Article

A social cost perspective in the wake of the Portuguese strategy for the fight against drugs

Authors:
  • Católica Porto Business School
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

This paper presents an analysis of the social costs of illicit drug use after the approval, in 1999, of the Portuguese National Strategy for the Fight Against Drugs (NSFAD). The strategy, which was explicitly grounded on the values of humanism and pragmatism, paved the way for the decriminalization of illicit drug use in 2000. Taking into consideration health and non-health related costs, we find that that the social cost of drugs decreased by 12% in the five years following the NSFAD's approval and by a rather significant 18% in the eleven-year period following its approval. Whilst the reduction of legal system costs (possibly associated with the decriminalization of drug consumption) is clearly one of the main explanatory factors, it is not the only one. In particular, the rather significant reduction of health-related costs has also played an important role.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... [100] Drug consumption and possession were decriminalised but not legalised. Henceforth, people using drugs identified by police authorities would have their drugs seized 15 and be directed to a Commission for the Dissuasion of Drug Addiction, a truly innovative system. ...
... Estimation based on public expenditure on drugs, private costs for people using drugs and indirect costs such as lost productivity.[15] 13600443, ja, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/add.16099 ...
... In 2001, the government issued a more detailed decree regulating the commissions -Decree Law n.130-A/2001.15 The drugs can be tested if necessary.13600443, ...
Article
Full-text available
Background In 2000, the Portuguese minority socialist government decriminalised the possession and consumption of drugs. This law made Portugal unique in having a formal system that directs the person using drugs to a panel under the purview of the Ministry of Health, as opposed to the Ministry of Justice, and hence constitutes an ‘Original Innovation’. In this article, we ask under which conditions such kinds of reforms are introduced and successfully implemented Argument After discussing the limitations of the existing literature, we present a new theoretical framework: the ‘six-stars’ framework. We argue that successful policy innovation in democracies will only occur and persist when six institutional and individual ‘stars’ are aligned: attention, motivation to innovate, a new solution, political strategies, quality and legitimacy of the decision-making process, and guarantees for full implementation. We then apply this framework to the Portuguese drug policy case through theory-testing/process-tracing. Relying on a qualitative analysis of three different types of data - primary and secondary sources, official documents emitted by key actors and interviews - we identify the presence of the six aligned ‘stars’. Conclusions The proposed ‘six-stars’ framework of successful drug policy innovation shows the importance of electoral mandates, communication, inclusion, transparency, deliberation, and evaluation when designing innovative drug policies. It also illustrates the importance of ensuring the support of implementing agents and quickly creating visible, positive policy feedback.
... Assim se iniciou um novo paradigma na política para as drogas, no qual Portugal foi pioneiro, empenhado na redução da procura e enquadrando a toxicodependência no domínio da saúde pública. A presente secção analisa o processo de discussão e implementação desta medida, que se revelou exemplo de um tipo ideal de política de longo prazo cujo investimento se traduziu numa diminuição prolongada do custo das drogas em vários domínios, tanto social, como no sector da saúde ou no sistema judicial (Gonçalves, Lourenço & Silva, 2015). ...
... Apesar de acompanhar as tendências gerais de crescimento de consumos na Europa, os valores registados em Portugal propendem a ser menores (Greenwald, 2009). Também no plano económico é possível encontrar resultados positivos: o custo social relacionado com drogas reduziu 18% nos primeiros dez anos de implementação da Estratégia Nacional de Luta Contra a Droga (Gonçalves, Lourenço & Silva, 2015). ...
... O consenso em torno da Estratégia Nacional de Luta Contra a Droga manteve-se ao longo dos anos. Por exemplo, o orçamento do IDT (hoje SICAD) varia cerca de 10M € ao longo de um período de 11 anos, o que mostra que os sucessivos governos e arranjos parlamentares não quiseram alterar substancialmente o modelo adotado em 2000, no qual esta instituição tem um papel central (Gonçalves, Lourenço & Silva, 2015). No período de 2005 a 2012, a despesa pública relacionada com drogas variou entre 0,03% e 0,05% do PIB (Observatório Europeu da Droga e da Toxicodependência, 2010, 2019), o que ilustra a estabilidade do consenso político em torno das medidas. ...
Book
A pandemia de COVID-19 chocou o mundo e demonstrou a relativa falta de planeamento dos governos para algo que vários peritos tinham alertado previamente. De facto, formular políticas de longo-prazo é politicamente custoso para os governantes porque os benefícios apenas são visíveis no futuro, apesar dos recursos terem de ser mobilizados no presente. Em democracias liberais, esta dificuldade é acentuada pelo fluxo noticioso, eleições e a pressão política que permitem o escrutínio público, mas também forçam os governantes a priorizar o imediato. Mesmo neste contexto, Portugal adotou várias medidas de longo prazo, mostrando que governar para as próximas gerações, e não apenas para as próximas eleições, é possível. O livro analisa medidas de longo-prazo para determinar as razões para a sua adoção ou rejeição.
... Losses in work productivity reached 930 million euros, about 45.7% of the total cost. Gonçalves, Lourenço, and Nogueira da Silva (2015) study how the social cost of drug consumption in Portugal has evolved since the Portuguese National Strategy for the Fight against Drugs (NSFAD) was approved in 1999. The results indicate that the social costs of drugs significantly decreased (12%) in the five years following the NSFAD's approval. ...
... Moreover, they follow a range of methodologies and use varied definitions for social cost. Other factors also make it difficult to make comparisons: the availability of data, the sources and registers that need to be accessed and the different ways in which the health care system and social structure are organised in each country (Gonçalves et al., 2015). ...
... In this way, most studies on the costs of substance abuse are based on four main cost categories: health care and productivity costs, those related to law enforcement and the criminal justice system and other expenses, such as property damage. This study follows the classification adopted by Kopp and Fenoglio (2001) or Gonçalves et al. (2015). As can be seen in Table 1 social costs are divided in terms of the main drivers (health-related vs. non-health related) and their relationship to drug use (direct or indirect). ...
Article
Background: Illegal drugs consumption not only has a notable impact on the population's health, but also leads to major socio-economic costs. A significant characteristic of drug consumers is that the majority are of working age. The main aim of this study is to estimate the economic impact of drug consumption in Spain from a social perspective. Methods: A cost-of-illness methodology is carried out and a distinction is made between health-related and non-health related direct costs, as well as indirect costs. Among the direct health care costs included are hospitalisations, primary and emergency care, support programmes and HIV outpatient care. Expenditure on prevention, law enforcement and research was included as direct costs falling outside of health care. Productivity losses due to premature deaths attributed to substance abuse and patient hospitalisation formed part of indirect costs. Results: For 2012, the total social cost related to drug consumption in Spain was somewhere between 1,436 and 1,651 million euros. The minimum cost of this consumption represented 0.14% of Spain's GDP for that year. Conclusion: The present cost estimations provide a measure of the social burden that illegal drug consumption represents for the community. When it comes to allocating resources, the obtained results quantify the potential economic returns that could be achieved from effective policies and programmes aimed at reducing the consumption of illegal drugs.
... Komiteen kom med en rekke anbefalinger, 9 som ble vedtatt i 1999 som den første portugisiske nasjonalstrategi som omhandlet rus og rusavhengighet, 'The National Strategy for the Fight Against Drugs' (NSFAD). NSFAD, eller det vi i dag kjenner som 'Portugal-modellen', innebar en narkotikapolitisk dreining i retning av opprustning og opptrapping av forebyggende arbeid, lavterskel-og skadereduserende tiltak, utbygging av poliklinisk-og døgnbehandling, ettervern, samt tiltak for å kontrollere tilgangen til illegale rusmidler (Félix & Portugal, 2017;Gonçalves, Lourenço & Da Silva, 2015;Hughes & Stevens, 2010;Laqueur, 2015;Marques, 2012). Avkriminalisering av bruk og besittelse av illegale rusmidler var et av 13 mer eller mindre kontroversielle strategier formulert i NSFAD (Gonçalves, Lourenço & Da Silva, 2015;Loo, Van Beusekom & Kahan, 2002). ...
... NSFAD, eller det vi i dag kjenner som 'Portugal-modellen', innebar en narkotikapolitisk dreining i retning av opprustning og opptrapping av forebyggende arbeid, lavterskel-og skadereduserende tiltak, utbygging av poliklinisk-og døgnbehandling, ettervern, samt tiltak for å kontrollere tilgangen til illegale rusmidler (Félix & Portugal, 2017;Gonçalves, Lourenço & Da Silva, 2015;Hughes & Stevens, 2010;Laqueur, 2015;Marques, 2012). Avkriminalisering av bruk og besittelse av illegale rusmidler var et av 13 mer eller mindre kontroversielle strategier formulert i NSFAD (Gonçalves, Lourenço & Da Silva, 2015;Loo, Van Beusekom & Kahan, 2002). ...
... 'Portugal-modellen' var tuftet på skadereduksjon og et helseorientert, pragmatisk og humanistisk menneskesyn, og den skulle begrense etterspørselen av illegale rusmidler gjennom blant annet metadonprogrammer (Gonçalves, Lourenço & Da Silva, 2015;Loo, Van Beusekom & Kahan, 2002). Strategien fremmet i tillegg konkrete forslag for integrerte tilnaerminger til forebygging, behandling, skadereduksjon og reintegrering i samfunnet, samtidig som bruk og besittelse ble avkriminalisert. ...
Technical Report
Full-text available
Et flertall på Stortinget vil avkriminalisere besittelse og bruk av illegale rusmidler, inspirert av Portugals reform fra 2001. Portugal flyttet besittelse og bruk av mindre kvanta illegale rusmidler fra straffe- til sivilretten, samtidig som de økte kapasiteten på tiltaksapparatet. Denne prosessen i Portugal har blitt en viktig referanseramme i debatten om narkotikapolitisk reform. Hensikten med denne rapporten var å etablere en kunnskapsbase, samt oppsummere den politiske prosessen og dens utfall i Portugal.
... For instance, in Portugal, there was a 12% reduction in the social cost of drugs in the first 5-year period of decriminalization. It was attributed to direct and indirect cost reduction in the criminal justice system, mostly associated with fewer imprisonments and indirect health cost savings, such as from reduced drug-related deaths (Domoslawski & Siemaszko, 2011;Gonçalves, Lourenço, & da Silva, 2015;Greenwald, 2009;Pinto Coelho, 2010). ...
... Decriminalization reduces the costs regarding CJS expenditures, such as for law enforcement, lawyers, and courts; however, the costs of treatment and prevention have increased during the same period (Hughes & Stevens, 2012). The reduction in the social cost of drugs was 12% in the first 5-year period, and 18% after ten years of decriminalization, most of which has been attributed to a direct and indirect cost reduction in the legal system associated with the fewer imprisoned individuals and indirect health costs such as drug-related deaths in Portugal (Domoslawski & Siemaszko, 2011;Eastwood et al., 2016;Gonçalves et al., 2015;Greenwald, 2009;Pinto Coelho, 2010). The number of drug offenses dropped from approximately 14 000 cases per year in 2000 to an average of 5000 to 5500 per year after decriminalization. ...
... The new structure, 'The Portuguese Institute for Drugs and Addiction (IPDT)' was initiated in 2000 and would work in cooperation with ministerial services. Finally, the government decriminalized all drugs, including cocaine and heroin, in 2001(Cabral, 2017;Gonçalves et al., 2015;C. E. Hughes & Stevens, 2010;Van Het Loo et al., 2002). ...
