In this guest post, Dr Les King and Rudi Fortson Q.C.  highlight how the last government’s meddling in legislation regarding cathinones, including mephedrone, at this time last year has generated confusion for forensic scientists and legal practitioners regarding the precise placing of some cathinones within Class B.  It is a problem that is only now being addressed.

Instead of accepting the generic definitions of cathinones drafted by members of the ACMD that would cover all the various types of cathinones, the Home Office took the unusual step of changing the legislation to specifically mention mephedrone to ‘send a message’ to the public, presumably in response to the (unfounded) hysteria over mephedrone use by young people.  In taking this course, one variant of methylmethcathinone (mephedrone) was listed in one sub-paragraph of Part 2 of Schedule 2 to the MDA, while other variants of methylmethcathinone were listed in another sub-paragraph, thereby generating confusion.  Logically, all variants of that substance ought to have been classified as a single group.     To understand  how this came about requires a little more understanding of the chemistry of cathinones.

Dr King explains: The crux of the problem is peculiarly technical, but rests on the existence of mephedrone isomers. While mephedrone is 4-methylmethcathinone , both 2- and 3-methylmethcathinone  can also exist. To distinguish those different isomers is a challenging task for a laboratory, and certainly cannot be done by the routine methods used in drug analysis. That is where well-crafted generic control is so useful: all three isomers can be controlled without ever mentioning them by name in the Act or needing to be analytically-specific about which one has been found in a questioned sample.

That advantage was lost following Home Office tinkering. Eventually, following many discussions between the forensic science community and the CPS, a legally acceptable work-around was concocted. Yet that legal fudge could only be a temporary measure, which is why the Government has announced that the original clauses in the Modification Order of 2010 will now be replaced with what should have been there in the first place. This is a clear case of government acting without a clear understanding of the issues. Instead of supposedly protecting the public from harm with the controlling of mephedrone, the previous government unnecessarily weakened legislation for political gain.
However, whilst recognising the advantages of generic descriptions from a technical point of view, Rudi Fortson has expressed a note of caution.  For him, the law should not only be precise but it should also be clear and capable of being understood by lawyers and non-lawyers alike.  There is a risk that various substances, readily identifiable by their popular name (such as “mephedrone”), will be lost in the language of chemistry, making it difficult for non-chemists to identify, when reading the MDA, which drugs are controlled and which are not.

http://www.publications.parliament.uk/pa/cm/cmtoday/cmstand/output/deleg/dg01110216-01.htm

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Addiction is a major health problem that costs as much as all other mental illnesses combined (about £40 billion per year) and about as much as cancer and cardiovascular disorders also.

At its core addiction is a state of altered brain function that leads to fundamental changes in behavior that are manifest by repeated use of alcohol or other drugs or engaging in activities such as gambling.  These are usually resisted, albeit unsuccessfully, by the addict.  The key features of addiction is therefore a state of habitual behaviour such as drug taking or gambling that is initially enjoyable but which eventually becomes self-sustaining or habitual. The urge to engage in the behaviour becomes so powerful that it interferes with normal life often to the point of overtaking work, personal relationships and family activities. At this point the person can be said to be addicted: the addict’s every thought and action is directed to their addiction and everything else suffers. 

If the addictive behaviour is not possible e.g. because they don’t have enough money then feelings of intense distress emerge. These can lead to dangerously impulsive and sometimes aggressive actions.  In the case of drug/alcohol addiction the situation is compounded by the occurrence of withdrawal reactions which cause further distress and motivate desperate attempts to find more of the addictive agent. This urge to get the drug may be so overpowering that addicts will commit seemingly random crimes to get the resources to buy more drug. It has been estimated that about 70% of all acquisitive crime is associated with drug and alcohol use.

Addiction is driven by a complex set of internal and external factors.  The external factors are well understood:  the more access to the desired drug or behaviour e.g. gambling the more addiction there is. 

The internal factors are less clear. Although most addiction is to alcohol and other drugs, addiction to gambling and other behaviours such as sex or shopping can occur. These tell us that the brain can develop hard-to-control urges independent of changing its chemistry with drugs.  All addictions share a common thread in that they are initially pleasurable activities, often extremely enjoyable. This results in these behaviours hijacking the brain’s normal pleasure systems so that naturally enjoyable activities such as family life, work, exercise become devalued and the more excessive addiction behaviours take over. 

