MY VIEWS ON DRUGS CLASSIFICATION

David Nutt, the Government's Former Chief Drugs Adviser, on How He
Formulated His Controversial Views on Drugs

Formulating policy in relation to drugs is obviously quite a
difficult thing to do. I comment on it, as I always have, from the
perspective of a psychiatrist who is interested in drugs and drugs
and the brain.

We have a range of expertise on the Advisory Council on the Misuse of
Drugs (ACMD); we're very strong in terms of chemistry and
pharmacology, and psychology; and we have a definite knowledge,
interest and responsibility to look at social harms as well. We
provide one arm of the policy-formulating perspective. In addition,
there are a number of other agencies, organisations and individuals
who contribute to policy formation.

There are also international partners - we have signed up to
international treaties - which determine that, in essence, the UK
follows United Nations policy on drugs. This can be quite a tough
constraining influence on how countries regulate drugs (although some
countries, such as the Netherlands, have managed to be more flexible,
even though they still sign up to the international conventions).

Then, of course, there are other factors feeding into political
decisions about drugs: what the general public thinks (or is thought
to think); and then there's the media. In recent years, the whole
process of determining drug classification has become quite complex
and highly politicised.

Cannabis - A Potent Problem

I am going to focus on cannabis because it is the only drug that has
been downgraded in the history of the 1971 Misuse of Drugs Act, an
interesting point in itself. The issues relating to cannabis pose a
challenge to whether the act is working as it was originally intended.

The ACMD was requested by the home secretary in 2007 to review the
status of cannabis because: "Though statistics show that cannabis use
has fallen significantly, there is real public concern about the
potential mental health effects of cannabis use, in particular the
use of stronger forms of the drug, commonly known as skunk."

So there was a skunk scare. Cannabis had gone from class B to C, but,
supposedly, skunk use had been increasing and it was getting
stronger, so we were asked to review whether the decision to go from
B to C was still appropriate. In our report we came to several conclusions:

. Cannabis is a harmful drug and there are concerns about the
widespread use of cannabis amongst young people.

. A concerted public health response is required to drastically reduce its use.

. Current evidence suggests a probable, but weak, causal link between
psychotic illness and cannabis use.

. The harms caused by cannabis are not considered to be as serious as
drugs in class B and therefore it should remain a class C drug.

There has been a lot of commentary and some research as to whether
cannabis is associated with schizophrenia, and the results are really
quite difficult to interpret. What we can say is that cannabis use is
associated with an increased experience of psychotic disorders. That
is quite a complicated thing to disentangle because, of course, the
reason people take cannabis is that it produces a change in their
mental state. These changes are akin to being psychotic - they
include distortions of perception, especially in visual and auditory
perception, as well as in the way one thinks. So it can be quite hard
to know whether, when you analyse the incidence of psychotic
disorders with cannabis, you are simply looking at the acute effects
of cannabis, as opposed to some consequence of cannabis use.

If we look on the generous side there is a likelihood that taking
cannabis, particularly if you use a lot of it, will make you more
prone to having psychotic experiences. That includes schizophrenia,
but schizophrenia is a relatively rare condition so it's very hard to
be sure about its causation. The analysis we came up with was that
smokers of cannabis are about 2.6 times more likely to have a
psychotic-like experience than non-smokers. To put that figure in
proportion, you are 20 times more likely to get lung cancer if you
smoke tobacco than if you don't.

There is a relatively small risk for smoking cannabis and psychotic
illness compared with quite a substantial risk for smoking tobacco
and lung cancer.

The other paradox is that schizophrenia seems to be disappearing
(from the general population) even though cannabis use has increased
markedly in the last 30 years. When we were reviewing the general
practice research database in the UK from the University of Keele,
research consistently and clearly showed that psychosis and
schizophrenia are still on the decline. So, even though skunk has
been around now for 10 years, there has been no upswing in
schizophrenia. In fact, where people have looked, they haven't found
any evidence linking cannabis use in a population and schizophrenia.

