DRUGS: HOW CAN WE ALTER MINDS?

Last week former minister Mo Mowlam argued that the war on drugs isn't
working and called for all narcotics to be legalised. In the second of an
occasional series, we asked theologian and former Bishop of Edinburgh
Richard Holloway to debate the issue with Professor Neil McKeganey, one of
Scotlands leading drug addiction experts

RH

Humans have always produced things they liked to ingest because it gave them
a change in mood or a heightening of mood. At what point, from your academic
understanding, did government start involving itself in private habits of
humans?

NM

Well, I'm no great historian, but the change was in the 1960s. Up until that
point heroin, for example, was made available by physicians to a relatively
small number of people in London, and they were people on the artistic
fringe so their heroin use was not seen to represent a problem for society.
But as their numbers increased and as heroin use started to take off in
other parts of the country, people from the provinces would travel to London
to make contacts with private medical practitioners in particular. That was
the beginnings of it being seen as a problem, because the profile of those
individuals was very different to the kind of bohemian types who had been
using heroin up to that point. Heroin was associated with a lack of life
opportunities for these individuals so much more rapidly their drug use
became problematic for them. So it was in that context in the 60s that the
government started to feel they had to legislate. Then that escalated as
heroin use spread from London to other parts of the UK, other urban centres
and principally amongst young, predominantly male, working class, kids whose
drug use is always immediately recognised to be problematic.

RH

But why the assumption that the best way to deal with that undoubtedly
distressing phenomenon was to ban the thing? Go back to the Volstead Act [a
US law, passed in 1920, which prohibited the sale and manufacture of
intoxicating liquors] ... I'm trying to get at the springs of the
prohibitionist approach as opposed to other ways of managing it, because it
doesn't automatically follow that because a thing is dangerous it would
automatically get a blanket ban put on it.

NM

Well, I think it was in part a recognition that treatment was pretty
ineffective. Once you have people using heroin over a long period of time,
getting them off it is extremely difficult, but that's not so much a society
problem where you've got a very small number of people in that situation,
because you can continue medically to make heroin available to them. Had
heroin abuse been confined to numbers in their hundreds, from the artistic
fringe of society, we would never have seen the imposition of common
legislation that we have actually seen since that time. The imposition of
that legislation, the decision to ban it, I'm sure in a way arose out of the
expansion of the number of people, and the knowledge that a much greater
number of people would be come addicted.

RH

I can see there's a problem dealing with addicts, what I'm trying to get at
is why the automatic assumption is that the best way to deal with this
situation, which manifestly has not dealt with it, is to outlaw it? I mean
alcohol clearly was a problem and still is a problem, the temperance
movements, the Just Say No campaign. They tried this massive social
experiment in the US that in fact simply industrialised and criminalised the
production of the drug that they decided to outlaw. Its the kind of
philosophy behind that thinking I'm intrigued by.

NM

That is not well understood. But I think from a philosophical point of view
the inclination to ban arose out of a recognition that once someone has
become addicted there is very little you can do to get them off it. So
whereas with alcohol you can have people using it in largely non-problematic
ways for many years, only a small proportion of whom become addicted, the
theory in relation to heroin is that anybody using it over a relatively
short period of time is going to become addicted to it.

RH

Are there no people who manage their use of heroin in a way that doesn't
addict them, or even if it does, they manage it in a way that a lot of
cigarette smokers do? I mean that's highly addictive yet they manage it. Why
is the addiction thing itself a trigger for a particular policy? I mean, the
biggest addictive drug in Scotland is tobacco and we haven't outlawed that,
maybe because we realise that it would be just plain stupid to try.

NM

I think that its very difficult to say why do something with one drug and
not with another. You say, well, rationally if you adopt a policy
restricting one drug why does that not carry over onto another drug? And I'm
sure that in part that decision isn't totally rationally based. The fact
that cigarettes are marketed, that they are legitimate product and generate
a huge amount of profit even at enormous personal ill health. But the status
of that product, throughout its history, is different to heroin which is
seen very rapidly to lead to addiction, and very rapidly to expand in the
numbers of people using it. Heroin is associated with much greater dangers
in terms of personal degradation. So I think in that context its
understandable.