Technical Report
Full-text available
The report aims to identify legal frameworks, models, and implementation practices of the decriminalization policies and to assess their empirical results. Statistics show that the prevalence of drug use has increased for decades all around the world despite all the strict measures taken. Decriminalization policy has emerged as a response to unbalanced prohibitionist drug policy, which creates not only social injustices at the individual level but also public health problems and high social costs at the macro level. On the other hand, decriminalization is a complex framework and is generally used as an umbrella term representing contemporary strategy. Governments have tailored this framework according to their priorities and expectations. The report categorizes models, implementations, and outcomes to evaluate results. Besides, by providing overall results from three European countries, we aim to assess the impact of the contextual factors and variation of the results. We hope the report will contribute to the discussion of developing better policy models managing drug problems.
... En la tabla 2 se amplía la información del cuadro 2 en el contexto del consumo de drogas. En ella se presentan la mayor parte de las categorías de costes que, idealmente, habría que tomar en consideración a la hora de estimar el coste social del consumo de drogas (Kopp y Fenoglio, 2001;Gonçalves et al., 2015). Sin embargo, no siempre es posible cuantificar todas las partidas de coste. ...
... Debe tenerse en cuenta que para incorporar el coste de otras patologías a la drogodependencia, debe de estar clara la relación de causalidad y, en muchos casos, hay poca evidencia al respecto. Por ejemplo, se han incluido los recursos consumidos para el tratamiento de ciertas enfermedades infecciosas, como el VIH o las hepatitis víricas, dado que en muchos casos estas enfermedades no se hubiesen originado sin un consumo previo de una droga (Gonçalves et al., 2015). En segundo lugar, aun asumiendo que determinado gasto debe ser incorporado, no siempre está clara la parte que debe ser imputada al consumo de drogas. ...
... Drug-and/or alcohol-dependence (DAD) generates substantial costs to society. Within the framework of cost-of-illness studies, these are usually classified as losses in productivity, direct costs and intangible costs [1][2][3]. Great advances have been to improve the homogeneity and comparability of cost-of-illness studies [3][4][5]. Nevertheless, the methodology requires further strides both in estimation techniques and the concepts being analysed. ...
... A convenience sample of 109 patients with substance use disorders, who were attending their first appointment, was recruited consecutively from five drug treatment centres located in the Spanish regions of Galicia (2), Navarra (1) and Andalucía (2), throughout 2015. As inclusion criteria, all participants were required to comply with the protocol of informed consent and have a diagnosis of illegal drug or alcohol use disorder-according to EuropASI or DSM-5-without serious cognitive impairment. ...
Article
Full-text available
Objective Drug and/or alcohol dependence (DAD) generates substantial costs to society. One of the main consequences of DAD is its negative impact on health-related quality of life (HRQoL). The main objective of this study is to analyse the impact of using EQ-5D-5L, SF-6DSG (SF-6D using standard-gamble as the preference-eliciting method) and SF-6DPG (SF-6D using a paired-gamble method), to estimate the HRQoL burden, attributable to DAD, within the cost-of-illness framework.MethodsA convenience sample of 109 patients with a diagnosis of substance use disorder was recruited. SF-6D and EQ-5D-5L were administered and then the utility scores were computed. The impact of employing different instruments to estimate the HRQoL burden was assessed by comparing the utility scores of patients and general population after controlling for sex and age through regression analysis. The analysis was reproduced for two subgroups of severity.ResultsAll instruments detect that DAD significantly affects the HRQoL. However, the estimated impact changes, according to the instrument used, whose pattern varies by severity group. Nonetheless, regardless of severity, SF-6DPG always estimates a higher or equal DAD burden than the other instruments considered. These results are compatible with the presence of the floor effect in SF-6DSG, the ceiling effect in EQ-ED-5L, and a smaller presence of both biases in SF-6DPG.Conclusions The SF-6DPG instrument emerges as a good candidate to avoid under-estimating intangible costs within the cost-of-illness framework. However, further research is needed to assess the validity of our results in the context of other health problems.
... En la tabla 2 se amplía la información del cuadro 2 en el contexto del consumo de drogas. En ella se presentan la mayor parte de las categorías de costes que, idealmente, habría que tomar en consideración a la hora de estimar el coste social del consumo de drogas (Kopp y Fenoglio, 2001;Gonçalves et al., 2015). Sin embargo, no siempre es posible cuantificar todas las partidas de coste. ...
... Debe tenerse en cuenta que para incorporar el coste de otras patologías a la drogodependencia, debe de estar clara la relación de causalidad y, en muchos casos, hay poca evidencia al respecto. Por ejemplo, se han incluido los recursos consumidos para el tratamiento de ciertas enfermedades infecciosas, como el VIH o las hepatitis víricas, dado que en muchos casos estas enfermedades no se hubiesen originado sin un consumo previo de una droga (Gonçalves et al., 2015). En segundo lugar, aun asumiendo que determinado gasto debe ser incorporado, no siempre está clara la parte que debe ser imputada al consumo de drogas. ...
Technical Report
Full-text available
En los estudios que abordan la estimación del coste social de la adicción se observa una amplia variabilidad en la metodología y en los enfoques utilizados para el cálculo de los costes y la presentación de los resultados, lo que hace difícil poder realizar comparaciones entre ellos. El objetivo principal de esta guía es presentar una metodología estandarizada para la valoración económica de las consecuencias del consumo de drogas sobre distintos ámbitos de nuestra sociedad. Además, con el objetivo de facilitar la comparación entre distintos estudios, se propone un esquema básico para la presentación de los resultados y un estándar mínimo de calidad que han de cumplir estas estimaciones. Para lograr estos objetivos, esta guía proporciona la información necesaria para estimar las categorías de coste que se han de incluir en un estudio de costes sociales de la adicción. La estructura de contenidos responde a la necesidad de que sea un documento útil y de fácil manejo para un público no especializado en el campo de la economía. Para cada una de las categorías de costes, se justifica su relación con el consumo de drogas, se exponen las alternativas metodológicas existentes para su cálculo, así como sus limitaciones, y se describen, si las hubiera, las fuentes primarias de información disponibles en España para su cálculo. Con el objetivo de imprimir un carácter más práctico al documento, muchas de las categorías incluyen un caso práctico de estimación. La guía se divide en tres grandes bloques. En el primero de ellos se introducen los conceptos teóricos más relevantes sobre la estimación del coste social de la adicción, tomando como referencia la metodología de los estudios de coste-enfermedad (Cost-of-Illness Studies, COI). Además de proponer una clasificación de los costes por categorías, identificando aquellas categorías mínimas que cualquier estudio de coste debiera incluir, se abordarán aspectos de gran relevancia para los estudios de coste social, como son la perspectiva del análisis, el ajuste temporal de los costes, o el análisis de sensibilidad. A continuación, se propone un esquema de presentación de los resultados. Finaliza este bloque con una pequeña referencia a la estimación de los costes evitables que se puede llevar a cabo una vez finalizado todo COI. El segundo bloque profundiza en la medición de los costes tangibles, distinguiendo entre costes directos y las pérdidas de producción. El tercer y último bloque aborda la medición de los costes intangibles (pérdidas de bienestar), centrándose principalmente en la propuesta de instrumentos de medición de la calidad de vida relacionada con la salud.
... Abolishing incarceration for use and possession of illicit drugs can result in a major reduction of incarceration episodes and in important health improvements among people who use drugs [6,[42][43][44][45][46][47]. For example, decriminalisation of minor drug offences in Portugal has resulted in important reductions in the number of individuals incarcerated for drug law offences, significant savings in legal system costs, large public health benefits and declines in problem drug use (i.e. a shift from heroin use to cannabis use) [43,46,48,49]. ...
... Given their consistency across countries and with other studies, our findings may have implications for health and drug policies regarding incarceration of PWID and HIV and HCV infection, even without considering other outcomes such as overdose and mortality. They add further evidence for strengthening service provision throughout incarceration and on release ('throughcare') and for considering alternatives to incarceration such as decarceration and decriminalisation (depenalisation, police diversion) policies, which have already been successfully introduced [43,48,49,72,73]. The COVID-19 pandemic has provided additional urgency to reducing the potential negative public health impact resulting from incarcerating people who use drugs, and decarceration has already been applied as a precaution to limit the spread of COVID-19 [74][75][76]. ...
Article
Full-text available
Background People who inject drugs (PWID) are frequently incarcerated, which is associated with multiple negative health outcomes. Aim We aimed to estimate the associations between a history of incarceration and prevalence of HIV and HCV infection among PWID in Europe. Methods Aggregate data from PWID recruited in drug services (excluding prison services) or elsewhere in the community were reported by 17 of 30 countries (16 per virus) collaborating in a European drug monitoring system (2006–2020; n = 52,368 HIV+/−; n = 47,268 HCV+/−). Country-specific odds ratios (OR) and prevalence ratios (PR) were calculated from country totals of HIV and HCV antibody status and self-reported life-time incarceration history, and pooled using meta-analyses. Country-specific and overall population attributable risk (PAR) were estimated using pooled PR. Results Univariable HIV OR ranged between 0.73 and 6.37 (median: 2.1; pooled OR: 1.92; 95% CI: 1.52–2.42). Pooled PR was 1.66 (95% CI 1.38–1.98), giving a PAR of 25.8% (95% CI 16.7–34.0). Univariable anti-HCV OR ranged between 1.06 and 5.04 (median: 2.70; pooled OR: 2.51; 95% CI: 2.17–2.91). Pooled PR was 1.42 (95% CI: 1.28–1.58) and PAR 16.7% (95% CI: 11.8–21.7). Subgroup analyses showed differences in the OR for HCV by geographical region, with lower estimates in southern Europe. Conclusion In univariable analysis, a history of incarceration was associated with positive HIV and HCV serostatus among PWID in Europe. Applying the precautionary principle would suggest finding alternatives to incarceration of PWID and strengthening health and social services in prison and after release (‘throughcare’).
... The reform was also a profitable investment for the state, as the economic benefits were higher than its costs. 6 This net benefit is caused by the reduction in indirect health-related costs and legal system expenses (fewer criminal proceedings, fewer people imprisoned, less indirect costs due to lost income and production of incarcerated people, Gonçalves, Lourenço, and da Silva 2015). ...
... Decree-law n.183/2001 6 Estimation based on public expenditure on drugs, private costs for the drug users and indirect costs such as lost productivity(Gonçalves, Lourenço, and da Silva 2015). ...
Article
Full-text available
In 2000, the minority Socialist government led by António Guterres decriminalised the possession and consumption of drugs. This law made Portugal unique in having a formal system that directs the drug user to a panel under the purview of the Ministry of Health, as opposed to the Justice Ministry, and hence constitutes a successful ‘Original Innovation’. In this article, we present a theoretical framework that claims that original innovation, though rare, only occurs when a series of variables are present at the same time. We then demonstrate that these variables were indeed all present in the Portuguese case. This research offers lessons to policy-makers and policy activists about the importance of electoral mandates, communication, inclusion, transparency, deliberation and evaluation when creating new policies - during and after policy-design. It also reminds us that the Portuguese model goes beyond decriminalisation. In fact, the rapid and positive effects of well-funded harm-reduction, drug treatment and prevention programs were fundamental for the success and resilience of the Portuguese drug policy.
