Decriminalizing substance use works in Portugal — and can in Oregon, says neuroscience and health journalist

Oregon’s Measure 110 — which decriminalized drug possession and directed more money into substance use disorder treatment — was modeled after Portugal’s drug policy approach. New York Times opinion writer and neuroscience journalist Maia Szalavitz has studied what’s happened over the last 25 years since the country began decriminalization. She’s written many articles and books on the subject of addiction, most recently “Undoing Drugs: How Harm Reduction is Changing the Future of Drugs and Addiction.” She joins to tell us how and why decriminalization worked in Portugal and the lessons she believes it holds for Oregon — and the U.S. as a whole.

This transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. We start today with Measure 110. That’s Oregon’s voter-passed law that decriminalized drug possession and directed more money into treatment for substance use disorder. We recently talked with Max Williams about this. He’s a former state lawmaker and former director of the Oregon Department of Corrections. He’s one of the leaders of the movement to recriminalize hard drugs. Maia Szalavitz says that is the exact wrong approach. She’s a New York Times opinion writer and a neuroscience journalist. Her most recent book is called “Undoing Drugs: How Harm Reduction is Changing the Future of Drugs and Addiction.”

She says our failure is a century of criminalization, not much needed attempts to end it. Maia Szalavitz, welcome to Think Out Loud.

Maia Szalavitz: Thanks so much for having me.

Miller: Yeah, thanks for being here. Your recent New York Times opinion piece was headlined, “Portugal Has Succeeded Where We’ve Failed With Addiction,” and I wanna start with their example. Many of our listeners may know that some public officials in Oregon have been going on trips to go to Portugal to look at exactly what you have been writing about for a little while and researching for a little while. When did Portugal start to decriminalize recreational drugs?

Szalavitz: Around 2,000.

Miller: And how did their system work?

Szalavitz: There’s a lot of misinformation about this. What happens is if a police officer cites someone for drug use, they get basically the equivalent of a bit of traffic ticket and they are supposed to appear before what is known as the “dissuasion committee.” And they make it deliberately low key. It includes a lawyer and a social worker and maybe a doctor. The third person varies, but they will talk with you about your drug use and if you do have a problem, about how to get treatment.

Nothing is actually mandatory, and a lot of people were arguing, “Well, Portugal worked and then Oregon didn’t because Portugal has the hammer and they force people into treatment.” In fact, 95% of people never get a second citation because most of the citations are for people who actually do not have drug problems. And this is a good indicator of why arrest is not a good way of diagnosing who needs treatment, for what?

Miller: So you skipped ahead. I do want to talk about Oregon but just to stick with what happens in Portugal. [Of] the people who get those, as you say, “traffic tickets,” how many of them actually end up going to the “dissuasion committee” as opposed to just ripping up the piece of paper and walking away?

Szalavitz: Well, most of them show up. And the thing is, what has been successful in Portugal is not this whole ticket and citation and all of this kind of thing. What was successful is they put a lot of money into making treatment available and kind and welcoming because a lot of people think that people with addiction would never get treatment on their own because they’re just having so much fun. And being homeless and staggering around and getting robbed and getting raped, it’s just so much fun that people would never hit bottom if they didn’t do a few days in jail. So, the reality is that most people with addiction will accept help if help is kind and welcoming and supportive, which is not how our treatment system tends to be. Our treatment system, because of criminalization, has tended to be harsh and punitive and confrontational…

Miller:  …and what does “kind and welcoming and supportive treatment” look like in Portugal, or anywhere?

Szalavitz: It just looks like an actual doctor being nice to you. It’s not very complicated. A lot of American addiction treatment is based on the 12 steps and when the 12 steps are done voluntarily, it can be a wonderful thing because people will take moral inventory and they’ll make amends for the harm done and all of these good things. But when you’re forced…the first step is about admitting powerlessness. And so a lot of treatment programs have historically tried to make people feel powerless and to tell them to shut up and listen and use really humiliating and confrontational tactics that nobody would voluntarily choose to be subjected to for the most part. So, treatment that just treats people with dignity and respect is enormously helpful.

