In an earlier post about my frustrating experience serving on a District of Columbia grand jury that handled indictments for drug-related offenses, I wrote approvingly about Portugal's novel approach to decriminalizing illicit drug use. In short, rather than receiving criminal sentences and jail time, people caught using small amounts of drugs in Portugal receive citations and are offered counseling and medical treatment. Since then, the city of San Francisco and the state of Oregon have both implemented versions of Portugal's non-punitive approach, with mixed results.
A January 31 New York Times article compared Portugal to San Francisco, which saw its overdose death rate spike during the pandemic to more than twice the national average. Addiction treatment in San Francisco is fragmented and rarely accepted by people caught using drugs: "From May 30 [2023] to Jan. 4, just 25 people accepted treatment after an arrest, in a city where tens of thousands of people use drugs regularly." Harm reduction programs in San Francisco, unlike in Portugal, do not always push clients toward treatment. The culture of the California city is more libertarian than conservative Portugal, where drug use is discouraged and stigmatized. Finally, the drug response in San Francisco is not guided by a comprehensive strategy. The public health department and law enforcement agencies are divided on how much of the approach to recreational drug users should be carrots versus sticks, and other than reducing the overuse rate, the city has no clear goal.
A February 7 NPR story examined Portland, Oregon's experience with decriminalization of drug possession since a state ballot measure passed in November 2020: "So far, police have handed out more than 7,000 citations, but as of December, only a few hundred people had called the hotline to get assessed for a substance use disorder. And even fewer accessed treatment through the citation system." Opioid-related overdose deaths across the state rose from 280 in 2019 to 956 in 2022, though given the rise of fentanyl and homelessness and the impact of the pandemic on health care services, it's hard to know if the new approach contributed to the difference. The story quoted an addiction medicine physician arguing that the primary drivers of Oregon's rising overdose toll are "our decades-long, underbuilt system of behavioral health, substance abuse disorders, shelter and affordable housing" - not the decision to treat drug use as a medical problem rather than a crime.
The U.S. health care system is a culprit, too. Not only is a sizeable percentage of our population uninsured at any given time, people with drug use disorders are overrepresented in that group. And if you can afford to see a doctor, you can't necessarily find one willing to prescribe medications for opioid use disorder. My friend and fellow family physician, Dr. Corey Fogleman, recently co-authored a column in the Lancaster newspaper that observed how and why our county's outcomes have positively diverged from the rest of the state of Pennsylvania:
Lancaster County health care providers are unique in their willingness to provide buprenorphine treatment for opioid use disorder. Further, the Lancaster General Hospital Family Medicine Residency Program teaches this care to every medical student and medical resident educated in our system. Since 2016, Lancaster County has increased buprenorphine prescribing by 79% compared to a statewide average of 30%.This has paved the way for crucial gains in fighting the opioid epidemic. Lancaster County has observed a notable and consistent downward trend in mortality due to this disease. Overdose deaths reached a peak in 2017, with more than 30 deaths per 100,000 residents that year. In 2022, per capita overdose deaths in Lancaster County dropped below 20 per 100,000 residents (106 total deaths). By comparison, Pennsylvania as a whole continues to observe a gradual upward trend in overdose fatalities, from 35 to more than 40 deaths per 100,000 residents during the same time frame (there were 5,155 total overdose deaths in the commonwealth in 2022).