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Drugs and the Whole Person


Whole Person
New Approach

The following is excerpted from an interview by Drs. Molly T. Laflin and David R. Black that was published in the American Journal of Health Behavior (vol. 28, #2, pp. 180-188) in 2004. The full interview may be found on the journal's website at

Author of 5 books, 20 book chapters, and more than 150 papers in scientific and professional journals, Prof. Duncan is a prolific researcher and scholar. The primary focus of his research has been on drug use and abuse, a field in which he was a pioneer of the harm reduction approach and co-originator of the self-medication hypothesis of the addictions. The diversity of his research in other areas has led to his making contributions in virtually every area of health education.

His career has alternated between work in research, clinical, educational, and public policy positions, often holding more than one position at a time. Living in Bowling Green, Kentucky, while recuperating from some serious health problems, he currently operates Duncan & Associates -- a small research consulting firm. He also teaches two web-based courses for Brown University Medical School and is one of the directors of a primary care center serving the health care needs of the poor in his medically underserved area.

Editors: How would you describe yourself?

Dr Duncan: I tend to do what pleases me rather than what people say I should do. I guess that makes me a maverick. I don't strive to be different for difference sake.

This often leads me to take positions that differ from my colleagues, so I am often the odd man out in a group. I'm much more interested in finding the truth than in pleasing people. I'm willing to question virtually anything. I'm very liberal, but I'm not politically correct. I don't believe people should unthinkingly follow an approved political view or ideol¬ogy.

Editors: How have these priorities affected your career?

Dr Duncan: I dont think my choices have had a devastating impact on my career, but certainly I've made less money. I have on more than one occasion quit a job that was paying a good salary to accept a position that paid less, but offered the opportunity to pursue some¬thing that I found more interesting. I have made choices my entire life that weren't fiscally sound, but fit my inter¬ests. I'm sure some people would say, "Gee, you may have an excellent publication record, but financially, you passed up a lot of money." True, but finances and material goods have never been a big motivator for me. I am quite satisfied with the choices I've made. If money and glory were top priorities, I'd probably be working for a pharmaceutical company.

Editors: How did you become interested in the area of substance abuse?

Dr Duncan: Early in my career I worked for the University of Kansas' Bureau of Child Research. I had become interested in a Skinnerian behavioral approach, the approach used by one of my professors and emphasized heavily at the Bureau of Child Research. While I was working at the Bureau, the Kansas state legislature passed a law that heroin addicts had to be treated in the state hospitals. I believe they allowed one series of outpatient treatments in a medical facility. If a person failed outpatient treatment, the only op¬tion was commitment to a state hospital. A number of people in the medical community who were involved in substance abuse treatment felt that this was a horrible decision. Some of the physicians, medical students, and a few others at the University of Kansas Medical Center formed a group to work outside the system to help heroin addicts who wanted to go through withdrawal and receive psychotherapy without being committed to the state hospital.

I became one of the volunteers who helped heroin addicts go through cold-turkey withdrawal. We used to take the addicts to a house on a lake owned by one of the professors and stay with them while they went through withdrawal. That was my introduction to the substance abuse field.

At the time, my career plans were in criminology. As I continued to work in criminal justice, I found substance abuse to be a recurring theme. As I became more disenchanted with the criminal justice system and its inability to achieve positive outcomes, I gradually moved into substance abuse work.

Editors: What motivated you to focus on caring for addicts?

Dr Duncan: My caregiving tendencies come from my parents. They were very caring, nurturing people. They believed in helping their neighbors, helping anyone with problems, and assisting the handicapped. They modeled care and nurturance; it was a major part of my life and an expectation in my family.

Editors: What is the process you use to come up with a research idea?

Dr Duncan: Research ideas often arise during the course of conversations and discussions with other people who are interested in the topic. The discussions focus on, "we dont know X' or "it would be valuable if we could figure out how to do Y." Sometimes, it's a case where we're dis¬cussing an issue, find something we all have always agreed upon, it seems obvious, but no one can think of any actual proof that it's true.

New research ideas are often the result of a social process, which for me involves a conversation with scholars -- sitting down with colleagues in the lunch¬room or over coffee, or attending a scholarly meeting and then going to dinner with several people afterward. This social approach often leads to collaborations, and I frequently wind up working with someone in that group.

Editors: What attitude is needed to be successful?

Dr Duncan: You cant be afraid to put your "neck on the line." For example, I'm not afraid to share an idea that may disturb or upset people. Although I'm willing to forcefully share my ideas, I'm also a good listener. Despite the fact I'm a big talker during most of these meetings, I do more listening than talking. I think you do more learning when you're listening instead of talking.

Editors: Have you always been self-confident?

Dr Duncan: I think my self-confidence comes from my home and family life. My parents expected us to be confident and to be able to deal with a variety of challenges. They placed faith in our good judgment. They wanted to know what we were doing, but they didn't tell us necessarily what we ought to be doing. Not that they didn't have rules, not that there wasn't guidance, but a lot of the time we had substantial independence to do what we chose. That helps build self-confidence.