RH

Take sex for instance. That's a pretty dangerous drug, its an essential
human activity, its very difficult to give it up all together. Why most
people would have some kind of policy, for instance with youngsters, is
because we want to encourage them in safe and responsible sexuality. You may
try campaigns for celibacy and just say no, but most realists would
recognise it isn't going to get you very far. You could say in a sense that
since they banned heroin its use has exploded.

NM

Well, its use certainly has exploded since they banned it. I wouldn't
personally say the expansion of its use is inherently because it was banned.
I think I would actually agree with you in that banning it has not been a
solution to the problem because it has continued to expand hugely. Scotland
alone has about 60,000 addicts. Now, 10 years ago we would not have put the
number anywhere near that. You might say, in that sense, the sheer increase
in the number of addicts in Scotland might suggest the policy of banning it
hasn't worked, which it hasn't. But you must ask what would have been the
level of heroin use were it to be much more freely and easily available than
it currently is.

RH

In Mo Mowlams piece in The Guardian [last Thursday] she called for the
legalisation of all drugs because she thinks the war on drugs isn't working.
Do you believe it would be possible say, if we legalised all drugs, to have
a safe way of marketing heroin for people who wanted to use it the way
people use cigarettes? Taken that there will always be dangers, and there
will be some people who will not manage it well. I'm a drinker, I like
alcohol but I'm not an alcoholic, but I know that a given percentage of the
population will be ruined by alcohol, that still doesn't add up to an
argument for banning it for the rest of us.

NM

No, I can't, and to me that is a nightmare scenario. If one envisaged, for
example, the numbers of people taking heroin in the same way that people
smoke, I think that is a nightmare scenario where you've got hundreds of
thousands of people on daily doses of heroin.

RH

Is it invariably catastrophically addictive? Is there no way of managing it?
Is there a percentage who get catastrophically addicted and a percentage
that manages it?

NM

Well, we don't know that. There are very few studies that follow people who
actually started using heroin who have not gone on to experience troubles
with it. So you couldn't say, for example, that 15 or 20% of people who
start on heroin could continue to use it in a controlled way without any
major ill effects, because we don't really know that. But what we do know is
that all the indications are that very rapidly after people start to
experiment with heroin they become addicted to it. They wake up one day,
experiencing physical discomfort and this can happen within a couple of
weeks and they realise the drug they've been taking for the previous weeks
that they thought they would be able to control their consumption of, and
not become addicted to, they actually are addicted to it. The rest of that
day is focused on getting access to the drug that they are desperately in
need of. It would be a huge gamble to say, well lets legalise all drugs
because there are some people who can use it in a controlled way with no
major ill effects, when we recognise that there are hundreds of thousands in
the UK, tens of thousands in Scotland, who are already using heroin to major
destructive effect on their lives.

RH

How much of that, however, is related to other social pathologies? I mean,
if you are a no-hope kid in a sink housing estate its an obvious way out.

NM

Well that's why I think the legalisation argument is a counsel of despair.
Heroin is not the way out for these kids. We know most of the problems
associated with heroin addiction are concentrated in the areas of multiple
deprivation.

RH

So its a symptom of deprivation?

NM

Its a symptom and a cause. Its not simply a reaction to the awful
circumstances and the absence of life opportunities for these young people
in these areas. It in itself is the cause of the destruction of those
opportunities. To my mind, it makes an already desperate set of
circumstances much worse than it would otherwise be.

RH

But then you add to it by criminalising their attempts to escape from the
awfulness of their lives. What about decriminalising as opposed to
legalising, and having a policy of actually prescribing for heroin addicts?
Its been tried in various places with some success, like Switzerland, where
you manage the addiction and accept the fact that they are on it and its
better to manage it with the state subsidising it rather than having these
rather criminal impulses, the need for the next fix, handled in a privatised
way and feeding into criminality and prostitution in a devastating way.

NM

At the minute 2% of 15-54 year olds use heroin in an addictive way. You
could say, would it not be a better response to that two percent to legalise
heroin?

RH

No, I said decriminalise and develop medical management.

NM

I've always felt there's a degree of sophistry between legalisation and
decriminalisation. Whatever the different definitions, they are both giving
a clear message to people that this is not actually a particularly dangerous
substance. If you want to use it we will actually assist you in that regard,
we will actually tell you where to go to get heroin, well tell you what
strength it is, well provide you with a setting in which to use it, some
people may become addicted to it, and then we have a problem because were
not actually sure how to get you off it, but never mind, we actually helped
you up until that point, and you wont have been criminalised in that
process.

