Media and expert reports highlight the public health threat of failed, lethal treatment approaches Oregon drug users are rejecting

by Clark Miller

Published December 4, 2022

Oregon’s noble Measure 110 decriminalization effort was doomed before any votes were cast, doomed for the hopes and desperate needs of citizens and supporters whose trusting intent was to create changes that would shift substance use treatment and outcomes from among the nation’s worst to something effective, something lifesaving, something progressive. 

Described here, and here, and here, those hopes were predetermined to be betrayed by a continuum of forces invested in keeping Oregon at the lethal bottom – from State political leadership, to Oregon’s benighted, impotent Health Authority, the sham treatment industry, confused Media and experts along for the ride, to the peer lobby committed to protecting its cronyism employment benefit system that requires protection and persistence of the failed systems and programs that are lethal parody of effective, evidence-based treatment. 

members of Oregon Recovers

There have been no surprises, only the predictable rationalizations for the lethal outcomes from systems established as predicting harm, not success. 

“Rehab” and “addiction treatment” programs whose archaic, ineffective programming is not remotely related to the evidence-based understanding of problem substance use and its treatment. 

A workforce for those programs comprised of individuals without competence to treat any behavioral health issue let alone the complex life-threatening condition of compulsive substance use. 

For Oregon’s increasingly lethal opioid use problem, the medical provision of substitute addictive, diverted, abused opioids in MAT programs, established as worsening rather than treating the crisis. 

A workforce – expanding by use of Measure 110 dollars – that provides cronyism employment to members of Oregon’s “recovery community” of individuals without training or competence in providing services. That recovery community a key player in 110 implementation including the closed door meetings immediately after passage. 

With constructed and designated experts and stakeholders for Measure 110 implementation coming from the lethal systems that employ them, any shift to effective, evidence-based treatment was never on the table. 

That’s the background and context for a growing consensus that Measure 110 has failed, a view hard to argue against. 

From this report – 

SALEM, Ore. (AP) — Two years after Oregon residents voted to decriminalize hard drugs and dedicate hundreds of millions of dollars to treatment, few people have requested the services and the state has been slow to channel the funds.

When voters passed the state’s pioneering Drug Addiction Treatment and Recovery Act in 2020, the emphasis was on treatment as much as on decriminalizing possession of personal-use amounts of heroin, cocaine, methamphetamine and other drugs.

. . .  But Oregon still has among the highest addiction rates in the country. Fatal overdoses have increased almost 20% over the previous year, with over a thousand dead.Of 16,000 people who accessed services in the first year of decriminalization, only 0.85% entered treatment, the health authority said. A total of 60% received “harm reduction” like syringe exchanges and overdose medications. An additional 15% got help with housing needs, and 12% obtained peer support.

. . .  Under the law, people receive a citation, with the maximum $100 fine waived if they call a hotline for a health assessment. But most of the more than 3,100 tickets issued so far have been ignored, Oregon Public Broadcasting reported. Few people have dialed the hotline.

That’s right, 0.85% means less than 1 percent. Engagement in treatment by less than 1 in 100 Oregonians encountering the new Measure 110 processes envisioned by implementors of Measure 110 to lead them into treatment. 

The predictable response by the responsible players – media, OHA, experts, lawmakers, cronyism system beneficiaries – is most accurately described as a weak, useless show of posturing and distraction

The credible, reasonable position is being staked out without a voice, by Oregon’s drug users declining the sham treatment systems that took Oregon to the lethal bottom. 

The most recent distraction

in Oregon’s Measure 110 dog and pony show is a return to the irrelevant question of whether the failure to engage Oregonians with problem substance use in effective treatment is due to 110’s reliance on voluntary engagement in treatment services when, instead, criminal justice system court-ordered treatment is needed. 

Because that was working before? 

In recent committee hearings and media reports, this debate has centered on the question: why have model Portugal’s decades-old decriminalization measures seemed to work, Oregon’s an apparent failure? 