... Abolishing incarceration for use and possession of illicit drugs can result in a major reduction of incarceration episodes and in important health improvements among people who use drugs [6,[42][43][44][45][46][47]. For example, decriminalisation of minor drug offences in Portugal has resulted in important reductions in the number of individuals incarcerated for drug law offences, significant savings in legal system costs, large public health benefits and declines in problem drug use (i.e. a shift from heroin use to cannabis use) [43,46,48,49]. ...
... Given their consistency across countries and with other studies, our findings may have implications for health and drug policies regarding incarceration of PWID and HIV and HCV infection, even without considering other outcomes such as overdose and mortality. They add further evidence for strengthening service provision throughout incarceration and on release ('throughcare') and for considering alternatives to incarceration such as decarceration and decriminalisation (depenalisation, police diversion) policies, which have already been successfully introduced [43,48,49,72,73]. The COVID-19 pandemic has provided additional urgency to reducing the potential negative public health impact resulting from incarcerating people who use drugs, and decarceration has already been applied as a precaution to limit the spread of COVID-19 [74][75][76]. ...
Article
Full-text available
Background People who inject drugs (PWID) are frequently incarcerated, which is associated with multiple negative health outcomes. Aim We aimed to estimate the associations between a history of incarceration and prevalence of HIV and HCV infection among PWID in Europe. Methods Aggregate data from PWID recruited in drug services (excluding prison services) or elsewhere in the community were reported by 17 of 30 countries (16 per virus) collaborating in a European drug monitoring system (2006–2020; n = 52,368 HIV+/−; n = 47,268 HCV+/−). Country-specific odds ratios (OR) and prevalence ratios (PR) were calculated from country totals of HIV and HCV antibody status and self-reported life-time incarceration history, and pooled using meta-analyses. Country-specific and overall population attributable risk (PAR) were estimated using pooled PR. Results Univariable HIV OR ranged between 0.73 and 6.37 (median: 2.1; pooled OR: 1.92; 95% CI: 1.52–2.42). Pooled PR was 1.66 (95% CI 1.38–1.98), giving a PAR of 25.8% (95% CI 16.7–34.0). Univariable anti-HCV OR ranged between 1.06 and 5.04 (median: 2.70; pooled OR: 2.51; 95% CI: 2.17–2.91). Pooled PR was 1.42 (95% CI: 1.28–1.58) and PAR 16.7% (95% CI: 11.8–21.7). Subgroup analyses showed differences in the OR for HCV by geographical region, with lower estimates in southern Europe. Conclusion In univariable analysis, a history of incarceration was associated with positive HIV and HCV serostatus among PWID in Europe. Applying the precautionary principle would suggest finding alternatives to incarceration of PWID and strengthening health and social services in prison and after release (‘throughcare’).
... Substance abuse in general, and alcohol misuse in particular, generates large social costs, generally classified as direct, indirect and intangible [1][2][3]. However, while direct and indirect costs have received considerable attention within the framework of cost-of-illness studies, intangible costs have rarely been addressed [4], despite the strong impact that their inclusion may have on the social cost [5,6]. ...
Article
Objectives: To estimate the impact of alcohol disorders using lottery equivalent (LE) and willingness to pay (WTP) methods and compute the WTP for a QALY (WTP-Q) derived from these values. Methods: Two samples of 300 people valued nine states of alcohol misuse. LE and WTP were used in sample 1 and 2, respectively. The ability to discriminate between methods was tested. Regression models were performed to estimate the preference weights of dimensions. Several values of WTP-Q were obtained by combining the estimated values from both samples. Results: LE and WTP produce the same ranking of states but LE is more sensitive. The estimated impact of the nine states ranges between 0.91 and 0.22 QALYs, and the WTP for avoiding them ranges between €10,444 and €4132. WTP-Q varies between €11,473 and €19,092 when the mean values of the states are used. The WTP-Q tends to decrease with the severity. Conclusions: Although LE and WTP provide values for cost-utility and cost-benefit analyses, respectively, LE seems to be preferable for measuring the impact of alcohol disorders. As the lower sensitivity of WTP seems to explain a WTP-Q decrease with severity, more research is needed before recommending the use of different WTP-Q values.
... Drug policies have also started to shift, even if the translation of evidence into policy remains difficult [25][26][27][28]. In some countries, there is cooperation between judicial and health authorities to mitigate harms associated with the criminalisation of drug use [29] and explicit or de facto decriminalisation of drug use [30][31][32]-these may often go together [33]-or even legalisation, in the case of cannabis [34][35][36][37]. Human rights-based approaches to drug treatment, incorporating harm reduction and social integration, have been implemented in a number of countries despite universal, national and global drug prohibition policies [38][39][40]. ...
Article
Full-text available
BACKGROUND AND AIMS: Despite advances in our knowledge of effective services for people who use drugs over the last decades globally, coverage remains poor in most countries, while quality is often unknown. This paper aims to discuss the historical development of successful epidemiological indicators and to present a framework for extending them with additional indicators of coverage and quality of harm reduction services, for monitoring and evaluation at international, national or subnational levels. The ultimate aim is to improve these services in order to reduce health and social problems among people who use drugs, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection, crime and legal problems, overdose (death) and other morbidity and mortality. METHODS AND RESULTS: The framework was developed collaboratively using consensus methods involving nominal group meetings, review of existing quality standards, repeated email commenting rounds and qualitative analysis of opinions/experiences from a broad range of professionals/experts, including members of civil society and organisations representing people who use drugs. Twelve priority candidate indicators are proposed for opioid agonist therapy (OAT), needle and syringe programmes (NSP) and generic cross-cutting aspects of harm reduction (and potentially other drug) services. Under the specific OAT indicators, priority indicators included ‘coverage’, ‘waiting list time’, ‘dosage’ and ‘availability in prisons’. For the specific NSP indicators, the priority indicators included ‘coverage’, ‘number of needles/syringes distributed/collected’, ‘provision of other drug use paraphernalia’ and ‘availability in prisons’. Among the generic or cross-cutting indicators the priority indicators were ‘infectious diseases counselling and care’, ‘take away naloxone’, ‘information on safe use/sex’ and ‘condoms’. We discuss conditions for the successful development of the suggested indicators and constraints (e.g. funding, ideology). We propose conducting a pilot study to test the feasibility and applicability of the proposed indicators before their scaling up and routine implementation, to evaluate their effectiveness in comparing service coverage and quality across countries. CONCLUSIONS: The establishment of an improved set of validated and internationally agreed upon best practice indicators for monitoring harm reduction service will provide a structural basis for public health and epidemiological studies and support evidence and human rights-based health policies, services and interventions.
... One clear example of the benefits of a combined approach is Portugal, which decriminalized the consumption and possession for personal use of all illicit drugs in 2001, with the goal of providing a more public health-orientated approach to illicit drugs [16]. The impacts have been well documented, showing significant reductions in public health, criminal justice and social problems [17,18]. It is less well known that, since decriminalizing illicit drug use, Portugal has also increased tobacco controls. ...
Article
Commentary to: The diverging trajectories of cannabis and tobacco policies in the United States: reasons and possible implications
... More recently, Gonçalves et al. (2015) document a significant reduction in the legal costs associated with criminal proceedings for drug-law offenses and in the number of consumption drug-law offenses in the period between 1999 and 2010, which is line with the health-oriented strategy of the policy change. The authors also estimate that police costs for detection of drug-law offenses increased in the case of the specialized police force responsible for major drug-law offenses and decreased in the case of the non-specialized police forces. ...
... La première baisse serait liée à la réduction des décès en lien avec l'usage de stupéfiants, qui a entraîné une baisse des coûts sanitaires indirects. La seconde serait imputable à une réduction significative des coûts liés au fonctionnement du système pénal (coûts des procédures en matière d'usage, pertes de revenus causés par les incarcérations des délinquants) et serait donc un effet direct de la dépénalisation (Gonçalves et al., 2015). ...
... There is increasing recognition that the criminalization of people who use drugs is counterproductive to human rights and public health objectives and that decriminalization of drug use and possession has the potential to reduce barriers to providing harm reduction services [46]. The decriminalization of drug use in Portugal is one measure in a comprehensive national drug policy, which includes high coverage of a range of quality harm reduction interventions, has proven cost effective, and has reduced the number of new HIV infections among people who use drugs from 1800 per year in 1999 to 18 in 2018 [47][48][49]. More recently, following an objective review of the evidence and a dynamic dialogue with drug user and civil society organisations, Norway has also transformed its approach to harm reduction and drug policy reform [50]. ...
Article
Purpose of review: We reviewed the global state of harm reduction for people who use and/or inject drugs. Key findings: Although harm reduction is now the key response to HIV among people who use drugs globally, intervention coverage remains suboptimal, exacerbated by chronic under-funding, declining donor support and limited domestic investment, particularly in low-income and middle-income countries. We describe the current environment and review recent innovations and responses, including peer distribution of naloxone, low dead space syringes, drug consumption rooms and drug-checking services. However, despite efforts by people who use drugs and supporting partners to sustain harm reduction services and to develop and implement novel interventions, programmes are often under-scaled and under-resourced and people who use drugs continue to face significant barriers to accessing services. Summary: There is an urgent need to bring existing harm reduction programmes to scale and to broaden their scope, as well to complement them with innovative interventions targeting new populations and new substances. Under and disinvestment in harm reduction and the absence of enabling legal environments threatens to undermine the global HIV response and exacerbate the morbidity and mortality associated with the current epidemic of opioid overdose.
... Un nombre croissant de pays à travers le monde s'essayent à la dépénalisation, ou même la libéralisation de l'usage, de toutes ou partie des drogues illicites. Il est évident que les résultats de ces expérimentations seront scrutés et analysés avec attention, comme cela a été le cas au Portugal et aux Pays-Bas où les résultats sont positifs (26,27) et dans d'autres pays sur la légalisation du cannabis (28) . / ...
Book
Full-text available
Les conduites addictives : prévention et prise en soins > Alcool, tabac, jeux, écrans, drogues… Parmi les aides et secours auxquels contribue la Croix-Rouge figure la lutte contre les addictions. De légères à immodérées, ces dépendances ou comportements irrépressibles nuisent aux individus jusqu’à devenir de véritables prisons psychologiques, avec des risques de santé physique et une mise en marge sociale. Cet ouvrage témoigne de cette réalité et illustre les actions de terrain tant du côté des difficultés à surmonter que des résultats obtenus. > Ce recueil d’expériences de professionnels de disciplines variées constitue une référence, voire une source d’accompagnement, autant pour les personnes addictives que pour leurs soignants. Sans éluder la complexité des problèmes, elle fait apparaître - heureusement - quelques perspectives de progrès.
... More recently, Gonçalves et al. (2015) document a significant reduction in the legal costs associated with criminal proceedings for drug-law offenses and in the number of consumption drug-law offenses in the period between 1999 and 2010, which is line with the health-oriented strategy of the policy change. The authors also estimate that police costs for detection of drug-law offenses increased in the case of the specialized police force responsible for major drug-law offenses and decreased in the case of the non-specialized police forces. ...