Is that a better alternative? My own feeling is that it isn't.

RH

I take danger as a fact. I don't think that danger is sufficient criteria
for banning a thing. I mean if danger was a criteria for banning something
then we wouldn't drive, we wouldn't mountaineer, we wouldn't smoke
cigarettes or eat fish suppers.

NM

Well, what if heroin use is much more dangerous?

RH

Are you saying there is no safe use of heroin at all?

NM

No, no, I'm not saying that. I'm saying we don't fully understand if there
are some people who can use heroin in a safe way, but all the indications
are from the people who we do know are using heroin, if it was prescribed
medically, they'd get into considerable of difficulty. Now if you add into
that the profound lack of life opportunities, then heroin is grasped
enthusiastically not as a way out, but as a way of escape.

I'm not saying there are no people who can use heroin in a way with no major
adverse effect. There probably are those individuals. If you moderate your
use of heroin, you use it at one point, you have a sufficiently long period
between that point and the next point you use it, you can, in a highly
confined way, avoid the development of an addictive dependence on that drug.

Heroin use is a largely clandestine activity. These people will not be
accessing heroin in an observable, public way, they wont be displaying that
to people like me. I personally feel is it not more appropriate to face the
dangers we know about and to develop policy in the face of the dangers we
know about heroin than to actually construe a policy on the theoretical
possibility that there is a small number of people who can use it without
any ill effect.

RH

Do you think existing policies are achieving that?

NM

No. I think the overwhelming evidence is that the drug problem in Scotland
is getting worse not better.

It seems to me no matter what level of investment into criminal justice
services and treatment you have made, you will never actually scale down the
size of the drug problem we are facing, until we find an effective way
basically to attack poverty. I don't think we show any great indications of
doing that, even despite millions of pounds targeted into urban
regeneration.

RH

It seems to me you are going in circles here, because you are saying we
don't know yet if it were decriminalised if you could have a kind of
moderate use, or whether it is intrinsically catastrophically addictive.
I've read a little, some drug experts who say heroin is not all that
dangerous a drug compared to some others, but I don't know, I'm just a
newspaper reader. If the only weapon you have in attacking the no-hope
situation these kids get themselves into is to add to their problem by
criminalising them because of the very need they have developed, rather than
moving in a direction that took some of the intensity out of the law,
without necessarily legalising or decriminalising, but applying criminal
justice budget to poverty rather to the war on drugs, which is incredibly
expensive and not very successful, is it not worth experimenting with
approaches in that direction?

NM

Is it worth experimenting with peoples lives? That's the question.

Take the people living in Castlemilk, Drumchapel and Possilpark, in what way
do you feel the lives of those individuals would be improved by legalising
heroin?

RH

I'm not so sure I want to make that jump. What I want to do is lift the
pressure of the criminal justice system of them.

I'm not necessarily saying that I have the new approaches, but I do think I
have a right as a citizen, as an interested person who happens to be
interested in the way poverty stunts people, to say when you are digging a
hole and you are not actually striking oil or hitting gold, the best thing
is to stop digging and have a radical rethink all round the subject.

There are, it seems to me, some places where they have experimented with
giving people prescriptions and they've helped people manage their habit in
less catastrophic ways and even managed to help them down a level of
addiction, sometimes right out of it. But they've certainly enabled them to
live lives in the rest of the community.

NM

But if you go down that way, which a number of people do advocate, of
providing heroin to people, providing a place where they can inject, at some
point along the line they are going to say: I don't want to do this anymore.
I don't want to actually be going along to this room three to four times a
day to get my heroin. I would rather start to get my life on some sort of
stability. And then you say to them: Well, actually sorry, what we didnt
explain to you at the time was, we don't know how to get you off heroin. We
know how to get it to you in a way that will actually make it less harmful

RH

And don't we know how to get people off it? Are there no systems? I mean,
what about the Swiss experiment?

NM

Well, that's far too early to generate information on how to get people off.
That is an experiment about, are there ways that we can actually better
control the addict population? Are there ways to get heroin to them that
doesn't cause them quite the same order of problems that addicts experience
in other countries? That is not about getting them off addictive substances.

