The Lancet and drug harms: missing the bigger picture

The Lancet this week published the long awaited paper on drug classification: ‘Development of a rational scale to assess the harm of drugs of potential misuse’ by David Nutt, Leslie A King, William Saulsbury, Colin Blakemore. Whilst the Lancet publishers will make you register to read it, those nice folks over at MAP have been good enough to put the complete text on their website for your reading pleasure.

This is the abstract:

Drug misuse and abuse are major health problems. Harmful drugs are regulated according to classification systems that purport to relate to the harms and risks of each drug. However, the methodology and processes underlying classification systems are generally neither specified nor transparent, which reduces confidence in their accuracy and undermines health education messages. We developed and explored the feasibility of the use of a nine-category matrix of harm, with an expert delphic procedure, to assess the harms of a range of illicit drugs in an evidence-based fashion. We also included five legal drugs of misuse (alcohol, khat, solvents, alkyl nitrites, and tobacco) and one that has since been classified (ketamine) for reference. The process proved practicable, and yielded roughly similar scores and rankings of drug harm when used by two separate groups of experts. The ranking of drugs produced by our assessment of harm differed from those used by current regulatory systems. Our methodology offers a systematic framework and process that could be used by national and international regulatory bodies to assess the harm of current and future drugs of abuse.

and this is the graph of harm rankings for the drugs they have considered:




The paper has had loads of media coverage focusing on the graph above (rather than the more interesting material about how they came up with it), mostly along the lines of 'alcohol more dangerous than ecstasy', or variations thereof. This minor media furore (‘Alcohol worse than ecstasy on shock new drug list’ blurted the Guardian on its front page) is a bit odd because it must be one of the most heavily trailed Lancet papers in history. Not only were the draft contents discussed in detail by the Science and Technology Select Committee drug classification inquiry report (see page 70), and ‘the graph’ published by them, but ‘the graph' has actually appeared as one of those jazzy front page tabloid splashes in the Independent. Last year. If you missed all that the Lancet paper was also discussed - in even greater detail - by the more recent RSA report which includes an entire section on ‘the Blakemore / Nutt hierarchy of harm’ (not sure what King and Salusbury think about that), and ‘the graph’, around which much of the recommendations are built. Some journalists either have short memories or they are banking on us having short memories - if you can get a 'shock' twice with the same story, why the hell not eh?

Anyway, the finished paper is undoubtedly a fine piece of work. It has very usefully put legal and illegal drugs on the same harm continuum (obvious really, but good to see it being said in the Lancet) and in doing so exposing the contradictions, lack of logic, and false assumption that underpin much drug policy thinking here and around the world. The matrix system they propose for ranking drug harms is definitely a good start. Clearly any system of regulation, be it sensibly based on established legal controls and public health principles, and stupidly based on criminal penalties and prohibitionist ideology, will require some sort of ranking system to make distinctions and policy decisions for different drugs.

I actually think it’s too simplistic, although to be fair, the authors do not claim it as the be all and end all. As discussed in more detail in the Transform briefing on drug classification:

Drug harms are mediated by the nature of the user, the dose of drug consumed and the method of consumption – making a system based upon broad sweep single classifications for each drug fundamentally unscientific, and meaningless in most practical terms.

So the whole idea that drug x is ‘more dangerous’ than drug y is only useful in the broadest population analysis. For an individual it’s fairly meaningless because, obviously, it depends how much of given drug you use, how often you use it, how you use it, whether you have a heart problem or mental health issues, and so on. There are still some oddities in the ranking (solvents, for example, seem too low to me), but it’s a massive leap forward from what we have at the moment which the authors politely describe as having ‘evolved in an unsystematic way from somewhat arbitrary foundations with seemingly little scientific basis’. If they were writing in a blog, not the Lancet, I suspect they would have said: 'it's a total joke'.

However, I take more substantive issue with the paper, not for what they covered, but for what they left out:

Firstly, the harms of a given drug will depend upon its legal status. The best way to demonstrate this point is with heroin, which is placed at the top of the Lancet-scale as the most harmful of all drugs. For street heroin this may well be the appropriate placing, but, if we are being scientific here, it is imperative to separate out the harms that follow from use of the drug per se, and the health and social harms exacerbated or created specifically by the drug's use within an illegal market. These, lets call them 'prohibition harms', include:

• Contaminated/cut product (poisoning, infection risks)
• Dirty/shared needles (Hep C / HIV risk)
• Vast quantities of low level acquisitive property crime to support a habit: illegal markets inflate the cost of an essentially worthless agricultural product to one that is worth more than its weight in gold. People on prescriptions don't have to nick stuff.
  
• Street prostitution (see above)
• Street dealing, drug-gang violence and turf wars
• Drug litter (needles in the gutter etc)

More useful would have been to rank both illegal street heroin, associated with the above harms which aren't going to help its ranking much, and prescribed pharmaceutical heroin, associated with none of the above harms. The latter would certainly be considerably further down the scale. Luckily, we can theoretically do this with heroin as both legal and illegal markets exist simultaneously in the UK, although the number of prescribed users (approx 400) is rather eclipsed by the number of illicit users (approx 250,000+). It’s a great shame the authors of this study failed to make that comparison (we do, confusingly, get 'street methadone' in the ranking, but not the prescription variety). It would have helped policy makers untangle the harms created by drug misuse from the harms created specifically by prohibition and had far wider implications for the future of the dominant criminal justice paradigm.

