Decriminalisation: What Works and what does not

Organised by Movendi International

Kristina Sperkova, International President, Movendi International: Welcome everyone to this side, event about the decriminalisation. We will be discussing what works and what doesn’t work. We really appreciate that you have chosen this side event out of many others. We are going to talk about decriminalization, as it is a term that is not really defined in our communities; but also, in general, many people are discussing decriminalization, but what is it that we are actually talking about? And we do not exactly know because it has different forms, and this we will also show in this side event. There are many countries that have decriminalised and are actually never mentioned in the discussion. And then of course there is a country that is mentioned very often and it’s the Portugal model, and we will look specifically at it and omplement it with our analysis of other countries that have also decriminalised. And then we will also be discussing a bit about the impact of the narrative about decriminalisation, but also about decriminalisation itself, on the work of civil society and of course on our societies.

Pierre Andersson, journalist / author: It’s a pleasure to be here thank you for, for inviting me. I will start sharing my screen right away. I will present a report on the decriminalisation of drugs in Portugal, what we can actually learn from what they did in 2001, and the background for this. This is a report originally published by the Swedish Drug Policy Centre. And the reason for doing this work from the beginning was that the Portuguese example is very much coming into the Swedish drug policy debate and has been for some years. People talk about Portugal all the time, basically saying that: look they decriminalised all drugs in 2001 and things went really well. But the kind of debate does not go any deeper than that. So we wanted to take a closer look at what they actually did to kind of have a more complete picture. And we also wanted to see over time what the results were because there was a very much looked at report from the CATO Institute in 2009, that has gotten a lot of attention about Portugal, there have been some studies of papers published in 2011-13 but not much after that, really. So we wanted to also look at the latest data. This report has been translated to English on the Swedish Drug Policy Centre’s website and the MOVENDI website. I visited Lisbon to make interviews to actually meet the people who are in charge of drug policy. The man who is in charge of of SICAD, the Portuguese drug authorities, was also in the expert committee coming up with these ideas. He’s been there all the way; he’s a really good source. I also visited some treatment, workers and the commissions that we’re going to talk about later. I also searched for journal articles papers written about Portugal and there isn’t a great lot, actually, written about what they have done and the results. There are some articles that I also refer to; they aremore descriptive, just telling what Portugal did and not so much focusing on the actual results and so on. Portugal was a dictatorship until right up until 1974, when they had a revolution and freedom and the country opened up. Before 74, the country was quite close to the world: not a lot of travelling in or out of the country. But this changed in 74, and the country opened up quickly. At the same time, before 74, the country was involved in colonial wars in Africa trying to keep colonies in Angola, Guinea Bissau, and Mozambique. And this, in combination with borders opening up fast and soldiers coming back with a cannabis habit, meant that drugs came into the country. And it was also, they describe it as drugs almost becoming a symbol of freedom for a number of people that are around this time, so they didn’t have a big drug problem before, at least compared to other parts of Europe, but after 74, during the 80s and the 90s, they started to build up to quite a massive problem. In the mid 90s they calculated that they had around 100,000 people using heroin in the country and this is a country with about 10 million citizens, the same Sweden, so it’s it’s very comparable in a way. And we have never even been close to that number, at least according to the to the official numbers that we have. So it was a big problem. It was a very visible problem. They had areas in Lisbon, where the sales of heroin was done openly; the use of drugs was very open. So they had to do something. They put together a group of experts, and basically said to them, come up with solutions; we are open to basically anything as long as you adhere to the UN Conventions. This work started in 98 and this was what led to the decriminalisation in Portugal, in 2001. First of all, we need to just touch upon the word, the term decriminalisation, because it’s not clearly defined really. We can see in the list of countries that supposedly have decriminalised that their policies actually look not similar at all; there are quite a number of differences. So debate and discussion around this sometimes get a bit confused but we’ll come back to this, after my presentation. But let’s look at what Portugal actually did when it comes to decriminalisation. First of all, we should point out that the use of narcotic drugs and all possession on narcotic drugs is still a violation of the law; it is still forbidden to use drugs, to have any number of drugs on you. But what they did was to move the consequences: instead of going to a prosecutor, when you have a small number of drugs on you, instead of going to the prosecutor the report goes to a civil commission. It’s an administrative consequence rather than a legal one. And we will come back to what that commission does in just a second. The police, they’ll have more or less exactly the same role as before, when they see someone using drugs or they discover that someone is carrying drugs, they will seize the drugs, and they will report this. But depending on the amount if it’s under this amount, the report will go to these commissions instead of going to a prosecutor. Basically it means the commission for the dissuasion of drug abuse. There’s one in every district in Portugal, I think it’s 24, something like that. So when you are caught with drugs on you or caught with using drugs, you are and reported and supposed to appear in front of the commission within three days. It’s supposed to go really fast. The reason for having three days instead of one day is that the commission is closed on Saturdays and Sundays so if, if you’re reported on Friday, you have until Monday. They make a very short interview or screening, you meet a psychologist when you show up at the Commission. They have a brief interview and they do a screening process to determine if you are dependent of drugs, or if you are in a risk group for becoming dependent. And then after that screening, you