Portugal had a drug addiction problem. A big one. To address it, the country engaged in systemic change in 2001 and achieved dramatically positive results. Today, Portugal has returned to the news due to a significant, though not total, return of its drug problem and the appearance of related experimental programs elsewhere such as in Portland, OR. Such articles often mention decriminalizing drug usage, emphasizing its centrality in the consideration and evaluation of programs like Portugal’s. How important is decriminalization in curtailing drug abuse? What can we learn about sustaining organizational change from the answer to that question?
Envisioning a solution for Portugal’s drug addiction problem
In 1999, Lisbon carried the moniker of the “heroin capital of Europe.” Consequential diseases such as HIV infection reached an all-time high in 2000, with 104.2 new cases per million people. A multi-partisan party coalition backed sweeping and coordinated change. Portugal redefined the problem of addiction and correspondingly envisioned a very different approach to addressing it compared to other countries, an approach that de facto followed the change model presented in Leading Successful Change.
First and foremost: Portugal defined addiction as an illness. Second, Portugal eliminated the distinction between hard and soft drugs. Third, Portugal concentrated on an individual’s unhealthy relationship with drugs and the likely accompanying frayed connections between the addict, others and the world at large.
To quote João Goulão, architect of the program, physician and head of the General-Directorate for Intervention on Addictive Behaviors and Dependencies within Portugal’s Ministry of Health: “Our first goal is to help people to resume their dignity [and the first task is getting them] the citizenship tools that they need — an identification card and a health card. … [After stabilizing their drug use] I can ask more from them, but always with them being assisted with those new focuses.”
Decriminalization: one part of Portugal’s eight-part change strategy
Portugal, in effect, set out to alter the environment around drug addicts in order to alter their behavior and, thereby, to reduce addiction and its toll on individuals and on society overall.
The Work System Model (WSM) presented in the book Leading Successful Change: 8 Keys to Making Change Work offers a way to understand Portugal’s approach, namely addressing eight aspects of the work environment that shape individual behavior — eight aspects that can become eight levers of change.
- Organization: Move from the court system for incarceration to the Commissions for the Dissuasions from Drug Abuse (CDTs) made up of professional, technical experts.
- Workplace Design: Construct mobile teams to provide care to addicts on the street.
- People: Staff mobile teams with professional experts.
- Task: Implement work processes to test, administer treatment (including often first-time primary care) and exchange syringes.
- Rewards: Decriminalize possession of small amounts of drugs (i.e., not legalization) and encourage addicts to seek treatment or to face penalties (such as fines, just not jail). Assist addicts with finding employment. Drug traffickers still go to jail.
- Measurement: Track the various costs of drug addiction, e.g., public health, addiction levels, unemployment, crime and total cost to society.
- Information Distribution: Educate the public (especially addicts) about this disease, its treatment as well as their healthcare and overall life options in the service of an enhanced sense of agency.
- Decision Allocation: Give treatment officials the power to make decisions about drug users instead of police officers.
These eight aligned aspects produced recurring and desired scenes covering the cycle of recovery and reentering society as a functioning member, e.g., finding employment or receiving ongoing medical care, including screening for HIV, methadone treatment and syringe exchange. As an illustration of these aspects applied, consider the following scene for a person identified as possessing illegal drugs:
Police take the person to a police station and weigh the drugs. If the weight exceeds amounts specified for personal use, then the person is charged and tried as a drug trafficker and can receive prison sentences of 1–14 years. Otherwise, the next day, the person appears at the Commission for the Dissuasion of Drug Addiction for an interview by a psychologist or social worker. Next comes an appearance before a three-person panel that will provide guidance about how to stop drug use.
A fast track leads the person to any accepted services. Refusal of such services can lead to required community service, a fine and confiscation of belongings to pay the fine.
In summary, drug possession remains illegal, drug possession for personal use is decriminalized and comprehensive treatment and recovery options become available as a viable next step for the identified user of illegal drugs.
Initial results of Portugal’s new drug policies
By 2018, Portugal’s number of heroin addicts had dropped from 100,000 to 25,000. Portugal had the lowest drug-related death rate in Western Europe, one-tenth of Britain and one-fiftieth of the U.S. HIV infections from drug use injection had declined 90%. The cost per citizen of the program amounted to less than $10/citizen/year while the U.S. had spent over $1 trillion over the same amount of time. Over the first decade, total societal cost savings (e.g., health costs, legal costs, lost individual income) came to 12% and then to 18%.
