Estimating drug harms: a risky business

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Estimating drug harms a risky business?

• David Nutt
• Edmond J Safra Professor of Neuropsychopharmacolog
  y
• Dept of Neuropsychopharmacology and Molecular
  Imaging
• Imperial College
• London
• d.nutt_at_imperial.ac.uk

2
Warning

• This talk has been approved by the Home Office
  and so might seriously damage your health!

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What is a drug? and who says?
4

• something given to a rat that results in a
  scientific paper
• Anon

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something a politician once used but now
regrets
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What the METRO says
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What I say
a drug is an exogenous substance that produces
physiological changes
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The present framework
MHRA Medicines Act
Recreational
khat
Psychoactive
alcohol tobacco
Substances
coffee
Home Office Misuse of Drugs Act
solvents
Unregulated sales Food/commodities
Regulated sales Food/commodities
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Many drugs are controlled under both Acts
MHRA Medicines Act
morphine, heroin amphetamines benzodiazepines ke
tamine GHB
Recreational
Psychoactive
alcohol tobacco
Substances
Home Office Misuse of Drugs Act
solvents
Unregulated Food/commodities
Unregulated sales Food/commodities
Regulated Food/commodities
Regulated sales Food/commodities
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The Misuse of Drugs Act 1971
The original intention of the MDAct was to have
a system of relative based harm against which
penalties would be applied (penalty fits the
crime). The Act states that Her Majesty may
make such amendments in Schedule 2 to this
Act as may be requisite for the purpose of
adding any substance or product to, or removing
any substance or product from i.e. changes
can be made as the evidence of relative harm
becomes clearer.
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How the MDAct works
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Recent movements in the Act
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Penalties under the MDAct

• Classes determine penalties
• A B C
• possession 7 5 2
  yrs
• supply etc life 14 14
  yrs
• note 1. having used a drug is not illegal but
  may incur civil and employment penalties
• note 2. penalties for class C supply markedly
  increased from 7 yrs when cannabis was
  downgraded to class C in 2004

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Cannabis a potent problem

• In 2007 the Home Secretary wrote to the ACMD
• Though statistics show that cannabis use has
  fallen significantly, there is real public
  concern about the potential mental health effects
  of cannabis use, in particular the use of
  stronger forms of the drug, commonly known as
  skunk.
• However the PM had said previously
• skunk is lethal
• the use of cannabis is harmful and not
  acceptable

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3rd ACMD cannabis report in 6 years 2008
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What did the ACMD conclude?

• Cannabis is a harmful drug and there are concerns
  about the widespread use of cannabis amongst
  young people
• A concerted public health response is required to
  drastically reduce its use
• Current evidence suggests a probable, but weak,
  causal link between psychotic illness and
  cannabis use
• Harms not considered to be as serious as drugs in
  class B, therefore should remain a class C drug

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Addressing the question - risks

• Odds ratio data demonstrates a probable, but
  weak, relationship between schizophrenia
  incidence and cannabis use
• ever users of cannabis about 2.6 for psychotic
  disorders (inc. schizophrenia)
• the odds ratio linking smoking and lung cancer is
  about 20 (representing a 20-fold increase in the
  likelihood of smokers developing lung cancer)
• The Keele University data indicate that the
  prevalence and annual incidence of schizophrenia,
  and the prevalence of psychoses, have decreased
  (1996 2005)
• Epidemiological data from the UK and Australia
  have failed to show a correlation between
  cannabis use, or THC content, and schizophrenia
  prevalence
• To prevent one episode of schizophrenia need to
  stop 5000 men aged 20-25 years ever using

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Prevalence total cases
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Incidence new cases
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Public opinion on cannabis

• In 2007 the Government launched a consultation on
  the new drug strategy that included questions on
  cannabis
• 1) Do you think cannabis should be reclassified
  and,
• 2) What are you views on tougher penalties
• 639 responses - many personal

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Public opinion on cannabis
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Public opinion on cannabis - ACMD
Ipsos-MORI poll conducted on behalf of the ACMD
for the 2008 review of cannabis - 1003
respondents from the general public Q. What class
should cannabis be? A. Class A 32 Class B
26 Class C 18 Legal
11 Dont know 13 over 1/2 for
increased class
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Public opinion on cannabis - ACMD
Ipsos-MORI poll conducted on behalf of the ACMD
for the 2008 review of cannabis - 1003
respondents from the general public Q. What
should the penalty for possession be? A. (class
A) 7 yrs 11 (class B) 5 yrs 13 (class
C) 2 yrs 41 No penalty
27 Dont know 9 over 2/3 for
status quo or less
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Main conclusions of ACMD poll

• Majority of public aware it is illegal, but not
  which class
• Public believes cannabis is a hazard to mental
  health
• Majority of respondents wished for cannabis to be
  reclassified as a Class A or B substance
• BUT, majority of respondents wanted the penalties
  to be maintained or less.