The Portugal model came up when testimony in the hearing asserted that Oregon’s experiment is failing because, unlike in Portugal, there is. no pressure forcing substance users to engage in treatment, only choice when treatment is offered. 

That view, of “All carrot, no stick” was picked up as the explanatory factor for the differences in outcome in this report – 

PORTLAND, Ore. — In the November 2020 election, Oregon voters approved a revolutionary approach to criminal justice and drug policy. Measure 110 decriminalized user amounts of narcotics while directing taxes levied on the state’s burgeoning cannabis industry toward expanded drug treatment programs.

The closest example Measure 110 supporters had to draw from on the world stage when drafting the initiative was the country of Portugal, which decriminalized small amounts of all drugs in 2001

All carrot, no stick

In late September, addiction experts spoke to Oregon lawmakers, and several of them excoriated the state’s rollout of drug decriminalization. One of the critics was Keith Humphreys, a psychologist at Stanford, considered to be a national expert on drug policy. He said that Oregon is doing nothing to stop people from using drugs, which is why these problems are playing out.

“Because the West Coast has an individualistic culture and significant tolerance for substance abuse, social pressures to seek treatment are also often minimal.,” Humphreys told KGW. “So, on the one hand we have highly rewarding drugs which are widely available. On the other hand, little or no pressure to stop using them. Under those conditions we should expect to see exactly what Oregon is experiencing: extensive drug use, extensive addiction and not much treatment-seeking.”

Well, that’s fascinating! 

And allows us, based on the expert analysis, to generate some predictions that can be easily evaluated. For example, comparing all states in the U.S., Pacific coast states should be similar in levels of substance use problems to each other, compared to other states and regions. That just doesn’t seem to hold up to the evidence, without an explanation for lower metrics in California compared to Oregon and Washington, and without explanation of equally severe problems in states in diverse regions across the U.S. See here, and here, and here, for example. 

We would also predict on that analysis that at least in some regions or states there would be evidence of benefit to public health from forms of social and legal pressures over past decades including severe criminal justice consequences associated with the “war on drugs” and associated social, cultural and educational pressures meant to manage problem substance use. Instead of evidence for that benefit, America has experienced over those decades no relief from the public health consequences of worsening substance use epidemics

But what about Portugal?

Back to the KGW8 interview and report – 

In other words: all carrot, no stick. Supporters of drug decriminalization sometimes point to Portugal as evidence that treating drug use as a health issue, not a criminal issue, works. Humphreys might agree if he thought Oregon were actually following Portugal’s example.

“Now, it’s worth noting that Portugal, which is often cited as the inspiration for Oregon’s drug policy, places heavy, social and legal pressure on addicted people to seek treatment,” he said. “The open use and flagrant drug dealing that we see in West Coast cities in this country are virtually absent in Portugal, which shuts them down and uses court pressure to get them in to treatment. I’ve spent a lot of time in Portugal, and I know the people who designed their policy so please, take it from me: Oregon is not following Portugal’s example and will not get its results.”

Portugal, the expert asserts, “places heavy, social and legal pressure on addicted people to seek treatment” due partly to Portugal’s use “of court pressure to get them into treatment”. 

That turns out to be a lie, as we’ll see from the interview with a Portugal drug policy expert, below. 

In fact, there is no court pressure or coercion in Portugal to force individuals into treatment. Instead there is always the option to decline treatment, just as in Oregon. 

Addressing the real needs

To get a closer perspective on Portugal’s policy, we asked Humphreys if he could connect us with someone involved in the country’s drug and addiction programs. He got us in touch with Dr. João Goulão, the national coordinator for drugs, drug addiction and the harmful use of alcohol in Portugal.

Goulão is an addiction expert, and he kickstarted Portugal’s program back in 2000. Now, 22 years later, he reports that the program has been a resounding success for the country of 10 million people.