RH

The profile of heroin addicts in Scotland, is it invariably people who live
in dreadful, stunting poverty or is there a middle-class trench there?

NM

I suspect there is. I sat in a chemists shop years ago to speak to people
who were buying needles and the chemist said to me: Just come along and sit
in the shop and you'll see who comes in and buys needles, and you can ask
them if they'd agree to be interviewed. I did go in there thinking, well Ill
spot pretty soon who are the addicts because they are people I have seen in
my day-to-day work. I actually was surprised at the range of people who were
going in to buy needles, because in many instances they weren't people I
would have spotted straight away as people who are going home, heating up
their heroin, sticking it in a needle and then injecting themselves. So that
was, to me, a pretty surprising recognition that the range of people using
heroin in society is actually much broader.

RH

Well, why hasn't more profiling been done? Is it because the criminalising
of the thing makes it very difficult for the people who are managing it and
living with it to come out and say: Look here I'm coping with it, but I
happen to have a job, and I support family and I shoot up at night, at
weekends or whenever. We don't know, do we?

NM

No, we don't, and I think the reason we don't know is actually not very
difficult to find. The Scottish Executive recently estimated the cost of
illegal drugs, the amount of financial resources targeting illegal drugs, is
something to the order of 330 million a year. That was a few years ago, that
estimate. Its almost certainly gone up to nearer 400m a year. The amount of
money allocated to research on drug abuse is around about half of one
percent. So 99.5% of our drugs money, the money directed at tackling the
drugs problem is somehow being directed on the basis of getting people to
stop taking drugs instead of finding out who takes them and why. We don't
know [if heroin can be managed] because we invest so little in actually
taking the time to actually do the work to find out. How can you tell in a
way that is not problematic?

RH

If the health service managed other medical procedures on the basis of that
particular template

NM

The US government internal audit office recently criticised the US
government for spending 10% of its drug budget on research on understanding
the nature of the drugs problem. They said that figure should be increased
to at least 15%. My response to that is, if you think its hard on 10% they
should come here where were trying to get by on half, or up until very
recently a quarter of one percent. These are decisions that are taken at a
pretty high level, but I think the mindset which permeates the way we tackle
the drug problem is a crisis management mindset, which says: This problem is
so enormous anything we do needs to be done. We can't take the time to try
and understand this problem, we've just got to try and do something about
it.

RH

That must betray something else. It can't just be crisis management. It must
be some deep, underlying, prejudiced assumption here; this is such an
intrinsically evil business that the only thing to do is drop bombs on it.
Its the moralisation of the thing that I think is the killer here.

NM

Well, I don't think they die of morals. They die of a range of things, but
its not morals.

RH

But they do die of morals.

NM

You are absolutely right that there is a moral dimension here, I would not
try to take that out of the equation at all. Although, I think the
government, for reasons to do with morality, are profoundly uncomfortable
with the image of hundreds and thousands of people, potentially, getting
involved with heroin, their lives ceasing to be productive both in an
economic sense and in a human sense. There is a moral position they do take
up on that. They do not want to see that scenario. I don't want to see that
scenario.

RH

Nor do I. Nor do I want to see young lassies crawling the curb sides of our
cities in order to sell their bodies to feed their habit.

NM

Well, I don't think we differ greatly. It seems to me that what you want to
say is: Take away the yoke of criminality from these young people who are
getting into drugs, and in a small way make their life a bit better. Target
some of the money which is saved by that process to rebuild these
communities. That seems to be your scenario. What I'm saying is, rebuild
these communities and then address the drug problem.

RH

Now I think I'm actually a further step back from that. My own instinct is
the moral one, that you can't make a policy work that forbids people to do
what they are hell-bent on doing anyway. But if it were working, I might be
persuaded.

NM

But you feel our current policies aren't working. If I said to you there are
just 2% of the Scottish population addicted to heroin. Now, you might say, I
thought it was higher than that. But that means 98% of the population are
not using heroin.

RH

But those 2%, I think most people probably don't care too much about them
unless they happen to be their family or people like you. What I'm saying
is, if we had a more rational approach and did really serious, well-paid
research we might come up with other approaches that might work better.

Do you think that the 98% are not on it because of the governments policies?