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Main conclusions of ACMD poll
Public appear to want deterrence not
punishment

• Majority of public aware it is illegal, but not
  which class
• Public believes cannabis is a hazard to mental
  health
• Majority of respondents wished for cannabis to be
  reclassified as a Class A or B substance
• BUT, majority of respondents wanted the penalties
  to be maintained or less.

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Information

• The Government (Department of Health) has public
  health information available via the FRANK
  website and associated literature
• Such websites should inform the public of the
  harms of drugs
• However, there is a
• media bias

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MDMA (ecstasy)

• Put in class A in 1980s ? Why
• - precautionary principle
• - as like LSD (which its not)
• - moral alarm (from the name?)
• - media frenzy
• Not reviewed for 20 years
• - too politically sensitive?
• - pressure from drinks industry?
• - misleading scientific claims of harm?
• Science and technology committee 2007 demand
  review
• - based on Lancet harm assessment paper
• - and their own Rand report
• Home Sec JS states review unwelcome

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alcohol
tobacco
Drug harm ranking
cannabis
MDMA
Nutt et al 2007 Lancet
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What drug users think
Morgan et al J of Psychopharmacology In press
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Media bias
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Dilbert
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Dilbert
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ACMD view

• MDMA equivalent to other amphetamine-type
  stimulants
• 19 recommendations re research and education
• Updated the health advice to users and clubs
• ? class B (clearly less harmful than heroin and
  crack)
• Consider providing drug testing facility for
  users

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What did the Government do?

• The former Home Secretary said in Parliament
• In reaching my decision, I have also taken into
  account the views of others, particularly those
  responsible for enforcing the law, and the public
  
• I have given the councils report careful
  consideration. Of its 21 recommendations, I
  accept all bar those relating to classification
  and testing

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What did the Government do?

• My decision takes into account issues such
  as public perception and the needs and
  consequences for policing priorities. There is a
  compelling case for us to act now rather than
  risk the future health of young people. Where
  there is a clear and serious problem, but doubt
  about the potential harm that will be caused, we
  must err on the side of caution and protect the
  public. I make no apology for that. I am not
  prepared to wait and see.

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The precautionary principle

• If in doubt rank high and penalise maximally
• Protection from the known unknowns
• Act of faith in deterrence
• but higher class may promote interest?
• Can mislead if not based on the evidence
• Could devalue confidence in scientists and
  government
• Cf. MMR

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Precaution may have perverse effects
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Precaution may have perverse effects
the problem is that cannabis is so hard to get
hold of that a lot of my friends have gone
straight on to smack
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Harm Assessment

• On the available evidence

Lancet 2007
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The nine parameters of harm
Harms can be measured ? more scientific/rational
classifications
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The drugs assessed
The drugs considered Alcohol and tobacco
included to give anchor points
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Drug harms

• What are the appropriate comparators?

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Peanuts?

• New Scientist Feb 2009
• Editorial Drugs drive politicians out of their
  minds
• IMAGINE you are seated at a table with two bowls
  in front of you. One contains peanuts, the other
  tablets of the illegal recreational drug MDMA
  (ecstasy). A stranger joins you, and you have to
  decide whether to give them a peanut or a pill.
  Which is safest?
• You should give them ecstasy, of course. A much
  larger percentage of people suffer a fatal acute
  reaction to peanuts than to MDMA.

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Other enjoyable yet dangerous activities?
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The illegality logic loop

• you cant compare harms from a legal activity
  with an illegal one
• why not?
• because ones illegal
• why is it illegal?
• because its harmful
• dont we need to compare harms to determine if
  it should be illegal?
• you cant compare harms from a legal activity
  with an illegal one
• repeats

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Current and future challenges

• GBL and 1,4-BD
• legal variants of GHB
• Spice
• smoking mixture with added synthetic cannabinoids
• Cognition enhancers

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The classification conundrum

• In light of this the current classification of
  drugs could be seen as arbitrary and illogical
  whats an A B or C drug? the experts and
  politicians dont agree!
• Agreement will always be difficult

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A starting point for a way forward?
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Some suggestions - 1

• Improve general understanding of relative harms
• Multi criteria decision making?

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CoRWMCommittee on Radioactive Waste Management

• Position Paper on Research and Development for
  Conditioning, Packaging and Interim Storage of
  Higher Activity Wastes and the Management of
  Spent Fuels, Plutonium and Uranium
• FINAL Document Number 2389 Date 16 June 2009

2 year scientific and public consultation using
Multi Criteria Decision Making Facilitated by
Prof Larry Phillips LSE
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Some suggestions - 2

• Gather evidence to understand the impact of
  changes in classification
• Accept that young people like to experiment
• Protect from harm at this stage in their lives
• Provide accurate and credible information
• Fully endorse harm reduction approaches at all
  levels
• Include alcohol and tobacco as equivalent to
  drugs as in Wales
• Remove the moral argument from the debate

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I was "big enough, strong enough, bold enough"
To accept the truth about drugs? Or to sack
Nutt?
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(No Transcript)
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• In a freedom-loving society no conduct by
  rational adults should be criminalised unless it
  is harmful to others
• (after John Stuart Mill)