meet with the actual Commission, and the Commission is three people: a social worker, a psychologist and a law graduate or attorney. If you are determined to be dependent on drugs, you will be referred to treatment, and you will have a first meeting within a week, who will then refer you to the actual treatment. If you are determined to be in the risk group they have the possibility to refer people to other instances like a psychologist or some kind of an employment centre or maybe youth centre, if they think that can can help this person, and, and lower the risk of actually becoming a drug dependent. If the commission determines that you are not dependent on drugs, they give you a warning if you the first time you show up, but if you come back within five years, they will be normally give a financial fine, but the Commission also have a number of other sanctions that they can use. They have quite a lot of power when it comes to delivering sanctions, especially for those who are not dependent on drugs. It can suspend professional licences. If you are a taxi driver or medical doctor, for example, you can lose that licence for a period of time. They can even give bans on being at certain places or meeting certain people, leaving the country, losing your firearm licence, or even seizure of funds; I’m not sure how often this is actually used but basically the Commission can can handle your funds if you get contribution money from public funds. And essentially, this is a graph showing the number of cases handled by the Commission’s from 2001. You can see it was basically growing quite slowly until 2011 and after 2011 it actually doubled. But if you look at the groups that are determined to be dependent and the non dependent, you can see that the increase is more or less, all in the group who are determined to be not dependent of drugs. If we look at what kind of action, the Commission decides to take, you can see the blue graph is a warning, that’s the most common action. The orange one is the people who are determined to be dependent and who are referred to treatment, the yellow bar is people who are referred to treatment, but they don’t accept the treatment or they don’t fulfil the treatment, and then the Commission can use some kind of sanction. In that case, when there is punitive sanction, in the next graph we will see what that is. These are the more punitive sanctions used: financial fine, regular presentations, community service and other sanctions. One really important thing to know and to remember about the Portuguese example is that the decriminalisation in itself is just a small part of a much larger package. These group of experts, put together a programme with 30 points. One of the points was the change of the law and the decriminalisation, but the other points were investments into treatment and care, prevention work, giving more resources to the police to stop the distribution and sales of drugs, and all in all it was calculated that the total budget for this work would double. So it’s quite a huge change in the resources available. Now, when they made an evaluation in 2004, a couple of years after, they couldn’t really say how much the budget actually increased. Then, we don’t know it was if it was doubled or not, but it’s clear that it was a substantial addition to budgets. For example, they managed to double the number of substitution treatment places available in just a couple of years. So a lot happened outside of the decriminalisation and personally I will come back to that in my conclusions. I think that the other 29 points in this programme probably had a much bigger impact than the decriminalisation in itself. As I said, this is often missed in the discussion. When we hear about Portugal, at least in Sweden. It’s constantly just only about the change of the law and the decriminalisation and nothing about the kind of massive reforms that they did outside of the decriminalisation in itself. So what were the results. I will look at the drug related mortality shortly, but first look at the drug related HIV cases; Portugal had a huge problem with this. If you go back to the beginning of 2000 this curve, this graph only goes back to 2008. If you go back more, it will be even higher. But as you can see, they have been really, really successful in lowering these numbers and in 2017, they are now at the same numbers as we have in Sweden, and I should say that all the graphs here, they compare Portugal and Sweden. If we look at the drug related mortality. This is what brought most of the attention, I think, to the Portuguese example and as you can see for the first number of years, they had really a huge decrease in mortality. This has been cited numerous times.  We should note though that something changed around, I don’t know 2008-2009. The trend seems to have changed. If we compare the numbers for the year before the decriminalisation year to 2000 and we compare that to the latest number in 2017, the numbers are actually virtually the same. We constantly hear that the number of deaths has been just going down. But as we can they’re going up again. There is also quite a lot of confusion in this discussion. I think a lot of that confusion comes from the fact that Portugal actually changed the way they count drug related deaths in 2007. The orange graph here is from the older method using basically tox screens. When a person dies and they find that they die with drugs in the system, they are counted towards this statistics. And as you can see you kind of capture a lot more cases using that method compared to the new method, which is the method that most European countries report to the EMCDDA, where you use the death certificates, written by doctors, and you kind of go through the list of codes and see all these included in the definition of the EMCDDA or not. And as you can see the differences are really large between these two methods. The problem occurs when people start comparing the two different methods and I see this constantly. This is a graph, found on twitter not too long ago where we can see people pointing out that they had 369 overdose deaths in 99 and only 32 in 2016 now. We have seen this in the debate in Sweden numerous times referring to these numbers. But then again, people are actually comparing pears to apples, they are comparing the old methodology of counting and reporting to the new one; it’s simply not correct. And according to the new method, the numbers are actually now virtually the same as the ones in the year 2000. But then again, you can of course, look at the numbers, according to the same kind of way of counting EMCDDA, and you can compare Portugal in 2016 to Sweden in 2016, and you will see a massive difference coming out, not Sweden not coming out looking very good. Of course, and I want to say from the beginning, it’s clear that Sweden has a problem with drug related mortality, it’s no question about that the numbers are far too