monica, California.

Dr Pacula doesn’t know which will win. But in an article in a special
issue of the International Journal of Drug Policy4 and in a lecture to
the London School of Hygiene and Tropical Medicine on 19 October she
put forward her hypotheses.

She told the BMJ: “In a recession heavy drinking goes down. So do
smoking and obesity. But can we expect to see the same for drugs?
Theory would suggest yes, but the evidence is not so clear.

“There is evidence from the US and Australia that people are more
likely to start using cannabis in a recession, especially younger
people. Unlike alcohol or tobacco, drugs are not part of the social
norm, so they may not follow the same pattern. Economic pressures make
alcohol less affordable for heavy users during recessions, but we
can’t be sure the same will be true of drugs.

“For example, it’s possible that young people who can’t get work will
be drawn into the black economy, where they will come into direct
contact with drugs and drug users. Some may be tempted to trade in
drugs to make some money. And unlike alcohol, drug prices may be more
responsive to changes in economic conditions. If illicit drug prices
fall, then price effects may offset income effects and illicit drug
use could rise.”

Another possibility is that drug users will try to get the greatest
possible hit from their drugs by injecting, a trend that has been
observed in France. “This has huge health implications because it may
contribute to HIV and other diseases.” Dr Pacula said.
Notes

Cite this as: BMJ 2011;343:d6881
Footnotes

Author Affiliations

nigel.hawkes1@btinternet.com
Competing interests: The author has completed the ICJME unified
disclosure form at www.icmje.org/coi_disclosure.pdf (available on
request from him) and declares no support from any organisation for
the submitted work; no financial relationships with any organisation
that might have an interest in the submitted work in the previous
three years; and no other relationships or activities that could
appear to have influenced the submitted work.

Provenance and peer review: Commissioned; not externally peer reviewed.

References


Pinto Coelho MF. Electronic response to Vale de Andrade P et al,
Drug decriminalisation in Portugal. BMJ 2010.
www.bmj.com/content/341/bmj.c4554/reply#bmj_el_243206?sid=c6aa9104-b947-4dba-85cf-e1568259c2c3.

NHS Information Centre. Smoking, drinking and drug use among young
people in England in 2010. 2011.
http://www.ic.nhs.uk/pubs/sdd10fullreport.

Campbell D. Illegal drug use is in decline, NHS figures reveal.
The Guardian2011 Jan 27.
http://www.guardian.co.uk/society/2011/jan/27/illegal-drug-use-decline.

Pacula RL. Substance use and recessions: what can be learned from
economic analyses of alcohol? Int J Drug Policy2011;22:326-34.
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