Oregon looks to struggling Portugal for answers on drug addiction

Oregon leaders hope Portugal will help them successfully transform the state’s approach to illegal drugs and addiction so that treatment and prevention – not the police – are at the center of the solution.

A group of Oregon legislators, advocates and others will travel in October to Portugal, which decriminalized drug possession in 2001 and stepped up treatment. 

The visit coincides with growing criticism in Oregon of Measure 110, the state’s drug decriminalization law. Passed by voters nearly three years ago, it decriminalized possession of small amounts of illicit drugs with the goal of making treatment programs more available. Yet the epidemic is increasingly visible and lethal, with open drug use in Portland and smaller cities, a surge in fentanyl and opioid overdoses and parks littered with drug paraphernalia. 

Measure 110 backers originally looked to Portugal as a model in drug decriminalization. It created a centralized institute with ample health care workers providing treatment that was easily accessible, put public health personnel on the streets and designated indoor sites for  drug use.

Experts worldwide hailed the system.

But now it’s under strain – and has been for several years. 

In response to an economic crisis, the Portuguese government in 2012 decentralized the institute, leaving a fragmented system, with addicts on waiting lists for treatment and growing demand for more professionals to provide addiction treatment. 

Fatal drug overdoses, still only a fraction of what they were in the 1990s, have trended upward in the last few years in Portugal. Like Portland and other Oregon cities, public drug use exists in urban cores like Lisbon, its hilly capital city with more than half-a-million people along the Atlantic coast.

Along with overdoses, the system in Portugal faces fatigue and criticism, according to a story in the Washington Post, with police blaming decriminalization on rising crime. 

In Portugal, the challenges include alcohol, illicit synthetic drugs and prescription drugs, a Portuguese official said.

“This is not a phenomenon only in Portugal,” João Castel-Branco Goulão, Portugal’s national drug coordinator, said in a video interview from his Lisbon office with the Capital Chronicle. “All Europe is facing a huge availability of drugs, new and old drugs. We are trying to put together again the means to counter this.”

Portugal is still doing better than its European neighbors and Oregon, experts said. The nation has largely avoided the lethal surge in fentanyl that has scourged the U.S. And the rate of young people using cocaine is one of the lowest in Europe, according to an international report.

“If you could swap Portugal’s problems for Oregon’s problems, it would be a good deal for Oregon,” said Keith Humphreys, professor of psychiatry at Stanford University School of Medicine in California and the co-principal investigator at the National Institute on Drug Abuse Clinical Trials Network.

And while Portugal and Oregon’s decriminalization efforts are often compared to each other, Goulão and other experts say there are differences, both in the approach to drug users and the availability of services.

A key takeaway: simply decriminalizing small amounts of drugs is not the goal. Outreach, services and treatment are also needed.

“Just to decriminalize per se does not lead you to any kind of results,” Goulão said. “It’s very important to decriminalize, but this movement has to be followed or has to be accompanied with the availability of treatment and harm reduction measures.”

Differences between Oregon and Portugal 

Both Portugal and Oregon prosecute drug traffickers and do not prosecute low-level drug users but systems differ in other ways. 

In Portugal, drug users must appear before a commission that determines whether the person needs treatment or should pay a civil penalty.

“They don’t just assume that everybody will pop into treatment on their own,” Humphreys said.

And the system includes other measures that don’t exist in Oregon. For example, the commission could suspend the driver’s license of a cab driver until after treatment, he said, giving state officials leverage over users. 

In Oregon, police officers write $100 citations that are not criminal penalties. Drug users are supposed to pay the fine or call a hotline to be assessed for treatment. But addicts often ignore the citation and don’t follow up with treatment, according to news reports. 

Humphreys said Portugal has a different culture than Oregon, too. It’s a Catholic-dominated country with strong families. Adults are likely to remain close to their parents, creating stronger social supports than those in Oregon, where family ties are often weaker, especially for people who move West from far flung parts of the country – or simply have an independent streak.

Portugal also has universal health care, which does not exist in Oregon.

Humphreys said he would love to see Oregon’s efforts work out, but said that’s not happened. The state was slow to get money to providers, creating a vacuum as drugs proliferated.

