How (Not) To Legalize Drugs

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Intro

This is a real place Portugal sends people caught by the police with drugs. It’s Quinta das Lapas, a drug rehab facility in the former mansion of a marquis, north of Lisbon. Here, offenders play volleyball, work in the woodshop, and stroll through lavish gardens between therapy sessions.

And it’s all paid for by the government.

It’s strange, comparing this to how America treats addicts. Here, people caught with drugs are fined, jailed, or sent to prison.

So which works?

Take New Jersey, an American state with the same population as Portugal. Here, about 3,000 people tragically die every single year from drugs. In Portugal, only about 50 people suffer that fate.

And it wasn’t always this way. In 2000, Portugal had the highest rates of heroin usage, HIV, and overdose deaths in the developed world. And now, they have some of the lowest, while hard drug usage and overdose deaths in America have skyrocketed in the same period.

Because in America, drugs are a crime, and in Portugal, they’re decriminalized.

At least, that’s what a lot of people think. And while Portugal was the first country in the world to decriminalize all drugs — if that were the real reason,

then why have decriminalization efforts modeled after Portugal failed so badly in Oregon and Canada that voters there repealed decriminalization programs just a few years in?

Because decriminalization is just the tip of the iceberg. In the words of Dr. João Goulão, the architect of Portugal’s revolutionary drug policy,

Decriminalization is not a silver bullet. If you decriminalize and do nothing else, things will get worse.

In the late ‘90s, Portugal was tired of seeing drugs rip their country and their families to shreds. They were tired of being the heroin capital of Europe.

So they didn’t just decriminalize and invite drugs into their communities to destroy more lives.

They built an entire policy and treatment regime from the ground up, defined by four key principles that every attempt to replicate their success has completely overlooked: Dissuasão, Passo, Malha, and behind it all, an unceasing dedication to Recuperação — Rehabilitation. Four steps that aren’t meant to go easier on drugs — or harder — just smarter.

So I’m gonna dig into these four concepts, explain what they mean and how they work, because I’m convinced they do work, not just on the Portuguese, but on humans.

Along the way, I’ll be honest about the serious challenges facing the Portuguese system. How do they deal with people who just don’t want to get off drugs? Is it all too expensive? And finally, why have attempts to imitate this failed so badly?

So, this is how Portugal did it: how they rewrote the drug policy playbook, their secret formula for success, and the big challenges still ahead.

Recuperação

In the 1980s and 1990s, Portugal was deep in a crisis of drug addiction. Heroin usage, along with HIV and Hepatitis — dangerous diseases commonly spread through shared drug needles — were more common than anywhere else in the developed world. [A]

In the capital, Lisbon, a neighborhood known as Casal Ventoso became known as the biggest open-air drug market in Europe. Each morning here, police would find the bodies of those who'd overdosed and died the night before. The government tried cracking down, tried escalating a war on drugs, but by 2000 everyone could see it wasn't working.

As Dr. Goulão put it,

Dr. Goulão: Every family had its own drug addict. It was so, so present in everyday life, that it turned public opinion. [B]

This was a nation of mourning mothers like Gandelina Damião, who lost three of her children to heroin in the 1990s. So in 2000 Portugal put together a team of 10 people — doctors, including Dr. João Goulão; experts; and former and current drug users — to come up with a new approach. These were people who didn’t just look at drugs as a political or legal issue. They understood it as a medical and personal struggle. They knew how getting clean actually happens.

And in the end, their plan was to do something that nobody had ever done before — decriminalize personal use of all drugs.

But make no mistake. This was not legalization. Nor was it a way to make doing drugs easier. The goal was to end an epidemic that had nearly destroyed the country. The big change was just how they planned to go about that.

Instead of prohibition and a war on drugs, they shifted their focus to Recuperação, to recovery. Getting addicts off of drugs required treatment and compassion, not criminalization. But it also required a clear desire to help the patient, not let him sink into his sickness.