One of the other things that our treatment system has historically also been bad at is that medication for opioid use disorder is the best treatment. We know that if you stay on either methadone or buprenorphine, your risk of dying from overdose is cut in half or more, we have no other treatment that is that effective. And that is true, even if people have relapses, which people frequently do because addiction is a hard behavior to change.

Miller: You’re talking about two different things in terms of what was made available to people in Portugal. And we focused on the quality of treatment options there. As opposed to being based somehow, even if not explicitly tied to the criminal justice system, you’re arguing that in the U.S., [has] been too punitive. So that’s the quality of it.

But what about the quantity of it? How do you compare just the number of treatment options or clinics or beds in Portugal to any average U.S. state?

Szalavitz: That is a very hard thing to do. We do know that Oregon is extremely low on treatment slots. We also know that historically, there’s been this obsession with beds and the idea has been that people need to go away for months and months in order to get treated. In reality, most people can be treated on an outpatient level if they have a place to live. If they don’t have a place to live, they need a place to live. And that doesn’t necessarily need to be the same place where they’re getting treatment because one of the things we’ve also historically failed to do, in which Portugal does better, is individualized care. One person might be using drugs because they’re in despair. They have no job; they have no hope. They have no education and getting them in education and getting them into meaningful employment is basically what that person needs. Someone else may have a long history of mental illness and they need the specific treatment for that particular condition.

Historically, our rehabs have been one size fits all. Everybody has to do the same thing. They go through the same program they have to do all of the same stages and all this kind of stuff. And it’s unlike any treatment for any medical condition because if I went to treatment for depression and somebody told me, “Well, the most important thing you can do is get on your knees and pray and go to meetings.” I would think, “Hm, I am not in mainstream treatment anymore.” But that is 90% of treatment in the United States. And it’s like, “Oh, it’s spiritual, not religious.” Whatever the case is, it is not typical of medical treatment in mental health or physical health. And the separation of addiction care from the rest of medicine has been enormously harmful.

Miller: What did Portuguese authorities start to see after they made these changes?

Szalavitz: They started to see more people voluntarily seeking help. And that meant that overdose was reduced to something like 86%. They were having a big HIV outbreak and HIV cases fell similarly. And they also did provide things like, now they have a safe injection facility so that people don’t inject on the street.

Now, the key difference between Portugal and here, that is very hard to replicate, is that they have a national healthcare system and people don’t have to worry about, oh, does your insurance cover this? And they can just get the care that they need in a way that is difficult here. They also have better access to a safety net in general, including housing. So, again, hard to replicate here.

Miller: What happened when Portugal started defunding substance use disorder treatment about a decade ago?

Szalavitz: Well, they started to see the problem get worse again. Now I must stress that their overdose rate is lower by an order of magnitude than ours. In other words, they measure in deaths per million, and we measure in deaths per 100,000. So their so-called failure recently, still would make any state delighted to get to their rate.

Miller: You outlined some gigantic societal and political differences between a European country like Portugal and the US. I mean, the lack of universal health care and a very different understanding of a social safety net… basically a much more porous net, if you can even call it a net in our country. Given that, how helpful do you think the comparison is?

Szalavitz: Well, I think one thing we know is that you don’t get better health care by being arrested. It is generally accepted that when you get arrested like, OK, you’re guaranteed health care. But let me just put it this way – A lot of people die from opioid withdrawal in jails and prisons. This doesn’t happen on the outside because basically you die from dehydration and you can get water. So any kind of healthcare in jail or prison tends to be worse and arrest doesn’t diagnose somebody. All the money that we spend arresting people for drug possession is thrown away. If we spend that money on treatment instead, it can only get better.

