Fighting Drug Addiction at The National Level: The Very Different Responses of Portugal and the United States

By Andrew Burki, Chief Public Policy Officer
Portuguese Drug Czar João Castel-Branco Goulão and Hanley Foundation's Andrew Burki

Portuguese Drug Czar João Castel-Branco Goulão and Hanley Foundation’s Andrew Burki

 

With the opioid settlement funding finally barreling into full view of reality, portending the threat of a tobacco settlement fiasco repeat in which only 2.4% of money collected went to prevention and cessation, I would implore America to look to the east for a functional solution. I was fortunate enough to recently sit down in Lisbon, with Portuguese Drug Czar and architect of Portugal’s current drug policies, João Castel-Branco Goulão, for several hours to dispel some myths about what his country has been doing since 2001, and get to the meat of why it’s been working so effectively.

The first and most important thing to understand about Portugal’s model is that they have not, contrary to what you may have heard or read, legalized drug use.

Portugal isn’t running a giant 10.6 million-person hippie commune by any stretch of the imagination. Rather, what they’ve done is engaged every segment of the population in the solution and rolled out a comprehensive, integrated response that is supported by conservatives and progressives alike. Is it all of what everyone wants? No. Does it contain many elements on which everyone agrees? Yes—and that’s really the point. In a world literally being torn apart by ultra-divisive temper tantrums at the most distant ends of the political spectrum, Portugal is in the midst of bowling a perfect game right down the middle and takes a hard-line moderate position, which works for the 90% of us who agree on 90% of issues in the middle, but seem to constantly get drowned out by cacophony of screaming from the tiny fringes of extremists in either direction. If you think that assessment is harsh, let me just take a moment and point out that “lock them up for decades without help” and “leave them homeless using opioids to face the consequences of their choices” are both garbage solutions that everyone, with any shred of common sense, knows are not working, directly resulting in those of us with substance use disorders dying at record rates in this country, and our families being devastated on an industrial scale.

We all recognize that children and their developing brains are vulnerable, deserve equitable access to evidence-based youth prevention, early intervention, and support if they develop substance use disorders and/or mental health concerns (oftentimes as the direct result of childhood trauma I might add).

The Portuguese, unsurprisingly, hold the same viewpoint as Americans on this issue. Where Portugal dramatically differs from us is that it provides evidence-based youth prevention to every single child in the country, equitable access to treatment for adolescents with substance use disorders and/or mental health concerns, and also equitable access to treatment for parents with substance use disorders to receive help with their young children, so they aren’t further breaking up and traumatizing struggling families at their most vulnerable with already woefully underfunded foster care systems and the like.

Also, similarly to most Americans, the Portuguese like living in a civilized society instead of a failed narco-state. I know it is very en vogue in the U.S. to bash our institutions such as law enforcement, as evidenced by the fact that every time an individual cop does something illegal or abusive (generally to one of us with a substance use disorder and/or mental health concern), it becomes a national news story about every single police department in the country, instead of solely a trial for the individual criminal. We don’t do this with other institutions, and it’s counterproductive to do so with law enforcement. I have yet to see a story about a teacher engaging in sexual activity with an adolescent that turned into a national discussion about how horrible all teachers are, even though it happens multiple times every single year. Nope—we just put the individual teacher on trial for statutory rape and bring in a substitute for English lit or whatever they were teaching.

U.S. Surgeon General, Dr. Jerome Adams and Hanley Foundation's Andrew Burki

U.S. Surgeon General, Dr. Jerome Adams and Hanley Foundation’s Andrew Burki

 

The overwhelming majority of our cops are just as overwhelmed and distressed by our dismal failure to properly address substance use disorders and mental health concerns as the rest of us.

Possibly even more so since they’re the ones out front getting traumatized by having to administer thousands of overdose reversals on a good week, tens of thousands on a bad week in the United States, and, like other citizens, they’re also burying family members to overdose because of our wildly dysfunctional system and inability to access adequate care for most of our country. That’s the “empathetic” argument for law enforcement. The “cold hard reality” argument for law enforcement is that we’re not getting anything resembling adequate treatment to the 1.5 million-plus of us that meet the medical criteria for substance use disorder and/or mental health concerns who are currently incarcerated, let alone comprehensive criminal justice reform without law enforcement as our allies in this fight.

Portugal has taken empowerment of frontline first responders more seriously than we have, and built an entire system around saving lives, getting people well, and keeping them that way.