As Dr. Goulão put it,

Dr. Goulão: We are dealing with a chronic relapsing disease, and this is a disease like any other. I do not put a diabetic in jail.

Dissuasão

Decriminalization meant that, without legalizing anything, Portugal replaced the police and the criminal court system with Dissuasão: the dissuasion committees.

Instead of enforcing criminal punishment, dissuasion committees are civil institutions tasked with facilitating rehabilitation. To do that, they have three major tools —sanctions, community service, and treatment — and you can end up there one of two ways.

The first is pretty intuitive. If you get picked up by the police for drugs — because they are still illegal — and they find you’re in possession of more than a 10-day supply, you get booked and can be charged for trafficking. But if you have less than a 10-days-supply, your drugs are merely confiscated, and you get referred to your local Dissuasão office, no record or criminal charge or fine.

Once at the Dissuasão you have a meeting with three people — a lawyer, a psychologist, and a social worker — where the objective is to assess your situation, your needs, and the best path forward to get you off drugs. Treatment is the first tool the committee goes to because in Portugal, they know it's the most effective. But it isn’t always so simple. [G]

According to Nuno Capaz, vice-president of Lisbon’s Dissuasão,

Dr. Capaz: Drug addiction is a complex problem that we’re likely not going to solve. The best we are likely to do is manage it and we need to devise ways to manage those situations. [C]

But sometimes people don’t show up for their meeting or don’t have any desire to make a change and get clean. The way Capaz sees it,

Dr. Capaz: If people are willing to comply with what we recommend, good. If not, that’s their problem. Treatment has to be voluntary. [C]

If voluntary acceptance of treatment isn’t forthcoming, Capaz adds, they have other tools. Typically, that looks like mandatory community service. But the Dissuasão also has more serious sanctions. They can levy fines, suspend occupational licenses, cut off welfare payments, or ban you from certain places like clubs, where drugs may be prevalent.

Sanctions like these are always the last resort, because the point isn’t to punish, it’s to induce people to cooperate with a positive program or Recuperação.

And the truth is, only about 10-20% of hearings end this way. 80-90% of every case that comes to Dissuasão actually results in the person accepting treatment. And that makes sense, because only about 20% of cases come through police referral. 80% of people who meet with the dissuasion office come through a second route; they call a publicly-advertised hotline or come into the office…voluntarily.

And this is so much the heart of why Portugal’s decriminalization has been so successful. Drugs have never lost a negative social reputation. But addiction is seen not as a crime but a disease which needs care. So the government has created tools that help, advertised their availability successfully, and reduced the danger to people who want to step forward and seek that help.

According to Dr. Goulão,

Dr. Goulão: Dependents are seen and treated as sick people, with the same dignity as those who suffer from other pathologies. These are little things that make the difference… Before, people feared being fired, but today they recognize that they have a problem and seek treatment. [A]

Passo

Whether you end up at Dissuasão through a police referral or you seek help on your own, the system is designed, in a word, around Passo: the step. The Portuguese approach attempts to meet people where they are and walk them step by step through to Recuperação.

But, what do those treatment options actually look like? For someone on an early Passo or step in the process of addiction, they may only need therapy or counseling. Services like these can be easily provided from any one of the country’s many government-operated outpatient facilities. And for those in a more advanced passo of addiction, the country also operates numerous in-patient facilities like this one — Quinta das Lapas — where people can stay for months and receive serious attention and care.

But others need something else. Take Francisco, a struggling musician who succumbed to drug addiction after his father died, and then became embroiled in a legal battle over the inheritance of his family home. Meeting him at his Passo meant getting him legal assistance before asking him to get clean — recognizing his humanity and his basic needs before demanding more from him. And in the end, with help he kept his home, giving him the stability and closure needed to get his life together and get off drugs.

Yet for some, their Passo may be a state of extreme addiction. For a drug like heroin, the most effective tool at this stage is often methadone — a drug-replacement substance that reduces cravings and can help people wean. But that can take a long time, and meanwhile, the addict continues using. Sometimes that means they quit the methadone program and relapse. But sometimes… it works. It’s about trusting the process, even if it is slow.