high. But my point here today, is that these numbers are really, really tricky to compare, and there are a lot of indications that methodology between countries is actually so different; which makes comparisons more or less meaningless. We can, for example, look at this, this is the last year 2007 where we have data from both methods; we have the toxicology reports, we have the same data for Sweden, so we can see the number of deaths where the people were screened positive for drugs in Portugal that year was 314, and in Sweden was 396. Still difference but much smaller. And if we then look at how many of these deaths were actually captured within the EMCDDA definition, the selection B, you can see in Portugal, it was 14, and in Sweden, it was 310. This is a difference of under 5% In Portugal, and almost 80% in in Sweden, and it’s hard to say exactly what’s going on here but I think this points to that there are massive differences in how these two countries, capture and report on this data. We can see some indications, when we look at what, what percentage of deaths in the countries are actually, resulting in post mortem examinations, it’s twice as high in Sweden. If we look at the number of chemical forensic analysis, it’s three times as high in Sweden; again two countries with more or less the same number, the same population. And there’s more, but we don’t really have time to go into that now. Just keep in mind that these numbers are really really hard to compare when you see the list that EMCDDA compiles every year. Another thing that I just want to mention that we don’t have time to go into is the the kind of competing diagnosis. There’s a Norwegian researcher named Helge Waal, who studied this 10 years ago when he compared Norway to Portugal. Basically looking at: the numbers are different but there are people dying from other diagnosis that are definitely drug related but that are not captured within the EMCDDA definition. So he started looking at people dying from drug related HIV, for example, and  some other diseases clearly linked to to drug use, and all of a sudden the numbers were not that different anymore. And in the report you can see a similar exercise that I do comparing Sweden and Portugal also kind of trying to estimate these competing diagnosis. Then what happened when it comes to the use of drugs? This is obviously a concern. Decriminalisation will send a signal to the public that it’s now okay to use drugs. We can see that Portugal and Sweden was more or less the same on the same level when it comes to prevalence in 15-16 years old. This is data from the ESPAD study. And if we go on then to 2015 the Portuguese numbers were more or less, almost three times as high as the ones in Sweden. It’s quite clear that cannabis use has increased in Portugal since the decriminalisation. This is a report on on hospitals admissions with cannabis related psychosis, and you can see it’s an increase with a factor of 30. There can be a number of explanations for this but the researchers themselves point that intensive use of cannabis seems to have increased quite a lot during these years. We can also see seizures of drugs, this is a graph of heroin seizures in Portugal from 2001 to 2017 it’s clearly going down, could be partly because it’s hard to get to the street level, selling, when we have this kind of high levels that you can have without the risk of being punished, basically. But there’s not been a lot of studies into that. I just also want to briefly mention other interventions that has been made during this time period. This is Cascais, in the west of Lisbon, where it was called the biggest supermarket for drugs in late 90s, this was almost brutally cleared up in 2001, they tore it down. A lot of these shanty town houses, they removed people and put them in other parts of Lisbon other parts of the country. And this happened in other places as well and we don’t know to what, to what extent, things like this also actually affected the results that they had. Now I don’t have time to go into details, I just want to mention an example of what they do when it comes to treatment, care. This is a low threshold programme with methadone. This is a civil society organisation with support from the government, they do this they go around with this minibus. And this place they show up every morning and every afternoon so people can come visit on the way to work and the way on the way home from work, basically they come up they identify themselves and they get methadone in the cup and the drink right away. This is very low threshold, you have to identify yourself and you basically have to prove that you have a heroin habit to get in the venue; there are no other demands on the users. One thing that struck me is that when they identify themselves they have a special number and they put that number into the computer, and this guy who received some he can actually see part of the medical journal. He can see if they have an appointment with another doctor and he can remind them, so it’s very integrated into the system. And that’s one thing I think Portugal does very well, this integration of different actors when it comes to treatment and care. Coming back to this, I think other other measures, rather than decriminalisation itself had the biggest impact. I think this graph, kind of confirms that in a way; we can see it was going down, now it seems that trend has changed, and this changed somewhere around 2008 2009 And this, as you remember, this was in the time of quite real dire economic crisis that affected Portugal really quite a lot. I haven’t really been able to look at exactly how much resources, the SICAD and other agencies dealing with these issues in Portugal, lost during that time but we know that SICAD had to reorganise and so on. And it seems that resources put into treatment, care prevention really had an effect on on mortality and mortality in Portugal. Just to wrap up, as I said these are broad reforms, and I don’t think that necessarily decriminalisation itself is the hero of the story here. I think one other thing to take away from this is that everything is fast you meet the commission within three days and then you have an appointment with a doctor within the week if you’re considered to be dependent. It’s well coordinated. I think one thing that we can learn is that it seems to be possible to not have sanctions, the same sanctions, if you are dependent on drugs, you can have alternative sanctions. And I actually think that you could have a system of alternative sanctions for drug dependent people without actually decriminalising. We can see that drug related mortality is back at the same level as before. We can also see that there are huge differences in methodology and reporting around drug related mortality, and as I said, it seems that drug use at least when it comes to cannabis has increased. There’s not a lot of data, when it comes to other drugs, unfortunately.

