Response to readers’ comments on ‘After the flood: twenty one principles to underpin a new approach to alcohol’
14/10/2010 by admin.
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My last blog on how to reduce the damage caused by alcohol consumption received more responses than any other to date. Work commitments have prevented me from responding until now – the below is a collated response to comments made by contributors. I have also updated the alcohol post with added references. This will be the last post at this URL: you can now find my blog at http://profdavidnutt.wordpress.com/.
Q1. “Most of your proscriptions won’t work - Drinking and violence have not markedly increased since 24 hour opening”
A: The data on drinking and associated violence is not as clearcut as that - Police say violence has increased
Q2. “Reducing the drink driving limit to 40mg/% will not reduce drink driving - both Finland and Sweden have a 20mg limit, and yet they both have higher levels of drink-driving than we do. In fact, Sweden has the highest proportion of deaths from drink-driving in the whole of Europe”A: However, as far as I am aware, wherever the limit has been lowered then lives are saved
Q3. “A lot of high alcohol content beers are brewed that way for taste rather than to get you drunk quicker, such as high hop content India Pale Ales and Imperial Pale Ales, doubly so for West-Coast style Double IPA’s. No one has yet figured out how to make an extremely hoppy beer with a low to moderate alcohol content that still tastes good”
A: I take your point, however, most of the high alcohol content larger/beers in the UK have less taste than the lower alcohol ones and are clearly being used by the young simply to get drunk. Indeed, as I said, some of the ciders are not even brewed they are synthetic combinations of alcohol and flavouringQ4. “Raising the drinking age to 21 only way makes sense is if you change the driving ages and age of majority along with it. Otherwise you end up with the same situation as in the US, where young people are not-quite full adults under the law”
A: Agreed – it’s a question of whether you want to save lives or not – but raising the age at which young people engage in risky activities, such as taking drugs, driving or sex, tends to reduce harmful outcomes
Q5. “We should to try and foster a healthy respect for alcohol (and by extension all drugs). They are something adults can enjoy without needing to use to excess. Make alcohol (or drug) impairment an aggravating factor in any and all criminal offences”
A: Agree with the education aspect [my point 16/17]. The aggravating crime idea is interesting - the opposite view tends to be taken currently - I would be interested in a legal view
Q6. “What are your stats on hospital admissions based on?”
A: Hospital Admissions linked to alcohol 65% increase over 5 years to 2008/9 (2010)
Data Dept. of Health
www.nwph.net/alcohol/lape
( lape =local alcohol profile England)Q7. “Why should a 4% can of lager cost twice as much as a 2% can? I can see the logic of a progressive taxation, but this would make wine, that facet of the Mediterranean cafe culture we’re all supposed to emulate, prohibitively expensive”
A: In fact, taxing per unit would not greatly affect the price of wine because that’s what we do currently between different forms of alcohol – wine taxed more because of its stronger alcohol concentration
Q8. “Most things are cheaper relative to incomes than they were in the ’50s. This is a positive not a negative”
A: That why we need new policies to change the trend! Alcohol related harms have increased as prices have decreased due to higher consumption
Q9. “Scandinavia also has problems with drinking, so we shouldn’t emulate their policies”
A: It’s about the population risk – alcohol health damage is less in Sweden, I believe
Q10. “I’ve been to the pub with many ladies over the years, and I’ve often bought them large white wines in 250ml glasses. Not one has ever slumped into an alcoholic coma”
A: But all their livers will have been more harmed than if you had bought them a smaller glassful
Q11. “If organisations such as Carnage UK cause a problem, why not enforce existing laws first?”
A: They encourage harms – not necessary lawlessness – hence regulation simplerQ12. “Alcohol free lager won’t work – the taste doesn’t compare to the regular stuff”
A: Untrue – I like it as do many other people who want beer/lager taste without impairment – and the quality is improving. Many experienced drinkers say they prefer the taste of alcohol-containing drinks because they are conditioned to them by the effects of the alcohol they contained. Indeed if alcohol free drinks were all that were available, I suspect most of us would be quite happy to drink them in preference to water or other alcohol-free alternatives
Q13. “We drink because this is a pressured, unhappy society in part because people think they can and it’s desirable to control the people”
A: Not true – in part we drink because we are subconsciously conditioned to drink by the alcohol in drinks
Q14. “Wouldn’t you see AIDs or Malaria as being more deserving of public funds? Doesn’t this show warped priorities?”
A: Alcohol kills more people per year in the UK than either of these
Q15. “I’m sure there are plenty of people who’d rather a line or two of coke than a pint of ‘ale’, but I suspect that’s not what you had in mind?”
A: Each to their own – assuming the choice is not driven by addiction
Q16. “How would banning of university-linked subsidised drinking be enforced in reality?”