Some policy makers are wise to this legality/harm equation. During the Science and Technology Committee inquiry evidence sessions there is a revealing section where they are discussing the harm matrix with Proffessor Nutt and Sir Micheal Rawlins, Chair of the ACMD (at this point, 2006, it is still unpublished and available only in draft). Dr Harris MP raises the point that the classification a drug is given will impact on the level of social harms it is associated with:

Q188 Dr Harris: In this matrix you include under “social harms” intoxication, health care costs, and other social harms. Included under “other social harms” do you include the harm that stems from criminalisation itself?

Professor Sir Michael Rawlins: Yes.

Q189 Dr Harris: You do not spell that out but that is understood?

Professor Sir Michael Rawlins: Yes and whether it leads to acquisitive crime.

A couple of questions later…

Q 195 Dr Harris: Your recommendation recommending classification into a particular class creates social effects, does it not?

Professor Nutt: Indeed it does.

Q196 Dr Harris: Because obviously it brings criminal justice along with it and that affects the price and availability and so forth. Do you recognize that? Your own actions impact on the evidence. Did you feed that back in before you made the recommendation?

Professor Nutt: We know it might happen but you can never be sure how big an effect that might have.

When translated through the prism of the Misuse of Drugs Act the harm rankings become, to a significant degree, strangely self-fulfilling, as is evident in the case with heroin: The more you criminalise the drug (by moving it up the rankings) the more risky you make its use and more social harms you create associated with its illegal supply. Given there is no evidence that these increased harms are offset by any deterrent effect associated with classification the whole system seems even more bizarrely unscientific and unsustainable.

Colin Blakemore, one of the authors and chief executive of the Medical Research Council is quoted in the guardian saying:

"We face a huge problem. Drugs ... have never been more easily available, have never been cheaper, never been more potent and never been more widely used".

"The policies we have had for the last 40 years ... clearly have not worked in terms of reducing drug use. So I think it does deserve a fresh look”

This leads us to the second, arguably more serious problem with the paper. The rankings of drugs, with the anomalous exceptions of alcohol and tobacco, are defined within the Misuse of Drugs Act 1971 and primarily intended to determine the accompanying hierarchy of criminal penalties, and not to provide public health information to potential drug users.

The evident problem is that there is no meaningful evaluation of the outcomes of this unique criminal justice approach to public health regulation. We can have excellent science ranking drugs public health harms, as this paper presents, but then no science at all regards the outcomes of these rankings when they are implemented as criminal policy. As the authors have noted, the use and availability of illegal drugs has risen steadily under the current system. A more scientific ranking of harm is not enough: the whole prohibitionist legal framework needs to be reassessed as well. To immodestly quote myself in the oral evidence I gave to the Sci-tech Committee:

"I have been trying to think of a metaphor for this and the best one I can come up with is that it is like arguing over what colour to paint a square wheel. Even if all the experts agree it should be blue it does not matter because that wheel does not turn. The classification system does not do what it is supposed to do, it does not reduce harm, it does not reduce misuse, it does not reduce mental health problems. In fact it seems to do the exact opposite so the whole thing is an exercise in distraction"

In the short term I despair that anything at all will happen. The Government give the pretence of supporting evidence based policy on drugs, but when it clashes with their ‘political judgements’ or 'beliefs' that all goes straight out of the window.

In a follow up oral evidence session to the publication of the Science and Technology Select Committee’s devastating 2006 critique of the classification system, the committee re-interviewed Sir Micheal Rawlins, Proffessor Nutt, and the minister with responsibility for drugs, Vernon Coaker.

It’s a truly remarkable interrogation, with the Minister not having a leg to stand on when he is repeatedly challenged on the lack of evidence base for the classification system's effectiveness, or the justification for certain howling anomalies within the system. He falls back on evasion, changing the subject or the excuse of decisions being ‘political judgements’ , or worse, merely that it is his ‘belief’ that the system works. There is not even the pretence that the system is evidence based. I recommend you read it all (or look forward to other choice quotes popping up on the blog in the future), but for the time being here are some low-lights, just so you know what you're up against.

First is a section about the reclassification of ecstasy:

Q109 Mr Newmark: If the ACMD discovered new evidence when it undertook the review, would you consider reclassifying ecstasy?

Mr Coaker: We would consider their evidence. As I say, we have no plans to reclassify ecstasy. The ACMD is independent of government, we obviously respect what they say, and they will bring their report forward, but the Government has no plans and no intention of reclassifying ecstasy.

Q110 Dr Harris: You say that you do not propose to move ecstasy and it will remain a Class A drug. Is that an evidence-based policy?