Kristina Sperkova: Thank you for this overview I think that this is a really valuable work that you have done to clarify a little bit the picture so we all understand what we are talking about when we are talking about Portugal model.

Peter Moilanen, Swedish Drug Policy Centre:  I will give you some additional comments on (poor sound quality). First, as mentioned, the models of decriminalisation look very different between countries; very astonishing. We got 10 voices in the report, and almost 10 different models with different limit of possessions before it becomes criminal different figures about if and how many plants to have at home. The most common thing then was the administrative fine, some kind of fine is  almost everywhere. Some have even administrative prison and withdrawn licence for a weapon or passport. Sanctions almost harder than some countries with criminalization, so it’s not so easy to differ sometimes. Others like Portugal have a treatment or other programmes as sanctions. All have sanctions pointing out that illegal drugs are not okay, in line with the UN conventions. But the difference makes it very hard to compare between countries in general. Second, when it comes to the question of decriminalisation, if it decreases drug related deaths, as Pierre was saying with Portugal, in general, there doesn’t seem to be any connection. In some countries it goes up, and in some countries it goes down. And in Portugal, it goes as we’ve seen, both  down, and up under the same period of decriminalisation. And, third, as drug use is a risk factor for a wide range of negative health and social outcomes, decreasing the consumption level is very important for a country. And decriminalisation doesn’t seem to decrease the level of consumption at all. The main question is more about whether or not it will increase consumption of course, and the scientific studies so far are very unclear if decriminalisation increases consumption. So it could be a risk that, in fact, increases. Portugal is an example where consumption of cannabis went up for 15 year olds, and it didn’t go down at all. But Portugal is also a typical example of the lack of studies, as they didn’t measure the adult consumption before the reform they did; they just measure it afterwards. And then we can’t compare before, just for 15 years old. So to summarise it that the effects of decriminalisation are hard to study, as it varies a lot between countries and science is very unclear. It doesn’t seem to be a useful tool if you want to decrease drug related deaths and drug use. If you want to decrease these figures, you have to look elsewhere. But there can be, of course, other advantages with decriminalisation.

