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US Answer to Opioid Crisis May Lie in Revolutionary Programs of Europe’s ‘Heroin Capital’

photo of prescription opioids, a new opioid bill just passed to address the opioid crisis
Prescription opioids from K-State Research and Extension. (Image via Flickr)

Ninety percent of the money spent by the Portuguese government on issues related to drug use is spent to increase access to treatment and rehabilitation and to fund harm reduction programs.

The opioid epidemic in the United States is a health crisis of staggering proportions, and many areas of the country hit hardest by addiction to opioids lack the proper resources or expertise to deal with the massive problem. The situation is so dire that Americans are now more likely to die from an opioid overdose than they are from car accidents. The likelihood of dying from an opioid overdose is also significantly higher than the risk of dying from other accidental causes such as fires, drowning or injuries caused by falling.

Johnson & Johnson and other drug manufacturers who caused the epidemic by misinforming doctors, patients and salespeople to sell more drugs are only just beginning to be brought to court in order to be held accountable for their actions. However, given the massive amounts of money these drug-pushing corporations have to spend on lawyers and settlements as a result of their massive profits, it is unlikely that real justice will be served any time soon.

Americans are left to wonder if there is any way to end the crisis, and many probably assume that this is a uniquely American problem caused by a lethal combination of capitalist greed, rural poverty and unscrupulous doctors. Even though the causal factors vary from country to country, America is far from the first country in the world to be facing an opioid epidemic of this scale, and other countries have managed to win their war against drug addiction without spending massive amounts of government money or increasing incarceration rates. In fact, Portugal’s revolutionary approach to drug addiction may be the answer to the U.S.’ opioid crisis.

The Cause of the Opioid Crisis in the United States

“National Overdose Deaths—Number of Deaths Involving Other Synthetic Opioids (Predominately Fentanyl). The figure above is a bar chart showing the total number of U.S. overdose deaths involving other synthetic opioids from 2002 to 2016 and provisional 2017 data. Other synthetic opioids is a category dominated by illicit fentanyl. The chart is overlayed by a line graph showing the number of deaths of females and males. From 2002 to 2017 there was a 22-fold increase in the total number of deaths.”
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What exactly caused the opioid crisis in the United States? Dr. Paul H. Earley, an addiction medicine physician and the president of the American Society of Addiction Medicine, explained to Citizen Truth the origins of the crisis.

“There were a couple of factors that created the perfect storm that led us to the point where we are today. The first factor was a shift in the health care system where pain became one of the more important things to address in patient care. This was a deliberate move by medicine where doctors were saying, ‘we really need to attend to a person’s pain.’ Opioids had been successful in treating cancer pain, so the shift came when they began using opioids to treat chronic pain that was not cancer-related.

“There is a very easy and active route for drugs to enter the United States, and in the past cartels and other criminal organizations focused primarily on cocaine. However, recently they have begun focusing their efforts on the production and traffic of heroin. The cost of heroin dropped dramatically as well,” Earley told Citizen Truth.

Finally, Earley adds, “After America woke up and said, ‘Wait a minute, maybe this idea of treating non-cancer pain with opioids is actually dangerous,’ what happened was that a lot of the treatment of non-cancer pain started to shift away from opioids. The people that were addicted to these opioid pharmaceuticals and were no longer able to obtain them turned to drugs that could be easily obtained on the street market, such as heroin.”

Addiction is a chronic disease, and medical professionals are only recently starting to understand the complex nature of this illness.

“The right way to think about addiction is to think about it as a chronic illness where it takes time for people to get better. Like any chronic disease, it often takes time before people can rally their strength and their forces to get better from that disease, whether it’s high blood pressure, diabetes, or addiction,” claims Earley.

Treating substance use disorders as criminal choices only serves to cause more harm to users and the people around them. In order to properly address the problem, addiction needs to be recognized as a chronic illness and treated as such. As Earley says, “If you have diabetes and you develop kidney problems, they don’t say to you, ‘well you have one chance to get the kidney problems fixed and then we’re not going to approve you for further treatment.”

By treating drug users with compassion and providing avenues to treatment and harm reduction, many of the worst aspects of the drug misuse crisis can be avoided, and overall rates of drug use can be reduced. But the solution might surprise hardline conservatives in the United States, who will need to abandon age-old prejudices about the criminal nature of drug use in order for these solutions to be successfully implemented.

The Portugal Model

For most of the late 1990s and the early years of the 2000s, Portugal, especially Lisbon, was widely known for a major heroin problem. Drug users roamed the streets looking for their next fix and general public safety and well-being was threatened. Lisbon was widely known as the “heroin capital”  of Europe, and people traveled there from around the world for a taste of the cheap and ultra-pure heroin that flowed through the city’s streets.

This all changed in 2001 with the passing of a creative and progressive law decriminalizing the use of and possession of previously illegal drugs, providing that the user only had a personal supply, an amount defined as enough of a substance to be used for ten consecutive days. This innovative policy was suggested by doctors, psychologists and other health professionals, and the pay-off has been enormous.

Nowadays the amount of people dying from overdose in Portugal is less than a quarter of the average reported across Europe. In fact, Portugal’s mortality rate from drug use is actually the lowest in Western Europe.

This approach, known as “The Portugal Model,” essentially is founded on the idea that drug use is not a criminal problem, but rather a public health issue.