It is not going to get worse because arrest isn’t deterring people.  The idea that suddenly the situation in Oregon is worse than the rest of the country is simply not true. In fact, you don’t even have one of the highest overdose [rates]… you have, I think, below the national average on overdose deaths. The highest overdose death rate in the United States is West Virginia, which I don’t think they decriminalize.

Miller: I want to turn to Oregon, in particular. As you well know, there are growing calls here to recriminalize the possession of hard drugs and that comes from a number of leaders at local and state levels. And that there have been some recent polls to show that perhaps a significant majority of voters are in favor [and] regret the decision. That was a pretty resounding victory just three years ago for the decriminalization side. And the basic idea that seems to be gaining momentum is that for some people, only coercion will get them into treatment. I mean, that’s the shortest version of the argument we heard from Max Williams.

So, I want to start with that particular piece that this is not the path for everybody, but for some people, it’s the only way. Forcing them into treatment with a stick is the only way to get the carrot of treatment.

Szalavitz: Where is the evidence for that? There is zero evidence that that is true. Like there’s no data suggesting that. The head of the National Institute on Drug Abuse which is our NIH Agency and it funds most of the addiction research in the world. Dr. Nora Volkow is in favor of decriminalization. Addiction is defined as “compulsive use that continues despite negative consequences.” Negative consequences is a nicer way of saying punishment. So if punishment worked to fix addiction, by definition, it wouldn’t exist. We have tried this for 100 years, literally. There is no evidence that for addiction, there’s some people that only coercion will work. It comes from this idea that you need to hit bottom.

Now again, if you are homeless and defecating on the street and mentally ill and shouting naked in the street, I generally think you are not really having a lot of fun and you might already be described as having hit bottom. How putting you in jail for a few days or a few weeks, which is basically what happens when somebody gets arrested for possession, is going to help, I do not know because we have this idea that people get arrested and then they get treatment. You are more likely to get treatment outside of jail than you are to get it in jail just because of the way it’s structured.

Miller: I’m sure you’ve heard people say…and this is not data, let me be clear about this. This is anecdotes and we’ve heard these stories from real people on this show over 15 years, a handful of people who are in long term recovery saying to us that the threat of prosecution was the only thing that actually worked to get them into treatment. I’m curious, how do you reckon with those individual stories?

Szalavitz: OK. Did they have 10 identical twins who didn’t get coercion and who actually got kind and caring treatment? No, I’m sure they didn’t because when you actually look at what works, what works is welcoming people into treatment. It just works a lot better. If you just think about any kind of human behavior, people really don’t like being told what to do. People who are using drugs are not using drugs generally. Now there’s jerks in every class of people. So I’m not saying that everybody’s perfect. But most people who are using drugs are using drugs because they’re miserable, because of mental illness, because of homelessness. Because of 10 zillion reasons a person could be miserable. The drugs work for them. They make them feel maybe a teeny bit better… over time, less and less.

What they need is better ways of coping. They need, hope they need a sense that life can be livable without chemical assistance that they are self-medicating with. That is what stops people from using. And yeah, sure…there’s people that have stories that say, “You know, I was at my worst and then I got better and I needed to be at the worst to get better.”

The thing is if you look at, for example, who is more likely to recover? A doctor with a wife and a cat and a dog and five kids and a very successful career and all kinds of supports, or a homeless guy? I’m gonna bet on the doctor, right? Because it is just common sense that people with resources are generally more likely to get better, not less.

So it’s just like we have this backwards view of addiction. We still really see it as a sin and we still genuinely believe that if we just make things bad enough, people will get better, and we don’t think that about any other disease. And we don’t think that about any other mental disorder. We recognize that people tend to get better when they have something to live for…

Miller: What do you think should happen when somebody is smoking fentanyl on a street corner?

Szalavitz: Well, I think we should have safe injection sites to minimize that, for one. But also, I think that it’s perfectly fair for the public not to want to see that. And I think most people who use drugs prefer not to do it in public and moving that person along or whatever is fine. What I just don’t think is helpful is arresting them, putting them in jail, leaving them in withdrawal for a few days and then they come out a week later with time served and now they have no tolerance and they die. Like people who just come out of incarceration are three to eight times more likely to die of overdose because they lose their tolerance. We don’t treat people in jail. We have this idea like, “Oh, you go to jail, you get treatment.” That is not what happens...