Article
Background: This study is an empirical assessment of the impact of the drug decriminalization policy followed by Portugal in July 2001, on the price of illicit drugs. Methods: The analysis is performed using a difference-in-differences approach and the Synthetic Control Method in order to construct a synthetic control unit from a convex combination of countries. Results: The results suggest that the prices of opiates and cocaine in the post-treatment period did not decrease in the sequence of the policy change. Conclusion: We conclude that the drug decriminalization policy seems to have caused no harm through lower illicit drugs prices, which would lead to higher drug usage and dependence.
... Social integration, the costs and harms of criminal justice processes, other crimes, organized crime and health harms will all have an influence on the total social costs of drug use and policy. Gonçalves et al. (2015) found a reduction in total social cost following decriminalization in Portugal, despite the increased expenditure on the drug treatment services to which some people were diverted. These increased treatment costs were mostly cancelled out by reductions in the costs of dealing with viral hepatitis and HIV and substantial reductions in drug-related court cases and imprisonments, with less lost income and productivity due to such incarceration. ...
Article
Full-text available
Alternatives to criminalization for the simple possession of illicit drugs are increasingly of interest to policy makers. But there is no existing theoretically based, empirically tested framework that can inform development and evaluation. This article presents a realist programme theory of such alternatives. It bases this on a realist review, which followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES). It describes the systematic process of searching the literature in English on nine relevant countries (Australia, Czech Republic, Denmark, Germany, Jamaica, Netherland, Portugal, the UK, the USA) for information on alternative measures in three categories: depenalization; diversion; and decriminalization. It shows how these measures – in theory and in practice – combine with pre-existing social conditions and institutional contexts to trigger mechanisms across three causal pathways (normative; criminal justice; and health and social services). It shows how some posited causal processes are more empirically supported than others. Alternative measures can reduce harms imposed by criminal justice processes without increasing drug use or related health and crime harms, but this depends on specific combinations of contexts, mechanisms and outcomes.
... There is increasing focus on challenging the 'war on drugs' through international commissions and innova tive approaches by some countries 179,246 . For example, an earlier approach to the twin epidemics (or syndemic) of HIV transmission and drugrelated deaths in people with OUD who inject drugs in Portugal was to increase the availability and access to primary prevention inter ventions in the community and remove criminal sanc tions from people who use drugs [247][248][249] . This approach started in 2003 and the combination of criminal justice reforms and investment in harm reduction has been viewed as a success, with indicators suggesting lower social costs, no adverse change in the price of drugs, and reduced risks of HIV transmission and overdose. ...
Article
Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.
... Portugal now has among the lowest drug overdose death rates among wealthy countries. 3,101,102 Thus, one example of a primordial prevention approach targeting political context and governance by physical therapists could reasonably seek to reframe the conversation surrounding criminal justice and addictions in the context of evidence-based policy recommendations. ...
Article
Full-text available
The physical therapy profession has recently begun to address its role in preventing and managing opioid use disorder (OUD). This topic calls for discussion of the scope of physical therapy practice, and the profession's role, in the prevention and treatment of complex chronic illnesses, such as OUD. OUD is not just an individual-level problem. Abundant scientific literature indicates OUD is a problem that warrants interventions at the societal level. This upstream orientation is supported in the American Physical Therapy Association's vision statement compelling societal transformation and its mission of building communities. Applying a population health framework to these efforts may provide physical therapists with a useful viewpoint that can inform clinical practice and research, as well as develop new cross-disciplinary partnerships. This Perspective discusses the intersection of OUD and persistent pain using the disease prevention model. Primordial, primary, secondary, and tertiary preventive strategies are defined and discussed. This Perspective then explains the potential contributions of this model to current practices in physical therapy, as well as provide actionable suggestions for physical therapists to help develop and implement upstream interventions that may reduce the impact of OUD in their communities.
... Nevertheless, our initial pilot results are surprising and incline us to encourage extensive research on the equivalent attitudes of citizens in different European countries. Many journalists, psychologists, and doctors in the Netherlands, Portugal, and the Czech Republic assessed the individual and social consequences of such regulations as beneficial [15][16][17][18]. ...
Article
Full-text available
Background: We discuss the countries that have liberalized legislation on the possession of small amounts of marijuana and other drugs, and explore the justifications that inclined authorities to introduce such changes. The Czech Republic is among these countries. We compared the prevailing opinions on this issue by conducting surveys among young people living in Poland, Slovakia, and the Czech Republic. Material/Methods: The data were collected with the help of Polish, Czech, and Slovak versions of the questionnaire. The data were acquired during 3 focus studies organized at the Department of Health Care, University of Trenčín, Slovakia, the Department of Health Care Studies, Tomas Bata University, Zlin, Czech Republic, and the Institute of Nursing, University of Applies Sciences, Nysa, Poland. We gathered the answers from 27 students of nursing in Zlin, from 43 students in Trenčín, and 33 students in Nysa. Results: It appears that even in the Czech Republic, many young people disagree with the liberalization of legislation for the possession of small amounts of drugs. The proportion of young Polish students who do not positively assess such legislation is similar. In Slovakia, young people overwhelmingly judge such legislation negatively. Conclusions: 1. The lack of social approval for the legal possession of small amounts of marijuana makes it difficult to fight dangerous “new psychoactive substances”. 2. Since many young people in the Czech Republic, Poland, and Slovakia does not approve of the liberalization of legislation on possessing small amounts of marijuana and other drugs, it is necessary to verify the hypotheses explaining the nature of these prejudices.
... Second, prevalence of use was the predominant metric used to assess the impact of drug law reform, despite its limited clinical significance (eg, much cannabis use is non-problematic) and limited responsiveness to drug policy. This is because ecological analyses have indicated little relationship between drug policies and prevalence of use, 52 as have studies assessing within-state change in use related to legal regulation. 21 These findings are supported by the preponderance of evidence synthesised in this review, although some variation is evident in relation to the specific provisions of legal reforms (eg, liberal vs tightly regulated medical markets 92 ). ...
Article
Full-text available
Objectives: To review the metrics and findings of studies evaluating effects of drug decriminalisation or legal regulation on drug availability, use or related health and social harms globally. Design: Systematic review with narrative synthesis. Data sources: We searched MEDLINE, Embase, PsycINFO, Web of Science and six additional databases for publications from 1 January 1970 through 4 October 2018. Inclusion criteria: Peer-reviewed articles or published abstracts in any language with quantitative data on drug availability, use or related health and social harms collected before and after implementation of de jure drug decriminalisation or legal regulation. Data extraction and synthesis: Two independent reviewers screened titles, abstracts and articles for inclusion. Extraction and quality appraisal (modified Downs and Black checklist) were performed by one reviewer and checked by a second, with discrepancies resolved by a third. We coded study-level outcome measures into metric groupings and categorised the estimated direction of association between the legal change and outcomes of interest. Results: We screened 4860 titles and 221 full-texts and included 114 articles. Most (n=104, 91.2%) were from the USA, evaluated cannabis reform (n=109, 95.6%) and focussed on legal regulation (n=96, 84.2%). 224 study outcome measures were categorised into 32 metrics, most commonly prevalence (39.5% of studies), frequency (14.0%) or perceived harmfulness (10.5%) of use of the decriminalised or regulated drug; or use of tobacco, alcohol or other drugs (12.3%). Across all substance use metrics, legal reform was most often not associated with changes in use. Conclusions: Studies evaluating drug decriminalisation and legal regulation are concentrated in the USA and on cannabis legalisation. Despite the range of outcomes potentially impacted by drug law reform, extant research is narrowly focussed, with a particular emphasis on the prevalence of use. Metrics in drug law reform evaluations require improved alignment with relevant health and social outcomes.
... 16 This showed that, among the diseases that contributed most to disability-adjusted life years (DALYs) in this country, disorders relating to use of alcohol and other drugs jumped from third place in 1990 to first in 2016 among men, and from tenth to seventh among women, over the same period. Furthermore, substance-related disorders have been indicated to be one of the costliest health conditions for a healthcare system, [17][18][19] especially regarding hospitalization. 20 In Brazil, there is a lack of data on the costs according to different drug users' profiles, especially considering their relationship to age at the start of use. ...
Article
Full-text available
BACKGROUND: It is well known that early start of drug use can lead users to psychosocial problems in adulthood, but its relationship with users’ direct healthcare costs has not been well established OBJECTIVES: To estimate the direct healthcare costs of drug dependency treated at a community mental health service, and to ascertain whether early start of drug use and current drug use pattern may exert influences on these costs. DESIGN AND SETTING: Retrospective cross-sectional study conducted at a community mental health service in a municipality in the state of São Paulo, Brazil. METHODS: The relationships between direct healthcare costs from the perspective of the public healthcare system, age at start of drug use and drug use pattern were investigated in a sample of 105 individuals. A gamma-distribution generalized linear model was used to identify the cost drivers of direct costs. RESULTS: The mean monthly direct healthcare costs per capita for early-start drug users in 2020 were 1,181.31 Brazilian reais (BRL) (274.72 United State dollars (USD) according to purchasing power parity (PPP)) and 1,355.78 BRL (315.29 USD PPP) for late-start users. Early start of drug use predicted greater severity of cannabis use and use of multiple drugs. The highest direct costs were due to drug dependence combined with alcohol abuse, and due to late start of drug use. CONCLUSIONS: Preventive measures should be prioritized in public policies, in terms of strengthening protective factors before an early start of drug use.
... The evidence base indicates that decriminalisation can contribute to improved public health (Dr Scott mentions Portugal, but does not mention this finding in that context) and that legal regulation does not necessarily stamp out criminal activity (consider the illegal trade of alcohol in South Africa (SA)). [7] Decriminalisation may be an achievable step locally for cannabis but does not preclude additional types of regulation for a range of drugs over time, based on evidence of what works to improve public health and to reduce harm. We hope that policy allows research on cannabis and other drugs for medicinal purposes, that when people use psychoactive substances measures are made available to prioritise safety (e.g. ...
... Para finalizar con este apartado, es interesante citar un estudio de Gonçalves et al (2015), quienes hacen un análisis costo-beneficio social de la experiencia portuguesa de descriminalización del consumo de todas las drogas. Los autores encuentran que la misma, entre 1999 y 2010, generó una reducción del costo social derivado de dicho consumo en una magnitud del 18%. ...
... PWID have been active in community mobilization activities, from ACT-UP to harm reduction and drug treatment activist groups, such as achieving policy goals like legalizing syringe exchange programs in some areas (Friedman et al. 1992). Relatedly, there is increasing domestic and international evidence that marijuana and other drug legalization or decriminalization can reduce the overall harms related to drug use (Goncalves et al. 2015). Further, a growing movement to reform criminal justice and the Black Lives Matter movement have brought increased attention to criminal justice disparities, including drug-related policing and criminal sentencing (Alexander 2010;Bassett 2015). ...
Chapter
People who inject drugs (PWID) have experienced the second highest number of HIV infections and HIV-related deaths of any risk group in the U.S. after men who have sex with men (MSM), and they also suffer from high prevalence of hepatitis C, other infectious diseases, and chronic health conditions. PWID in the U.S. are currently most affected by three overlapping syndemics: 1) substance use, HIV/AIDS, and Hepatitis C; 2) these 3 conditions along with an epidemic of sexually-transmitted infections, particularly among PWID who are African-American, Latino, and/or MSM; and 3) these 4 conditions along with an epidemic of fatal drug overdose. These syndemics represent an enormous amount of suffering that is largely preventable. Syndemic theory can help us better understand the etiology and epidemiology of HIV and related conditions by revealing the links among social determinants, networks and behaviors that expose PWID to multiple synergistic health problems.11
... In Portugal, they are currently integrated into the primary health care network and cover opioid maintenance programs. It should be noted that, in both countries, social support for this population has varied over the years and is marked by political and economic cycles that reflect in greater or lesser support (6,9) . ...
