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The U.S. is facing its worst overdose crisis ever, and help with addressing this epidemic may be found over 4,000 miles away in Portugal. NPR addiction correspondent Brian Mann traveled there and learned how fatal overdoses dropped 80%.
UNIDENTIFIED PERSON: (Speaking Portuguese).
BRIAN MANN, BYLINE: It's a spring-like day in Lisbon, Portugal's capital, and I've come to a part of the city most tourists never see - a blue-collar sprawl of apartment blocks home to a government-run drug consumption clinic. Liliana Santos, who has a sad, weathered face, sits outside, enjoying the sun.
LILIANA SANTOS: Cocaine is my drug, but I smoke brown.
MANN: Brown is a form of heroin that Santos buys on the street. Inside the clinic, men and women sit at a table surrounded by plumes of smoke, using their crack and heroin pipes. In a room next door, Ana Batista, a soft-spoken woman in her mid-50s, has brought heroin to inject.
ANA BATISTA: (Speaking Portuguese).
MANN: "It's different using drugs here," Batista tells me - safer than using alone on the street. This clinic is part of a nationwide network of addiction services, part of Portugal's wider taxpayer-funded national health care system. This is one of the fundamental differences in Portugal. Unlike the U.S., no one here has to pay for addiction care. No one scrambles to navigate the kind of complicated, costly and often poorly regulated recovery system we have in the U.S. As I talked to drug users at the clinic, I hear something else very different. In the U.S., addiction is deadly. But when I ask Batista if she's lost anyone to drugs, she looks startled.
BATISTA: No, no. No.
MANN: Liliana Santos, the woman who smokes cocaine and heroin, tells me the same thing.
Have you had friends overdose?
SANTOS: No.
MANN: Have you overdosed?
SANTOS: No.
MANN: No?
SANTOS: No.
MANN: The simple fact is that overdose deaths are incredibly rare here. Portugal has roughly the same population as the state of New Jersey. But while new Jersey sees roughly 3,000 fatal drug overdoses a year, Portugal - the entire country - averages roughly 80.
MIGUEL MONIZ: The statistics really speak for themselves.
MANN: Miguel Moniz is an anthropologist at the University of Lisbon who studied drug policy and addiction in the U.S. and Portugal for decades. He says Portugal's approach to addiction shifted in the late '90s, when the country experienced its own opioid crisis. Rather than follow the U.S. drug war model, which focused on arresting people, often giving them lengthy prison sentences, Moniz says Portugal prioritized health care.
MONIZ: Someone who has problematic drug use isn't someone who's a criminal or has a moral failing. They're someone who has a physical or mental health problem, and that is a tremendous societal shift.
MANN: While the U.S. was building state and federal prisons to house hundreds of thousands of drug offenders, Portugal decriminalized personal use amounts of drugs and invested in a very different infrastructure.
MONIZ: So there is training for jobs, various robust treatment programs, the involvement of police at every level.
MANN: Moniz mentioned police. Another big difference here is how Portugal reinvented the role of cops dealing with street drugs. Police still break up drug gangs in Portugal and arrest people committing drug-related crimes like theft. They also work to disrupt open-air drug markets like the ones that have emerged in some U.S. cities. But when Portuguese police encounter people using small, personal-use amounts of drugs, there's no arrest. Instead, cops schedule meetings for people using drugs with counselors. Police are trained in strategies to cajole and encourage people to attend these sessions.
ARTUR VAZ: (Speaking Portuguese).
MANN: Artur Vaz heads the national police unit in Portugal that targets drug trafficking. In the beginning, he tells me, most policemen were very, very skeptical about this policy. In the U.S., this kind of approach has also been controversial. In Oregon, for example, where small amounts of drugs have been decriminalized, police regularly hand out information cards referring people to a drug counseling hotline. Court data shows drug users rarely call. In Portugal, it's very different. National data in Portugal shows roughly 90% of people referred by police for counseling turn up.
VAZ: (Speaking Portuguese).
MANN: "Most police have come to believe this is a balanced approach," Vaz says. "People who consume drugs should be treated by the health system, not the criminal system."
Police referrals are only one pathway to treatment. Portugal's national system nudges drug users constantly toward recovery programs - all voluntary, all free of charge. Dr. Joao Goulao is Portugal's national drug czar. He says one reason the system works is there's no stigma in the process - no threat of punishment or prosecution.
JOAO GOULAO: It's not fair to treat this disease in a different way from what we do with other diseases.
MANN: The results are striking. Over the last 20 years, U.S. drug deaths kept surging, first with heroin, crack cocaine and prescription pain pills, now with methamphetamines and fentanyl. During that same period, Portugal cut drug-related HIV/AIDS cases in half. People here now are 45 times less likely to die from a drug overdose compared with the U.S.
GOULAO: We are happy that most of them are there, alive.
MANN: Things aren't perfect in Portugal. Like everywhere in the world, addiction is often wrenching. During the COVID pandemic, drug use in Portugal got worse - nothing like the U.S., but there was an uptick of overdoses. People here also worry about the arrival of fentanyl, which, so far, hasn't gained popularity on Portugal's streets. In part to prepare for the threat of fentanyl, the government is once again spending more money on health care and addiction programs.
Back on the street in Lisbon, I encounter one more big difference in the way Portugal treats people who use drugs. Elda Coimbra is a neatly dressed, middle-aged woman who recently started using drugs again.
ELDA COIMBRA: (Speaking Portuguese).
MANN: And have you also used heroin?
COIMBRA: Yeah.
MANN: In the U.S., where addiction care is often abstinence-based, this kind of relapse often means people are kicked out of treatment. They lose housing and other support. Portugal's system, by contrast, views Coimbra's struggle as a painful but normal part of addiction.
COIMBRA: (Speaking Portuguese).
MANN: Coimbra tells me she is getting help, including housing and a job. "I can get my life back together," she says.
Again, no one here thinks Portugal's model is perfect. Drugs still cause a lot of suffering. But two decades of data shows Portugal's approach helps a lot more people stay alive, keeps them out of prison and offers chances to recover when they stumble.
Brian Mann, NPR News, Lisbon, Portugal.
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