Media Bias

I want to move on now to look at how people gather information about
drugs and the challenges of communicating the best evidence relating
to drug harms to the public. This is difficult in the face of what
you might call a peculiar media imbalance in relation to drugs. The
following data illustrates a remarkable finding. It derives from the
PhD of a Scottish graduate, Alasdair JM Forsyth, who looked at every
single newspaper report of drug deaths in Scotland from 1990 to 1999
and compared them with the coroners' data.

Over the decade, there were 2,255 drug deaths, of which the Scottish
newspapers reported 546. For aspirin, only one in every 265 deaths
were reported. For morphine, one in 72 deaths were reported,
indicating that editors were not interested in this opiate. They were
more interested in heroin, where one in five deaths were reported,
and methadone, where one in 16 deaths were reported.

They were also more interested in stimulants. With amphetamines,
deaths are relatively rare at 36, but one in three were reported; for
cocaine it was one in eight. Amazingly, almost every single ecstasy
death - that is, 26 out of 28 of those where ecstasy was named as a
possible contributory factor - was reported. So there's a peculiar
imbalance in terms of reporting that is clearly inappropriate in
relation to the relative harms of ecstasy compared with other drugs.
The reporting gives the impression that ecstasy is a much more
dangerous drug than it is. This is one of the reasons I wrote the
article about horse riding that caused such extreme media reactions
earlier this year. The other thing you'll notice is that there is a
drug missing, and that's cannabis. Also missing is alcohol, which
will have killed a similar number - 2,000-3,000 people - in Scotland
over that time, maybe more. Of course, cannabis wouldn't have killed
anyone because it doesn't kill. And that's one of the reasons why we
thought cannabis should be class C, because you cannot die of
cannabis overdose.

Assessing Harm

We've tried very hard for at least the last 10 years to put together
a structure for assessing drug harms. This eventually became a
research paper, Development of a Rational Scale to Assess the Harms
of Drugs of Potential Misuse, published in the Lancet in 2007.
Despite - or perhaps because of - its novelty and remit, it was very
hard to get a paper published that challenged some of the current
(mis)perceptions about drugs.

In principle, we broke down drug harms into the following parameters:
physical harm (acute, chronic and intravenous), dependency (intensity
of pleasure, psychological dependence, physical dependence), and
social harms (intoxication, other social harms and health-care costs).

We looked at all the drugs in the Misuse of Drugs Act and added some
others that weren't already covered by it. For example, we included
ketamine, which wasn't covered by the act at the time, solvents, and
tobacco and alcohol, because we thought it was very important that
harms of illicit drugs were assessed against the harms of drugs that
people know and use. This analysis eventually established a ranking
order presented opposite.

A number of important points emerged. The ranking suggested that
there are clearly some very harmful drugs (you might say these would
be class A drugs) and there are some drugs that aren't very harmful,
such as khat or alkyl nitrites, which aren't controlled by the act at all.

Interestingly, some class A drugs scored much lower than other class
A drugs, suggesting that there is some anomaly in terms of that part
of the current statutory classification system.

The ranking also suggests that a tripartite classification system
might make sense, with drugs ranking as more harmful than alcohol
being class A and those ranking lower than tobacco as class C. The
exercise also highlighted how dangerous alcohol is. I believe that
dealing with the harms of alcohol is probably the biggest challenge
that we have in relation to drug harms today.

One problem is that sometimes you get into what I think of as an
illegality-logic loop. This is an example of a conversation I've had
many times with many people, some of them politicians:

MP "You can't compare harms from a legal activity with an illegal one."

Professor Nutt "Why not?"

MP "Because one's illegal."

Professor Nutt "Why is it illegal?"

MP "Because it's harmful."

Professor Nutt "Don't we need to compare harms to determine if it
should be illegal?"

MP "You can't compare harms from a legal activity with an illegal one."

I have been surprised how difficult this concept is to get across to
some people, whether they are politicians, fellow scientists or
members of the general public.