Article
Full-text available
Objective: To compare the consequences of psychoactive substance use among users of mental health services in Brazil and Portugal. Method: Cross-sectional, comparative, quantitative study, carried out with 362 users of two specialized treatment services in the cities of São Paulo (n = 200) and Lisbon (n = 162). Data collected in 2019 through the application of the Substance Addiction Consequences scale. A descriptive analysis and ordinary least squares and logistic regressions were performed. Results: All dimensions assessed by the scale were more severe for Brazilian users, with a difference for the physical domain and cognitive skills (p < 0.01). Brazilian participants were more likely to consume cocaine (p < 0.01) and have psychosis (p = 0.02) and Portuguese participants to have hepatitis (p < 0.01), personality disorders (p < 0.01), use benzodiazepines (p < 0.01) and tobacco (p < 0.01), and receive pharmacological support (p < 0.01). Conclusion: It was found that Brazilian users have more serious consequences related to substance use, and Portuguese users have more comorbidities and exposure to risky consumption. It emerges that Portuguese responses minimize the consequences severity.
... PWID have been active in community mobilization activities, from ACT-UP to harm reduction and drug treatment activist groups, such as achieving policy goals like legalizing syringe exchange programs in some areas (Friedman et al. 1992). Relatedly, there is increasing domestic and international evidence that marijuana and other drug legalization or decriminalization can reduce the overall harms related to drug use (Goncalves et al. 2015). Further, a growing movement to reform criminal justice and the Black Lives Matter movement have brought increased attention to criminal justice disparities, including drug-related policing and criminal sentencing (Alexander 2010;Bassett 2015). ...
Chapter
Full-text available
People who inject drugs (PWID) have experienced the second highest number of HIV infections and HIV-related deaths of any risk group in the U.S. after men-who-have-sex-with-men (MSM), and they also suffer from high prevalence of Hepatitis C, other infectious diseases, and chronic health conditions. PWID in the US are currently most affected by 3 overlapping syndemics: (1) substance use, HIV/AIDS, and Hepatitis C; (2) these 3 conditions along with an epidemic of sexually-transmitted infections, particularly among PWID who are African American, Latino, and/or MSM; and (3) these 4 conditions along with an epidemic of fatal drug overdose. These syndemics represent an enormous amount of suffering that is largely preventable. Syndemic theory can help us better understand the etiology and epidemiology of HIV and related conditions by revealing the links among social determinants, networks and behaviors that expose PWID to multiple synergistic health problems.
... This evolution in terms of the application of the law took place despite the concurrent tendency toward the moderate general increase in drug uses observed at the time. More recently, Gonçalves, Lourenço and Silva (2015) have studied the social cost of the Portuguese Drug Strategy approved in 1999, taking into consideration both health-and non-health-related costs. The study concluded that the social costs of drugs had decreased by 12% in the five years following the law's approval, and a significant 18% in the eleven-year period of its implementation. ...
Article
Full-text available
This paper is organized into four parts of discussion. Firstly, we present the Portuguese decriminalization law and the central role of harm reduction within this framework. The second section discusses the mainstream meanings ascribed to the 'HR double' mainly anchored in problematic drug uses. The third section highlights the need to take into account the specificities of recreational drug uses, users and environments. Thus, the paper highlights the experience of the Kosmicare Project at the Boom Festival, which combines principles of harm reduction, crisis intervention and Grof's approach. The fourth section draws upon the project's experience itself and in the idea of the normalization of drug uses to acknowledge and to discuss the potentialities, tensions and limitations of these contributions when it comes to analyzing and constructing a strong version of the 'HR double'.
Article
Fifteen years ago when Portugal decriminalized the consumption of all narcotic drugs and psychotropic substances it was both a bold and a desperate move to curb the drug problem that the country faced at the time. In this paper, I analyse the Portuguese drug policy, its historical foundation, its success and its possible future.
Technical Report
Full-text available
Käesoleva uuringu eesmärk oli igakülgselt hinnata Eesti õigussüsteemis pakutava narkosõltlaste ravi- ja rehabilitatsioonisüsteemi vastavust inimeste vajadustele, tuvastada probleemid olemasolevas süsteemis ja teenustes ning teha ettepanekuid süsteemi muutmiseks ja teenuste parandamiseks. Uuringus kombineeriti kvalitatiivseid ja kvantitatiivseid meetodeid. Andmekogud, mida kasutati: 1.) Statistikaameti, Tervise Arengu Instituudi andmekogud, Justiitsministeeriumi kinnipeeturegistri andmed. 2.) RAKE küsitluse andmed: 2016. a alguses vanglates ja arestimajades viibinute valimisse kuulus 327 õigusrikkujat (sh 3 naist), küsimustikuga koguti andmeid uimastite tarvitamise, ravi- ja rehabilitatsiooniteenuste tõhususe ja hoiakute kohta. 3.) Intervjuude andmed: 13 ravikogemusega õigusrikkujat. Intervjuudes uuriti täpsemalt ravikogemusi. Lisaks viidi läbi fookusgrupid õigussüsteemi esindajatega (kohtunikud, prokurörid, kriminaalhooldajad) ja raviesindajatega. Toimus ringreis vanglatesse ja raviasutustesse koos välisekspert dr Jouni Touruneniga (Soome, A-Klinikka). Küsitluse ja intervjuude teostamiseks said uurijad kooskõlastuse Tartu Ülikooli eetikakomiteelt. Tulemused ja järeldused. 1.) Ravi- ja rehabilitatsiooniga seotud teenuste pakkumine (süstlavahetus, rehabilitatsiooniprogrammid, nõustamisteenused, asendusravi jm) ning rahastus ei ole erinevate osapoolte hinnangul hetkeseisuga stabiilne ja piisav selleks, et tagada kõigi uimastitarvitajate toimetulek ja naasmine ühiskonda. Üldistatult, praegune Eesti ravi- ja rehabilitatsioonisüsteem ei vasta uimastisõltuvusega õigusrikkujate vajadustele. Soovitatav on jätkata tõenduspõhiste meetmete rahastamist ja stabiilset pakkumist (stabiilsus ajas ja ruumis). 2.) Ravile pöördumisel on eelduseks indiviidi sisemine motivatsioon, mida on võimalik soodustada motiveeriva intervjueerimise kaudu, kuid vastavate oskustega spetsialiste napib nii vanglates, raviasutustes kui ka karistussüsteemis; vaja on koolitada õigussüsteemi töötajaid viimaks läbi esmast motivatsioonihindamist ning õpetada neile probleemi märkamist ja abivajaja suunamist spetsialistide vastuvõtule. 3.) Erinevad õigusrikkujate raviga seotud ametnikud ja asutused (vanglad, raviasutused) on senini tegutsenud pigem autonoomselt ilma regulaarse infovahetuse ja koostööta, kuid soovitatav on informatsiooni vahetamine ja pidev kontakt näiteks ühiste regulaarsete infopäevade kaudu. 4.) Ravi- ja rehabilitatsiooniteenuste kättesaadavus ning kvaliteet vanglates ja arestimajades erineb ravist ja rehabilitatsioonist väljaspool kinnipidamisasutusi, kuid soovitatav on ravi kvaliteet ja kättesaadavus ühtlustada. 5.) Ravi ja rehabilitatsiooni on seni karistuse asemel rakendatud üksikutel juhtudel, kuigi kolmandik vanglas viibivatest õigusrikkujatest on sõltuvushäirega; soovitatav on kasutada sõltuvusravi kõigi nende puhul, kes seda vajavad. 6.) Sõltuvushäirega õigusrikkujad eelistavad ise ravivõimalustest kõige enam individuaalset lähenemist (sotsiaaltöötaja või psühholoogi nõustamine), kuid Eestis on uimastisõltlaste ravis puudus erialaspetsialistidest (sotsiaaltöötajad, psühholoogid, juhtumikorraldajad jt) ja tõenduspõhistest teenustest, mille vahel valida. Soovitatav on suurendada ravi ja rehabilitatsiooni erialaspetsialistide arvu ja laiendada koheselt tõenduspõhiste raviteenuste valikut õigussüsteemis. IN ENGLISH The aim of this study was to assess how drug treatment and rehabilitation is organized in the Estonian penal system, and how services provided are in accordance with expectations of clients. Recommendations for improving the system were expected. Methods: Qualitative and quantitative methods were combined. Databases used: Statistics Estonia, data from The National Institute for Health Development, data from the Ministry of Justice. In addition, a survey about effectiveness of drug treatment and rehabilitation and attitudes was conducted in prisons: 327 criminal offenders (including 3 women) responded. 13 interviews about personal experiences of drug treatment were carried out with criminal offenders and group interviews were conducted with judges, procecutors, probation officers and addiction rehabilitation specialists. An independent expert from Finland (A-Klinikka, Dr Jouni Tourunen) was invited to visit Estonian prisons and rehabilitation centers for criminal offenders. The study was approved by the ethics committee at the University of Tartu. Results and conclusions: 1.) Estonian rehabilitation services and treatments (needle exchange programs, counselling, substitution therapy, etc.) and funding have not been stable and sufficient to prevent relapses and rehabilitate all criminal offenders. It is recommended to finance and provide scientifically proven services regularly (from the client’s perspective it is necessary to provide stability). 2.) The criteria for entering drug treatment is – internal motivation, this can be enhanced by motivational interviewing; however, offices in the penal system have not received training in motivational interviewing. It is recommended to educate officers to notice the need for motivational interviewing or to provide this service themselves. 3.) Different institutions in the system (prisons, rehabilitation centers, etc.) have been working autonomously, and very little information has been shared between different institutions. It is recommended that information exchange and cooperation should be regular and common between people working in this system. One option would be to organize yearly conferences or information seminars where all parties concerned could meet. 4.) The quality and availability of different services in prisons and outside prisons is different. It is recommended that the services available in prisons and outside prisons would be equal in quality and availability. 5.) Treatment as an alternative punishment has only been used in a few cases in Estonia; in contrast, 1/3 of prisoners are drug addicts. Therefore, it is recommended that treatment and rehabilitation should be available for all criminal offenders who have a drug use disorder. 6.) Drug addicts prefer individual counselling (with a social worker or a psychologist), but the number of specialists (social workers, psychologists, case managers, etc.) and different evidence-based services available in Estonian prisons is extremely low. It is recommended to provide a variety of different alternative evidence-based services, and to include more educated specialists.