Kristina Sperkova: So this, this is also very useful and actually compliments Peter’s report.

Pubudu Sumanasekara, International Vice President, Movendi: I briefly tell you how this kind of global trends affects countries like us. Sri Lanka is an island in the Indian Ocean. So, when it comes to the topic of cannabis, the Sri Lankan weather is very good to grow cannabis, and historically we have cannabis in our country, and ayurvedic medicine which is one of the major practice, and where people seek support. They use cannabis to manufacture some other medicines, but it’s not direct cannabis; it has gone through a kind of huge process. And in the recent past, just like  other countries in the world in the global trend, there were a few groups in treatment actually forcing the policymakers to legalise cannabis and so that started, like, three, four years back, and it was not very successful and then actually change the strategy and they actually coming, kind of different approaches to say doctors do not have enough cannabis to manufacture those medicines. Doctors came up and say that they have actually cannabis enough amount to actually manufacture their medicine, and then at the same time it’s kind of misleading campaign, saying cannabis is used in ayurvedic medicine; that the cannabis smoke is a kind of medicine. It means that it is good for people. So actually we as civil society think it’s a very serious campaign run by some people, because it gives a kind of idea to young people and children that cannabis use in medicine,  that cannabis smoking, cannabis itself, is a kind of medicine. We had to work a lot with hiring doctors and others and civil society representatives to clean up this kind of misleading facts and figures. When it comes to the topic today, decriminalisation; we also had  groups coming up with very calm, very sensitive stories about because of the criminalisation, people will get into trouble, the families and some users, young people, things like that, but those kinds of presentations are very, very attractive and sometimes it’s very sensitive. But what we found was that those actually very limited incidence. We look for a kind of public health approach. So I would like to stress it here that countries like Sri Lanka, developing countries, can work on every approach and define what is best for common people in the country. In that sense, in Sri Lanka, the approach was the public health approach looking at everybody: the children, young people, men, users, non users, everybody, and understood that the public health approach is more appropriate. Actually it is cost effective and accurate serves the general public and the problems in the country. So what I want to stress is that sometimes that people coming out with sensitive stories about criminalization of cannabis or some other drug and how people get into problems… True, there are some stories and I know that there are countries in the world that the police people actually taking action, more than (…) There is a lot of issues of that; but those kinds of stories are not enough to take a decision whether the country’s going to decriminalise cannabis, because our country experienced that the criminalization of drug use, including cannabis actually helps, in many ways; it’s the most effective way to control it. And the second thing is that decriminalisation as Peter very nicely explained, it is not a kind of single thing, it must have a kind of package. So that has a cost, you need professionals, academics to implement it. So therefore, for a country like Sri Lanka, if we are going to do a kind of single decriminalization, that will end up with a kind of huge issue. So therefore, as a country that we always look for kind of approach which is good for everybody in the country, and which we can prevent young people getting into the habit, and which we can help users to get out of the habit. So in a kind of holistic way. So therefore, we believe that the public health approach is the most appropriate approach for us. And when it comes to the debate of decriminalisation or legalisation, we still think that there is no such necessity and need to decriminalise cannabis in Sri Lanka at the moment. So, only thing that we have to do is, actually we are doing it, we have to increase the support given to the users and the dependent people, that we are doing, services and treatment or whatever, but it doesn’t mean that the decriminalisation is the kind of good public health approach for a country like Sri Lanka.

Pierre Andersson: Yeah, maybe I can just comment on the one question I didn’t answer in text  from Ann Fordham, if I think drugs should continue to be criminalised. I think this is hard to answer in one minute. But I do think that criminalisation actually can have a preventative effect, but I also think that we should look into much more closer to have alternative sanctions for people who are actually drug dependent and refer them to care, rather than to a financial fine, but for, for people who are non dependent I do think that criminalization actually can help in reducing the use of drugs.

Kristina Sperkova, International President, Movendi International: I believe it’s also connected to drug use prevalence. We don’t have someone here from Norway but we understand in Norway there is a discussion. Young people in Norway don’t use drugs because they aren’t legal and they would be sanctioned. It’s obviously a preventative measure. But at the same time, as you say, people who are using drugs shouldn’t end in jail but get alternative solutions.

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