International acclaim for Portugal’s originally maligned “experiment” came from sources as varied as the American Psychological Association, Vancouver Sun and The Guardian. Still, in 2017, The Guardian reported local frustration with inaction regarding supervised injection sites, overdose treatment and needle exchange programs in prisons. In short, some feared insufficient recognition of the ongoing need to maintain “a web of health and social rehabilitation services.”
The unraveling of a system — decriminalization is still just a part of a larger issue
Two forces have led to the at least partial unraveling of Portugal’s efforts over the last few years and, predictably, to less favorable results. First, global drug traffickers continued to use Portugal as an entry point for access to Europe’s illegal drug market dealers. They battered the entry points of this coastal country, hence a supply of illegal drugs continued. Second, Portugal reduced resourcing of its programs as the country faced multiple difficult economic years.
The financial crisis of 2007–2008 led to program cuts, held to 10% due to continued bipartisan support, initial successes and demonstrated long-term benefits. Still, significant program (system aspects/levers) compromises occurred, e.g., the extent of research and measurement of results. Ongoing ripple effects followed from cost-cutting through the elimination of government assistance for employing recovering users (often in smaller businesses), which hamstrung efforts to reintegrate users into society (and contributed to the closing of numerous small companies.)
Funding ebbed still more recently due to new national budget pressures, which undercut efforts encouraging addicts into rehabilitation programs. The results of “disinvestment” and “a freezing in [their] response” led Goulão to state that “what we have today no longer serves as an example to anyone.”
Speaking more quantitatively, drug users in treatment declined from 1,150 to 352 (from 2015 to 2021) as funding dropped in 2012 from $82.7 million to $17.4 million. Budget pressures and the apparent desire to cut immediate program costs of drug addiction (distinct from the total societal cost of drug addiction) led to program decentralization and the use of NGOs. Anecdotal evidence of a fragmenting, even breaking, system abounds: Demoralized police no longer cite addicts to get them into treatment and at least some NGOs view the effort as less about treatment and more about framing lifetime drug use as a right.
The number of Portuguese adults who reported prior use of illicit adult drugs rose from 7.8% in 2001 to 12.8% in 2022 — still below European averages but a significant rise nonetheless. Overdose rates now stand at a 12-year high and have doubled in Lisbon since 2019. Crime, often seen as at least loosely related to illegal drug addiction, rose 14% just from 2021 to 2022. Sewage samples of cocaine and ketamine rank among the highest in Europe (with weekend spikes) and drug encampments have appeared along with a European rarity: private security forces.
A few lessons from the rise and decline of Portugal’s drug policy
- Design a system by working backward from what you want it to deliver, i.e., the behaviors desired.
Implication: Carefully construct the desired stories and then carefully consider which system aspects, if changed, might deliver those stories or outcomes. Keep all of that in full view and, like the Portuguese, change everything — or at least everything that you can. Francisco Rodriguez, president of the Order of Portuguese Psychologists, demonstrated this by noting, “You cannot work with people when they’re afraid of being caught and going to prison … It’s not possible to have an effective health program if people are hiding the problem.”
- “If you want truly to understand something, try to change it,” said Kurt Lewin, often called the father of social psychology. Restated: Changing enables learning … if you’re paying attention.
Implication: Carefully monitor which coordinated system changes most affected outcomes. Beware, even amidst financial hardship, to cut back on measurement and research, i.e., key ingredients to ongoing learning and program improvement.
- Altering a system that produces desired behavioral outcomes necessitates careful monitoring.
Implication: Systems generate outcomes and altering aspects of those systems, especially multiple aspects of them, can easily lead to unanticipated and undesired changes in outcomes. Systems require maintenance. Sustaining change does not just happen. Changing enough aspects of a system changes the system and, therefore, the behavior it generates.
- To code the case of Portugal’s illegal drug initiative (as with many attempts at change) as a binary choice — in this case, to decriminalize drugs or not — misrepresents the change effort required and, consequently, how to sustain it.
Implication: To paraphrase an aphorism often attributed to Einstein, “Everything should be made as simple as possible, but no simpler,” i.e., Beware of silver bullets and binary choices when envisioning, designing, implementing and sustaining change. Think systems. As Goulão said, “Decriminalization is not a silver bullet … If you decriminalize and do nothing else, things will get worse.
The model presented in Leading Successful Change will help you act in accord with these lessons and succeed in changing your organization and in sustaining that change.
[Knowledge at Wharton first published this piece.]
The views expressed in this article are the author’s own and do not necessarily reflect Fair Observer’s editorial policy.
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