Article
Background. Previous reviews of the effectiveness of measures to divert those who use drugs from the criminal justice system have focused mainly on post-conviction or post-sentence programs and report mixed results. The present systematic review synthesizes evidence on the effectiveness of police-based diversion measures in reducing criminal offenses and other harms related to drug use and then summarizes evidence from qualitative studies to identify facilitators and barriers associated with the implementation of such measures. Methods. Eight databases were searched to find evaluations of police-based diversion measures for drug-related offenders. Twenty-seven studies were identified. The vote-count method and the Maryland Scientific Method Scale were used to assess the impact of police-based diversion measures. Themes related to barriers or conditions facilitating the implementation of these measures were extracted from qualitative studies. Results. Evidence from quantitative studies indicates that in general police-based diversion measures are effective in preventing criminal offending and show promising results for improving participants’ health and diminishing social costs as well as costs associated with processing drug-related offenses. There was insufficient evidence to draw conclusions about the effect of police-based diversion measures on drug use, drug accessibility, or changes in participants’ socioeconomic conditions. Findings from qualitative studies suggest that program acceptance by police officers, constructive intersectoral collaboration, clear eligibility criteria, and timely access to services seem to facilitate the implementation and delivery of police-based diversion measures. Conclusion. Police-based diversion measures can be effective in preventing drug-related criminal offenses and harm. Additional research is needed to evaluate their effect on participants’ socioeconomic conditions and drug use as well as drug accessibility.
Article
Issues: Drug use accounts for one of the main disease groups in Europe, with relevant consequences to society. There is an increasing need to evaluate the economic consequences of drug use in order to develop appropriate policies. Here, we review the social costs of illegal drugs, alcohol and tobacco in the European Union. Approach: A systematic search of relevant databases was conducted. Grey literature and previous systematic reviews were also searched. Studies reporting on social costs of illegal drugs, alcohol and tobacco were included. Methodology, cost components as well as costs were assessed from individual studies. To compare across studies, final costs were transformed to 2014 Euros. Key findings: Forty-five studies reported in 43 papers met the inclusion criteria (11 for illegal drugs, 26 for alcohol and 8 for tobacco). While there was a constant inclusion of direct costs related to treatment of substance use and comorbidities, there was a high variability for the rest of cost components. Total costs showed also a great variability. Price per capita for the year 2014 ranged from €0.38 to €78 for illegal drugs, from €26 to €1500 for alcohol and from €10.55 to €391 for tobacco. Implications and conclusions: Drug use imposes a heavy economic burden to Europe. However, given the high existing heterogeneity in methodologies, and in order to better assess the burden and thus to develop adequate policies, standardised methodological guidance is needed. [Barrio P, Reynolds J, García-Altés A, Gual A, Anderson P. Social costs of illegal drugs, alcohol and tobacco in the European Union: A systematic review. Drug Alcohol Rev 2017;00:000-000].
Article
Background: The illicit selling and use of cannabis is prevalent among marginalized people who use illicit drugs (PWUD). Given that participation in illicit drug markets has been previously associated with a range of health and social harms, we sought to examine the predictors of selling cannabis among PWUD in Vancouver, Canada, a setting with a de facto legalized cannabis market, on the eve of the planned implementation of legalized non-medical cannabis including measures to regulate the existing illicit market. Methods: Multivariable generalized estimating equations (GEE) logistic regression was used to analyze longitudinal factors associated with selling illicit cannabis among three prospective cohorts of PWUD between September 2005 and May 2015. Results: Among the 3258 participants included in this study, 328 (10.1%) reported selling illicit cannabis at baseline, and 46 (5.1%) initiated cannabis selling over the study period. In the multivariable analysis of the whole sample, factors significantly associated with selling cannabis included cannabis use (Adjusted Odds Ratio [AOR] = 4.05), dealing other drugs (AOR = 3.87), being male (AOR = 1.83), experiencing violence (AOR = 1.40), non-medical prescription opioid use (AOR = 1.32), non-custodial involvement in the criminal justice system (AOR = 1.31), being stopped by police (AOR = 1.30), crack use (AOR = 1.25), homelessness (AOR = 1.23), age (AOR = 0.96 per year) and participation in sex work (AOR = 0.67) (all p < 0.05). The subanalyses indicated that dealing drugs other than cannabis, cannabis use, and non-custodial involvement in the criminal justice system were the only factors significantly associated with selling cannabis in all four subgroups. Conclusion: These findings support existing evidence indicating that selling illicit cannabis is often a survival-driven strategy to support the basic needs and substance use of some PWUD. Our findings suggest jurisdictions with planned or impending cannabis legalization and regulation should consider the vulnerability of PWUD when seeking to eradicate illicit cannabis markets, for example, in setting criminal penalties for selling cannabis outside of regulatory frameworks.
Chapter
Prisons are the unchallenged institution of punishment in contemporary society. They have replaced a more diverse range of institutions, such as the asylum, the workhouse, and the borstal. In contrast to these other institutions, prisons continue to grow. Incarceration is an institution of “unequal power,” between the dominant social structure and the individual who is contained within. By its nature a coercive institution, operating under the auspices of the state, framed in a paramilitary mold, the modern prison should function within a human rights and international legal framework. Apart from the ethical and philosophical issues implicit in this “relationship,” the health consequences of incarceration can be extreme, not only on the individual, but also on the community from which the prisoner comes and will return. Public health practices can contribute to the safer conduct of custodial practices and better understanding of the impacts of mass incarceration on community safety.
Article
Objectives: There has been advocacy for legalization of abusable substances, but systematic data on societal beliefs regarding such legalization are limited. People who use substances may have unique beliefs about legalization, and this study assessed whether they would be in favor of drug legalization/decriminalization. It was hypothesized that those who use particular drugs (especially marijuana) would support its legalization/decriminalization, but that this would not be the case across all classes (especially opioids and stimulants). Methods: A nationwide sample of 506 adults were surveyed online to assess demographic characteristics, substance misuse, and beliefs regarding drug legalization/decriminalization. Legalization/decriminalization beliefs for specific drugs were assessed on an 11-point scale (0, strongly disagree; 10, strongly agree). Results: For persons with opioid misuse (15.4%), when asked about their agreement with: "heroin should be legalized," the mean score was 4.6 (SEE = 0.4; neutral). For persons with stimulant misuse (12.1%), when asked about their agreement with: "cocaine should be legalized," the score was 4.2 (0.5). However, for persons with marijuana misuse (34.0%), when asked about their agreement with: "medical marijuana should be legalized" the score was 8.2 (0.3; indicating agreement), and for "recreational marijuana" the score was also 8.2 (0.3). Conclusions: These results suggest that persons who used marijuana strongly support the legalization of both recreational and medical marijuana, whereas persons who primarily have opioid or stimulant misuse have less strongly held beliefs about legalization of substances within those respective categories. By including those who misuse drugs, these data assist in framing discussions of drug legalization and have the potential to inform drug policy considerations.
Thesis
The opioid crisis has negatively affected many people around the world, claiming many lives from overdoses, creating financial distress from loss of employment, and destroying family units. The opioid crisis has particularly taken a life toll in the United States, where over 63,000 deaths have been reported in 2016 (CDC). The crisis in the United States gained increased attention when it began to affect young, white, wealthy individuals. Portugal and Spain, two additional developed Western countries, with a high proportion of Caucasian populations, but with a national health care system were selected for comparison. In response, all three countries have addressed their perspective crisis in subjective manners. Portugal has seen the best outcomes due to the steps they implemented to overcome their crisis, especially when compared the United States and Spain. Portugal’s success resulted from a multidisciplinary approach, including a change in its cultural perspective on individuals who misuse drugs. Spain, unlike the United States, has had stagnant numbers of drug misusers, and overdose deaths within their population. Although the statistics are not increasing, they have also not decreased, as seen in Portugal. As an intervention and with further observation of Portugal’s successful changes, specific examples can be implemented in the United States for improvement. Barriers will exist when including aspects of Portugal’s model, but modifications can be applied to overcome them. The opioid crisis has had tremendous public health implications due to the significant number of individuals suffering from substance use disorder, increasing mortality rates resulting from opioid overdoses, and the impact across geographic and socioeconomic populations.
Article
Full-text available
This essay is based in a self-reflexive collective process and intends to present the chemsex scene in Lisbon and harm reduction responses implemented to address the needs of chemsex practitioners. The analysis considered professional experiences, participant observation, literature review of the relevant data in Portugal and autoethnographic data from a chemsex practitioner and peer educator. This essay aims to present the community-led creation of a transdisciplinary collaborative network able to assess and respond to chemsex-related risks in Lisbon. Specifically, we aim to: (i) present the chemsex scenes in Lisbon; (ii) discuss the setting up and preliminary results of a collaborative network and harm reduction responses targeting chemsex practitioners. The work implemented in Lisbon demonstrates that chemsex is a global trend with localized idiosyncrasies that must be addressed when designing local tailored interventions. It also reiterated that harm reduction organizations are in a privileged position to detect, monitor and respond to emerging trends at local level. Moreover, the work implemented in Lisbon demonstrated that transdisciplinary collaborative networks, involving communities—chemsex practitioners, gay-friendly and queer venues and collectives—and professionals working in the fields of intersection of chemsex (drugs, sexual health, mental health, gender diversity, gender-based violence), can be effective in the local early detection and response to chemsex-related risks.
Article
Full-text available
Dans cet article, nous nous interrogeons à savoir si le choix d’une décriminalisation de la possession pour usage personnel de l’ensemble des drogues qu’ont adoptée plusieurs pays a conduit vers moins d’usage du pénal à l’égard des usagers et plus de soins aux usagers problématiques, considérant l’influence du contexte politique, social, économique, juridique et judiciaire du pays dans lequel a eu lieu ce choix. Cela permettra ainsi d’identifier les éléments qui peuvent accroître ou diminuer les bienfaits de ce choix juridique. Pour ce faire, nous présenterons d’abord les fondements théoriques d’examen de ce choix et les critères méthodologiques qui en ont découlé dans le choix des pays qui font l’objet de notre examen. Par la suite, nous présenterons les pays européens qui ont choisi cette politique et examinerons leur traduction juridique et les éléments contextuels qui sont venus en moduler la mise en œuvre. Nous ferons de même par la suite avec les pays d’Amérique latine qui ont fait ce choix, montrant la spécificité de leur situation. Nous terminerons en présentant le bilan qui se dégage de ce tour d’horizon sur les éléments contextuels qui viennent moduler les bienfaits et les méfaits de ce choix. Cela permettra d’identifier les éléments nécessaires à une politique de décriminalisation de la possession simple des drogues pour qu’elle constitue une étape vers une politique en matière de drogues inscrite en santé publique où le droit pénal est un dernier recours. Mots-clés : Décriminalisation, drogues, possession simple. Abstract This article examine whether the choice of decriminalizing the possession for personal use of illicit drugs adopted by several countries has led to less use of criminal sanctions against the users and more care for problematic users, considering the influence of the political, social, economic, legal and judicial context of the country in which this choice was made. This will allow us to identify the elements that can increase or decrease the benefits of this legal choice. To this end, we will first present the theoretical foundations for examining this choice and the methodological criteria which have resulted in the choice of the countries which are the subject of our review. Subsequently, we will present the European countries that have chosen this policy and examine their legal translation and the contextual elements that have come to modulate the implementation. We will do the same with the countries of Latin America that have made this choice, showing the specificity of their situation. We conclude by presenting the main points that emerges from this overview on the contextual elements that come to modulate the benefits and the harms of this choice. This will make it possible to identify the elements necessary for a policy of decriminalizing the possession of drugs for personal use to constitute a step towards a policy on drugs in public health where the criminal sanctions are a last resort. Keywords: Decriminalisation, drugs, drug possession
Chapter
While substance use and substance use disorders (SUDs) are increasing in prevalence and severity throughout the United States, a minority of people with SUDs are in formal treatment. The ED is a key site of medical care for patients with SUDs and presents an important opportunity for SUD treatment initiation and linkage to care. Even in a brief clinical encounter, emergency clinicians can have a meaningful impact on patients’ lives through SUD screening and identification, provision of harm reduction services, initiation of and linkage to SUD treatment, and linkage to services to address unmet health-related social needs. SUDs have complex biopsychosocial components and a bidirectional relationship with social determinants of health. Therefore, a comprehensive approach to SUDs must include addressing health-related social needs. Partnering with community organizations, specialty societies, and policy makers, EDs and hospitals can work to address social determinants of health which are related to harmful substance use and present barriers to treatment initiation and retention. In this chapter, we describe a social emergency medicine approach to caring for people with SUDs in the ED, highlight model ED and health system initiatives to address SUD and social determinants of substance use, and outline key structural and social determinants of SUDs.
