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Portugal's approach to the opioid epidemic is a flashpoint in U.S. fentanyl debate

JUANA SUMMERS, HOST:

Portugal cut its number of fatal drug overdoses by 80% at a time when drug deaths here in the U.S. were exploding out of control. Now the Portugal model, which focuses more on health care and less on tough crime laws, has emerged as a flashpoint in the debate over how to solve America's fentanyl crisis. NPR addiction correspondent Brian Mann spent time in Portugal, and he's here to tell us more. Hi there.

BRIAN MANN, BYLINE: Hi, Juana.

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SUMMERS: So, Brian, just help us understand the stakes here. How stark is the drug crisis here in the U.S. compared with Portugal?

MANN: You know, it's a heartbreaking disparity. The U.S. and Portugal both experienced deadly opioid epidemics beginning back in the early 2000. But Portugal's response appears to have really worked. Drug deaths there are now incredibly rare, while they're common in the U.S. Fatal overdoses are now a leading cause of death for young Americans. Here's one data point that really stunned me. Portugal has roughly the population of the state of New Jersey. But while New Jersey sees nearly 3,000 drug deaths a year, Portugal averages fewer than 80.

SUMMERS: That's incredible. Brian, what can you tell us about what accounts for that sharp difference?

MANN: Yeah. Fentanyl is part of it, right? The powerful street opioid is killing a lot of Americans right now, and it hasn't caught on yet among drug users in Portugal. No one's really sure why. But even before fentanyl hit, the U.S. and Portugal were moving in really different directions. Over the last 20 years, the U.S. responded to rising rates of addiction with tough drug laws, spending hundreds of millions of dollars on police and prisons. Portugal, by contrast, invested in drug treatment and health care. Keith Humphreys is at Stanford University. He's one of the top U.S. experts on addiction, and he studied the Portugal model.

KEITH HUMPHREYS: I think they showed when you make services extremely available to people who are struggling with problems with drugs, you get a lot of good outcomes.

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MANN: And, Juana, Portugal's drug treatment programs are free. They're widely available, part of the taxpayer-funded national health care system. And, again, this is a huge contrast with the U.S., where even now, in the midst of this deadly overdose crisis, it's often really, really hard to find affordable, high-quality addiction care.

SUMMERS: And, Brian, I mean, listening to you describe Portugal's approach, it sounds like it's very promising. So what makes it so controversial here in the United States?

MANN: A lot of it comes down to the role of police. Beginning in 2001, Portugal decriminalized personal use amounts of drugs, and that made a huge difference for people living with addiction like Ronnie Duchandre, who I met on the street of Portugal's capital, Lisbon.

RONNIE DUCHANDRE: Nice to meet you.

MANN: Duchandre lives in a tent outside a church in Lisbon. He's addicted to alcohol and hashish and also sometimes smokes crack.

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DUCHANDRE: (Speaking Portuguese).

MANN: Duchandre told me he fell into addiction gradually. "I believe, with some help, maybe with some education, I will come out of it," he said. Like most people who use drugs in Portugal, he's getting a lot of help - counseling and medical care, again, all of it free - which means Duchandre has a much lower risk of dying compared with drug users in the U.S. And he's also not afraid of being arrested. When I asked about police, Duchandre actually got excited.

DUCHANDRE: (Speaking Portuguese).

MANN: "The police are our friends," Duchandre said. "As long as I'm respectful, they're respectful and helpful." I spoke about this very different role for police in Portugal with Dr. Joao Goulao. He's Portugal's national drug czar. He said convincing law enforcement to shift from a get-tough approach to drugs to this focus on health care changed everything.

JOAO GOULAO: Decriminalizing drug use is a good step - treatment, harm reduction measures, shelters.

MANN: Now, it's important to say, Juana, that police do still play a big role in Portugal with street drug use. But instead of making arrests, cops are trained to counsel and nudge people in addiction toward treatment.

SUMMERS: So police in Portugal - they're more like social workers.

MANN: Yeah. Part of the time, that's right. And they regularly do get people in addiction to go to these addiction counseling sessions. Street cops in Portugal, of course, do more traditional work as well. They break up drug gangs. They work to protect neighborhoods from drug-related crime. And they've actually had a lot of success disrupting the kind of open-air drug markets that we've seen in some U.S. cities like Philadelphia and San Francisco. I spoke about this with Miguel Moniz. He's an anthropologist at the University of Lisbon who studies drug policy.

MIGUEL MONIZ: There's an impression in the U.S. that if you decriminalize, then everybody - then it's a Wild West where everyone uses drugs. That hasn't been the case in Portugal.

MANN: And this really is the major fear in the U.S. among politicians and other critics who oppose the Portugal model. They worry that if we decriminalize drugs and change the role of police in the way Portugal's done, we'll see a lot more rampant drug use, more drug-related crime.

SUMMERS: But if Portugal's system is saving lives there without creating chaos, why couldn't or wouldn't that work here?

MANN: Yeah. This is interesting. I mean, some experts believe the U.S. is just culturally different. In Portugal, people who use drugs still live in fairly tight-knit communities. They're surrounded by families. Keith Humphreys, the researcher at Stanford who we heard from a moment ago - he thinks people experiencing severe addiction here in the U.S. don't have those kinds of support networks.

HUMPHREYS: The challenges we have here is they don't have a job that's putting any pressure on them. They don't have relationships. They're isolated. And if there's no law pressure, there is no pressure at all.

MANN: So Humphreys thinks police in American cities will have to keep playing a more aggressive, forceful role, arresting drug users and using courts to get them off the streets and into treatment.

SUMMERS: Brian, as I understand it, despite those concerns, there are places here in the United States where some parts of the Portugal model are being tried. Tell us about that. How's it going?

MANN: Well, it's been rocky. A lot of cities across the U.S., especially in states like California, New York and Oregon, have slowly turned away from the drug war model, adopting some of Portugal's strategies. That means fewer drug arrests, more of a focus on harm reduction and physical and mental health care. Supporters hoped that would quickly reduce drug deaths. But so far, it really hasn't worked out that way. Drug deaths have continued to rise. One problem appears to be that, in some places, drugs have been decriminalized before really good treatment programs are widely available to pick up the slack. I spoke about this with Morgan Godvin. She's a drug policy expert and activist in Portland, Ore., where drugs were decriminalized in 2020.

MORGAN GODVIN: We still suck at access to voluntary treatment - treatment on demand for everyone who wants it. I want our policymakers to see that decriminalization does not equal chaos.

MANN: So a lot of addiction experts I talked to do believe creating a treatment system more like Portugal's would save a lot of lives in the U.S. and help get people off the street, but it would take time. And meanwhile, a lot of people, including a lot of voters and politicians, are impatient right now. They want public drug use cleaned up. In Oregon, there's a big movement to recriminalize drug use that looks like it might succeed. There's growing pressure in California to toughen drug laws again and boost arrests. Juana, no one I talked to believes we're going to make the kind of big pivot away from drug war-era policies that put Portugal on this very different path.

SUMMERS: NPR addiction correspondent Brian Mann. Brian, thank you.

MANN: Thank you.

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Brian Mann
Brian Mann is NPR's first national addiction correspondent. He also covers breaking news in the U.S. and around the world.