09/27/2011 06:06 pm ET Updated Nov 27, 2011

Banning Psychoactive Substances -- Well, Except for Those We Like

I debated Neil McKeganey in Glasgow and Edinburgh last Wednesday and Thursday. (You will be able to see the Edinburgh debate here.) Neil has become the spokesperson for denying the value of harm reduction and drug policy reform in the UK. I am known for the opposite position in the United States.

In the UK, harm reduction is the status quo among public health professionals, researchers and most clinicians (although the same is not so true for elected officials and the general public). In the U.S., the goal of abstinence from drugs and alcohol as the only solution for addiction and substance abuse is almost universally held by treatment personnel (who nearly all follow AA's 12 steps); it is the emphasis of researchers like those at the National Institute on Drug Abuse. (Note that the "drug abuse" as part of the NIDA's name rules out the idea that any use of drugs can be benign or permissible.)

In fact, the audiences at both places (the University of Strathclyde and Edinburgh University, where the 12 steps are not pervasive, as they are at American Universities) were more on my side.

Despite our being opponents in a debate, Neil and I are not diametrically opposed on several critical issues. Among these are: the need for abstinence in recovery, whether people can recover on their own and whether addiction is a permanent state. These are three of the keystones of the disease model of addiction endorsed both by the 12 steps and the NIDA.

Yet, Neil's positions are closer to mine than to disease advocates' positions on all three of these: He accepts that non-abstinent recovery is possible, he just prefers abstinence and believes it is more conclusive. Neil also recognizes -- as do I -- that recovery without treatment is the most common type of recovery. Finally, Neil emphatically believes that people can overcome addiction. Indeed, Neil's primary objection to harm reduction (HR) is that he rejects the idea that -- since addicts can never recover -- they can at best aspire to some form of palliative care (e.g., methadone maintenance). I am on exactly that same page, both in regards to methadone maintenance and in my general position towards treating addicts.

I believe that people regularly overcome addiction and alcoholism in the course of their lives. For me, treatment is a matter of accelerating the more-often-than-not natural process of recovery and of having people relinquish the self-concept of being a lifelong addict or substance abuser.

That Neil and I are fairly close in our attitudes towards these questions says something about Americans' views on addiction. (I should also note the generally civilized tone of the debates and of the audience participation in Scotland -- much more so than what characterizes similar debates in the U.S.)

Where Neil and I disagree most distinctly is in our views on the possibility and preferability of abstinence. Neil feels that society and treatment should both make total abstinence their primary goals. But I don't think the evidence indicates abstinence is a viable society-wide solution. I believe people are often slow to achieve total abstinence, and don't really have to in order to recover; and I don't see abstinence as an especially worthwhile state in and of itself.

Neil places a moral value on abstinence. I, on the other hand, place a moral value on three things concerning substance use: maintaining one's health, avoiding anti-social behavior and self-determination. It is important to me that people avoid harming themselves and others. It is equally important to me that they choose their own approach to substance use. Indeed, this is to me essential in recovery. My personal value system obviously allows for only non-harmful substance use.

Neil rejects abstinence in one specific area. Meeting at reception at a BBC radio show where we did the morning of our first debate, I mentioned to Neil that I was proceeding on to Denmark to give some workshops. Neil then complained about the high price of wine he had encountered in Denmark due to the heavy taxation of alcohol in Scandinavian countries.

So, in the second of our debates (in Edinburgh), I asked Neil, "Why is it that you make an exception for wine in your desire for all of the UK to abstain from intoxicants? And how do you approach the topic of drinking with your young teen daughter (whom I had met at the first debate in Glasgow)?"

Neil's answer to the first question seemed a bit fuzzy to me. He mentioned something about people drinking too much, while claiming that they were only moderate drinkers. But not him. (I can attest that Neil is a moderate social drinker, since we ordered two bottles of wine for the four of us at dinner in Edinburgh, and we didn't finish both.)

As to the second question, Neil was more definitive. "I'm not naive. I know that young teens are going to go out and drink. So I want to introduce my daughter to safe drinking practices at home, in a controlled environment." But isn't that harm reduction?