NM

No. What I do feel is that our current policies do not well serve the 2% who
are on heroin and are in profound difficulty. Now I don't see the answer to
their problems is to find ways to make heroin more available to them.

RH

And also in many ways, is probably the only decent job going, if you can
actually get into dealing it.

Can we look at other substances that are less catastrophically addictive,
and I'm not saying that any of them are not dangerous. I don't think that
that itself defines a valid moral response. There are many things that are
dangerous. But a greater danger, it seems to me, is to limit human freedom.
I would rather have the dangers of freedom than the dangers of coercive
order. And I'm thinking of the drugs that are lower in the classification,
such as pot. I know its dangerous. I know it can do weird things to people.
I also happen to know most young people who use it manage it reasonably
well. It may for some be a gateway. But by what philosophical moral right
does the government have to dictate to me the particular euphoric substances
that I choose to ingest, provided they are not at the catastrophic level?
I'm still not persuaded by you, but I think there is a big quantitive,
qualitative difference here.

NM

Talking about cannabis, I think I have to accept there is a dubious moral
right to ban cannabis. In fact when we looked at the most recent Scottish
social attitudes survey, it is now evident that more than half of people in
Scotland would want cannabis legalised. So the moral case for keeping it
illegal is highly questionable, in a situation where pretty darn close to
half the population say this isn't a drug we think presents much major
problems, and we don't think should be criminalised, and we don't think that
we should be criminalised if on occasion we want to smoke it, and we don't
think our children or indeed ourselves should be needing to contact people
involved in drug dealing to access this substance. So there is, without any
doubt, a change in public attitude towards cannabis and that question the
morality of maintaining it as an illegal product.

RH

Do think the subtle shifts in the governments policy towards being found to
have a small quantity of cannabis on you, is helping us move towards a
rational approach, or are they muddying the waters and confusing people?

NM

It depends what you mean by a rational approach. In the one sense, yes. We
know enough about cannabis to know it is nowhere near as dangerous as
heroin, or is nowhere near as dangerous as it was once thought to be a few
years ago. So if you attempt to reclassify cannabis in a way like the Home
Secretary has clearly said he wants to do, that is a reclassification based
on the research and clinical evidence that shows cannabis is not as
dangerous as many people think it is. And in that sense it is rational. But
if you are saying we can embrace it enthusiastically because it looks like
one of those rare occasions when there is an element of rationale in drugs
policy, I would agree with that, although I would say there is also a
danger. It is not necessarily a rational danger, but its nevertheless an
important one, which is that you are by token, by that reclassification of
cannabis, giving out the message that its a less risky drug. Its a message
founded in the research that its a less risky drug than it was previously
thought to be. You may then see an increase in the number of children
starting to smoke cannabis. Smoking cannabis obviously, the smoking and the
cannabis, both carry risks. So you might see there is a downside to this
apparently rational policy, that actually more children start to smoke
cannabis than was previously the case. And in Scotland we have a higher
number of children smoking cannabis than any other part of the UK and most
other parts of Europe. When I speak to Dutch colleagues and we talk about
doing surveys with schoolchildren to measure the levels of cannabis use,
they often found something around about 10%. And they say, what do you find
in Scotland. I say, we find by their mid-teens 40-50% of children smoking
cannabis. They are absolutely horrified. They say we would never even have
imagined that there would be people dealing with that level of cannabis use.
My response then to the policy of reclassifying cannabis is, I accept it is
not as dangerous as many people said it was, but in what sense is that
policy tackling an already high level of cannabis use that we face in
Scotland and in other parts of the UK. It doesn't seem to me at least to be
a route to reduce the extent of cannabis use.

RH

Can you not be neutral about whether people smoke it or do not smoke it? You
may disapprove of the fact that 40% smoke it in Scotland instead of 10%, but
if it is their choice to smoke it then There are lots of things that people
disapprove of. A lot of people disapprove of gay sexuality. It took us a
hell of a long time to get the country to realise that people have the right
to make private choices, sometimes dangerous private choices. But upon what
right the government takes upon itself the duty of policing private choices?

You may also find the forbidden fruit syndrome kicks in here. Its very
dominant in Scotland. Its no accident the most puritanical part of the
country has the highest rate of teenage pregnancies. There is a clear
connection here. If you normalise a thing you can then have sensible
educational policies about it. You can tell people: These are dangerous
substances, but there are ways you can use them more safely. Sex is
dangerous business, its also pleasurable as are some of these other things.
Lets have a sane, non-emotional policy about it. We want our young people to
live wisely and prudently. You can't even talk about it in our culture.