When Portugal’s decriminalization program was approved, Goulão said, they estimated that about 100,000 people were using heroin — about 1% of the country’s population. Now the government estimates that there are about 33,000 people using drugs of any kind in a “problematic way,” according to Goulão.

That’s impressive progress for public health in Portugal, a reduction by about two-thirds of problem drug use. It’s not clear that would warrant any claim that Portugal’s substance use problems are solved. 

We asked Goulão about Humphreys’ claim that Oregon has failed to follow Portugal’s model. He went through the similarities — and where the two plans part ways.

Like in Oregon, Portugal has not legalized drugs, but it has decriminalized personal amounts; up to what someone might have on hand for a 10-day supply of the drug in question.

Portugal still deals with drug dealers and traffickers through the criminal justice system, which Oregon does as well. Drug users, however, are handled within the health care system.

There’s no penalty with using at home, but in Portugal the police can order someone caught using drugs in public to attend a special drug panel, where their drug use is discussed — this is the social pressure, or “stick.”

There’s no penalty with using at home, but in Portugal the police can order someone caught using drugs in public to attend a special drug panel, where their drug use is discussed — this is the social pressure, or “stick.”

Okay. Remember that the “stick” or social pressure we are comparing Portugal to Oregon on is pressure to enter treatment. As becomes clear as we continue in the interview with the Portugal expert, the only pressure in Portugal is to attend that “special drug panel”, a one-time meeting to interview the user, identify their needs, and offer services. Once that is completed, there is no pressure, coercion, or consequences for not entering treatment

That’s right, no “court pressure to get them into treatment”. 

Let’s continue. 

“Those who are caught using drugs or in possession of small amounts are addressed by the police authorities to a channel which we call the Commission for Dissuasion of Drug Addiction, a panel under the Ministry of Health where people are going to be assessed for their needs, the kind of use of illicit substances that they have,” Goulão said. “But first of all, the first attempt is to identify problematic drug users, people in need of treatment for addiction and to distinguish from those who are mere occasional or recreational users.

In Oregon, the approach is more hands-off. Drug users can be cited by law enforcement, which carries a fine. That fine can be waived if the user agrees to contact treatment resources. Either way, there’s not much in place to see that the user in Oregon follows through.

Oregon’s approach is no more hands-off than Portugal’s. In Oregon, there is a criminal justice fine assessed if a cited user does not access a screening, also to identify needs and offer services. 

In Portugal, the cited user who doesn’t attend the meeting and who is cited again will be instructed again to appear before the panel of behavioral health and other treatment providers, but still not forced into treatment – “The drug user is not forced to accept help” –  

“What that panel tries to do is address the real needs of the person,” Goulão said. “If the someone is addicted, this person is invited to join a treatment facility.”

The drug user is not forced to accept help. They are, however, instructed to stay away from certain areas and certain people. If they violate those conditions, they are brought back before the drug panel.

. . . “It’s not very frequent that people do not show up,” Goulão continued. “But once they are there, they are invited to join, if in need of that, they are invited to join a treatment facility, and the Commission itself makes that phone call instead of telling the citizen, ‘Now you must search for a place to treat yourself,’ or ‘You have this phone number,’ no, they call themselves and they book for the citizen.”

Officials set up an appointment for the drug user with a specific facility, for a specific time, and they make sure that both the user and the clinic are both on board. Goulão said there aren’t waiting lists, the access to treatment is free: it’s pragmatic and “centered in the needs of the citizen.”

No forced treatment in Portugal, but radically different approaches and orientations to the initial and repeated contact with with users and the use of trained professionals in those roles. We’ll get to that, below. 

Goulão said that these days the vast majority of people caught by police are using cannabis, and most say that they do not have a problem with drugs. Still, the drug panels try to drill down deeper and see if there is anything else going on that might be contributing to the drug use.