A: Private organisations can do what they want but not with a taxpayer subsidy via the university
Q17. “Having a lower age for frontline combat troops than for drinkers, as in the US, is illogical”
A: Agreed - a more sensible approach would be to raise the age for combat troops
Q18. “Alcohol is already more expensive in real terms (ie. price has exceeded inflation). I think what you mean is you want it to be make it as expensive as it was in the 1950s relative to income. No thanks.”
A: Correct, that’s what I suggest and why not? An average drinker would save much more in terms of reduced health and policing costs than they would lose in extra taxation
Q19. “Could you give a reference for Point 1: current estimates of damage from alcohol. £27bn is almost incredible!”
A: To clarify – that’s the overall cost of alcohol harms. The cost of alcohol related harm to NHS is £2.7 billion at 2006/7 prices, cost to society is £17.7 to £21.5 billion, ref. (2008) Dept of Health www.direct.gov.uk/en/Nl1/newsroom/DG_170745
Q20. “Education regarding the costs to the taxpayer seems to be lacking. If people knew how many hundreds or thousands of pounds it cost each of us… Maybe that could form a part of the warning notices”
A: Good idea
Q21. “Reducing the licensing hours just sends people home to drink what they want or makes them drink as much as possible within the time allotted”
A: Agreed – this would only work if other outlets also closed earlier or completely
Q22. “Minimum pricing would unfairly affect the poor”
A: Many of the poor are poor because they are addicted to alcohol and tobacco – tobacco price increases have helped reduce demand so why not for alcohol?
Q23. “Your desire to make another person’s decision whether to drink alcohol for them through taxation or other means can only come as a result that you believe you have made a better decision than that someone is capable of doing themselves”
A: Not necessarily true because alcohol has a profound impact on people’s normal decision-making processes which is a major reason that it’s so misused and causes so much harm
Q24. “The decision whether or not to engage in any activity is one of cost vs. benefit. Your analysis looks only at the costs of alcohol, not the benefits”
A: Agreed, a cost-benefit analysis is required for all drugs legal and illegal
Q25. “The mortality of a teetotaller doesn’t meet that of a drinker until the drinker is taking 60 units a week. There is plenty of evidence that the occasional couple of beers or Glass or two of wine in the evening is not just harmless, but good for you”
A: This may be due to some teetotallers being ill. The health benefits of alcohol are not proven – see Academy of Medical Science. Calling Time: The Nation’s Drinking as a Major Health Issue: Academy of Medical Sciences; 2004.
Q.26 “Banning didn’t work in the US with prohibition, why should it work now?”
A: I didn’t mention banning but in fact, it did reduce alcohol health harms dramatically, however, the increase in social harms from crime was deemed to offset the health benefits
Q27. “You can’t have researched alcohol consumption statistics. If you had, you’d know that there isn’t a problem. Okay so we have a few thousand binge drinkers, but we have laws to deal with them. They can be arrested for their behaviour. It’s always been thus”
A: Not true - 20% of all male and 12% of female deaths 18-40 in the UK are due to alcohol. Read the report by the House of Commons Health Committee: Alcohol. London: House of Commons; 2010. Report No.: HC 151-I
Q28. “I’m going to ask a very simple question: why do we care? If someone chooses to spend their life smoking, having a beer and hates taking exercise (that about sums me up) then let them. We should know of the dangers and then be allowed to get on with it”
A: We should care because the costs of not caring fall on us all
Q29. “I’ve heard that you have shares in GlaxoSmithKline, the friendly neighbourhood pharmaceutical multinational“
A: No – I bought shares from the Wellcome Trust 20 years ago when they disposed of some of their assets to raise money for medical research. These were shares in Burrows-Wellcome that then became SKB and then GSK. I have since sold them to avoid people –such as the Guardian - assuming (incorrectly) that they might influence my thinking
Q30. “There’s no evidence to suggest increased hours of availability leads to greater alcohol misuse - l stats available from the NHS and ONS suggest that since licensing hours were liberalised, binge drinking, total alcohol consumption and alcohol related harm have all declined”
A: As previously discussed, the cost of alcohol related harm to NHS is £2.7 billion at 2006/7 prices, cost to society £17.7 to £21.5 billion. (2008) Dept of Health www.direct.gov.uk/en/Nl1/newsroom/DG_170745.
Hospital Admissions linked to alcohol subject to 65% increase over 5 years to 2008/9 (2010) Data Dept. of Health www.nwph.net/alcohol/lape ( lape =local alcohol profile England).