Mr Coaker: That is a judgment the Government makes on the basis of what we believe to be something that is in the interests of the public at large to keep ecstasy as a Class A drug.

Q111 Dr Harris: Is it an evidence-based view?

Mr Coaker: It is a judgment that we make based on all the evidence we have had no recommendation from anybody to reclassify ecstasy from an A to a B. We think it is a drug which is harmful. There is no safe dose of it. We were talking about alcohol earlier on and one of the problems you have with alcohol is there probably is a safe dose. Like many here, I have a drink now and again, but there is no safe dose of ecstasy, we think it would send out totally the wrong messages and, as I say, we have no intention of reclassifying ecstasy.

Q112 Mr Newmark: Because it kills unpredictably?

Mr Coaker: As I say, there is no safe dose. This is the point, just half a minute—

Q113 Dr Harris: There is no safe dose of tobacco.

Mr Coaker: It just does make the point very well, the exchange that we have just had between two members of the Committee, quite rightly, about the difficulties that there are in this area and the different views and opinions that people have. I think what we all wrestle with is using evidence and using science and also trying to think about it from a non-scientific point of view in the social judgments and the individual judgments and the community judgments that we make. We wrestle with that and, as I say, as a Government we have no intention of doing anything with respect to ecstasy because we do not believe there is a safe dose, it is harmful, it kills unpredictably, as Brooks has said, and we just think that it is a very important way to use the classification system.

Q114 Dr Harris: If the ACMD reviewed the evidence and that review made recommendations to you, are you saying now it is not worth them doing it because your decision on this will not be evidence based, it will just be a reassertion of your "no intention to reclassify ecstasy"? Even if they said there will be fewer deaths, for whatever reason, if it is reclassified, are you saying that you will never consider an evidence-based decision on this drug?

Mr Coaker: I am not saying that at all. What I am saying is the ACMD, of course, can conduct research and look at whatever they wish to with respect to drugs and make recommendations to the Government. What I am saying quite clearly is that we have no intention of reclassifying ecstasy.

Q115 Dr Harris: I am keen to pursue this one. I understand you have no intention and I assume that is current because I do not think you could bind your successors if the evidence changed. Is it your view that all drugs for which there is no safe dose should be in Class A or is there something special about ecstasy which means it is one of the drugs for which you say there is no safe dose which means it must be in A?

Mr Coaker: In talking about ecstasy, it kills unpredictably, we do not believe that there is a safe dose; we will not reclassify ecstasy.

Q116 Dr Harris: Does that apply to all drugs that meet those criteria?

Mr Coaker: What we try to do where we have evidence and where people come to us with recommendations is make individual judgments, as we will do whenever people come to us. All I am saying with respect to ecstasy is that we have no plans and no intention of doing so.

Q117 Dr Harris: So do you think you are wasting your time, Professor Rawlins, if you end up doing a review in this area?

Professor Sir Michael Rawlins: No, I think we will give advice on whatever we feel is appropriate but perhaps in a way more importantly we will also be able to, I hope, give better advice on harm reduction, which is actually rather important, and on what further research is needed in order to understand the dangers of it.

Q118 Dr Harris: Will the fact that the Minister has said quite categorically that he is not going to change the classification have any bearing on whether you follow through and do a report?

Professor Sir Michael Rawlins: None at all because we are going to do it.

Now here is a second section from slightly earlier in the session. Creationism gets a mention in reference to the Minister's scientific discourse; it seems an appropriate comparison (and couldn't help but remind me of this).

Q45 Chairman: Vernon, in response to us, you said that the Government "fundamentally believes that illegality is an important factor when people are considering engaging in risk-taking behaviour . . . It believes that the illegality of certain drugs, and by association their classification, will impact on drug-use choices". Where is the evidence for that?

Mr Coaker: That is the belief and the judgment that the Government have.

Q46 Chairman: I did not ask you that. People believe in creationism and they are entitled to do that, though I do not agree with that, but I am asking you, where is the evidence?

Mr Coaker: To be fair to the response that we tried to make in response to the Committee where the Committee has challenged us, we have ourselves said that we need to do more research into the deterrent effect, that we need to establish a better evidence and research base for that, so we have accepted the point of the need to actually do something about it, but we do believe, and strongly believe, that the classification of drugs in the current system, A, B and C, with respect to Class A does act as a deterrent system. That is a judgment we make, it is a belief that we have and we have accepted that there is more to do with respect to that.

Q47 Adam Afriyie: If when you carry out and conduct this research the evidence shows that you are completely mistaken in that view, will change your view?

Mr Coaker: I cannot prejudge what any research is going to tell us. Clearly you make judgments about the research that you receive and that is obviously the point.

Q48 Chairman: Vernon, you have not commissioned any research and nor have the ACMD.

Mr Coaker: No, but what we have said in response to where the Committee challenged us and said, "Where is your evidence base for that?", as we have done with a number of other things, we said that we understand that point, we accept that point and we need to look at establishing a better evidence base for that, but it does not alter the fact or change the fact that the Government believes that the tripartite system, the classification system, does send out a strong message and does impact on, and affect, behaviour.