Tuesday, 5 April 2011

On the Ropes: David Nutt

Sir Humphrey Appleby: [discussing how to stop the PM's anti-smoking legislation] I think the crucial argument is that we are living in a free country and we *must* be free to make our own decisions. After all, government shouldn't be a nursemaid, we don't want the nanny state.
Sir Frank Gordon: Oh, that's very good.
Sir Ian Whitworth: Excellent.
Sir Humphrey Appleby: The only problem is that that is also the argument for legalising the sale of marijuana, heroin, cocaine, arsenic and gelignite.Sir Frank Gordon: Well maybe that's a good idea if we can put a big enough tax on them.
Sir Ian Whitworth: Politically difficult.
Sir Frank Gordon: Pity.
(The Smokescreen, Yes Prime Minister)

I've just been listening to "On the Ropes" where Professor David Nutt talks to John Humphrys about his short, controversial tenure as Chair of the Government's Advisory Council on the Misuse of drugs.

He wrote a contentious paper comparing a made-up condition 'equasy' (an addiction to horse-riding) with the dangers of ecstasy. He recalls a phone-call from the then Home Secretary, Jacqui Smith, who was infuriated by what he had written. She felt he was belittling the dangers of a Class A drug, and attempting to meddle in Government policy. Unbowed, he then gave a lecture where he re-stated his views. By this time Alan Johnson was Home Secretary and Professor David Nutt - in what he describes as an 'e-dismissal' - was sacked from his advisory role.

Professor Nutt describes the events leading up to his dismissal, and discusses the impact on him personally when The Sun ran a piece illustrated by photos of his children, one of them apparently drunk (she wasn't) the other smoking a roll-up (of tobacco). The Sun later printed an apology. (1)

Professor Nutt is an advocate of a rational assessment of risk, based on scientific evidence, which means that whether or not a drug is illegal should be bracketed out of consideration at that stage, although he is the first to say that a "free for all" policy is not what he is advocating. He wrote:

IF THERE is one thing that politicians can and should do to limit the damage caused by illegal drugs, it is to take careful note of the evidence and develop a rational drug policy. Some politicians find it easier to ignore the evidence, and pander to public prejudice instead. I can trace the beginning of the end of my role as chairman of the UK's official advisory body on drugs to the moment I quoted a New Scientist editorial (14 February, p 5). Entitled, fittingly enough, "Drugs drive politicians out of their minds", the editorial asked the reader to imagine being seated at a table with two bowls, one containing peanuts, the other the illegal drug MDMA (ecstasy). Which is safer to give to a stranger? Why, the ecstasy of course. I quoted these words in the Eve Saville lecture at King's College London in July. This example plus other comments I have made - such as horse riding is more harmful than ecstasy - prompted Alan Johnson, the home secretary, to say that I had crossed the line from science to policy. This, he said, is why I had to go. But simple, accurate and  understandable statements of scientific fact are precisely what the advisory council is supposed to provide. Why would any scientist take up some future offer of a government advisory post when their advice can be treated with such disdain? (2)

It was an interesting interview, and John Humphreys pressed Professor Nutt quite hard about what he would advise his own children to do, and how his assessment of risk might change if there was a personal element involved.

What Humphreys shied away from tackling in any real depth, and what Nutt did not really bring up, was the problem of risk with legal drugs - such as nicotine (in tobacco) and alcohol. But Nutt has tackled alcohol elsewhere in a Guardian article in which he noted that it kills up to 40,000 people a year in the UK and over 2.25 million worldwide in the latest 2011 WHO report. In the article, he wrote:

There is no safe dose of alcohol for these reasons:;

. Alcohol is a toxin that kills cells such as microorganisms, which is why we use it to preserve food and sterilise skin, needles etc. Alcohol kills humans too. A dose only four times as high as the amount that would make blood levels exceed drink-driving limits in the UK can kill. The toxicity of alcohol is worsened because in order for it to be cleared from the body it has to be metabolised to acetaldehyde, an even more toxic substance. Any food or drink contaminated with the amount of acetaldehyde that a unit of alcohol produces would be immediately banned as having an unacceptable health risk.

