Posts Tagged ‘demand reduction strategy’

Portugal’s experiment with decriminalizing drugs & added intervention

Friday, April 24th, 2009

My colleague, former medical director of the Genesis Recovery Center in southern Oregon, psychiatrist Dr. Abraham Genack, keeps very current on a wide variety of issues that impact treatment and public policy regarding substance use disorders. He recently shared his views on Portugal’s move to decriminalize drug use. This information inspired me to take a much closer look at the long running controversy and debate regarding drug decriminalization in our nation.

Faced with rapidly growing intravenous heroin use and other drug problems plus experiencing the highest rate of HIV amongst injection drug users in the European Union, Portugal enacted a law that decriminalized use, possession and acquisition of all types of illicit drugs for personal use in July 2001. Possession for personal use was defined as possessing up to ten days supply of the substance used. It is imperative to note that this law (Law 30/2000)  did not legalize drugs in Portugal, illicit drug use and possession are still illegal but are subject to police “intervention” rather than the criminal justice system. Criminal penalties continue to be imposed on drug dealers, growers and traffickers. Use and possession of illegal drugs for personal use is treated as an administrative violation and processed in non-criminal proceedings.

What I find most encouraging about this is its strategic intent to equally address both the supply and demand reduction initiatives of Portugal’s war on illicit drug abuse. Other nations, including our own, expend huge resources into supply reduction often to the neglect of demand reduction efforts.

Portugal’s drug decriminalization law requires initial implementation of a system of referrals to newly established regional panels designated as Commissions for the Dissuasion of Drug Addiction (Comissoes para a Dissuasao da Toxicodependencia o CDT). Police refer those in possession of drugs for personal use to appear before these CDTs within 72 hours. The CDT panels consist of a social worker, a legal advisor, and a medical professional who as a group assess these referrals as either occasional or dependent drug users. Those assessed to be drug-dependent are recommended for either treatment or education programs and not fined. Occasional users are sanctioned with fines, community service, suspension of professional licenses, and/or bans on attending designated places. Drug abuse treatment resources were expanded to accommodate the increased number of individuals determined to be in need of therapy. The treatment expansion was funded by diverting the money formerly needed by the criminal justice system to prosecute and punish drug offenses. The savings realized by this change enabled Portugal to double its investment of public funds for treatment. The number of treatment providers was increased and a centralized support department for the regional CDT panels was created. The savings were also used to expand social and vocational rehabilitation services and to increase enforcement of drug trafficking and distribution laws. Police are able to refocus their resources on those who profit from the illegal drug trade (Supply Reduction) and public health programs are in place for those abusing drugs (Demand Reduction). Primary prevention efforts were given a boost as well since funding was provided to increase the number of schools that provide drug education. Portugal’s Drug Decriminalization Law was certainly enlightened and well thought out. Other nations (i.e. Luxemburg and Argentina) have decriminalized personal use of drugs like marijuana but did so without expanding treatment or law enforcement.

The impact or effect of the July 2001 drug decriminalization law on Portugal’s drug problems was rigorously evaluated six years after its implementation by the Beckley Foundation Drug Policy Programme in 2007. The Beckley Foundation was very forthcoming in disclosing the many limitations of their work and presented caveats regarding the interpretation of their findings. For example, general population surveys of drug use did not commence in Portugal until the 2001 decriminalization law was introduced and no regular surveys have been conducted measuring recent use. How can reduction of problematic drug use, a major goal of drug decriminalization be measured without such data? Also, it is difficult to assess drug use within one culture or individual nation without taking into consideration: the general drug trends in that part of the world, illicit drug market trends, and the difficulties inherent to measuring a highly stigmatized activity like drug abuse. Does an increase in substance use after decriminalization signify a greater social acceptance of drug use or is the increase merely an artifact of increased use disclosures as criminal penalties are eliminated, or was there an increase because the climate for drug abuse in that part of the world increased unrelated to Portugal’s new law? Do decreases in drug use, drug-related deaths, diseases, and crimes indicate the drug decriminalization policy is successful or does it just represent a general trend in that culture or part of the world? Given the multitude of limitations regarding data collection and interpretations it is understandable why stakeholders interviewed during the Beckley Foundation evaluation often inferred opposite points of view for the very same single piece of data being examined.

Despite the intrinsic data interpretation issues, indicator statistics at the six year post-implementation milestone of Portugal’s drug decriminalization law is still very intriguing:

  • Cannabis use has risen significantly amongst Portuguese youths; cocaine and ecstasy (methylenedioxymethamphetamine) use has slightly increased.
  • Heroin use has decreased significantly.
  • There has been a dramatic increase in utilization of drug treatment in response to CDT efforts and an increase in drug treatment providers and resources.
  • The number of schools providing drug education has increased.
  • New drug-related HIV and Hepatitis C & B cases have significantly decreased despite an increase in the number of people treated for those conditions.
  • Drug-related deaths due to “other drugs” has increase significantly but is  offset by a huge decrease in opiate (mainly heroin) related deaths resulting in an actual overall decline (59%) in all drug related deaths by 2003.
  • Drug-related crime slightly increased by 2003, attributed to increase police focus on interrupting large-scale drug trafficking operations.
  • The proportion of prisoners sentenced for drug offenses decreased because only traffickers were jailed after 2001.

This data, even with its limitations appears to demonstrate that Portugal’s drug decriminalization law may have led to overall increases in marijuana and other drug use but reduced many drug-related public health problems. Glenn Greenwald of the Cato Institute joins others with a much more positive view on the same data. Greenwald believes the data clearly demonstrates that drug decriminalization in Portugal is a great success. I tend to agree with Caitlin Hughes and Alex Stevens of The Beckley Foundation who look at the future of drug decriminalization in Portugal as being dependent partly on the evidence-base and partly on national views as to whether it is the best policy response for that country. Both of these factors are hard for outsiders to assess. Still, if drug decriminalization could similarly expand substance use disorder treatment and prevention while positively impacting drug-related crime and drug-related health problems in this nation, maybe it is time to give this controversial policy deeper consideration.