Article
Full-text available
Evaluation of the impacts of recent cannabis regulation policies includes important political dimensions and should not be reduced either to binary verdicts of success versus failure, or to a unidimensional assessment criteria. Based on the Uruguayan case, the article discusses the complexity of evaluating the results of cannabis regulation, assessing, among other aspects, the political dynamics surrounding implementation. In the case presented, the predominance of concerns about crime and public security was a decisive factor.
Chapter
Full-text available
Illicit crop cultivation often occurs in forested areas and contributes to deforestation when it results in the clearing of woodland. Moreover, illicit crop cultivation frequently takes place in biodiversity hotspots hosting a large number of species with a limited habitat, some of which are pro- tected areas. It tends to occur close to the agricultural frontier, which demarcates the border between pristine forest and developed areas, and can result in the clearing of forests. Although empirical evidence and rigorous analy- sis do not support the claim that illicit cultivation is the major driver of deforestation, research does suggest that a lack of rural development drives the phenomenon. Analy- sis has shown, moreover, that drug trafficking can have a direct impact on deforestation through the construction of infrastructure such as landing strips and illegal roads, as well as indirectly through the privatization of public land to create “narco-estates”. When eradication induces a displacement of the location of drug crops it may result in deforestation as farmers react to eradication initiatives and seek places out of the reach of law enforcement. The disposal of chemicals used in the illicit manufacture of cocaine and opiates can also have negative consequences on the environment, contributing to pollution and health hazards in rural communities. In the case of synthetic drugs, the consequences in urban settings not only pose health risks but may also have an impact on the urban and industrial environment.
Article
Full-text available
The number of studies on public expenditure is growing in view of the growing importance of the evaluation of drug policies. Public expenditure is an important indicator of government efforts to tackle the drug problem. Studying public expenditure and comparing the methodology and the results of existing research is challenging. In the present article, the concepts and methodologies used in studies of public expenditure are reviewed. Public expenditure and social cost models are compared to determine their scope. The possibilities and limitations of studying drug budgets are discussed. A workable methodology for estimating public expenditure on drugs is proposed.
Article
Full-text available
The issue of decriminalizing illicit drugs is hotly debated, but is rarely subject to evidence-based analysis. This paper examines the case of Portugal, a nation that decriminalized the use and possession of all illicit drugs on 1 July 2001. Drawing upon independent evaluations and interviews conducted with 13 key stakeholders in 2007 and 2009, it critically analyses the criminal justice and health impacts against trends from neighbouring Spain and Italy. It concludes that contrary to predictions, the Portuguese decriminalization did not lead to major increases in drug use. Indeed, evidence indicates reductions in problematic use, drug-related harms and criminal justice overcrowding. The article discusses these developments in the context of drug law debates and criminological discussions on late modern governance.
Article
Full-text available
In a special issue of the journal Addictions (1995) academics, researchers and health care professionals debated the status of the empirical in socially orientated drugs research. A number of researchers noted that our knowledge and understanding of drugs and drug users has changed significantly since the 1990s. Post AIDS this shift is identified as a consequence of the development of qualitative research methods. The qualitative turn in drugs research has involved a shift away form traditional epidemiological approaches and the pursuit of more socially focused methods. Whilst qualitative research has yielded important empirical data on risk behavior the pursuit of these methods has not been without controversy. In addressing the debate on methods in the drugs field this article investigates the effects of social science methods for research on injecting drug use. In so doing I examine what counts and what gets left out of research on injecting beaviour. Drawing on Actor Network Theory (ANT) I suggest Bruno Latour's methodological approach offers critical insights for addressing the empirical objects of injecting drug use.
Article
The evolution of the consumption and the control systems of drugs is widely different among the countries. The same differences could be also found in the current experiences of drug decriminalization. The author using historical and empirical data concerning the « Portuguese Experimentation » argue that we are presently observing the end of « drug war ». Can the drug consumption be regulated outside the penal law ? This paper presents an analysis of the data from the Portuguese experience that positively answers to that question. In addition, this analysis suggests that the decriminalization do not leads to an increase on public health problems and crime.
Article
This paper focuses on the main aspects of the 1999-2004 Portuguese drug policy evaluation. The general objectives of the Portuguese National Strategy and Action Plan for that period are briefly presented and both the internal and the external evaluation processes and results are described. Using data from the national information system on drugs, several demand and supply reduction indicators are discussed to show the influence of policy implementation on drug use related health and social consequences. The recommendations from the evaluation exercises were taken into account and had a clear impact in the drafting of the new National Action Plan on Drugs - Horizon 2008.
Article
Drug use is an increasing problem in Portugal. In response, following the advice of a select committee, the Portuguese government has recently issued a number of laws implementing a strong harm-reductionistic orientation. The flagship of these laws is the decriminalization of the use and possession for use of drugs. Use and possession for use are now only administrative offenses; no distinction is made between different types of drugs (hard vs. soft drugs) or whether consumption is private or in public. Although most people favor decriminalization in principle, doubts have been expressed about the way the law will be implemented because the law only sets a framework for those communities that wish to undertake such activities--it is an enabling law. This has led to a considerable lack of clarity and increases the risk of dissimilarity of implementation in different parts of the country. The future will show the effects.
Article
On July 1, 2001, a nationwide law in Portugal took effect that decriminalized all drugs, including cocaine and heroin. Under the new legal framework, all drugs were "decriminalized," not "legalized." Thus, drug possession for personal use and drug usage itself are still legally prohibited, but violations of those prohibitions are deemed to be exclusively administrative violations and are removed completely from the criminal realm. Drug trafficking continues to be prosecuted as a criminal offense. While other states in the European Union have developed various forms of de facto decriminalization — whereby substances perceived to be less serious (such as cannabis) rarely lead to criminal prosecution — Portugal remains the only EU member state with a law explicitly declaring drugs to be "decriminalized." Because more than seven years have now elapsed since enactment of Portugal's decriminalization system, there are ample data enabling its effects to be assessed. Notably, decriminalization has become increasingly popular in Portugal since 2001. Except for some far-right politicians, very few domestic political factions are agitating for a repeal of the 2001 law. And while there is a widespread perception that bureaucratic changes need to be made to Portugal's decriminalization framework to make it more efficient and effective, there is no real debate about whether drugs should once again be criminalized. More significantly, none of the nightmare scenarios touted by preenactment decriminalization opponents — from rampant increases in drug usage among the young to the transformation of Lisbon into a haven for "drug tourists" — has occurred. The political consensus in favor of decriminalization is unsurprising in light of the relevant empirical data. Those data indicate that decriminalization has had no adverse effect on drug usage rates in Portugal, which, in numerous categories, are now among the lowest in the EU, particularly when compared with states with stringent criminalization regimes. Although postdecriminalization usage rates have remained roughly the same or even decreased slightly when compared with other EU states, drug-related pathologies — such as sexually transmitted diseases and deaths due to drug usage — have decreased dramatically. Drug policy experts attribute those positive trends to the enhanced ability of the Portuguese government to offer treatment programs to its citizens — enhancements made possible, for numerous reasons, by decriminalization. This report will begin with an examination of the Portuguese decriminalization framework as set forth in law and in terms of how it functions in practice. Also examined is the political climate in Portugal both pre- and postdecriminalization with regard to drug policy, and the impetus that led that nation to adopt decriminalization. The report then assesses Portuguese drug policy in the context of the EU's approach to drugs. The varying legal frameworks, as well as the overall trend toward liberalization, are examined to enable a meaningful comparative assessment between Portuguese data and data from other EU states. The report also sets forth the data concerning drug-related trends in Portugal both pre- and postdecriminalization. The effects of decriminalization in Portugal are examined both in absolute terms and in comparisons with other states that continue to criminalize drugs, particularly within the EU. The data show that, judged by virtually every metric, the Portuguese decriminalization framework has been a resounding success. Within this success lie self-evident lessons that should guide drug policy debates around the world.
Article
In this Harm Reduction Digest two observers and scholars of the 2001 Portuguese drug policy reform consider divergent accounts of the reform which viewed it as a ‘resounding success’ or a ‘disastrous failure’. Acknowledging from their own experience the inherent difficulties in studying drug law reform, Caitlin Hughes and Alex Stevens take the central competing claims of the protagonists and consider them against the available data. They remind us of the way all sides of the drug policy debates call upon and alternatively use or misuse ‘evidence’ to feed into discussions of the worth, efficacy and desirability of different illicit drug policies. In doing so they provide pause for thought for those of us who operate as drug policy researchers and drug policy advocates. Simon Lenton Co-editor, Harm Reduction Digest
Article
A supervised injection facility (SIF) has been established in North America: Insite, in Vancouver, British Columbia. The purpose of this paper is to conduct a cost-effectiveness and cost-benefit analysis of this SIF using secondary data gathered and analysed in 2008. In using these data we seek to determine whether the facility's prevention of infections and deaths among injecting drug users (IDUs) is of greater or lesser economic cost than the cost involved in providing this service - Insite - to this community. Mathematical modelling is used to estimate the number of new HIV infections and deaths prevented each year. We use the number of these new HIV infections and deaths prevented, in conjunction with estimated lifetime public health care costs of a new HIV infection, and the value of a life, in order to calculate an identifiable portion of the societal benefits of Insite. The annual costs of operating the SIF are used to measure the social costs of Insite. In using this information, we calculate cost-effectiveness and benefit-cost ratios for the SIF. Through the use of conservative estimates, Vancouver's SIF, Insite, on average, prevents 35 new cases of HIV and almost 3 deaths each year. This provides a societal benefit in excess of $6 million per year after the programme costs are taken into account, translating into an average benefit-cost ratio of 5.12:1. Vancouver's SIF appears to be an effective and efficient use of public health care resources, based on a modelling study of only two specific and measurable benefits-HIV infection and overdose death.