Miller: To be clear, I know that you’re talking about jail and it makes sense because we’re talking about the potential of recriminating these drugs. But the proponents of recriminalization, they are saying over and over now that the point of this is not putting people in jail - we didn’t really do that in Oregon for decades, not for simple possession. It was more the threat of prosecution and they’re saying that really what we want to do is to have drug court set up in diversion programs. And so I think it’s a little bit of a straw man to focus too much on people who are incarcerated in the future because of drug use.

Szalavitz: I spoke to the leading expert on drug courts for my New York Times piece. The vast majority of drug courts are set up for people who have committed felonies like serious crimes. If you try drug courts for possession, they don’t really work very well because people end up doing more time because they relapse than they would do if they just did their few months that they were going to do. So drug courts, again, you have judges practicing medicine. Most drug courts don’t allow medication, which is the best treatment that we have. So there’s a problem right there. The idea that a possession charge is going to get you into a drug court in a way that makes sense for you to get effective care, it’s basically just putting another expensive barrier in there. Why not just make treatment accessible? Like because, “If you build it, they will come.” People actually want good treatment and if you make it so that they don’t have to jump through 10,000 hoops and get arrested to get it, it will be much more effective.

So this idea that we need to arrest people to put them in treatment…when you look at, for example, homeless people who have both mental illness and addictions. There’s a study done in Los Angeles where they offered lots of support, housing resources, whatever. They were able to get 85% of people who were amongst the most seriously mentally ill and addicted folks voluntarily into treatment. So why are we so obsessed with using coercion when we can actually do this voluntarily, both more effectively and cheaply more cheaply?

Miller: We are almost out of time but before we go, you’ve talked about data so many times, for understandable reasons, but politics and policies are often not based on data. They’re based on feelings and there is a growing feeling that I see among leaders and residents in Portland and in Oregon as a whole, that something is broken, and that Measure 110 is, if not at the heart of it, then at least partly to blame. How do you suggest getting at that without only talking about data?

Szalavitz: Well, I’m just going to say that Oregon does not have the worst problem with this in the country. The places that did not decriminalize have almost the same kind of thing. Now it’ll be different in different places because that relates to shelter and housing prices and all of these things. But this notion that if you just have this extra thing to arrest people for, you will get more people into treatment. It’s just not true. What happens when people get arrested is not treatment. It has historically never been treatment. They always claim that it’s going to be and then the money for the treatment never materializes. Instead, decriminalization takes that money out of the prosecution system and puts it into treatment directly. It is just a much more sensible system.

I’m sure you saw the recent New York Times piece about the police work in Portland, where there was a person’s child was kidnapped and they couldn’t get that person arrested because the cops took so long to show up. Now perhaps, it would be nicer for them to be able to arrest people for things like kidnapping, and not have them spending time arresting people for lesser crimes. I’m a person in recovery, myself. I know the criminal justice system did not help me. And I certainly understand that nobody wants to see people running naked in the street and scaring children and doing all kinds of terrible things and nodding out and looking awful, like none of us wants that. Harm reduction people don’t want that. People who support criminalization don’t want that. But to solve that, we have to do what actually works rather than cycling people repeatedly through coercive systems for a few days.

It just works better to provide care and I know people are like, “Well, shouldn’t we provide housing for the nice person who isn’t shouting in the street and making a mess?” First, we should provide housing for everybody. But if you want to get the person who is bothering you off the street, then you actually have to do what works as opposed to what feels good, which is putting that person in jail.

Miller: Maia Szalavitz, thanks for joining us today.

Szalavitz: Thank you.

Miller: Maia Szalavitz is the author most recently of “Undoing Drugs.”

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