However, not everyone who engages in drug use or gambling becomes addicted to them so clearly other factors are important. These are not yet understood but are now being actively studied. Some people may be particularly sensitive to the pleasurable effects of alcohol, drugs or gambling, perhaps because of coming from deprived backgrounds. In others, addiction may occur because of an inability to adopt coping strategies.  Others may have an underlying predisposition to develop compulsive behaviour patterns. Some unfortunate people may have several of these vulnerability factors and there are also genetic predispositions to some of them.

Also a significant amount of drug use is for self-medication, examples include  cannabis for insomnia, alcohol to reduce anxiety, opioids for pain control etc. This therapeutic use can escalate into addiction in some people though by no means all. Not all drugs which are used for recreational purposes are addictive. LSD and magic mushrooms seem not addictive at all, and some have a low risk of addiction (MDMA/ecstasy; cannabis). The most addictive drugs are nicotine, heroin and crack cocaine plus metamfetamine (crystal meth) although this is not much used in the UK.

Just because some people – including leading politicians – have used drugs but stopped before they became addicted does not mean that anyone can stop that easily.  Starting to use drugs may be a lifestyle choice but once addiction sets in, choosing to stop is very much more difficult if not impossible.

We are beginning to understand how addictions start in the brain. The pleasurable or rewarding effects of addictions are mediated in the brain through the release of chemicals such as dopamine [by cocaine, amphetamines, nicotine] or endorphins [heroin] or both [alcohol].  The pleasures are then laid down as deep-seated memories, probably through changes in other neurotransmitters such as glutamate and GABA that make memories. These memories link the location, persons and experiences of the addiction with the emotional effects. These memories are often the most powerfully positive ones the person may ever experience, which explains why addicts put so much effort into getting them again.  When the memories re-occur, which is common when people are still using drugs or gambling, as well as when in recovery/abstinence, they are experienced as cravings.  These can be so strong and urgent that they lead to relapse.

A great deal of research has been conducted into the role of dopamine in addiction and we now know that the number of dopamine receptors seems to predispose to excessive pleasure responses from stimulant use. This excessive response is thought to initially occur in the reward centre of the brain – [the nucleus accumbens] – but then move into other areas where habits are laid down.  This shift from voluntary (choice use) to involuntary (habit-use) explains a common complaint of addicts that they don’t want to continue with their addictions, and even that they don’t enjoy them anymore, but cant stop themselves.  In this sense addiction can be seen as a loss-of-control over what starts out as a voluntary behavior.  Thus addiction is not, as some like to suggest, simply a “lifestyle” choice. It is a serious, often lethal, disease caused by an enduring (probably permanent) change in brain function.

We know that personality traits especially impulsivity, predict excess stimulant use and in animals this can be shown to correlate with low dopamine and high opioid receptor levels.  Similarly in humans low dopamine and high opioid receptor levels in brain predict drug use and craving.  These observations give new approaches to treatment, both psychological interventions such as behavioural control, and anti-impulse drugs such as those used for ADHD e.g. atomoxetine and modafinil, are being tested. 

For some addictions, especially heroin, the risk to the addict (life expectancy less than that from many cancers) and to society (from crime and infections), is so high that the prescription of substitute opioid drugs or even heroin itself saves lives and reduces crime. These substitute drugs are methadone and buprenorphine [Subutex]. As well as reducing crime and social costs by removing the need for addicts to commit offences to feed their habit, they also protect from accidental overdose and reduce risk of infections such as HIV and hepatitis.  Similar substitute pharmacological approaches exist for other addictions e.g. gammahydroxybutyrate (Alcover) and baclofen for alcohol addiction, and varenicline (Champix) for nicotine dependence.