Per capita consumption of alcohol has doubled from 6.l per year in1960s to 11.5 per year in 2000, whilst price (relative to income ) halved since 1960s Institute of Alcohol Studies (2008) “Alcohol: Tax, Price and Public Health”. Institute of Alcohol Studies, www.ias.org.uk/resources/factsheets/tax.pdfQ31. “The corresponding benefits of the drinks industry should be considered- such as the £8bn paid in duty by brewers every year, the £28bn contributed to the economy every year by the beer and pub industry (source: HMRC) and the general beneficial effect of a relaxing drink enjoyed by the vast majority of drinkers”
A: True – it’s a complex argument – I am not saying destroy the beer and pub industry – indeed some of my suggestions might strengthen it by diverting drinking away from supermarket sales and back to it
Q32. “What would you suggest as an alternative to alcohol? A synthetic, psychoactive drug, rather than a naturally occurring substance that we’ve been drinking for 10,000 years?”
A: See my other writings on this e.g. Nutt, D. 2006. Alcohol Alternatives: A Goal for Psychopharmacology? Journal of Psychopharmacology, 20: 318-320.
If alcohol was discovered today, its toxicity would make it illegal – saying this was maybe the main reason I was sacked last year!Thank you for the numerous thoughtful commnts made - join me over at http://profdavidnutt.wordpress.com/ for more debate.
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Damming the flood: 21 principles to underpin a new approach to alcohol
24/08/2010 by admin.
(Updated with additional references)
The past 50 years have seen the worst epidemic of public harm from a legal drug since the introduction of cheap gin in the 1700s (1, 2). Although alcohol intake has doubled in this period (3), alcohol related harms have increased many times more on account of the culture of heavy and, particularly, binge drinking that has developed. There are a number of reasons for this epidemic. The major ones have been the last government’s policies of reducing the real price of alcohol (4) and increasing drinking hours (5), plus the massive increase in the marketing of alcohol in supermarkets, often as a loss-leader (6). There has also been a marked growth in strong lagers and ciders of up to 8% alcohol content that appear designed to facilitate rapid intoxication rather than to satisfy palates (7).Attempts to rectify this situation, such as the report by the Chief Medical Officer last year (8) and NICE this month that recommended pricing per unit of alcohol in drinks (9), and the Royal College of Physicians report the year before (10), were dismissed by government and the drinks industry as soon as they were published on spurious and intellectually dishonest grounds (see previous post Alcohol: the new opium of the masses?). Thankfully we have a new government and one that in the run up to the election pointed out the issues especially of high strength ciders that have never been near an apple; some are a purely synthetic mixture of malic acid and alcohol! (11) So what should the coalition do to reduce the harms of alcohol? Here are my top twenty suggestions:
1. Make alcohol a national health priority: current estimates are that the damage from alcohol costs the NHS the order of £20bn per year and the violence it induces cost £7billion in police time.
2. Tax according to alcohol content since alcohol is the dangerous drug in drinks. Everyone accepts the rationality of this between alcohol classes – e.g. sherry is taxed more than beer and less than spirits, so there is a precedent that could easily be brought into action. A can of 8% lager should cost twice that of a 4% one and 4 times that of a 2% one. This was planned by the last Labour government and the coalition missed a real opportunity to make a statement about alcohol harms by not increasing the tax in this way despite their manifesto commitment (12).
3. Increase alcohol tax to bring the cost of alcohol in real terms back to where it was in the 1950s before the progressive rise in consumption started, i.e. gradually, say over 5 years, triple the price. All available evidence shows that the price of alcohol determines use for almost everyone with the only possible exceptions being severely dependent drinker (13)s. The increased health burden of alcohol is largely driven by non-dependent drinkers so would be significantly reduced by an increase in price. I have estimated that the average taxpayer would save the order of £2,000 per year by the reduced costs of alcohol-related harms if we increased the price as suggested. In the case of wine drinkers, only those consuming more than several hundred bottles a year would be worse off with this scheme, and they are drinking at a dangerous level anyway.
4. Stop selling strong alcohol in supermarkets; use the Swedish model where only alcoholic drinks of less than 3% can be sold outside licensed shops that have more limited opening times than supermarkets (14). Supermarket alcohol sales are not only destroying lives but also public houses and other alcohol outlets where drinking is conducted in a social manner and where intoxication can be monitored and young people can learn to drink socially and more sensibly.
5. Ban special discounting of alcohol in bars e.g. happy hours, all you can drink for £10 etc.
6. Stop selling wine in larger 250 ml glasses that have crept up on use in recent years - we should go back to smaller glasses again. For a medium size female, 5 large glasses of wine in one hour will lead to a blood alcohol level of 300mg/% which is that needed to produce coma.
7. Repeal the 24 hr licensing law so bars close at 11pm.
8. Ban organisations such as Carnage UK that promote dangerous levels of drinking as entertainment (15).
9. Make it a law that all alcohol outlets must sell non-alcoholic beers and lagers so that those who like the taste of ales can get it without the risk on intoxication. Make these drinks be sold at below the cost of equivalent alcohol-containing ones and make it obvious that they are available.