Article
AIM, DESIGN AND SETTING: The economic costs of alcohol, tobacco and illicit drugs to French society are estimated using a cost of illness framework. For the cause of disease or death (using ICD-9 categories), pooled relative risk estimates from meta-analyses were combined with prevalence data by age and gender to derive the proportion attributable to alcohol, tobacco and/or illicit drugs. The resulting estimates of attributable deaths and hospitalizations were used to calculate the associated health care, law enforcement, productivity and other costs. The results were compared with those of other studies, and sensitivity analyses were conducted by alternative ways of measuring risk attribution and costs. The use of alcohol, tobacco and illicit drugs cost more than 200 billion francs (FF) in France in 1997, representing 3714 FF per capita or 2.7% of the gross domestic product (GDP). Alcohol is the drug that gives rise to the greatest cost in France, i.e. 115420.91 million FF (1.42% of GDP) or an expenditure per capita of 1966 FF in 1997. Alcohol takes more than half of the social cost of drugs to society. The greatest share of the social cost of alcohol comes from the loss of productivity (57555.66 million FF), due to premature death (53168.60 million FF), morbidity (3884.0 million FF) and imprisonment (503.06 million FF). Tobacco leads to a social cost of 89256.90 million FF, that is an expenditure per capita of 1520.56 FF or 1.1% of GDP. Productivity losses amount to 50446.70 million FF, with losses of 42765.80 million FF as a result of premature death and 7680.90 million FF linked to morbidity. Health care costs for tobacco occupy second place at 26973.70 million FF. Illicit drugs generate a social cost of 13350.28 million FF, that is an expenditure per capita of 227.43 FF or 0.16% of GDP. Productivity losses reach 6099.19 million FF, with 5246.92 million FF linked to imprisonment and 852.27 million FF to premature death. The cost of enforcing the law for illicit drugs occupies second place at 3911.46 million FF, followed by health care costs of 1524.51 million FF. Substance abuse exact a considerable toll from French society in terms of illness, injury, death and economic costs.
Article
The aim of this study was to estimate costs attributable to substance use and misuse in Canada in 2002. Based on information about prevalence of exposure and risk relations for more than 80 disease categories, deaths, years of life lost, and hospitalizations attributable to substance use and misuse were estimated. In addition, substance-attributable fractions for criminal justice expenditures were derived. Indirect costs were estimated using a modified human capital approach. Costs of substance use and misuse totaled almost Can. $40 billion in 2002. The total cost per capita for substance use and misuse was about Can. $1,267: Can. $463 for alcohol, Can. $262 for illegal drugs, and Can. $541 for tobacco. Legal substances accounted for the vast majority of these costs (tobacco: almost 43% of total costs; alcohol: 37%). Indirect costs or productivity losses were the largest cost category (61%), followed by health care (22%) and law enforcement costs (14%). More than 40,000 people died in Canada in 2002 because of substance use and misuse: 37,209 deaths were attributable to tobacco, 4,258 were attributable to alcohol, and 1,695 were attributable to illegal drugs. A total of about 3.8 million hospital days were attributable to substance use and misuse, again mainly to tobacco. Substance use and misuse imposes a considerable economic toll on Canadian society and requires more preventive efforts.
The 'resounding success' of Portuguese drug policy: The power of an attractive fallacy
  • M P Coelho
Coelho, M. P. (2010). The 'resounding success' of Portuguese drug policy: The power of an attractive fallacy. Lisboa: Associaç ão para um Portugal livre de drogas.
As drogas em Portugal. Coimbra: Pé de Página. Direcç ão-Geral da Administraç ão da Justiç a Tribunais de 1 a Instância–Indicadores, Dezembro 2007
  • L N Dias
Dias, L. N. (2007). As drogas em Portugal. Coimbra: Pé de Página. Direcç ão-Geral da Administraç ão da Justiç a. (2008). Tribunais de 1 a Instância–Indicadores, Dezembro 2007. Ministério da Justiç a. Direcç ão-Geral da Administraç ão da Justiç a. (2009). Tribunais de 1 a Instância–Indicadores, Dezembro 2008. Ministério da Justiç a. Direcç ão Geral da Política de Justiç a. Estatísticas Oficiais da Justiç a, online database avaliable from http://www.dgpj.mj.pt/sections/estatisticas-da-justica/index Direcç ão Geral dos Serviç os Prisionais. (2006). Relatório de Actividades de 2005–06.
Análise económica da toxicodependência: aspectos conceptuais. Study Commissioned by IDT
  • N Garoupa
  • M Soares
Garoupa, N., & Soares, M. (2007). Análise económica da toxicodependência: aspectos conceptuais. Study Commissioned by IDT.
Calculating the social cost of illicit drugs: Methods and tools for estimating the social cost of the use of psychotropic substances
  • P Kopp
  • P Fenoglio
Kopp, P., & Fenoglio, P. (2001). Calculating the social cost of illicit drugs: Methods and tools for estimating the social cost of the use of psychotropic substances. Pompidou Group, Council of Europe Publishing.
A(s) droga(s) e a(s) toxicodependência(s): representaç ões sociais e políticas em Portugal (Master dissertation) Faculdade de Economia da Univer-sidade do Porto
  • A R Marques
Marques, A. R. (2008). A(s) droga(s) e a(s) toxicodependência(s): representaç ões sociais e políticas em Portugal (Master dissertation). Faculdade de Economia da Univer-sidade do Porto. Ministério da Administraç ão Interna. (2005). Relatório Anual de Seguranç a Interna de 2004.
Etude du coût économique direct des interventions et de la politique publique en matière de drogues et de toxicomanies. Séries de recherche no
  • A Origer
Origer, A. (2002). Etude du coût économique direct des interventions et de la politique publique en matière de drogues et de toxicomanies. Séries de recherche no. 4. Luxembourg: Point focal EMCDDA Luxembourg -CRP-Santé.
Dossier Justiç a–Novembro
  • Secretaria
  • Ministério
  • Justiç
Secretaria-Geral do Ministério da Justiç a. (2010). Dossier Justiç a–Novembro 2010. Ministério da Justiç a.
Cost-of-illness studies – A primer North Carolina: RTI-UNC Center of Excellence in Health Promotion Economics, Research Triangle Park Available from http://www.rti.org/pubs/COI Primer Studies on public drug expen-diture in Europe: Possibilities and limitations
  • J E Segel
Segel, J. E. (2006). Cost-of-illness studies – A primer. North Carolina: RTI-UNC Center of Excellence in Health Promotion Economics, Research Triangle Park. Available from http://www.rti.org/pubs/COI Primer.pdf Accessed 03.04.014 Vander Laenen, F., Vandam, L., & De Ruyver, B. (2008). Studies on public drug expen-diture in Europe: Possibilities and limitations. Bulletin on Narcotics, LX, 23–39.
Estatísticas Oficiais da Justiç a, online database avaliable from http://www.dgpj.mj.pt/sections/estatisticas-da-justica/index Direcç ão Geral dos Serviç os Prisionais
  • Geral Direcç
  • Da Política De Justiç A
Direcç ão Geral da Política de Justiç a. Estatísticas Oficiais da Justiç a, online database avaliable from http://www.dgpj.mj.pt/sections/estatisticas-da-justica/index Direcç ão Geral dos Serviç os Prisionais. (2006). Relatório de Actividades de 2005–06. Ministério da Justiç a.
As drogas em Portugal. Coimbra: Pé de Página. Direcç ão-Geral da Administraç ão da Justiç a
  • L N Dias
Dias, L. N. (2007). As drogas em Portugal. Coimbra: Pé de Página. Direcç ão-Geral da Administraç ão da Justiç a. (2008). Tribunais de 1 a Instância-Indicadores, Dezembro 2007. Ministério da Justiç a. Direcç ão-Geral da Administraç ão da Justiç a. (2009). Tribunais de 1 a Instância-Indicadores, Dezembro 2008. Ministério da Justiç a.
Tribunais de 1 a Instância–Indicadores
  • Direcç Ão-Geral Da Administraç Ão Da Justiç A
Direcç ão-Geral da Administraç ão da Justiç a. (2009). Tribunais de 1 a Instância–Indicadores, Dezembro 2008. Ministério da Justiç a.
Estimativa do impacto do programa Diz não a uma seringa em segunda mão " no risco de infecç ão por VIH
  • Exigo Consultores
Exigo Consultores. (2002). Estimativa do impacto do programa " Diz não a uma seringa em segunda mão " no risco de infecç ão por VIH/SIDA na populaç ão portuguesa de utilizadores de droga injectada.
Relatório Anual de Seguranç a Interna de
  • Ministério Da Administraç Ão Interna
Ministério da Administraç ão Interna. (2005). Relatório Anual de Seguranç a Interna de 2004.
Relatório de Actividades de 2008. Ministério da Justiç a
Direcç ão Geral dos Serviç os Prisionais. (2008). Relatório de Actividades de 2008. Ministério da Justiç a.
Tribunais de 1 a Instância–Indicadores, Dezembro
  • Direcç Ão-Geral Da Administraç Ão Da Justiç A
Direcç ão-Geral da Administraç ão da Justiç a. (2008). Tribunais de 1 a Instância–Indicadores, Dezembro 2007. Ministério da Justiç a.
A(s) droga(s) e a(s) toxicodependência(s): representaç ões sociais e políticas em Portugal
  • A R Marques
Marques, A. R. (2008). A(s) droga(s) e a(s) toxicodependência(s): representaç ões sociais e políticas em Portugal (Master dissertation). Faculdade de Economia da Universidade do Porto.
Sistema de Classificaç ão de Doentes em Grupos de Diagnósticos Homogéneos (GDH) -Informaç ão de Retorno -2006. Unidade Operacional de Financiamento e Contratualizaç ão
ACSS. (2006). Sistema de Classificaç ão de Doentes em Grupos de Diagnósticos Homogéneos (GDH) -Informaç ão de Retorno -2006. Unidade Operacional de Financiamento e Contratualizaç ão, Ministério da Saúde.
Relatório de Actividades de 2005-06
Direcç ão Geral dos Serviç os Prisionais. (2006). Relatório de Actividades de 2005-06. Ministério da Justiç a.
Relatório de Actividades de 2009. Ministério da Justiç a
Direcç ão Geral dos Serviç os Prisionais. (2010). Relatório de Actividades de 2009. Ministério da Justiç a.
Relatório de Actividades -2008. Ministério da Administraç ão Interna
  • Psp Direcç Ão Nacional Da
Direcç ão Nacional da PSP. (2009). Relatório de Actividades -2008. Ministério da Administraç ão Interna.
Report to the EMCDDA by the Reitox national focal point of Portugal
EMCDDA. (2000, November). Annual report on the drug phenomena 2000. Report to the EMCDDA by the Reitox national focal point of Portugal. Instituto Português da Droga e da Toxicodependência.
Portugal: New developments, trends and in-depth information on selected issues
  • Emcdda
EMCDDA. (2005). Portugal: New developments, trends and in-depth information on selected issues. In 2005 national report to the EMCDDA by the Reitox national focal point of Portugal.
Grupos de Diagnósticos Homogéneos -Relatório Nacional de
  • Igif
IGIF. (2005). Grupos de Diagnósticos Homogéneos -Relatório Nacional de 2005. Departamento de Desenvolvimento de Sistemas de Financiamento e de Gestão, Ministério da Saúde.
Dossier Justiç a-Novembro
  • Secretaria-Geral Do Ministério Da Justiç A
Secretaria-Geral do Ministério da Justiç a. (2010). Dossier Justiç a-Novembro 2010. Ministério da Justiç a.
Cost-of-illness studies -A primer. North Carolina: RTI-UNC Center of Excellence in Health Promotion Economics
  • J E Segel
Segel, J. E. (2006). Cost-of-illness studies -A primer. North Carolina: RTI-UNC Center of Excellence in Health Promotion Economics, Research Triangle Park. Available from http://www.rti.org/pubs/COI Primer.pdf Accessed 03.04.014