Another major reason for relapse in addiction is stress. This may work through increasing dopamine release in brain so priming this addiction pathway or by interactions with other neurotransmitters such as the peptide substance P. As antagonists of these neurotransmitters are now available they are being tested in human addictions and may offer an alternative to substitution treatments.
Further reading

Nutt DJ  King LA Phillips LD (2010) Drug harms in the UK: a multicriteria decision analysis  Lancet 376: 1558-66

Nutt DJ Lingford-Hughes A (2008) Addiction the clinical interface Brit J Pharmacology 1-9

Nutt DJ, Law FD (2008) Pharmacological and Psychological aspects of drug abuse. New Oxford Textbook of Psychiatry 2nd edition

Robbins TR, Everitt B,  Nutt DJ (2010) The Neurobiology of Addiction – New Vistas.   OUP

A guest blog from Paul Myles

Alcohol is a major public health problem and one that is growing in young people mostly from the increase in binge drinking. There are several reasons for the increase in drinking in this age group particularly the availability of low priced strong ciders lagers and breezers but advertising plays a significant role as well.

The recent BMA publication ‘Under the Influence’ [British Medical Association 2009] clearly shows that the drinks industry cynically targets very young people, revealing the techniques that they employ, of which many parents are unaware.  These include targeted email campaigns with embedded film clips advertising alcohol, Facebook links and mobile phone text messaging.

How can we combat this sophisticated and cynical approach? One approach is to tell young people directly of the dangers of alcohol. However it seems that direct scare tactics about the outcome of alcohol use or any other substance that can be misused has been ineffective and may even be counterproductive (Drugscope 2010) (Coggans et al 1991).

Another way is to develop a teaching module for school students that reveals the subtle ways in which positive messages about alcohol are communicated. This how now been done and piloted in East Sussex with great success.

The teaching module shows the students how the drinks industry makes its own voluntary codes and them blatantly ignores them. It shows how the Portman Group [that has responsibility for alcohol education] whilst appearing to be concerned about alcohol harm is actually dominated by the drinks industry. Also it is revealed that the public health message in the UK  is left to the drinks industry. The myths surrounding alcohol are discussed and then the students are asked to make up their own mind about the issues. Profit motives of the drinks industry, the tax income and political agendas are exposed and compared with the cost to society, mortality and shortening of life caused by alcohol use.

The rationale for the module is to enable students to critically evaluate the way that young people are targeted to buy alcohol. The lessons examine the mechanics behind the commercial enterprise of alcohol sales. The students analyse the management /mismanagement of the substance misuse issue.

This approach does what the advertisers do, get this message out to as many people as possible, to show the public how they are being hoodwinked by the drinks industry. It is hoped that the British public will realise that they are being duped and react accordingly by contacting their MP and local authorities.

The Independent Scientific Committee on Drugs (ISCD) is now working to see how this might roll out the programme to many more schools

Notes

This comprehensive package includes a 2 lesson module for students, a teacher training session and a presentation to parents and interested members of the community developed by Paul Myles from his MSc research at Sussex University. The module contains multi media and is designed to address a wide spectrum of learning abilities. The lesson plans were developed by researcher Paul Myles supported by East Sussex County Council.

British Medical Association 2009. Under The Influence:The damaging effect of alcohol marketing on young people. BMA Science and Education Department and the Board of Science. BMA Marketing & Publications London. www.bma.org.uk

Coggans N, Shewan D, Henderson M and Davies JB ‘National Evaluation of Drug Education in Scotland’, ISDD 1991.

Paul Myles BSc Psychol (Hons) MSc Substance Misuse MBPsS

Paul is a Fellow of the Royal Society of Medicine and a Graduate member of the British Psychological Society contact 01273 477723 pmyles@btclick.com 13 Hill Rd Lewes Sx BN7 1DB

The last government had a peculiarly Stalinist approach to public wellbeing. It created over 1200 new laws, a record number for any government, many of which reflect a naïve belief that these would change public behaviour. Some were clearly stupid; thinking that drinkers would be deterred from behaving badly when drunk for fear of legal sanctions misses the point that many people get drunk deliberately to lose the inhibitions that such sanctions bring!

Perhaps the most pernicious principle of law was the one declared  in 2005 by way of a decision of the Court of Appeal (Criminal Division)  which did not, prior to the hearing, make it into the public arena for discussion, nor was the reasoning the product of debates in Parliament.  The effect of this decision is to  deny the defence of necessity to those growing or possessing cannabis to treat medical conditions for which other treatments were ineffective.   In the words of the Court, “its role [of the defence] cannot be to legitimise conduct contrary to the clear legislative policy and scheme”.  The consequence was that ill people for whom cannabis might be the sole means to relieve suffering are no longer able to plead that this was the reason they had the drug if they get arrested.