“For instance, I have someone who tells me, ‘No, I have no problems with drugs. It’s not a concern. It’s not, but my parents are divorcing, or my father just lost his job, or myself. I have been in trouble with my gender options or whatever,'” Goulão said. “And the panel may invite the person to join. Would you like to discuss this with a psychologist? Would you like to discuss with a social worker that may help your family to deal with the difficulties?”

Additional descriptions of Portugal’s system are congruent with that of Gaulao, for example here, and here, and here, and here

That approach described by Goulao is, unlike the orientation in Oregon, “evidence-based” i.e. actually supported by bodies of research results. In focusing on the expressed needs and concerns of each individual user it draws on evidence based models including Community Reinforcement and Family Training (CRAFT), the adverse childhood experiences (ACE) model, client-centered and strengths-based approaches, Motivational Interviewing (MI), and dominant psychology therory Self-Determination Theory (STD). 

All of these approaches point to the instrumental need to downplay and avoid focus on the behavior of compulsive substance use itself, or “addiction“, instead to invite users to seek help for inner distress and stressors underlying the compulsive behavior – the inner distress and problems they’ve been using substances to try to forget or temporarily escape. 

Effective use of those evidence-based approaches is provided by trained, experienced behavioral health professionals, like licensed clinical social workers and psychologists, especially in initial contacts in which the inclination of a user to trust, risk openness, and invest in difficult change depends largely on the quality of the interaction with those professionals and the expectation for effectiveness in the services offered. 

That’s where Portugal’s approach is “not at all” like Oregon’s. 

As described in detail here and here, Oregon voters passed Measure 110 with existing provisions to ensure that actual behavioral health professionals would be the point of contact for the critically important therapeutic interactions with users being “invited” and motivated, as in Portugal, to understand the potential value of treatment and enroll in it. But that provision in 110 – for use of trained professionals – was removed shortly after 110 passage in Oregon Health Authority (OHA) closed door meetings with OHA-identified stakeholders. Subverting the intent of voters for Oregon to begin to move toward more effective treatment, a lobby for “peers” – individuals hired as part of Oregon’s cronyism treatment system and without training or competence in any areas of behavioral health – were designated for that role. That hasn’t turned out well, peers in that workforce for example tending to relapse to problem substance use frequently. Other stakeholders at the OHA closed door meetings included representatives of Oregon’s failed, lethal treatment systems. 

If Goulão’s description of the program in Portugal is accurate, Humphreys is correct — Oregon’s system is not at all like Portugal’s. The social pressure is lacking, but so is the compassion and availability of care.

Oregon’s system is not at all like Portugal’s.

That’s true, they are very different. 

The social pressure is lacking

That’s a lie – as we’ve seen there is no more pressure in Portugal than in Oregon.

That real difference compared to Portugal in use of trained, qualified professionals predicts the failure and harm we see in Oregon and it runs through Oregon’s entire sham treatment system. Users who do choose or are forced to enter treatment programs do not receive treatment in any meaningful sense. In Oregon, as in much of the nation, “addiction treatment” in programs is provided by individuals without competence to treat any behavioral health condition, let alone the complex, potentially life-threatening condition of compulsive substance use – that is, to treat the ACE, trauma, environmental and interpersonal stressors and psychodynamic forces underlying compulsive substance use. It’s much cheaper and more profitable to pay someone from Oregon’s Recovery Community cronyism system to sit in a group with clients, as an “addiction counselor” and have a 12-step meeting. 

That’s right, the dominant treatment modality – currently – in private and publicly-funded “treatment” programs is comprised of the bizarre, established-as-harm-predicting, counter-therapeutic principles and prescriptions of a religious subculture. 

Do we think that’s what’s passing as “treatment” in Portugal? 

Oregonians rejecting sham treatment are displaying sound judgment. Here’s my take on Twitter – 

Tweet image

Oregon’s betrayal of voters and abdication of ethical responsibility to use public funds for evidence-based treatment delivered by qualified professionals is the problem. 

Measure 110 was doomed before the first vote was cast. 

Your system is a lie. 

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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