Last week’s recommendation from Europol and EMCDDA for an EU-wide ban on mephedrone is remarkable for its lack of scientific evidence. The report primarily relies on user experiences and a handful of hospital admissions, with no formal studies to demonstrate the actual or potential harms of the drug and with only one case  formally cited as having mephedrone as the cause of death.

It is not yet possible to say how harmful mephedrone is given the lack of evidence. However, by legislating on a substance without reliable scientifically-based evidence, we run the risk of causing more harm through criminalising users than might be caused by the drug itself. The evidence on drug harms should not be sacrificed for political and media pressure.

A minimum data set, specifying what needs to be known about a substance in order to deal with it effectively, through legislation or otherwise, is urgently needed, at both the domestic and international level. The Independent Scientific Committee on Drugs (ISCD) have been developing a minimum data set for this purpose. I will be discussing its development at the ISCD/Lancet joint summit Drug science and drug policy: Building a consensus on 1 November 2010.

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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 https://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 flavouring

Q4. “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 simpler

Q12. “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.pdf

Q31. “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 https://profdavidnutt.wordpress.com/ for more debate.

 

[Updated 26 October 2010]
I spent a week over the summer lecturing in New Zealand where I had the chance to speak with a number of politicians, lawyers and health professionals who were engaging in a review of their drug and alcohol laws under the leadership of their Law Commission. This independent body has made sensible recommendations that would reduce drug and alcohol related harms by providing more just laws but is experiencing a similar stonewall response from their government as we have from ours in the UK.

I had assumed that New Zealand was a land of mature attitudes and common sense and so was surprised to discover that pro-rata New Zealand  has a greater proportion of its population in prison than we do [2 – v – 0.15%] and a greater conviction rate for cannabis possession [roughly 30 per thousand –v- 25 in the UK]. The current government [National Party] is conducting a policy of increasing police interventions and building more prisons to deal with the increase in criminals, seemingly oblivious that much of the “crime problem” is of their own making. Hopefully they won’t reach the absurd position of the USA where over 0.7% of the population is imprisoned, mostly for drugs and other minor offences that have statutory sentences e.g. a 3rd cannabis conviction can lead to someone spending the rest of their life in jail [The Economist 24th July 2010].

Why does any country criminalise the personal use of cannabis?  The fundamental purpose of the law is to optimise the quality of life in society and justification for drug laws is usually couched in terms of reducing personal and social harms from drug use [e.g. the UK MDAct 1971]. So does criminalising cannabis users reduce harms?  Of course not, especially if we take into account the proven harms that a criminal record brings. Moreover the huge costs of policing and criminalisation are economically damaging.

The MDAct was brought into law in 1971 yet since then cannabis use in the UK has increased 20 times [Rawlins et al 2008] despite heavy sanctions of up to 5 years in prison for possession for personal use, and increasing numbers of convictions to 160,000 per year [Lloyd and McKeganey 2010]. But have cannabis harms increased with the increase in use? The UK government’s figures for hospital admissions for cannabis related illness suggest about a thousand per year [Rawlins et al 2008]. In contrast, alcohol use which has about doubled in the same 40 yr period  is associated with and rising epidemic of harms that lead to over 1million hospital episodes in 2009 [NHS statistics].

There has been much media concern over the increase in schizophrenia that cannabis is supposed to be causing yet this 20-fold increase in use has not been accompanied by an increase in either schizophrenia of psychosis, whereas the 2 fold increase in alcohol intake has lead to death rates from liver disease increasing year on year [Leon and McCambridge 2006 Lancet] so that within a decade, liver deaths will outnumber deaths from heart disease so becoming the biggest killer in the UK .

Given the harms of alcohol are much greater than those of cannabis, why do so many countries persist in the prohibition/criminalisation route for cannabis users? This is particularly relevant because of the growing evidence from a number of countries e.g. The Netherlands [cannabis in coffee shops], Australian states [decriminalisation of cannabis for personal use] and Portugal [abolition of criminal sanctions for personal use of all drugs ] are viable policies that have major public health benefits – and are also more just. The answer is complex reflecting a mixture of ignorance denial and deliberate obfuscation on the part of policy makers. However an important factor is the macho model of politics initiated by the USA/UN “War on Drugs” which deludes many politicians into believing that being “hard” is necessary and a voter-winner, a view they hold even in the face of contradictory public opinion [Nutt 2009].

Sadly, I found this attitude just as prevalent in the New Zealand parliament as in the UK, where in 2009 the then Home Secretary Alan Johnson famously said in the House that he was “big enough, strong enough, bold enough” to sack me for saying cannabis was less harmful than alcohol. We need voters to make it clear to future MPs and political leaders that policies based their desire for political machismo rather than evidence will not be acceptable.