Surprisingly many do get arrested sometimes in very aggressive ways.  Just last week I received an email detailing how a middle aged ex teacher with multiple sclerosis has had her front door broken down by the police in dawn raids on three occasions over the last six years to combat her use of cannabis for medicinal purposes.  I presume everyone, except perhaps the police involved, would agree this is inhumane, a travesty of justice, and a complete waste of public money. There are regular court cases in which this defence is denied and so individuals are obliged to plead guilty to possession of what is now a Class B drug which carries a sentence of up to 5 years’ in prison, or up to 14 years if the court decides intent to supply (dealing) was present. Such judgments  are devastating to the patient and their families but also quite distasteful to those charged with enacting the penalties. I have spoken with many magistrates and a significant proportion express privately their extreme dislike of being forced to criminalise such users of cannabis.

Why did the Court of Appeal do this? Since the reclassification of cannabis to class B in 2009 the UK has some of the most punitive laws on cannabis in Europe. Until 1971 cannabis was legal in the UK if in medicinal form and had been so for centuries. It was greatly beloved of Queen Victoria who swore by its analgesic properties claiming that she would never have had so many children without the help of this medication.  The  medical license was removed in 1971 because a couple of rogue GPs in London, who were campaigning to make cannabis legal, began to prescribe medicinal cannabis with the recommendation that it be added to tobacco and smoked.  Whether the threat to UK society of this behaviour was sufficient to ban a whole class of medication is very questionable, but since then we have had no cannabis medicines in the UK. This puts us in clear contrast to many other European countries where it is available on prescription [1]. Even in the USA, which has even more extreme laws for recreational cannabis use than the UK, many states make cannabis available for health reasons on a doctor’s recommendation.

Until 2005, users arrested for cannabis possession did  invoke the defence of medicinal necessity (encompassed in the concept of Duress of Circumstance) which was that they needed cannabis as no other medication worked for their condition. So why did the Court of Appeal ban it in 2005?  Reading the legal arguments the same circular attitudes that permeated the Labour government’s whole biased and ignorant attitude to drugs are recapitulated [2].  The decision is logical if we make two flawed assumptions, that cannabis is illegal because it is harmful to society, and that punishment is an acceptable and effective deterrent.  This translates to illogical conclusion that ill people with conditions such as multiple sclerosis, chronic pain and spasticity need to be protected from the potential harms of cannabis by criminalising them! As was noted following the decision the Court was influenced by the government’s refusal to relax the legislation in this context despite recommendations to do so by the House of Lords Select Committee.

Another reason was that the defence was becoming too common and that there would be obvious risks for the integrity and the prospects of any coherent enforcement of the legislative schedime.   No concern for patient suffering there then, just some difficulties for the enforcers. Nowhere in the judgements is there any discussion of the historical precedents that cannabis was a useful medicine and that the decision to make it illegal was based on legal and moral rather than medical grounds. Perhaps not surprising given that the UK is one of the few western countries where drug control is vested in the ministry for justice/law rather than health. Nowhere is there any scope for allowing a doctor to decide if cannabis might be useful. The intention of the decision is clear – reduce cannabis use for whatever reason – by punitive means.

Is this just? Of course not, the judgment  reflects the nastiness of a statutory scheme that makes no provision for the medicinal use of cannabis, and existing law reflects a  blinkered and regimented view  of life and behaviour.  The consequences of this distasteful state of affairs  is that it not only denies medical help to a profoundly suffering group of disabled people but also adds huge mental distress from the legal process and the public embarrassment of court exposure to a group of otherwise law-abiding citizens. Even worse some have had their possessions and bank accounts seized under the new proceeds of crime legislation where there is evidence that the offender has “benefited” from his “criminal conduct” (expressions that have a legal meaning but the confiscation laws are draconian).  This situation surely would not continue if the public were aware of the iniquity of the law.  Some patient test cases are now under review in the European Court and so hopefully it will soon be overturned.

The recent release of the cannabis extract spray medicine Sativex has been a move in the right direction but it will not deal with the needs of all patients and most doctors are still not willing to prescribe it.  Some patients have used the right of freedom of trade in Europe embodied by the Schengen agreement to obtain medicinal cannabis from European countries such as the Netherlands where it is a prescription medicine [3]. There is some uncertainty about the legality of this approach – the Home Office recently released a statement denying the legality of this approach in contrast to letters previously sent to individuals that sought clarification on the matter.  It would be much preferred by patients, carers and doctors alike for justice to be enacted by revoking the current law. The new coalition government has asked for the public to suggest laws to be revoked – this is one I and surely any sane and humane citizen would recommend repealing.