10. Enforce the law that makes serving drunk customers illegal in bars: have breathalysers in bars and clubs so that seemingly intoxicated people can be tested and denied more alcohol if they are above 150mg/%.
11. Add warning notices to all drinks warning of the damage alcohol does, as with those on cigarette packets.
12. Reduce the drink driving limit to 40mg/% to deter drink driving and hence reduce drinking. And if caught, get people properly assessed and repeal their licences if they flout DVLA guidance. Encourage the wider use of alcohol detectors in cars.
13. Invigorate the treatment of alcohol dependence by making alcohol a priority for the national treatment agency; encourage the use of proven treatments that reduce drinking and stop relapse.
14. Provide incentives to the pharmaceutical industry to develop new treatments for alcohol dependence and its consequences.
15. Encourage research into developing an alcohol alternative that is less dangerous, intoxicating and addictive than ethanol and for which an antidote or antagonist can be made available to prevent deaths in overdose.
16. Educate from primary school age about the dangers of alcohol.
17. Develop public campaigns to make alcohol unfashionable just as was done for tobacco.
18. Ban all alcohol advertising as with tobacco.
19. Ban all government supported organisations e.g. universities from having subsidised bars. Ban drinking games and pub-crawls in public organisations such as university sports and social clubs; remove financial support from clubs that allow these.
20. Raise the drinking age to 21. When this was done in the USA in the 1990s it was estimated that over 170,00 lives were saved in road deaths (16).
Finally, a measure that could be a powerful tool in the implementation of the above would be to reduce the use of alcohol by politicians as it could distort their objectivity in law-making in relation to the harms of alcohol. Get them to openly declare any association with the alcohol industry. The government’s wine cellar should be closed and the subsidy of alcohol in the Houses of Parliament stopped. Somehow though, it seems unlikely that MPs would call time on that particular perk…
References:
1. The cost of alcohol related harm to NHS £2.7 billion at 2006/7 prices, cost to Society £17.7 to £21.5 billion. (2008) Dept of Health
www.direct.gov.uk/en/Nl1/newsroom/DG_1707452.Hospital Admissions linked to alcohol 65% increase over 5 years to 2008/9 (2010)
Data Dept. of Health
www.nwph.net/alcohol/lape
( lape =local alcohol profile England)3/4. Institute of Alcohol Studies (2008) “Alcohol: Tax, Price and Public Health”. Institute of Alcohol Studies,
www.ias.org.uk/resources/factsheets/tax.pdfper capita consumption of alcohol has doubled from 6.l per year in1960s to 11.5 l a year in 2000, price (relative to income ) halved since 1960s
5. LicencingAct 2003 HMSO - commenced Nov. 2005
6. Bennetts, R (2008) Use of Alcohol as a Loss Leader. IAS briefing.
www.ias.org.uk/resources/papers/occasional/lossleading.pdfdiscusses “pre-loading” with alcohol ( he suggests link with reduction in “happy hours “)
7. Doward , J (2010) Super Strength alcohol is killing more people than “crack” or heroin. Observer 29/08/10
www.guardian.co.uk/society/2010/aug/29/super-strength-alcohol-killing-homeless
not referenced, interview with homelessness workers8. Donaldson, L On the state of the Public Health (2009)
www.gov.uk/en/publicationsandstatistics/publication/annualreports/DH_096206good overview, discusses concept of “passive drinking” cf smoking, minimum pricing ie 50p per unit of alcohol, per capita adult intake (England) = 120 bottles of wine per annum
he says alcohol use is up 40% from 1970s ( NB see ref 3 ).9. NICE Alcohol use disorders, preventing the development of hazardous and harmful drinking. (June 2010) Public Health Guidance, 24
suggests minimum price per unit alcohol, reduce availability
states between 1980 and 2008 alcohol became 70% more affordable
lists Government initiatives since 200410.Royal College of Physicians, (2009) Submission to Health Select Committee Enquiring into Alcohol
www.rcplondon.ac.uk/professional-issues/public-health/documents/RCP-HSCl/alco...11.refers to James Crowden who on his blog www james-crowden.co.uk
explainshow super strength cider is made
author and poet, “expert “ on Cider12. Not in Conservative Manifesto per se. ( Oct 2009) Chris Grayling (Shadow Home Sec.) proposed in speech 1. significant tax increase on “alcopops”, strong beer and strong cider, 2..supermarkets banned from selling below cost price 3 amuch tougher licencing regime
13. Pursehouse, Meier,P, Brennan,A, Taylor,K, Rafia,R, (2010) Estimated effect of alcohol pricing policies on health epidemiological model. Lancet 375 (9723), 1355-64
14. Swedish system for licencing alcohol.
Alcohol is sold by state monopoly since 1955. Stated aim “to reduce alcohol related harm by selling alcohol in a responsible way without profit motive” (quote)
15 .www.carnageuk.com
16.Wagenaar, AC, Toomey,TL, Effect of minimum drinking age laws. A review of the literature 1960-2000. (2002) J of Studies on Alcohol, suppl. 14: 206-22579 studies of MDLA (minimum legal drinking age) Conclusion preponderance of evidence indicate found higher MDLA inversely related to traffic crashes and amount of alcohol consumed.