As Dr. Goulão describes it,

Dr. Goulão: Our approach is incremental. Our system works by asking citizens what he can give at that given moment… An addict has to do whatever to get his fix each day. I cannot ask him or her to behave as a free citizen… I have to help him with his limited capacity to make his own choices. And, step-by-step [ — passo a passo — ], the ability of the citizen increases. [D

Warning

But Goulão doesn’t want us to lose sight of the target, of Recuperação. Once you meet someone on their Passo — at their step — the point is take them further, through the steps to recovery. And the way Goulão sees it, this is something a lot of countries get wrong when they try to copy Portugal.

A lot of people will focus on programs that reduce harm. That could mean setting up places where people are allowed to use drugs. This means healthcare workers can watch people and make sure they don't overdose. Reducing harm could also mean setting up places where drug users can get clean needles. This can decrease spread of disease in a big way. Or it might mean giving out naloxone — a shot that can prevent death when someone has overdosed.

And the value of these efforts can't be overstated. Addicts are victims of a disease, and they can't recover if they're dead. But you might see a problem here. These programs make doing drugs safer, even easier. And that can be dangerous, too. Dr. Goulão saw that first-hand, when he visited Vancouver, Canada.

Dr. Goulão: I was shocked. What I saw took me back to the end of the 1980s and 1990s in Lisbon… There, it’s as if the institutions caught a client. And they won't let go of him anymore, because as long as he's there they're being paid. [E]

In other words, the Canadian program poured money into harm reduction. And they had good reasons. Those efforts stopped a lot of people from dying. But according to Goulão, they didn't take the next step, the next passo. They let harm reduction become the goal. But that doesn't help people get clean, or help them rebuild a life worth living. Francisco, the struggling musician and recovering addict, is critical of efforts like this that he calls too soft. He mentions one group in Portugal that believes in legalization and doesn't use the term "addict" because "it stigmatizes people." He disagrees. He calls himself an addict, he says, because strong words are the ones that create action.

Francisco: I can understand drugs, but I can’t accept them. Doing drugs is an illusion because it is a weight on your soul…One day, you wake up and the drug controls you. The first thing you want to do is go and inject… Every day, when I wake up, I think I have come to the jungle, with the danger always lurking. [F]

Malha

Decriminalization in Portugal works, because they never lost sight of their real objective: Recuperação. Portugal's policy is about recovery. Portugal uses harm reduction. But they haven't let harm reduction become the goal. That kind of focus and clarity of purpose is how you really help people.

But I’ve made this all sound pretty easy. Do the harm reduction, then do the next thing. Just get people real help. But that’s where things get difficult, where Portugal’s model becomes so hard to copy. Because to work, that means weaving all sorts of programs into one big effort. It means building Malha: the weave.

As Goulão says,

Dr. Goulão: It only works if there are well-trained street teams, a wide service network, a range of tools available; a very present national coordination. We have a [council where] the Ministries of Health, Justice, Economy and Agriculture, among others, all [meet and] work [together] thoroughly and precisely. [A]

Building a program to help people get clean means weaving together Dissuasão offices, treatment programs, counseling, education, and more — tools to meet people at every single passo on the path to Recuperação. That malha, that weave, is Portugal’s secret. But that’s really hard to do. Even Portugal has some trouble keeping up.

In recent years, the country’s economy has struggled. And they’ve had to cut spending on the drug programs. It now takes months to get into places like Quinta das Lapas. Even out-patient programs have lost resources, too.

But let's be clear, Portugal isn’t cutting costs because they found fat to trim or realized these programs were too expensive. In fact, they saved Portugal a ton of money. Between 2000 and 2018, it's estimated that, thanks to its drug policies, Portugal saved a total of 18% on total social costs like healthcare, legal fees, and lost income. Spending on the drug policy came to about $10 per citizen, per year. In that same time, America spent more than $150. Cheaper and better.