When I was 14,1 moved to a bedroom my father had built in our furnished basement. The basement had a back door, so throughout my teenage years, I could leave the house in the middle of the night if I wanted, and nobody would know. I had a great deal of independence and was practically living in a separate apartment. Having that sort of independence, and the fact that my parents trusted me and were confident that I wouldn't misuse that independence, helped to build self-confidence and instill a willingness to take chances and to value unorthodox approaches.

I believe strongly in letting others make their own choices, not judging people, and giving them freedom of action. I believe in the old slogan "I hate what you say, but I'll fight till the death for your right to say it." I'm committed to that.

Editors: Do you have a favorite research project?

Dr Duncan: Yes, and it is what I sometimes describe as a unicorn study. There's a general assumption that there is no such animal as a unicorn. All you need to disprove that theory is find one unicorn. The unicorn notion can be applied to the substance abuse field. In 1997, we used the Internet to survey the hidden population of illicit drug users - as distinguished from drug abusers. The study had serious sampling limitation, and presented interpretation challenges and difficulties in establishing how much confidence to place in the data. Despite the methodological challenges, it addressed interesting questions and had important policy implications.

There's a general assumption, for instance, that everyone who uses cocaine is a cocaine addict. We surveyed hundreds of cocaine users who weren't addicted. This raises serious questions about the assumptions used in the development of public policy regarding cocaine. We used questions based on the SCID questionnaire for the Diagnostic and Statistical Manual of Mental Disorders to rule out a diagnosis of substance abuse and questions from the General Well-Being Schedule that the Census Bureau developed for the National Center for Health Statistics. I'm particularly interested in some of the analyses of the subpopulations, particularly parents. We asked if their children knew about their illicit drug use and what concerns they had regarding their children. This line of research has been extremely interesting to me, in part because epidemiologic data have clearly indicated for decades that most drug users are NOT abusers. These data didn't have a human face, so many rejected this fact out of hand. There was no description of who these people were. We wanted to learn more about nonabusive users, successful users, or whatever you want to call them.

Editors: What is it about this study that captivates you?

Dr Duncan: This study is really fun because we're dealing with the challenges inherent in exploring a new medium. We're not the only people using the Internet for surveys, but ours is one of the largest and one of the pioneering ones. I think what we are doing is similar to the early use of telephone surveys. At that time, there were many people who didn't have telephones, so telephone surveys had an inherent bias. Today, males are overrepresented on the Internet, as are the well educated. This bias has been declining over time. Dealing with some of these complications is exactly what I find interesting.

Editors: How do you address confidentiality?

Dr Duncan: Initially we exchanged e-mail with people in order to provide them surveys, and then moved to the website-based version we're running now. We don't ask for names and don't keep records of their e-mail addresses. The first page provides instructions about how they can use an anonymizer that will keep them from being linked to the site. If they want to do that, they exit our page, go to the anonymizer, which is a free service, and log on it. It logs onto our page, scrambles their identifier, their IP address, and allows them to fill out our form completely anonymously.

We're using qualitative analysis methods when we invite people to express themselves in their own words, and are conducting a content analysis study that also has been interesting and challenging. This is a difficult type of study to do.

Editors: What research issues do you feel are important to the profession?

Duncan: Most health behavior research is content specific with too little focus on the motivations and processes involved. We still don't have an adequate model to deal with health behavior -- the health belief model is incomplete and PRECEDE is not empirical. Research that gives us a fuller view of tie process of shaping human behavior is one priority.

In the realm of drug research, we don't know nearly enough about how knowledge, emotion, attitude, and desire affect behavioral choices. We don't understand what determines who will become users versus abusers. We don't know what role culture plays in determining drug use and abuse.

Perhaps a good place to start is to look at the functions that drug use performs -- what roles do peer pressure and pleasure play? Another interesting fact is that moderate alcohol use is healthy for us. If this is so, is it the same for illegal drugs? Should we promote other ways to get the same effect or accept moderate use?

We need to focus on policy and evaluation and examine very carefully the efficacy of treatments. There is little evidence regarding treatment effectiveness. Even less on policy approaches. We still need to know what approaches work best: decriminalization, legislation, prohibition, or other innovative approaches.

We need to do more research and model building on what brings about recovery from addictions. It is interesting that Most people "get over" addiction to illicit drugs without need for treatment - it's called "maturing out." We need to figure out what we can do to facilitate this process.

Editors: What are you most proud of in your professional career?

Dr Duncan: I take the greatest pride in helping create the Rhode Island needle exchange, getting it working and approved, and what it has accomplished for AIDS prevention. Doing something that I feel saved lives is important to me, along with working with talented people who have similar commitments to helping others.

Editors: Do you ever reread your publications?

Dr Duncan: Not all that often, but occasionally something comes up where I go back and reread something if I'm going to take a new angle on some of the material.

Editors: What's your usual reaction to rereading something you have previously published?

Dr Duncan: I'm usually pleased, although I always find myself thinking the paper might have been better, if I'd phrased i sentence another way or moved a paragraph to another location. No publication is ever perfect.

Editors: How do you respond to the praise you have received during your career?

Dr Duncan: I usually find it embarrassing. Being praised is nice, but it's also a little difficult to respond to. I tend to feel like an imposter.


See Wikipedia's article on Dr. Duncan.

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at the 2007 meeting of the American Public Health Association in Washington, DC

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