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Muddying the waters – should we ban naphyrone?
22/07/2010 by admin.
The ACMD recently recommended banning naphyrone. Relatively unheard of until the banning of mephedrone, it is now being sold as the new legal alternative, though one small survey of products found that most of what is sold as naphyrone – or as NRG-1/energy – is in fact mephedrone or similar substances [Brandt et al 2010]. The ACMD itself supports these findings: “Limited samples of test purchasing would suggest that the prevalence of the compound naphyrone is currently relatively low and makes up a relatively small percentage of the total compounds found in marketed ‘legal highs’”.
If there is little use of naphyrone by the public, why do the ACMD wish to ban it? Is there evidence of harm? Judging by the ACMD report, the answer is no - they could find little if any evidence of human harm from naphyrone and they present no evidence of toxicity in animals either. The ACMD decision was made on the grounds that it has a (weak) chemical similarity to mephedrone and other cathinones and is 10 more potent than some of these. “The ACMD believe that naphyrone is likely to exhibit a similar spectrum of harmful effects as the other previously controlled cathinones. The data that are available for naphyrone suggest that its high potency, in comparison with the other cathinones, is likely to be associated with a higher risk of accidental overdose” [my emphasis].
An interesting choice of words and one which bears comparison with Brown’s public pronouncements as Prime Minister demanding cannabis upgrading three years ago: “the greater damage it appears to be doing…is that there is a stronger case for sending out a signal that cannabis use is … unacceptable…new lethal forms of cannabis such as skunk” [my emphasis].
The ACMD disagreed with this analysis that the potency of cannabis warranted Class B status [Rawlins et al 2008] as greater potency only results in more toxicity if drugs are taken in equal doses. Suppliers of naphyrone understand this and the unit dose sold is proportionately lower than that for mephedrone for this reason.
To reduce accidental harms, users need to be provided both with education on drugs and their harms and the option to know what they are taking. Whilst I was chair of the ACMD last year, we recommended to government that we should gather evidence about the efficacy and value of testing schemes for drugs that have been tried in the Netherlands and Australia. The suggestion was dismissed without justification by the then Home Secretary. Hopefully, the ACMD can present the suggestion again to the new government which may be more receptive.
A major problem with the ACMD report is its lack of critical appraisal of the science behind naphyrone. The pharmacology on which the ban is recommended is that it blocks brain reuptake sites for the neurotransmitters noradrenaline, 5HT (serotonin) and dopamine. Such actions are a feature of antidepressant rather than stimulant actions. Based on the ACMD’s logic then, potential new antidepressants such as NS2359 [Wilens et al 2008] as well as established ones such as bupropion, venlafaxine and even imipramine could be the next to be banned by the ACMD! Needless to say, these drugs do not have abuse liability.
Another important consideration is that the development of naphyrone was driven by a desire to find new treatments for addiction [Meltzer et al 2006]. Such research will inevitably suffer once the compounds are outlawed – another perverse consequence that must always be taken into account [see my post Precaution or perversion: eight harms of the precautionary principle]. MDMA (ecstasy) was originally developed as adjunctive treatment in psychiatric therapy. This research stopped when it was made illegal in the 1970s and has only just been resumed – with major benefits emerging [Mithofer et al].
The case for banning naphyrone is weakened by the fact that that most products sold as naphyrone are in fact mephedrone or related substances [Brandt et al 2010], which are already illegal. Indeed, this legislative approach may increase awareness of naphyrone as an alternative to mephedrone and we may see an increase in use in the weeks before it is made illegal as happened with mephedrone [Measham et al 2010, Drug and Alcohol Today]. This is, of course, assuming that the government goes with the ACMD recommendations, which seems certain as no UK government has ever resisted a request to impose more legal constraints on drugs.
The emergence of naphyrone as a potentially more dangerous variant of mephedrone raises further questions about the value of banning mephedrone in the first place when it was already widely used without causing a great deal of harm [see my post Hysteria and hubris: lessons on drug control from the Scunthorpe Two]. As predicted by me and many others, making it illegal has only displaced interest to other compounds about which less is known and which are potentially more dangerous. I discussed these perverse consequences of prohibition in an earlier blog [Precaution or perversion: eight harms of the precautionary principle].