This system — Passo, Dissuasão, Malha — it doesn't cost much, it saves everyone money, and it builds flourishing. But it requires a motivation, an obsession with recuperacao, and a willingness to make the up-front investment. And so much of that motivation for Portugal is bound up in the shared trauma of the 1980s and 1990s: the trauma that took Gandelina Damião’s three children.

Damião: I was a good mother. I never gave them money for drugs. But I couldn't save them. [B]

A national sickness so consuming,

Dr. Goulão: So present in everyday life, that it turned public opinion. [B]

But today, Gandelina is in her 80s. Many others who bear the worst memories are just as old or have themselves passed on. It’s not yet a lifetime ago, but the memory is fading, in part because Portugal has been so successful that the motive to care has begun to disappear.

Failure

These are the details that explain why nobody has been able to copy Portugal. And there may be no better example of what not to do than Oregon.

In 2020, Oregon voted to decriminalize drugs. The new law dropped criminal charges for people caught with small amounts of drugs. Instead, they'd receive a $45-$100 fine that would be waived if they called a treatment hotline.

On the face of it, this sounds just like what Portugal did. Decriminalization, plus treatment, equals success. Except…Oregon failed to follow these four key ideas. Remember, Portugal got addicts to the Disuassão office, where experts got people help first, before ever resorting to punishment.

Oregon did the opposite. Their system opened with a fine. Then, they directed people to a phone number for treatment, not an in-person meeting with professionals at a treatment facility. A bad start, but it gets worse.

If someone didn't call the number or pay the fine, they were supposed to appear in court. So addicts ended right back up in the criminal system, where the solution is jail, not treatment.

And yet it gets even worse. Apparently, paying the fine and appearing in court were optional. Nobody was punished for not doing either. So if you got caught, you could just ignore the process entirely—no fine, no treatment, no problem. You can guess which route most people took.

Worse still, those who did want treatment found it hard to get. Police officers weren’t trained to help people find it. And the state completely under-delivered on treatment. Programs weren’t organized or well-run. They were spread across a bunch of different non-governmental organizations. And they only offered about half the things they were supposed to.

So, Oregon's system did none of what Portugal's did. Instead of Dissuasão there were courts and fines. Instead of programs to move people to the next passo, they had a hotline. And instead of a carefully woven malha, they had chaos.

And the results shouldn't surprise us. Just four years later, the people of Oregon voted to end the experiment.

Conclusion

Perhaps what failed in Oregon was a lack of clarity in what, exactly, the policy was trying to achieve. Was it a path to responsible drug legalization? An attempt at harm reduction? A reform of the criminal justice system? Or, as in Portugal, a plan to end drug abuse?

Because in Portugal, that clarity was there. Goulão and others had a sophisticated understanding of the problem in front of them, but they also understood what they wanted in very simple terms: to end drug abuse and addiction in their country. But Portugal’s policymakers also knew that they could only get to that point by treating addiction as a disease, not a crime.

Dr. Goulão: I do not put a diabetic in jail.

That meant separating the addict from the drugs.

Jorge Antunes fell into heroin addiction when he was a teenager. He wanted to fit in. Two of his friends overdosed. It didn't stop him.

Antunes: It’s not OK to do drugs here...The problem is that drugs are toxic things. They have a destructive effect.

The Portuguese know better than most that drugs and flourishing cannot coexist. Addiction is a problem that needs to be solved, not a habit that only needs harm reduction. But while drugs are evil, the person addicted to them isn't. They're not a criminal. They're the first victim.

In Dr. Goulão's words,

Dr. Goulão: No one uses things to suffer. [They] are either used to enhance pleasure...or to combat suffering.

Jorge Antunes wanted to fit in. Francisco sought comfort after the death of his father. Who knows why Gandelina's children started to use. Addiction happens for human reasons to human beings. And addiction doesn’t make someone any less human, any less deserving of care and respect, any less full of a capability for goodness and recovery. It means that they need help.