This commentary analyzes the drug policy recently implemented in Brazil in light of concepts from modern liberalism and the scientific literature.

The paper addresses four aspects of Brazil’s current legal framework on drugs: (i) compulsory hospitalization of persons that use drugs; (ii) complementariness (as opposed to the postulated polarization) of harm reduction and therapies focused on harmful/addictive substance use; (iii) (in)definition of the Therapeutic Community in relation to its classical conceptualization; and (iv) the mistaken understanding - according to documents by Alcoholics Anonymous (AA) and the formulations by A. Thomas McLellan - of abstinence as a legal imperative and not as a dynamic process, subject to complications and discontinuities.

The context

We in Brazil are now experiencing an unprecedented combination of a self-proclaimed liberal order and renewed authoritarianism. The latter obviously shares various characteristics with the other variants of authoritarianism, while maintaining historical specificities. I refer interested readers to the historical synthesis on Brazilian authoritarianism by Lilia Schwarcz ¹1. Schwarcz L. Sobre o autoritarismo brasileiro. São Paulo: Companhia das Letras; 2019.. I would highlight here the fact that Brazilian society was built on the opposition between The Masters and the Slaves (or between “The Big House and the Slave Quarters”, in a more literal translation of Gilberto Freyre’s classic Casa Grande e Senzala, although permeated by an attenuation of the magnitude, depth, and brutality of black slavery in the country, as criticized by dozens of intellectuals, including Mário de Andrade, in a work until recently unpublished, Estudos sobre o Negro²2. Andrade M. Aspectos do folclore brasileiro. São Paulo: Global Editora; 2019.). I further highlight the centuries-old persistence of the patriarchal family, that is, the subordination of Brazilian women that persists to this day.

As for liberalism, it is important to distinguish between its original formulation ³3. Manent P. Histoire intellectuelle du libéralisme. Paris: Fayard/Pluriel; 2012. and its modern watershed, supposedly underlying the current government’s economic matrix, a spinoff of the original formulations by the Chicago School in the 1960s, led by Milton Friedman.

Fifty years later and after a series of conceptual shifts in the Chicago School itself, the Brazilian version still adheres to the watershed that prevailed half a century ago. The seminal contributions of Daniel Kahneman (Nobel Laureate in Economics, 2002) and Amos Tversky, and of coauthor Richard Thaler (Nobel Laureate in Economics, 2017) are ignored when the attempt is to extend beyond the deterministic models based on expectations defined as “rational” for so-called “Homo economicus”. According to the logic in the recent presentation of compilation models by Scott Page ⁴4. Page SE. The model thinker: what you need to know to make data work for you. New York: Basic Books; 2018., it is as if Brazil were focusing exclusively on Chapter 4 (of the 29 comprising the textbook). In addition to strict adherence to models from a half century ago, which the progress of economic science and mathematical modeling have rendered imprecise and unrealistic, a fundamental error is to ignore the environmental and climate change issue, since it pertains to the planet’s survival and that of coming generations. There is also an unavoidable mismatch here between the formulations prevailing in the 1960s and the current world and its redoubled challenges.

The understanding of nature as the limiting factor for the economy ⁵5. Cechin A. A natureza como limite da economia. São Paulo: Senac São Paulo/Edusp; 2010. was originally formulated by Romanian expatriate and ecological economist Georgescu-Roegen (1906-1994). More recently, with the serious effects of current climate changes, the concepts (and respective models) have been incorporated by which the environment and climate are central parts of any economic formulation, and the issue has not only penetrated mainstream academia, but has also been fully integrated into neoclassical models, culminating in the Nobel Prize for Economics awarded to William Nordhaus in 2018 ⁶6. Nordhaus WD. The climate casino: risk, uncertainty, and economics for a warming world. New Haven: Yale University Press; 2015..