They’re not running a free-for-all drug haven. They’re running a massive national pretrial diversion program, with everything from harm reduction to treatment on demand, and everyone from the bean counters to the voters to the cops to the judges are all in agreement that it’s working. The process, in a nutshell, is that if you get caught with drugs, they bring you to the police station and weigh the drugs. If determined that the amount is for personal consumption (based on 1993 laws originally enacted for sentencing purposes), you get referred away from the courts and appear before a commission that has a therapist and a doctor on its panel. The commission then conducts a pleasant, informal conversation with you and determines, in conjunction with you, whether you need help, or just got a little too rambunctious with your non-problematic recreational use.

If you don’t have a problem, it’s: “See you later. Don’t come visit us again for at least six months, or we’re going to start giving you fines and other annoying consequences for wasting our time. You’re a responsible citizen don’t run around high in public.” If you do have a problem, it’s: “How can we help you and your family?”

Can you imagine what our relationship to law enforcement in the U.S. would look like if police were just another pathway to recovery, stable housing, therapy, parenting support, etcetera, no longer viewed as the looming threat of long-term incarceration, instead of the help for perfectly treatable health conditions that they can and should be? We can. Less overdoses, less broken families, less gun violence, less suicides, less anxiety, less depression, less devastated families … pretty much just a better and more humane society across the board.

So, what does all of this cost? That’s why the Portuguese fiscal conservatives support these programs right alongside their progressives. These programs are net positive for the Portuguese economy. Dr. Goulão’s annual budget is around $90 million U.S. dollars in a country with 10.6 million people. When we consider that the annual impact of the opioid crisis alone in the United States is north of $500 billion, even if you don’t care about the 70,000 plus people dying each year from drug overdoses and the 88,000 dying from alcohol-related illnesses … even if you don’t care about their devastated families and orphaned children … you do care about your wallet, so you should fully support this approach if you take a moment to consider.

It’s just a matter of a few strokes of the right pens to deploy these opioid settlement dollars to the frontlines, subsidize Medicaid rates up to in-network private insurance rates, provide every American access to the help they’re literally dying for, create wraparound services to transform harm reduction into a meaningful pathway to recovery, instead of existing as hospice care for the poor without proper funding, and finally start winning the Drug War.

Hanley Foundation's Andrew Burki and U.S. Drug Czar, Jim Carroll

Hanley Foundation’s Andrew Burki and U.S. Drug Czar, Jim Carroll

 

We are, to our nation’s credit, starting to make long-overdue progress toward these goals here in America. I was also fortunate enough to recently attend an event with the U.S. Drug Czar, Jim Carroll, and U.S. Surgeon General, Dr. Jerome Adams, about expanding naloxone access.

Similarly to the bipartisan legislative efforts taking place in Congress, both the Office of National Drug Control Policy and the Office of the Surgeon General are pushing for common sense approaches to addressing our substance use disorder crisis that start with the general premises that it is impossible for those of us with substance use disorders to recover if we’re not alive to do so.

That may sound like a flippant remark, but it is unfortunately deadly serious for millions of Americans and our families that are faced with this perfectly treatable health condition on a daily basis.

If we still have policymakers pushing the false, “their choice, they get what they deserve” narrative, we will continue to bury our fellow citizens to drug overdose at 70 plus times the rate per capita that Portugal does to the exact same disease.

The answer, of course, requires funding because people who get access to full continuums of care generally get better, and people that get denied care generally do not. Hanley Foundation was fortunate enough to participate on a congressional briefing panel on Capitol Hill set up by our colleagues over at Young People in Recovery on the issue of funding subacute recovery supports. This panel resulted in several proposed ways that we can start to meaningfully scale up access to care when it is needed and reduce levels of substance use disorder in our population by following Portugal’s example—rolling out equitable access to evidence-based youth prevention to every single child in our country the way they have in their country.

It is simply unacceptable for the wealthiest country on earth to deny equitable access to evidence-based youth prevention and quality care to every single child and adult in this country based on the socioeconomic status of families and communities.

We’re about to go into another undoubtedly miserable election year. It will certainly be characterized by our fellow Americans hating one another and arguing endlessly, even though we all agree on vastly more issues than those on which we disagree. Let’s please, for the love of God, agree that at least on this one issue we can come together and demand our politicians on both sides of the aisle get it to together, stop paying lip service to the seemingly endless crisis, and support national reform in our drug, mental health, and evidence-based youth prevention policies.

Evidence-based youth prevention, harm reduction with wraparound services, equitable access to actual treatment, pretrial diversion, criminal justice reform, recovery ready communities, recovery high schools, collegiate recovery, recovery housing, access to employment … all of it.

Don’t settle for the soft bigotry of low expectations and anything less than a comprehensive overhaul of the whole system that includes adequate funding mechanisms and empowerment of stakeholders.

At the very least, we can all agree on that … and we’ve simply lost too many of us to graveyards and prisons to accept anything less than a meaningful victory on this fight for the very heart and soul of who we are as a society.