. Although most people do not become addicted to alcohol on their first drink, a small proportion do. As a clinical psychiatrist who has worked with alcoholics for more than 30 years, I have seen many people who have experienced a strong liking of alcohol from their very first exposure and then gone on to become addicted to it. We cannot at present predict who these people will be, so any exposure to alcohol runs the risk of producing addiction in some users. (3)

The government's view was that if a drug was declared illegal, then it was not legitimate to compare risk in the same way was if the drug was legal. Horse riding, while it might be inherently more risky statistically, was legal, but taking ecstasy was not, and hence anyone considering taking the drug should also consider the risk of prosecution.

Nutt's point of view was that the legality of the drug was a matter of political discrimination, and should not be factored into any calculation on scientific risk - how safe the drug was, because legality and safety were two different matters, and different countries had different political judgments on what they would permit as legal, whereas a scientific assessment should be neutral on that.

He was also clear that assessing risk did not mean that drugs were safe, but  that a consensus could be reached on which drugs were more harmful than others - heroin, LSD, for example - while he argued that ecstasy was given too high a classification, because the consensus on its risk did not place it that high - it was far less lethal than LSD, for example. Nutt suggested that the reason for this was not scientific assessment of risk, but political decisions which chose to ignore the scientific consensus.

He also suggested that giving certain drugs too high a classification might also inhibit researchers looking for safe compounds based on the drugs themselves, because to get a medicinal version accepted there would be an extra barrier of prejudice to overcome. He didn't give an example, but I can thing that a medical denatured drug based on cannabis, for example, could well help arthritis sufferers greatly, but that kind of research tends to be discouraged because of the stigma associated with the illegal version.

Humphreys also pressed him on the issue of scientific consensus. This is, of course, a widespread problem, not just with a matter of drug safety, but also with matters like global warming. If scientific experts back each side, said Humphrey, then what does it mean to talk about consensus, and how can it be achieved. Who does the layman trust when the research seems to be ambiguous, and both sides can call upon their own "experts"? Nutt's reply was to say that drugs such as ecstasy should be assessed on the same kind of rigorous drug analysis that would take place with a licensed pharmaceutical product to assess its risk and side-effects, which he contended that his critics had not done.

Hacker: The statistics are irrefutable...
Humphrey: Statistics? You can prove anything with statistics.
Hacker: Even the truth.
Humphrey: Yes... No!
(The Smokescreen, Yes Prime Minister)

Nevertheless, even if there is a question over how one determines "consensus" when scientists disagree, it is certainly clear that there is an inconsistency with regard to the treatment tobacco and alcohol which stems not from scientific evidence, but from its political history which has given it a special legitimacy which it really does not deserve.

Professor Nutt: Well, there are so many myths about drugs, one thing we do at the ISCD is try to make people understand that alcohol is a drug and that is the most important one because that is the drug we should really be targeting in terms of reducing health damage and improving health outcomes. (4)

I'm not saying that Prohibition would be a good idea, or that all illegal drugs should be legalised, but I do suspect that part of the problem with assessing risk is that there are drugs whose effects are considerably less than alcohol, but have been branded illegal while alcohol continues to enjoy a privileged status that is quite unjustified in terms of risk.

There is therefore a contradiction between a fact based assessment of risk, and how drugs are legitimised or stigmatised, and until this can be satisfactorily resolved, or matters improved, the legitimacy of drugs policy will always seem to have an overlay of not purely assessing risk, but also policing morals. The exceptions given to tobacco and alcohol undermine the moral case for restricting other drugs because that is a historical exception, based on powerful business lobbies, and not a rational one.

Declaration of interests: Because this is a controversial subject, I should state my own position. I don't take drugs, as I have enough trouble keeping my physiology in harmony without adding unnecessary risks.  I would not recommend drug taking to anyone. I don't go horse riding either!

I do have the odd glass of wine socially, or a odd sip from a chalice of wine or mead. I disagree with Professor Nutt on "safe level"; a sip of communion wine, for example, is really not going to cause any harm to most people, and I would defy him to prove otherwise.

(1) http://www.bbc.co.uk/iplayer/episode/b00zf6qv/On_the_Ropes_Professor_David_Nutt/
(2) http://www.newscientist.com/article/dn18099-david-nutt-governments-should-get-real-on-drugs.html
(3) http://www.guardian.co.uk/science/2011/mar/07/safe-level-alcohol-co
(4) http://neurobonkers.com/?p=1856

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