Drug policy

It is impossible to conceive of drug policy in Brazil today without referring to the original critiques against intervention by the “heavy hand of the state” (an expression coined by classical liberalism) in the approach to the phenomenon. The critiques stem from two basic sources: critical criminology (here I cite Scheerer & Vogt ⁷7. Scheerer S, Vogt I. Drogen und Drogenpolitik. Frankfurt/New York: Campus Verlag; 1989., notwithstanding high-quality Brazilian research output on the topic), but also the founding father of the Chicago School, Milton Friedman! Friedman’s critiques of the drug policy drafted by the U.S. Administration of the time (Republican, which Friedman served as a Presidential advisor) traverse various passages of his Complete Work. Here I select a short quote ⁸8. Friedman M. An economist's protest: columns on political economy. Glen Ridge: Thomas Horton & Daughters; 1972. (p. 162): “In drugs, as in other areas, persuasion and example are likely to be far more effective than the use of force to shape others in our image”.

The issue of compulsory hospitalization

Compulsory hospitalization is an exceptional measure (in the face of imminent risk of death), and not a rule for managing harmful and addictive substance use. In Brazil today, such practice has become a human rights violation, condemned by all the agencies of the United Nations system (https://www.who.int/hhr/JC2310_joint_statement_20120306final_en.pdf?ua=1). The Universal Declaration of Human Rights, although led by U.S. First Lady Eleanor Roosevelt (1864-1982) and promulgated in 1948 ⁹9. Glendon MA. A world made new: Eleanor Roosevelt and the Universal Declaration of Human Rights. New York: Random House Trade; 2002., has been dismissed out of hand in Brazil today. But it is not necessary to turn to this international milestone. The confirmation that compulsory hospitalization does not work as a treatment strategy has been demonstrated by a recent review ¹⁰10. Werb D, Kamarulzaman A, Meacham MC, Rafful C, Fischer B, Strathdee SA, et al. The effectiveness of compulsory drug treatment: a systematic review. Int J Drug Policy 2016; 28:1-9., based on prevailing policies in Indonesia, China, and the Philippines ¹¹11. Lunze K, Lermet O, Andreeva V, Hariga F. Compulsory treatment of drug use in Southeast Asian countries. Int J Drug Policy 2018; 59:10-5..

Harm reduction and abstinence: continuum versus opposition

Gaining force in contemporary Brazil is the idea that harm reduction policies are opposed to the pursuit of abstinence, a contention that lacks the most basic logic, since for an abstinent person there is no harm resulting from consumption of substances (which do not exist, by definition). Such confusion is due in the first place to a misunderstanding of the concept of harm reduction, which is more comprehensive than any specific interventions such as needle exchange programs or replacing heroin with methadone or related substances, measures in force in all Western countries dealing with harmful and addictive use of opiates/opioids, although prohibited in countries with authoritarian leanings ¹²12. Idrisov B, Murphy SM, Morrill T, Saadoun M, Lunze K, Shepard D. Implementation of methadone therapy for opioid use disorder in Russia: a modeled cost-effectiveness analysis. Subst Abuse Treat Prev Policy 2017; 12:4..

I worked for more than 10 years as a volunteer in an outpatient clinic for the poor homeless population, originally affiliated with the Archdiocese of Rio de Janeiro. I started with various simple but effective harm reduction measures such a providing baths, meals, and treatment for various health problems for my patients. After having dealt with these needs, I proposed to the patients that they treat their harmful/addictive substance use per se.

The continuum between harm reduction measures and treatment of harmful/addictive drug use is evidenced in the international clinical literature (e.g., Gabor Maté ¹³13. Maté G. In the realm of hungry ghosts: close encounters with addiction. Berkeley: North Atlantic Books; 2010.). Such clinical observations are backed by scientific studies demonstrating that harm reduction programs are the prime route for recruiting patients (especially the most destitute and the most far-removed from the network of care) into treatment programs ¹⁴14. Waye KM, Goyer J, Dettor D, Mahoney L, Samuels EA, Yedinak JL, et al. Implementing peer recovery services for overdose prevention in Rhode Island: an examination of two outreach-based approaches. Addict Behav 2019; 89:85-91..

What are Therapeutic Communities?

It is not difficult to define and standardize what a Therapeutic Community is. The systematization of standards, procedures, and work philosophy conducted by George De Leon allows understanding the basis of these institutions ¹⁵15. De Leon G. Therapeutic communities. In: Galanter M, Kleber HD, editors. The American psychiatric publishing textbook of substance abuse treatment (American Psychiatric Publishing Textbook of Substance Abuse Treatment). Washington DC/London: American Psychiatric Publishing; 2008. p. 459-76..