“So far, it’s been pretty disastrous, unfortunately,” he said.

At this point, Oregon has paid $214 million to organizations that provide services that include mentoring and support, screenings and outreach to people with addictions, state data show. 

But advocates say those efforts fall short of critical needs, such as detox and other treatment programs that help people as they endure the agony of withdrawal. 

Humphreys’ advice for Oregon leaders going to Portugal includes talking to more people than those on the scheduled tour, visiting with local officials and asking questions about the drug problem.

“You have to get outside that bubble to really see what’s going on,” he said.

Portugal’s system 

Portugal offers a variety of services for drug users. 

For example, the state has vans that travel in neighborhoods, offering methadone treatment to get people off illicit drugs. It also has designated drug consumption rooms where people can access drugs and inject them in a comfortable, private setting. 

The sites include social workers and mental health professionals to encourage people to enter treatment. The goal is to start people on a path to health – even if they don’t start treatment immediately, said Brendan Saloner, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

“The entire kind of logic of the rooms is very much designed around: ‘Let’s bring these folks indoors, they’re using drugs. They are here in our community,’” he said.

Many in the community – even older Portuguese people – support this approach. Saloner said a Portuguese nurse that he visited on a trip told him that grandmothers have praised the effort. 

“They said, ‘These are people that we step over every day when we’re just trying to go to the market or take our grandkids to the playground. So, we would rather they have a place where they can go and they can be safe,’” he said.

Saloner said Portugal has made addiction services that would be deemed controversial in the U.S. – like the drug consumption rooms – part of routine care.

He stressed that Portugal’s system – while struggling – has had more time than Oregon’s to grow and spread.

“The key innovation of Portugal is having services that people need when they need them,” he said. “And I think that a lot of the bones of that could kind of come together in Oregon, but it’s going to take resources, time and patience.”

Oregon officials seek solutions 

The Oregon Health Justice Recovery Alliance, an organization with members that backed Measure 110, is paying for the five-day trip with private dollars, not Measure 110 funding, according to Devon Downeysmith, the alliance’s spokesperson. The alliance was formed after Measure 110 passed and some of its members are now providing Measure 110-funded services.

Each person is eligible for a $2,500 stipend to defray costs. She said the alliance does not know the trip’s full cost yet because some people might not accept the stipend.

Besides the alliance’s staff, at least another 15 people are going, including four lawmakers, police officials, service providers and advocates, according to a list the alliance provided.

They’re keeping an open mind, said Tera Hurst, executive director of the alliance.

“I’m not going to Portugal with pre-predetermined outcomes,” Hurst said. “It’s really about learning.”

They’ll visit Goulão and other experts, tour Lisbon’s largest drug treatment center and meet with other people, including some who have been in prison for drug use.

They’ll hear about how to get more people into treatment and from law enforcement about what helps and hampers their work.

The trip could give lawmakers insights to guide them during the 2024 short 35-day session. 

“This is going to be a thing that is going to dominate the 2024 session,” said Rep. Rob Nosse, D-Portland and chair of the House Health Care Committee. “And I think going to the place where this is sort of modeled after and getting an up-close examination of how it’s working or not working is probably the best thing I can do.”

Nosse said it’s too soon to know what 2024 legislation lawmakers will propose, but he said the state needs more medical detox programs to help people with withdrawal symptoms – and housing for people when they leave residential treatment programs.

Among the group: Rep. Lily Morgan, R-Grants Pass, a vocal critic of Measure 110.

Morgan said the negative impact of public drug use is a problem that reaches beyond Portland, including the parks in her district which are littered with needles and other drug gear.

“I hope that we have an opportunity to see really what is going on in the streets and to ask those tough questions of why are their crime rates increasing? Why are their overdose rates increasing?” Morgan said.

Another lawmaker who’ll be on the trip, Senate Majority Leader Kate Lieber, D-Beaverton, said Measure 110’s passage was a message from voters to treat addiction as a public health crisis, not a criminal justice crisis.

Yet the system needs to improve, Lieber said.

“One of the things that I’m very interested in is understanding how we can put more accountability into our public health response,” Lieber said. “I think Portugal has figured out how to do that and I just need to go and see it.”

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