Once naphyrone is banned, what will be the next ‘legal high’? I don’t know but I can guarantee many chemists and manufacturers already do. Will these new compounds be banned without any testing of pharmacology or any knowledge of harms? What is an appropriate threshold of harm that should lead to a drug being considered for banning? These are important scientific and social issues that the ACMD need to develop guidelines to address; I hope that they are doing so.
Brandt, S. D., Sumnall, H. R., Measham, F., Cole, J. (2010). The confusing case of NRG-1. British Medical Journal. 341:c3564.
Wilens TE, Klint T, Adler L, West S, Wesnes K, Graff O, Mikkelsen B. A randomized controlled trial of a novel mixed monoamine reuptake inhibitor in adults with ADHD. Behav Brain Funct. 2008 Jun 13;4:24.
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Precaution or perversion: eight harms of the precautionary principle
23/06/2010 by admin.
The precautionary principle is frequently invoked in relation to drugs laws. The argument goes like this: if we are unsure of the risks of harms of a drug then it is safer to ban it as a precaution rather than wait until harms become apparent. As a principle, it is based on the supposition that since there are assumed to be no benefits of “illegal” drugs then banning them will have no downside or ‘disbenefits’ with the anticipated result that the banning of them will be beneficial to society and to users.
At face value, the precautionary principle seems reasonable but, as I argued in the Eve Saville lecture at the Centre for Crime and Justice Studies last year, it is fraught with hidden harms and injustices especially if applied in an unthinking and arbitrary manner.
Here are eight examples where the precautionary principle with drugs falls down:
1. Increases personal harms
The penalties enforced in the banning legislation may cause more harm than the drug itself: a criminal record or even imprisonment for cannabis possession will almost certainly be more damaging to the individual and society than the drug itself. Criminalising users to deter them and others is the central plank of the current legislation that makes cannabis a Class B drug and the explicit reason why it was regraded up to Class B last year. This damages users who are caught in possession as it limits their career opportunities and is particularly hurtful to those using for medicinal reasons. It also costs the public purse large amounts through police and court time and prison costs - which was one reason why cannabis was downgraded to Class C in the first place!2. Distorts markets to greater harm to society
When precaution results in a variety of different drugs being made illegal then markets and competition between them develop. There are incentives for drug dealers to sell the most profitable, most addictive and least likely to be detected drugs. This pushes the market in the direction of drugs such as heroin and crack which use small volumes and have no odour and away from cannabis which is bulkier and smelly. The harms of the former are much greater than those of cannabis yet the penalties for possession and supply are similar [7-v-5 years and life-v- 14 years respectively]. There are examples of young people initiating illegal drug use with heroin rather than cannabis simply because cannabis is harder to get hold of and deaths have been the result.
3. Impossibility to refute
When the precautionary principle is used to deal with a concern for health effects of drugs, such concerns can never by fully allayed since any drug can be associated with harms of some sort if widely enough used. There is therefore always justification for maintaining precautions and keeping drugs illegal. This was the basis of the last government’s decision to keep ecstasy Class A even though the evidence of harm was clearly much less than with other Class A drugs such as heroin and crack. Although the immediate harms were not as severe as Class A drugs, the Home Secretary said that there were concerns about the long-term effects so it would consequently not be downgraded. Not much consolation to the many people in prison for up to 5 years for possession of ecstasy for personal use – an unlikely and unknown long-term possible health consequence is given as justification for an immediate destruction of liberty and livelihood.4. Disproportionate penalities
The precautionary principle also fails to take into account the proportionate risks from drugs and the absolute level of risk that should be required to ban a drug. I have argued that some metric of harm developed in reference to other harmful behaviours e.g. horse riding, rock climbing or sun-tanning should be invoked as a threshold of risk to decide if any drug should be made illegal. Some argue that as illegal drugs have no value then there are no dis-benefits of banning them. The flaw in this argument vis a vis criminalisation has been made in Point 1.5. Entrenchment of a flawed institutionalised moral position on drugs
Precaution is often either overtly or subconsciously based on the argument there are no benefits to the use of the drug so that it should therefore be made illegal. This argument reflects a biased and entrenched institutional position that the establishment and law makers alone understand costs and benefits and that drug users are all dependent, addicted losers. In fact, most people who use illegal drugs do so because they want to, NOT because they are addicted. For those for whom illegal drug use is a choice, benefits include relaxation, dancing, mind expansion etc; these are real benefits/motivators that should not be ignored by legislators6. Encourages other drug use