A low-profile book by Victor Leonardi ¹⁶16. Leonardi V. Exercícios de liberdade. Guaratinguetá: Fazenda da Esperança; 2009. describes his empirical experience with Therapeutic Communities in operation in Brazil. Unfortunately, work such as that of Leonardi and institutions like those he describes are not only rare, but habitually mixed with organizations that follow a distinct if not diametrically opposite philosophy. Unfortunately, we observe the following in Brazil:

(i) Non-observance of the philosophy and standardization proposed by De Leon, such as the voluntary nature of treatment and a clear and central definition of therapeutic and educational activities. What persists are establishments of confinement and control, repeatedly denounced for abuses and mistreatment (https://site.cfp.org.br/publicacao/relatorio-da-inspecao-nacional-em-comunidades-terapeuticas/).

(ii) There is a persistent lack of distinction (incomprehensible given an economic policy with a supposedly liberal orientation) between non-profit organizations and private for-profit clinics. A blatant contradiction with the “market” economy is the fact that for-profit clinics mix with non-profit organizations to be eligible to receive government funds and benefit from fiscal waivers.

Science, mutual help groups, and the dynamics of addiction

The drug policy currently under way in Brazil defines abstinence as the norm, and not as a target. The nature of compulsive and harmful substance use, as well as other conducts of compulsive appropriation such as addiction to gambling or internet, is not only chronic, but subject to complications, including relapses.

The philosophy of AA underscores the chronic nature of the addiction process, translated as the pursuit of sobriety in the next 24 hours and the addict’s self-definition as someone “in recovery” (which for AA has a perennial nature, since relapse is a possibility always present on the horizon), that is, as someone in a situation of abstinence, and not legally abstinent.

On a complementary note, more than 20 years ago Professor A. Thomas McLellan of the University of Pennsylvania published one of the most widely cited articles in the specific literature ¹⁷17. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000; 284:1689-95.. McLellan et al. compare substance addiction to a wide range of chronic medical conditions such as hypertension, diabetes, and asthma. In the authors’ view, dealing with substance addiction as an acute health condition is a mistake, even as an objective evaluation of outcomes from different therapeutic interventions. McLellan is the principal author of the widely adopted ASI (Addiction Severity Index) ¹⁸18. McLellan AT, Cacciola JC, Alterman AI, Rikoon SH, Carise D. The Addiction Severity Index at 25: origins, contributions and transitions. Am J Addict 2006; 15:113-24., used worldwide to assess progress (or lack thereof) in a variety of health interventions and therapies. The ASI is multiaxial and extends beyond abstinence as the exclusive criterion, assessing the patient as a whole, in his or her interaction with the family, work, the social context, etc. According to the authors, neither is there a palpable difference between the difficulty in maintaining full adherence to medication to treat hypertension or diabetes and medications or other therapies in the field of addiction. The relapse rates are virtually similar across these different chronic conditions (for example, diabetics who “cheat” on their diet or spend a period in their lives with a sedentary profile, even while their blood glucose rises).

In short, continuous monitoring, careful management of relapses ¹⁹19. Marlatt GA, Donovan DM. Relapse prevention: maintenance strategies in the treatment of addictive behaviors. New York: The Guilford Press; 2007., and understanding the complexity of addiction dynamics are key elements of any proposal for care and treatment.

Revisiting Milton Friedman’s words, the strength (or weakness) of laws and their enforcement will never replace the therapeutic alliance between patients and those caring for them; the resilience of both parties, patient and therapist, in the face of failures and new beginnings; and the exercise of compassion and serenity.

Respect for human beings’ individuality and self-determination, even for those whose self-esteem and free will are jeopardized (due to disease, extreme poverty, or other conditions placing them at a disadvantage to others) are lessons from classical and modern liberalism and constitute inalienable rights.

As proposed by John Rawls ²⁰20. Rawls J. A theory of justice. Cambridge: Harvard University Press; 1999., equitable rights, which he defined as absolutely basic and indispensable, equal opportunities, and active promotion of the interests and rights of the most vulnerable members are pillars for any society that aims to be just and democratic.

References

Publication Dates

History