NM

Now, when we interview children who are not using cannabis, which is
something that we do, we ask them to describe a situation in which they have
come across cannabis. One of the things that they say is they often
experience great difficulty declining cannabis. They don't want to get into
it, but they often feel pressured by the offer. Some of those children say
they don't want to get into it because it is actually illegal at the moment
and I don't want to get into something that is illegal. To those children,
it seems to me, the illegality of cannabis, even if it is accepted as being
irrational, is a way for them to decline offers of this drug. The risk is
you take that away, you take away one of the devices children use not to get
into this drug.

RH

But do you think that admittedly potent, but on the whole fairly singular,
justification adds up to enough of a criteria for an outright banning of the
thing? Kids make bad choices. Kids make bad choices in relation to alcohol
which in many ways is an increasingly difficult problem with youngsters.
That's already a legal drug and there are many ways in which they can in
fact access it at a certain age. Would it not be better to take the moral
momentousness out of this thing and acknowledge that these are dangerous, to
classify them at a licensed premises, to make sure you have proper
surveillance on the quality of the stuff that they are getting, and let
human beings make their choices, and some of them will be ruined by them?

NM

There is a lot of popular public support for that. The question of should
people be free to make the choice to use whatever drugs they wish is an
important one around discussions involving illegal drugs. Its an issue which
one can't wholly set aside from what is known to be the dangers of those
drugs. You could say, if people choose to partake in something that is
hugely risky then that's their own free will. There are huge consequences of
that. It is a stronger argument in relation to heroin, if someone dies of an
overdose then somebody is orphaned in that moment. So the potential costs go
way beyond the individuals. They are also creating considerable difficulties
for others who are dependent on them. The vast majority of addicted drug
users in Scotland are parents. But that isn't an argument you can apply to
cannabis. No one dies of a cannabis overdose. My only worry in relation to
that is more in terms of children. How do you police this drug so young
children don't get access to it? If you look at the two other drugs that are
legal, that we've attempted to reduce children's access to, we've failed
absolutely miserably. Children in Scotland have absolutely no difficulty in
accessing cigarettes. We have major problems with pre-teenage alcohol
consumption and smoking.

RH

If we were in a different culture where tobacco and alcohol were not legal,
say an Islamic culture, would you be applying these arguments as to the
maintenance of the ban on alcohol and tobacco, given that tobacco is
probably the most dangerous of the things on offer?

NM

We recently had a researcher from Saudi Arabia looking at people getting
into difficulty with alcohol in the country. One of the things he found was
that a very high proportion of those people were also using heroin. If you
go to a population in the UK of people who have a drink problem you will not
find they are awash with heroin problems. They are entirely different groups
of people. In Saudi Arabia they are getting into difficulty with alcohol,
and they are also getting into difficulty with heroin. So it is an open
question as to whether that is because heroin, alcohol and tobacco have the
same illegal status in the country. I don't know the answer to that, but
there is a genuine question there. Are you creating a problem by maintaining
the illegality of those substances?

RH

Mo Mowlam makes a point that some of the drug cartels have economies larger
than Spain. It seems to me that globally the negative effect on the human
community of the war on drugs, I think, is much more impressive and
formidable than any gains that have been made.

NM

But I want our leaders to have some more imagination as to how you tackle
poverty than to actually say decriminalise drugs. I don't see the road to
regenerating communities is to say: Lets legalise drugs.

RH

Part of the problem with politicians is they get into systemic mindsets
where they are not allowed to think outside the box. I don't have a
confident policy here, but what I think we need is the ability to look at
all options and to think our way through them. You've already hinted at the
fact that the research aspect of the drugs budget is derisory. We know that
what we are doing isn't working, are there things that might work better,
that we might come up with if wed more money to apply to them?

NM

Well, it isn't working and the drugs problem in Scotland is getting much
worse and we are now seeing crack cocaine, something which has been talked
about for many years but which was not actually being seen to be used in
Scotland. In the areas where crack has become a problem, it has become a
major problem associated with violence, sexual risk taking. That's just a
marker of how little on top of the drugs problem we are in Scotland.