Whereas many conservatives in the United States advocated hardline policies involving stiffer legal penalties and increased police presence, Portugal’s solution has been just the opposite. Ninety percent of the money spent by the Portuguese government on issues related to drug use is spent to increase access to treatment and rehabilitation and to fund harm reduction programs. Only ten percent of the money is used to fund police task forces and other law enforcement initiatives.

Portugal decriminalized being in possession of personal amounts of psychoactive substances from hash to heroin, but this doesn’t mean that drug users get a free pass to abuse substances wherever they want. Instead of being taken to a holding cell or a police station, when a drug user is arrested with a personal amount of a controlled substance, he is sent to what is called a “dissuasion commission.” The purpose of these commissions is exactly what the name suggests, to attempt to dissuade drug users from abusing these substances by identifying the underlying causes of the problem and providing options for treatment. In addition, this method is cheaper than a law enforcement-oriented approach.

It is still possible to receive a fine as a consequence of drug possession in Portugal, but this is waived if the individual decides to pursue the treatment options provided by the commission.

A Centralized Approach

Many American cities already have needle exchange programs and other efforts at harm reduction in existence, but these are almost always organized and staffed by volunteer efforts with little to no help from the government. The programs are also often met with resistance from local authorities. In fact, in fifteen US states, including Texas, Florida and Missouri, needle exchange programs are actually illegal.

However, in Portugal the national government has organized a central agency to oversee local groups running harm reduction programs like needle exchanges and safe injection sites, ensuring that no part of the country is without these invaluable programs.

Further, in the United States, it is often very hard for people with substance abuse problems to access treatment such as rehab or counseling due to the fact that it is incredibly expensive and typically not covered by insurance. This leaves many people who want help with no option but to continue using as they wait for treatment. In Portugal, the country’s national health service provides integrated and accessible treatment for individuals with substance abuse at no cost to the patient. Non-government organizations also provide additional support, distributing methadone and clean needles while providing counseling services in the streets and allies of Portugal.

In addition to the typical problems associated with addiction such as drug dependence, homelessness and poverty, Portugal also had an extremely high rate of HIV infection during the ‘80s and ‘90s. Most of these cases were as a result of injecting drugs with dirty needles. After the law decriminalizing drugs was passed and clean needles became more easily accessible, the number of people infected with HIV began to steadily drop and continues to do so. From 2007 to 2016, the number of people newly infected with HIV fell by more than 50 percent, from 2167 to 1030.

In Portugal’s community of intravenous drug users, the numbers are even more astounding. Hugo Amaral Faria, who works for the Ares do Pinhal Association for Social Inclusion in Lisbon, told the American Psychological Association that when his organization first started working with drug users on the streets of Lisbon in the late ‘80s, over half of the people they served were HIV-positive. Now the rate of people infected with the virus is just 13 percent. Portugal’s drug policy and drug treatment programs are not only helping people with substance use disorder, but benefiting public health in general by reducing rates of infectious diseases such as AIDS and hepatitis.

So why hasn’t America adopted a model similar to Portugal’s yet?

“America was founded on somewhat puritan ethics, so America has a somewhat harsher way of looking at substance use and medical care than countries in Europe for example. There’s no doubt that that backdrop also contributes to how the United States treats its addiction problem,” explained Earley.

Access to treatment and care is one of the biggest problems contributing to America’s current opioid crisis, but fortunately, the visibility and massive scope of the problem have led to an increased effort at providing affordable and accessible treatment options.

“In all of the darkness that we’ve had in the United States with the heroin, fentanyl and opioid overdose epidemic, the only bright side that we can see in it is the concerted effort in many areas to increase access to treatment,” said Earley.

The US Struggles to Treat Addiction

Still, many people in dire need of medical treatment for addiction still are unable to access the care they need, and even when they are able to get help, patients are often treated using methods that aren’t grounded in science and medicine. Jess Keefe, who works with Shatterproof, an organization that attempts to combat addiction, told Citizen Truth that “Right now only 1 in 10 Americans with a substance use disorder receives treatment for their illness—and far fewer get treatment that is actually based in science and evidence.”

Earley echoed Keefe’s statements, commenting, “Addiction treatment programs in the U.S. are hard to access, and they’re not based on as much science as we would like. We’re trying to increase the role that science plays in addiction care and addiction treatment protocols and also prevention issues as well.”

“Treatment centers started off using an acute term cure for a long-term disease. There was no follow up after you finished the initial dose of treatment. The other piece of good quality care is long term follow up on the patient, just like what would happen in cases of high blood pressure, diabetes, and high cholesterol,” Earley told Citizen Truth. He adds that a major part of the problem is that “the treatment industry started in a specific way and it’s having a hard time shifting to a more chronic disease treatment protocol.”

As Earley explained, addiction is a chronic disease just like hypertension and autoimmune disorders, and it’s impossible to treat addiction effectively without thinking about it as such.

It’s unlikely that the opioid crisis in America will end any time soon unless drastic changes are made to American drug policy and the way addiction is viewed by mainstream society.

“We should consider everything that’s going to help people get better from addiction,” says Earley and there are a number of innovative reforms that American policymakers could consider to address the problem. Until that occurs, hundreds of thousands of lives will continue to be lost due to antiquated laws, lack of education and negative stereotypes.

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