Subsequent studies of drug decriminalization in Portugal must address other important implementation issues. How is the ten-day’s personal supply of drugs determined? Body size, age, hydration, genetics, medical condition, and a host of other factors determine how a drug will work in any individual. This, along with an ever increasing tolerance for a drug, could make ten-day’s drug supply variable for each person. What happens to those dependent users who reject or refuse to use the treatment recommendation of the CDT? What happens to those who are non-compliant with their treatment or those who chronically relapse into a progressively more serious addiction? How is marijuana dependence being treated? What does the drug prevention/education curriculum consist of? More and more questions pop into my head as I think about this marvelous opportunity to study the unique public policy strategy to combat drug problems in Portugal

Darryl S. Inaba, PharmD., CADC III

April 2009

References

  1. Caitlin H and Stevens A (2007). The effects of decriminalization of drug use in Portugal, Briefing Paper Fourteen, The Beckley Foundation Drug Policy Programme, December 2007, http://www.idpc.net/php-bin/documents/BFDPP_BP_14_EffectsOfDecriminalisation_EN.pdf.pdf accessed 4/11/09
  2. Greenwald G (2009). Drug decriminalization in Portugal: Lessons for creating fair and successful drug policies. Cato Institute, Washington, D.C., 4/2/09, www.cato.org/pub_display.php?pub_id=10080 accessed 4/11/09
 
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Rethinking Drinking

Friday, April 3rd, 2009

Former Deputy Director of the US Office of National Drug Control Policy Dr. Andrea Barthwell was one of the featured speakers at a conference I was a part of last spring. Her focus was prevention and she identified six “gaps” in our current efforts – Awareness, Motivation, Treatment Access, Treatment Success, Treatment Completion, and Long-Term Outcome. Dr. Barthwell believes that a successful demand reduction strategy relies heavily upon effectively closing those gaps. The Awareness Gap is the most significant because studies indicate that 76% of those individuals who meet established criteria for alcohol or drug problems don’t believe they have a problem.
(Inaba, DS (2008). Current Status of Prevention Efforts, www.CNSProductions.com May 9)

Over the past year, I have noticed an attempt to close the Awareness Gap by implementing Screening, Brief Intervention, Referral, and Treatment initiatives known as SBIRT. Hospitals and other health care providers have imbedded research-validated substance use disorder (SUD) assessment tools in their intake forms to identify patients with potential SUD issues. Some government agencies and private businesses have made these assessment tools part of their employment application forms.

Studies by the National Institute of Alcohol Abuse, and Alcoholism (NIAAA) found a wider spectrum of alcohol-use disorders than previously thought. These are associated with certain patterns of consumption that clearly correlate to the development of future problems. NIAAA established a web site: http://rethinkingdrinking.niaaa.nih.gov to allow people to screen themselves anonymously. Visitors can compare their daily and weekly alcohol use to that of the general public and problem drinkers. This screening helps people recognize problem drinking patterns early and suggests changes they can make before they fall into more harmful patterns. The site also provides information on what responsible or low-risk use of alcohol really consists of.

I am increasingly irritated by the “drink responsibly” tag line found on every beer and alcohol ad. In my opinion, this is a hollow attempt at “political correctness”, because the ads never explain, define, or clarify what “responsible drinking” actually means. An explanation would, of course, not be in the best interest of the advertiser. Rethinking Drinking is a great way to close the awareness gap and perhaps even do a lot to prevent problem drinking.

The NIAAA Rethinking Drinking website asks “how much is too much?”, defines the standard drink equivalent for beer, wine, and liquor’; and provides strategies for cutting down alcohol consumption while suggesting alternatives to drinking. There is also a section on refusal skills for social situations, and an “urge tracker” to record when, why and how the urge to drink was avoided. The site also helps to identify and deal with external situations and internal emotions that tempt one to drink.

The sections are comprehensive and practical. “Low-risk” for serious alcohol problems is defined as consumption of no more that four standard-size drinks a day for a man and no more than three for a woman. The weekly limit for “low-risk” is 14 drinks for a man and 7 for a woman. Several studies demonstrate that drinking more than the daily or the weekly limit has been associated with higher risk of alcohol abuse or dependence. Studies have demonstrated that about 35% of Americans don’t drink alcohol at all. Of the 9% of Americans who exceed both daily and weekly levels of consumption, half (50%) have alcohol use problems. 19% of Americans exceed either the daily or weekly levels and about 1 in 12 of this group has already progressed to alcohol abuse or alcoholism. Then, of the 37% of Americans who always stay within the daily and weekly low-risk levels of alcohol consumption only 2% of them ever progress to serious alcohol problems. The site also clarifies that low-risk levels of alcohol use can be risky for pregnancy, those on certain medications, and those with liver, heart, kidney, chronic pain or bipolar disorders.

Though SBIRT and Rethinking Drinking are clearly having impact on closing the Awareness Gap in prevention of substance use disorders, the Motivation and Treatment Gaps need to be addressed as well. Of those individuals who recognize that they have a problem with drugs or alcohol, only 5% will try to find treatment, this is the Motivation Gap. The individuals who want or need treatment but are unable to access help fall into the Treatment Gap – undercutting the prevention efforts. Still, the current efforts provide great optimism for future success. SBIRT studies show that once screened and identified, just five minutes of discussion with a physician, or perhaps exploring the Rethinking Drinking website can reduce heavy alcohol consumption by 25%!

Darryl S. Inaba, PharmD., CADC III
April 2009

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