Annabel Bentley: Evidence of drugs and alcohol down the pub
19 Nov, 09 | by BMJ Group
A debate on the harms of drugs and alcohol hosted in a pub - surely not?
This week I was lucky enough to visit the epicentre of drinking and critical thinking at what claims to the be the world’s largest regular pub meeting. An open invitation to join a garrulous group of sceptics at a forum hosted by the Westminster branch of Skeptics In The Pub promised to be loud, messy, and disorganised - and very democratic - according to the Economist. As an opportunity to escape the contrived debate generated by the X-Factor and join a real debate with real scientists, lawyers and people probably proud to be identified as geeks, it was a pull too hard to ignore.
The evening started with Professor David Nutt, Imperial College’s Neuropsychopharmacology Chair and the ex-chairman of the UK government’s Advisory Council on the Misuse of Drugs (ACMD), giving his views on the state of evidence about drug harms, from legal drugs such as alcohol to illegal drugs cannabis and ecstasy. He pointed out that there are various ways to define what a drug is … such as “something taken by a rat that results in the publication of a paper” (which got a ripple of laughter from the scientists in the room) or “something taken by an MP that they later deny” (which got a laugh from the cynics in the room). Professor Nutt then argued for drug policy to be based on evidence of relative harms, a view he previously gave at this year’s Eve Saville Lecture, including his opinion that harm from alcohol is probably the biggest drugs challenge we face. So to me it seemed somewhat ironic that the debate was being held in a pub, with many participants clutching gently-warming glasses of bitter and a few hardened addicts even daring to pop outside to smoke tobacco legally.
We then heard from Dr Evan Harris MP, who opposes the sacking of Professor Nutt from the ACMD, and has recently written to the Home Secretary about this (the letter and response are posted on his personal blog). Dr Harris also added a light-hearted comment about scientific understanding “MPs don’t understand peer-review. They think it’s when a baroness casts an eye over a press release.”
Despite Professor Nutt’s argument for evidence-based drug policy I can’t help worrying that it’s not that simple - evidence is rarely black and white, and almost always comes in nuances of grey. However, getting better evidence on relative harms of all drugs is a worthwhile common goal for scientists, policy makers, drug workers and health professionals to help reduce the burden of avoidable harm.
Annabel Bentley (MBBS FRCS) is interested in evidence that matters to patients and health risk communication. Originally trained as a surgeon, she is now assistant medical director at Bupa. The views in this blog are her own and not of any organisation she works for.
With respect to drug (and other) policies, the data that scientists think is evidence has to do with harms of the drugs and benefits of policies, while the data that politicians think is evidence has to with winning or losing votes (assuming that the politicians are rational).
Scientists and politicians are thus guaranteed to talk past each other. Politicians should take more notice of scientific evidence. Scientists should try to engage the media more, so that voters better understand the science, and become more likely to vote for science-based policies. And, the media should be more responsible in reporting science and more balanced in reporting stories.
Michael
November 19th, 2009 at 12:13 pm
Perhaps all those concerned with drug policy, whether scientist or politican, could learn to take a more holistic view on the subject. There are individual and societal aspects to consider: broken lives, broken communities, increasing healthcare costs. There are also global costs, such as the effects of trendy cocaine snorting (and not so trendy crack intake)on the leafy countries of South America and that of heroin in the mountains of Afghanistan and Pakistan, plus others. Drug policies going back to prohibition have been more about cant and power than about true concern. Journalists have played their parts in this, too, and their role should not be forgotten in this debate.
Ed Rowe
November 20th, 2009 at 11:03 am
Making policy based on evidence sounds like a bloody good idea to me. Evidence isn’t just chemical reactions but also the impact of drugs on society - which should be more important than the impact of drugs on vote counts and bank accounts.
The best people to have in politics are people who don’t want to be politicians - an unfortunate paradox. Scientists have a tendency to fall into this category…
Chris Nickson
November 20th, 2009 at 2:30 pm
That’s a very good point about evidence not being black and white. But surely the more uncertain it is, the more important legalisation is.
By banning something and making it a class A drug, you are saying that you are willing to arrest and imprison someone who decides to take it.
It would be highly immoral to take away years from someone’s life like that without very strong evidence to show that what they were doing was harmful.
Simon Perry
November 20th, 2009 at 5:35 pm
the classification system, for all its manifest failings is at least clear that the hierarchy of penalties is based on harm rankings as established by the ACMD. That advice is based on the harm matrix as published in the lancet and the best evidence available. The harm matrix is not beyond critique - but it is all we have at the moment and is better than nothing, which is what we had before - so until something better comes along it will have to serve, and again, it is clear in its methodology and published (albeit belatedly) for critique (which I, amongst others, have done). The evidence on which the rankings are based is also inadequate and incomplete - but the committee at least have, to there credit looked at all the published and available evidence, spoken to the leading experts, and invited evidence from all interested parties. the reports they have produced are excellent in that context. This is not really the problem - despite all the fuss around Nutt’s dismissal.
If one wanted to criticise the ACMD they would be much better asking them, as I have repeatedly, why they do not look at the evidence in terms of the policy outcomes of translating the harm rankings into criminal penalties, which is of course what the MDA 1971 does. The committee don’t do this, which is inexcusable if they are really claiming to be following the evidence; they are more than happy to examine policy outcome evidence in other areas such as education and prevention for example (the excellent 2007 ‘pathways to problems’ report). It doesn’t matter if the rankings are right or wrong if the policies that flow from them, as translated through the criminal justice system, are demonstrably a catastrophic failure on all meaningful indicators (aside from political ones). Which they are.
The debate around tweaking relative drug harm rankings is a distraction from this far more pressing issue.
Steve Rolles
November 21st, 2009 at 12:28 pm
The debate is fascinating. The illicit drug policies in the US have been an expensive failure: we have imprisoned 1% of our population, the bulk of these incarcerations occurring in males from minority groups for drug-related offenses. We have spent countless billions of dollars on the “War on Drugs” without much hope of curtailing the supply stream.
Nothing brings out the politics of drugs more clearly than the illegal status of cannabis: evidence suggests that it may be less harmful than tobacco or alcohol, and hemp would be a sustainable way to produce paper, textiles and other goods. Yet, the plant remains illegal due to the strong political position of alcohol and tobacco in this country.
Clearly, evidence for scientists and evidence for policy makers are very different animals.
Marya
November 24th, 2009 at 6:04 pm
This article helpfully provides links to documentation supporting the arguments of the debate’s participants, but a reader (like myself) unfamiliar with the state of the clinical literature has to dig rather deeply to discern the methodology by which Dr. Nutt comes to his conclusions about relative harm. After such digging, one finds from the Lancet that the relative harm rankings are obtained from the deliberations of a Delphi panel, which, despite having certain advantages for such complex issues as drug policies, relies ultimately upon subjective scoring rather than objective weighting of evidence.
Mr. Rolles’ comment, however, is on target: that this methodological criticism is rather beside the point, that the real lacuna in these debates is considering what sorts of interventions are likely to be effective in altering these harms, and what are their concomitant cost, whether obtained through the justice system or another sort of public health or service intervention.
Charles Betley
December 1st, 2009 at 12:06 am