The most costly and perverse consequence of the precautionary principle is that it encourages the use of legal drugs which are more harmful than the ones being banned. It can be argued that the epidemic of alcohol-related health harms that the UK is experiencing now is partly driven by people who might use drugs that are safer than alcohol, such as cannabis and ecstasy, being deterred by the risks of criminalisation and/or misinformation about the relative harms of these drugs, so are driven to drinking instead. It is seriously questionable whether there is any health justification for criminalising the use of drugs that are safer than alcohol. Punishing drug users - but not drinkers or tobacco smokers - to protect them and society from health harms is ineffective, uneconomic, morally indefensible and patently unjust. The growing use of cannabis in retired people in the USA when they no longer have to fear workplace drug-testing reflects the true deterrent effects of the law to limit free choice.7. Blocks new drug discovery
The precautionary principle also limits the development of new drugs that might be safer than alcohol – such as alcohol alternatives – which would be subject to a much higher level of safety than alcohol itself.8. Denies innovation and medical progress
Some drugs, particularly LSD, MDMA and psilocybin, were showing promise as therapeutic agents before they were made illegal. This research then stopped as a consequence and only now, 40 years on is being resurrected with very promising findings. The recent banning of mephedrone means that new antidepressants and other treatments e.g. for obesity and narcolepsy that might have emerged from that chemical series will now not happen. It is not that such drugs would necessarily be illegal but the regulatory and legal complexities of working in this chemical arena and the possibility that new drugs might be outlawed if legislation changes in the future provides too big a disincentive to the pharmaceutical industry.Drugs present a variety of dangers to those that take them – however, using the precautionary principle as the basis for prohibition risks creating unnecessary harms without properly protecting users. If we are going to have a coherent and effective strategy to tackle the problems that drugs cause, removing the harms caused by the precautionary principle must be a priority.
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Crutch or cure? The realities of methadone treatment
09/06/2010 by admin.
The Tories’ actions in the run up to the election showed a worrying conviction that methadone is a short term solution to addiction. One option they appear to be considering is to encourage opioid addicts to seek “cure” rather than continued treatment, achieved by limiting the duration of methadone treatment, say to 6 weeks. This ambition would be both scientifically inaccurate and economically insane. It is based on a discredited view of addiction being a transient single event equivalent to moral lapse that can be cured – in medical terms the equivalent of a fractured bone or a chest infection. All medical evidence in the past 40 years has supported the centuries old view of addicts themselves that is incorporated in the Alcoholics Anonymous axiom – once an addict always an addict. This doesn’t mean that drug or alcohol use is inevitable, merely that the addiction reflects both a personal vulnerability and a learned behaviour so that once experienced there is no “resetting” back to normal: experience can’t be erased! The risk of relapse is always present and most people will experience more than one episode of drug misuse during their life. Addiction is best conceptualised as a chronic recurring illness such as diabetes and asthma where life stresses and other factors predispose to relapse so ongoing prophylactic treatment is required. Longitudinal studies of many addictions show that the outcome for long-term treatment is similar to that for these other enduring illnesses.
Even if you deny the medical model of addiction, the economic evidence also strongly supports the value of maintenance methadone treatment with multiple studies over the past 50 years proves that enduring treatment with this heroin substitute leads to reduced deaths and other medical illnesses and less crime both acquisitive and violent. For every unit of investment in methadone, three are saved from these other sources. It seems likely that similar values obtain for other heroin maintenance treatments such as buprenorphine, and for treatments of other addictions e.g. varenicline in smokers, acamprosate and naltrexone for alcoholics. This does not mean that abstinence treatments should not be offered or that psychological interventions have no value, rather if these don’t work or are unacceptable to the addict then maintenance should be allowed.
It seems perverse that the UK government might be considering reverting to a primitive discredited moral model of addiction when the USA – previously the bastion of this approach - has recently appointed Tom McLelland to the role of deputy director of drug policy. Tom’s research played a major role in the medical model of addiction gaining acceptance and will play an increasingly important place in US policy.
The Conservatives see residential rehabilitation as the alternative to methadone. It certainly may be for a proportion of (although not all) addicts. However, the costs involved in residential rehabilitation are significantly higher than methadone treatment. Whether the Conservatives prove willing to fund such treatment, particularly in an era of austerity within the public sector, remains to be seen. Methadone treatment may yet survive, if only for reasons of financial expediency.
References:
McLleland AT Lewis DC O’Brien CP, Kleber HD (2000) Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcome evaluations J American Medical Association 284,1689-1695 doi:10.1001/jama.284.13.1689Posted in Uncategorized | 22 Comments »
Alcohol – the new opium of the masses?
03/06/2010 by admin.
