Highs and lows of drug decriminalisationBMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d6881 (Published 26 October 2011) Cite this as: BMJ 2011;343:d6881
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
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.
Cite this as: BMJ 2011;343:d6881
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.