Comments in italics are taken from the report by Stephen Leake, Barrister R. v Quayle and Other Appeals; Attorney-General’s Reference (No.2 of 2004), Re Ditchfield

Thanks to Dr Chris Lawson for research input.

Refs
1.    http://eldd.emcdda.europa.eu/html.cfm/index5175EN.html

2. Neutral Citation Number: [2005] EWCA Crim 1415
IN THE SUPREME COURT OF JUDICATURE COURT OF APPEAL (CRIMINAL DIVISION)

3.  http://peterreynolds.wordpress.com/2010/10/01/legal-medicinal-cannabis-in-britain/

Drug harms paper: a summary

December 9, 2010

Drug harms in the UK: A multi-criteria decision analysis

The ISCD’s first published work, launched in the Lancet on 1 November 2010, has attracted considerable attention in the media worldwide and from the public. The summary below lays out the basics of what the papers shows and what it cannot. To read the paper in full, download it for free from the Lancet’s website.

Overview of paper
An assessment of the various harms of drugs used recreationally in the UK using multi-criteria decision analysis (MCDA) – a method that uses relevant experts’ knowledge and experience to assess the actual and relative harms.

What is its purpose?
To assess drugs in terms of their known harms to individuals, those around them and more broadly, to domestic and international society. Showing drugs’ harms relative to each other also enables more objective and informed assessment of their harms individually and in relation to their current controls.

What does it show?
The report found heroin, crack cocaine, and methyamphetamine to be the most harmful drugs to individuals (part scores 34, 37, and 32, respectively), with alcohol, heroin, and crack cocaine as the most harmful to others (46, 21, and 17, respectively). Overall, alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack cocaine (54) in second and third places.
It also found the legal status of most drugs to bear little relation to their harms.

What does it not show?
Because of the many factors that could change, the report does not take the legal status of a drug into account. This will clearly have some impact on its level of harms, for instance alcohol’s regulated availability means that many more people have access to it than most drugs, which will have an effect on its level of harm. Similarly, the controlled status of some drugs will make them more harmful as unsafe production of the drug introduces contaminants and risky practices by users puts them at risk of diseases such as Hepatitis C and HIV.

The rankings of harm to the user  would be unlikely to change drastically if all drugs were controlled or, conversely, not controlled, as those harms are intrinsically linked to their effects on the mind and body.  However, the harms to society could change if a drug’s legal status changed. There are examples in a number of countries of different levels of control, such as in Brazil, Mexico, Portugal, Spain, the Netherlands, Finland and parts of Australia and the USA, amongst others. However, it is not possible to expect identical results if replicated in the UK, given the wide variety of cultural and historical factors that can influence drug use and especially problem drug use.

Areas of development
This paper represents a step forward in our understanding of drug harms but is by no means the definitive answer. Repetition of the MCDA process with other relevant groups (such as police, teachers, doctors, politicians, users) and in other countries would help to build a fuller picture of the range of harms. Taking into account the various benefits of drugs would also enable better understanding of why people take drugs and how they might positively impact on users and society.

Science goes AWOL in the EU

December 3, 2010

Today’s EU-wide ban on mephedrone based on recommendation from Europol and EMCDDA is remarkable for its lack of scientific evidence. The Europol/EMCDDA 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 mephedrone only formally cited in one case 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, especially given recent research by Sheila Bird positing that a drop in cocaine deaths in 2009 was due to users switching to mephedrone.

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. You can find it here or at http://www.drugscience.org.uk/minimumdataset.html.

Yesterday’s launch

November 2, 2010

Yesterday, we launched the Independent Scientific Committee on Drugs’ first piece of research – Drug harms in the UK: a multi-criteria decision analysis – at a summit held in association with the Lancet, Drug science and drug policy: Building a consensus.

The event was held under Chatham House Rule to enable participants to speak their minds freely, however, we will be publishing outputs from the event as soon as possible. In the meantime, the full paper is available to read for free on the Lancet website. I welcome your feedback.