The debate about the costs of alcohol has been resurrected today by the NICE report (http://www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf) that recommends that the price of alcohol should be regulated according the concentration of alcohol in the drink. Obvious you might think – why should there be differences in the pricing of the active drug component of different drinks – since the effects of the drug are simply and causally related to the dose taken? Yet when the Scottish parliament attempted to bring in this as law last year, the Labour party blocked it on the grounds that it would penalise the poorest members of society. A truly bizarre idea that is wrong in both fact and in principle. The poor who are dependent on alcohol find this addiction eats up their income in the same way as the costs of tobacco used to until ten years ago when the original New Labour government put up the price and drove down use. What is never discussed is why alcohol use should not be price sensitive when tobacco use is, probably because it is well known that both are equally susceptible to cost controls.
Today we have a repetition of this intellectual dishonesty but this time from the drinks industry. In response to the NICE report we heard the usual mealy-mouthed protestations that there is no evidence that unit pricing reduces intake. This statement is technically correct since it’s never been explicitly tried but already alcohol is priced through taxation according to strength. Beers are priced lower than wine which in turn is cheaper than spirits, and people do tend to drink lesser volumes of the more expensive formulation. Moreover the “lack of evidence” claim is an attempted distraction as there is overwhelming proof from many countries over many centuries that increasing the price of alcohol lessens intake.
On top of this we get the claim that alcohol dependent people would not be deterred by price increases so the policy wouldn’t work anyway. Personal anecdotes of dependent drinkers who claim that price wouldn’t deter them are wheeled to support the industry position. What is conveniently overlooked is that most drinkers are not dependent and so are price sensitive and this particularly applies to the young and novice drinkers. The rise of youth drinking is directly related to the reduction of the real price of alcohol that has occurred over the past twenty years. Increasing the cost of alcohol will therefore reduce the rising wave of binge drinking in the young with its accompanying toll of deaths, disability and enduring medical complications. It will also have a minor, but likely significant, effect to reduce drinking in the older age groups which are increasingly experiencing alcohol-related heart and liver disease.
There can be no moral argument for some forms of alcohol, such as 8% cider, to cost less than a fifth of the same amount of alcohol in wine or spirits when the intoxicating value is the same. The health effects are these ciders are therefore 5x more damaging than those of comparable strength drinks which is why they make a major impact on our health care costs. Alcohol related damage in the UK runs to tens of billions of pounds a year so each middle class wine drinking tax payer is paying thousands of pounds in taxation to cover this. Most would surely agree that a small hike in the costs of alcohol that significantly reduced overall alcohol consumption and health damage would make economic sense.
Posted in Uncategorized | 11 Comments »
Hysteria and hubris: lessons on drug control from the Scunthorpe Two
28/05/2010 by admin.
The announcement today of data obtained several weeks ago that the “Scunthorpe two” – the young men who supposedly died of mephedrone (meow meow, M-cat) poisoning – had not taken this drug raises a number of fundamental questions over the decision to make mephedrone a Class B drug just before the election.
The ensuing media hysteria over their deaths that was fuelled by the local police holding an international press conference was probably the tipping point in the decision to ban mephedrone, that was made by an incomplete ACMD in an intemperate and rushed manner.
At the time, it seemed unlikely that mephedrone was to blame as the two young men had been drinking heavily until the early hours of the morning and stimulants like mephedrone usually attenuate counteract to some extent the sedative effects of alcohol.
What appears likely is that they took some other sedative drug – probably methadone – which is highly dangerous in combination with high levels of alcohol.
It is too late now to reverse the government decision to make mephedrone Class B but we do need to learn the lessons from the debacle of its being banned. The main ones are:
1. That the police should not make pronouncements and certainly not hold press conferences on mere conjecture.
2. The media should wait for evidence and allow the scientific process to take place before claiming harms of new legal highs.
3. The government and their advisers should have the courage to face down media hysteria and let the truth evidence drive decision making.
4. Proper investment in the science of new drugs is required - we at the Independent Scientific Committee on Drugs [www.drugscience.org.uk] are currently developing guidelines on the minimum data set that will be made public and should be acquired for any new drug before a decision to ban it is made.
5. There is a real need for a new approach to the drug laws; the 1971 Misuse of Drugs Act is forty years old, fatally flawed in its current classification system and not fit for purpose in this new internet-based environment in which it must be used; it needs fundamental revision or better still, a completely new approach should be taken.
6. The message must be conveyed to anyone who drinks and takes drugs that alcohol itself is very toxic (killing by acute poisoning, hundreds of young people each year through stopping breathing) and these actions are magnified when in combination with other drugs that lower breathing. If you do consider taking drugs whilst drunk then avoid at all costs other sedative drugs such as opioids and GHB/GBL.
If the media, the police and the government are serious about reducing the real harms that drugs are causing in the UK, they need to address the drug that is killing a young person every day purely through poisoning: alcohol. Until they do, no sense can enter the debate.
Wednesday, 16 March 2011
David Nutt’s blog - Evidence not exaggeration
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